Management of Spinal Dural Tear

Essay

Submitted in Partial Fulfillment of the Master Degree

in Orthopedic Surgery

Presented by

Mohamed Tawfik Mahdy Elgebely M.B., B.Ch. Ain Shams University

Under Supervision of

Prof. Dr. Ali Ibrahim Abdullatif Hussein Professor of Orthopedic Surgery

Faculty of Medicine - Ain Shams University

Dr. AbdEl-Rady Mahmoud AbdEl-Rady Mahmoud

Lecturer of Orthopedic Surgery Faculty of Medicine - Ain Shams University

Faculty of Medicine

Ain Shams University

2014

قطع طبقة الأم الجافية المحيطة معالجة

الشوكي حبلبال

رسبلة تىطئة للحصىل على درجة الوبجستٍر فى جراحة العظبم

هقدهــه هــن

هحود تىفٍق ههدي الجبٍلً هحود تىفٍق ههدي الجبٍلً الطبٍب/ الطبٍب/ جبهعة عٍن شوس –كلٍة الطب –بكبلىرٌىس الطب والجراحة

تحت إشراف

حسٍن عبد اللطٍفحسٍن عبد اللطٍف علً ابراهٍنعلً ابراهٍنالأستبذ الدكتىر/ الأستبذ الدكتىر/ أستبذ جراحة العظبم

جبهعة عٍن شوس -كلٍة الطب

هحوىدهحوىد هحوىد عبدالراضىهحوىد عبدالراضى عبد الراضًعبد الراضًالدكتىر/ الدكتىر/

جراحة العظبم هدرس

جبهعة عٍن شوس -كلٍة الطب

كلٍة الطب

جبهعة عٍن شوس

0214

الهدف من الدراسة

تهدف هذه الدراسة إلى تىضيح الأسباب المختلفة لقطع الأم الجافية

والطزق الحديثة لتشخيصه وعلاجه ومضاعفاته وعلاجها.

-i-

Title Page Table of Figures ii

Abbreviations

Introduction

i

1

Aim of the work 3

Anatomy ,CSF Composition & Physiology 4

Etiology 21

Complications 28

Diagnosis 44

Treatment 51

Summary 91

References 93

Arabic summary 106

-ii-

Title Page

Figure (1) Diagram showing Illustration of the central nervous

system and associated meninges 5

Figure (2) Photograph showing Scanning electron microscope

view of human dura mater. 7

Figure (3) Diagram showing Transverse section through the

spinal cord and meninges . 10

Figure (4) Diagram showing Part of the spinal cord exposed from

the anterior aspect . 12

Figure (5) Circulation of CSF 19

Figure (6) Diagram showing Classification of cerebrospinal fluid

leak 22

Figure (7) Photograph of a female patient in the prone position,

revealing a large fluctuant mass consistent with a

pseudomeningocele in the posterior lumbar location. 36

Figure (8) Photograph of Intraoperative photo before capsule

incision of pseudomeningocele. 36

Figure (9) Photo of Myelogram confirmed the diagnosis of a

pseudomeningocele subarachnoid space 39

Figure (10) Photo of abdominal CT showed a large fluid collection

in the left. 39

Figure (11) Photographs of MRI Illustrates nerves herniating

through the closure site 43

Figure (12) Photograph of Sagittal T1 (left) and T2-weighted MR

images obtained of the lumbar spine demonstrating a

large dorsal fluid collection . 46

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Title Page

Figure (13) Photo of Axial dynamic CT myelogram at the level of

the T7–T8 interspace 48

Figure (14) Photo of Lateral views of the thoracic spine acquired

during digital subtraction myelography. 50

Figure (15) Proposal for modified management protocol for

incidental dural tears. 54

Figure (16) Drawing showing of Running stitch& Interrupted

sutures. 56

Figure (17) Photo of Postoperative MRI cervical spine. 61

Figure (18) Drawing showing Illustration of the use of collagen

matrix for sutureless repair. 63

Figure (19) Drawing Single-person fascia lata harvest. 64

Figure (20) shows the incorporation of an autogenous fat graft

with a suture as a means of closing a dural defect

65

Figure (21) Drawing of Midline tears are readily repaired by

suture. 67

Figure (22) Drawing showing the harvesting of fat graft from a

patient’s subcutaneous layer at the operative site. 68

Figure (23) Drawing showing Left: The fat graft is placed over the

entire exposed dura, 69

Figure (24) Drawing showing Use of 360° fat enclosure to seal an

anterior durotomy. 70

Figure (25) Photograph of image is an axial CT scan performed 10

years after previous fat grafting. 72

Figure (26) Photograph Shows a fat graft in situ 6 years after a 73

-iv-

Title Page

surgical procedure

Figure (27) Drawing showing Reinforcement of Spinal Dural

Suture Lines 74

Figure (28) Illustrates nerves herniating through the closure site 76

Figure (29) 26G Atraucan® Double Bevel Design 83

-v-

Abbreviations B.T.P. Beta trace protein

C.B.F . Cerebral blood flow

C.N.S. Central nervous system

C.P. Choroid plexus

C.S.F. Cerebrospinal fluid

C.S.F.P. Cerebrospinal fluid pressure

C.T. Computed tomography

D.B.C. Dural border cell layer

D.T. Dural tear

E.B.P. Epidural blood patch

F.D.A. Food &drug administration

Fig. Figure

I.C.H. Intra cranial hypotension

I.C.P. Intra cranial pressure

I.P.distance Inter pedicular distance

L.P. Lumber puncture

M.R.I. Magnetic resonance imaging

P.D.P.H. Post dural puncture headache

R.B.Cs. Red blood cells.

