Unique Bone Suture Anchor Repair of Complex Lumbar Cerebrospinal Fluid Fistulas

Abstract

Background: Spine surgeons encounter occasional complex cerebrospinal fluid fistulas/dural tears (CSF/DT) during lumbar spinal surgery. In some cases, these leaks are found during the index procedure, but others may appear postoperatively, or in the course of successive procedures. Here we asked, whether these complex CSF fistulas/DT could be more readily repaired utilizing a "bone suture anchor" technique, particularly where there is no residual dural margin/remnant.

Methods: With the combined expertise of the orthopedist and neurosurgeon, mini/micro bone suture anchors, largely developed for hand surgery, facilitated repair of complex DT occurring during lumbar spine surgery. This technique was utilized to suture in place fascia, periosteal, or muscle grafts, and was followed by the application of microfibrillar collagen, and a fibrin sealant.

Results: This mini/micro suture anchor technique has now been utilized to repair multiple significant intraoperative and/or postoperative recurrent DT, largely avoiding the need to place lumbar drains and/or lumbo- peritoneal shunts.

Conclusions: Here, we reviewed how to directly suture dural grafts utilizing a mini/micro bone suture anchor technique to repair complex intraoperative primary/recurrent DT occurring during lumbar spine surgery. The major advantages of this technique, in addition to obtaining definitive occlusion of the DT, largely avoids the need to place lumbar drains and/or lumbo-peritoneal shunts with their attendant risks and complications.

Keywords: Complex Repair; Dural Leak; Lumbar; Massive; Patch Grafts; Suture Anchors.

Figure 1:

Biotek Titanium Mini-Vim-Suture-Anchor (Arthroscopic Implants). This mini-Vim-Suture-Anchor-with-Needle is produced by Biotek and the anchor portion is made of Titanium. It is 2.8 mm to 3.5 mm in diameter, and 2.8 mm wide. They come preloaded with USP #2 BioFiber suture. In most cases it can be inserted without the need for a drill, although one is available.

Figure 2:

Depuy Mitek Mini Gill II Titanium Anchor Suture Anchor (QuickAnchor: DepuySynthes, Part of Johnson&Johnson Family Companies). The nitinol arcs are used to reattach soft-tissues to bone. The GII Anchor is small with a high pull-out strength. The drill hole is 2.4 x 8.8mm. It utilizes multiple suture types including ORTHOCORD^®, PANACRYL^® & ETHIBOND^®. It’s indications for use include Ulnar or lateral collateral ligament reconstruction in the hand.