S.S. Superficial sedrosis

Introduction Dural tear

1

Introduction

Dura mater is the outermost of the three layers of the meninges

surrounding the brain and spinal cord and it is responsible for keeping in

the cerebrospinal fluid. The name dura mater is derived from

latin“toughmother”.

Unintended dural tear is a frequent complication of spinal surgery

with a reported incidence ranging from 1% to 17% . It varies according

to the type of surgical procedure performed.[1]

The risk of dural tears is increased by conditions such as fibrotic

adhesion, scar tissue from prior surgery, eroded dura, or redundant dura

in patients with large disc herniations.[2]

When dural injury occurs, in the majority of cases it is detected

intra-operatively, and primary repair is mandatory with the established

surgical techniques. Unfortunately not all dural tears can be recognized

and repaired adequately primarily. Even with experienced surgeons,

inadvertent, pin-hole-type dural tear may go unrecognized during

surgery. If a defect goes undetected or is not properly closed, the patient

is likely to experience a postural headache with a combination of the

following symptoms: nausea, vomiting, pain or tightness in the neck or

Introduction Dural tear

2

back, dizziness, diplopia due to sixth cranial nerve paresis, photophobia,

tinnitus, etc.[ 3]

Possible sequelae of dural tear include the formation of a pseudo-

meningocele, a cerebrospinal fluid cutaneous fistula, arachnoiditis,

meningitis, epidural abscess and deterioration in neurological status. [1]

A cerebrospinal fluid leak also predisposes the patient to poor

wound healing and possible wound dehiscence.[1]

Recommendations for the treatment of dural tears have included

primary repair, closed subarachnoid drainage, grafts consisting of

muscle, fat or fascia, blood patches, fibrin-adhesive or cyanoacrylate

polymer sealant, application of Gel foam to the tear and bed rest.[4]

Management of subsequent cerebrospinal fluid leakage remains

controversial. Many surgeons advocate primary repair, while others

recommend a trial of cerebrospinal fluid diversion for postoperative

cerebrospinal fluid fistula.[1]

Dural tear Aim of the study

3

Aim of the Essay

This study aims to explore the recent trends in diagnosis, methods of repair

of dural tear due to different etiologies and its complications.

Dural tear anatomy

4

The Meninges of the Spinal Cord

The spinal cord is enclosed within three membranes. These are

named from without inward: the dura mater, the arachnoid, and the pia

mater (5)

.

More in depth studies on meningeal function and ultrastructure

have recently changed the view of meninges as a merely protective

membrane. Accurate evaluation of the anatomical distribution in the

CNS reveals that meninges largely penetrate inside the neural tissue.

Meninges enter the CNS by projecting between structures, in the stroma

of choroid plexus and form the perivascular space of every parenchymal

vessel. Thus, meninges may modulate most of the physiological and

pathological events of the CNS throughout the life. (6)

1- The Spinal Dura Mater (dura mater spinalis; spinal

dura)

The dura mater is a thick and dense inelastic membrane, forms a

loose sheath around the spinal cord, and represents only the inner or

meningeal layer of the cranial dura mater; the outer or endosteal layer

ceases at the foramen magnum, its place being taken by the periosteum

lining the vertebral canal, as seen in Fig. (1) (5)

.

Anatomy Dural tear

5

Fig. (1) (A)Illustration of the central nervous system and associated meninges.(B)

superior sagittal sinus & its relation to meninges , (B) Cerebral meninges ,(D) Spinal

meninges . (10)

The spinal dura mater is separated from the arachnoid by a

potential space, the subdural space; the two membranes are, in fact, in

contact with each other, except where they are separated by a minute

Anatomy Dural tear

6

quantity of fluid, which serves to moisten the opposed surfaces. It is

separated from the wall of the vertebral canal by a space, the epidural

space (7).

The spinal dura mater is attached to the circumference of the

foramen magnum and to the second and third cervical vertebrae it is also

connected to the posterior longitudinal ligament, especially near the

lower end of the vertebral canal, by fibrous slips(8)

.

The subdural space ends at the lower border of the second sacral

vertebra; below this level the dura mater closely invests the filum

terminale and descends to the back of the coccyx, where it blends with

the periosteum. The sheath of dura mater is much larger than is

necessary for the accommodation of its contents, and its size is greater

in the cervical and lumbar regions than in the thoracic (9)

.

On each side may be seen the double openings which transmit the

two roots of the corresponding spinal nerve, the dura mater being

continued in the form of tubular prolongations on them as they pass

through the intervertebral foramina. These prolongations are short in the

upper part of the vertebral column, but gradually become longer below,

forming a number of tubes of fibrous membrane, which enclose the

lower spinal nerves and are contained in the vertebral canal(9)

.

Anatomy Dural tear

7

With the use of electron microscopy, Eismont et al (10)

found three

distinct layers of the human dura: a fibroelastic outer layer, a fibrous

middle layer, and a cellular inner layer. Some controversy exists with

regard to the orientation of the fibers in the dura. Classic teaching

contends that the fibers in the dura mater run longitudinally as seen

figure (2). (10)

Fig. (2)Scanning electron microscope view of human dura mater samples arrows

showing the longitudinal direction of the gross anatomic specimen. Most fibers

run in the same direction (A), with only a few fibers visible in nonlongitudinal

directions (B).

The dural border cell layer was characterized by multiple

interdigitating cell processes. Paravascular vesiculated nerve profiles

were encountered within the fibroadipose epidural tissue. (11)

The dura is known to be displaced during flexion and extension

movements of the spine. Furthermore, it is tensed during limb

movement as a result of the displacement of the spinal nerves and their

dural cones in the intervertebral foramina. (11)