Enhanced Dural Repair Using Biodegradable Sealants Based on Photocurable Hyaluronic Acid.

Cerebrospinal fluid (CSF) leakage is a common complication of intradural surgery or incidental durotomy in neurosurgery. Dural suturing is a common method for durotomy repair, but this technique requires a long operation time and includes the risk of CSF leakage by incomplete sealing. Glue-type sealants are effective for watertight dural closure. However, unresolved shortcomings include insufficient sealing performance, poor biocompatibility, and excessive swelling. Here, a dural sealant using light-activated hyaluronic acid (HA) with multi-networks (HA photosealant) that provides fast sealing performance and high biocompatibility is reported. The HA photosealants form a watertight hydrogel barrier with multilength networks under low-energy visible light exposure (405 nm, <1 J cm-2) for 5 s and allow firm tissue adhesion on the wet dural surface. In a rabbit model of craniectomy and durotomy, HA photosealants exhibit the faster sealing performance of dural tears and enhance dural repair with accelerated bone formation compared to commercial surgical glues, with no degenerative changes, such as inflammation or necrosis, in histopathological evaluation. This biocompatible HA photosealant can be applied in a variety of clinical settings that require fast wound closure as a promising potential.

American Rhinologic Society expert practice statement part 1: Skull base reconstruction following endoscopic skull base surgery.

The goal of this American Rhinologic Society expert practice statement (EPS) is to summarize the best available evidence for technical factors that optimize outcomes in skull base reconstruction following endoscopic skull base surgery for intradural pathologies. These topics include the use of free mucosal grafts versus vascularized pedicled nasoseptal flaps; the use of autologous versus synthetic grafts; and the roles of lumbar drains, dural sealants, and nasal packing. This EPS was developed following the recommended methodology and approval process as previously outlined. As there are a myriad of techniques and limited agreement on the accepted principles of skull base reconstruction, this EPS aims to summarize the existing evidence and provide clinically meaningful guidance on these divergent practices. Following a modified Delphi approach, five statements were developed, four of which reached consensus and one of which reached near consensus. These statements and the accompanying evidence are summarized along with an assessment of future needs.

Surgeon education through a surgical cost feedback system reduces supply cost in endoscopic skull base surgery.

OBJECTIVE: A large proportion of healthcare expense is operating room (OR) costs. As a means of cost mitigation, several institutions have implemented surgeon education programs to bring awareness about supply costs. This study evaluates the impact of a surgical cost feedback system (surgical receipt) on the supply costs of endoscopic skull base surgery (ESBS) procedures. METHODS: The supply costs of each ESBS surgical case were prospectively collected and analyzed before and after the implementation of a nonincentivized, automated, and itemized weekly surgical receipt system between January 2017 and December 2019. Supply cost data collected 15 months prior to intervention were compared with cost data 21 months after implementation of the surgical receipt system. Demographics, surgical details, and OR time were collected retrospectively. RESULTS: Of 105 ESBS procedures analyzed, 36 preceded and 69 followed implementation of cost feedback. There were no significant differences in patient age (p = 0.064), sex (p = 0.489), surgical indication (p = 0.389), or OR anesthesia time (p = 0.51) for patients treated before and after implementation. The mean surgical supply cost decreased from $3824.41 to $3010.35 (p = 0.002) after implementation of receipt feedback. Usage of dural sealants (p = 0.043), microfibrillar collagen hemostat (p = 0.007), and oxidized regenerated cellulose hemostat (p < 0.0001) and reconstructive technique (p = 0.031) significantly affected cost. Mediation analysis confirmed that the overall cost reduction was predominantly driven by reduced use of dural sealant; this cost saving exceeded the incremental cost of greater use of packing materials such as microfibrillar collagen hemostat. CONCLUSIONS: Education of surgeons regarding surgical supply costs by a surgical receipt feedback system can reduce the supply cost per case of ESBS operations.

Delayed cauda equina compression after spinal dura repair with BioGlue: magnetic resonance imaging and computed tomography aspects of two cases of "glue-oma".

BACKGROUND CONTEXT: Bovine serum albumin and glutaraldehyde (BSAG) (BioGlue) is a surgical adhesive widely used for off-label applications in neurosurgical procedures to minimize the risk of cerebrospinal fluid leakage after dural closure. PURPOSE: To describe magnetic resonance imaging (MRI) and computed tomography (CT) aspects of two cases of postoperative BSAG expansion causing delayed cauda equina compression requiring further surgery. STUDY DESIGN: A case report. PATIENT SAMPLE: Two cases of delayed cauda equina compression complicating the closure, with BSAG, of small unintentional tears in the dura requiring lumbar decompressive surgery. OUTCOME MEASURES: They included postoperative CT and MRI findings. METHODS: We compared postoperative imaging and perioperative findings during subsequent surgery. RESULTS: In both cases, imaging showed cauda equina compression due to epidural masses found during subsequent surgery comprising BioGlue. These masses appeared slightly hyperdense on CT scans and markedly hypointense on T2-weighted MRI scans. CONCLUSIONS: When applied as a thick layer during use as a dural sealant, BSAG may swell, leading to a symptomatic "glue-oma" giving a hypointense image on T2-weighted MRI scans.

Evaluation of complication rates of pediatric cranial procedures in which a polyethylene glycol sealant was used.

OBJECT: Polyethylene glycol (PEG) sealant in conjunction with standard closure techniques is effective in preventing CSF leaks after cranial procedures in adult patients, but the safety of PEG sealant in the pediatric population has not been shown. METHODS: The authors performed a retrospective analysis of pediatric neurosurgery patients (0-18 years of age) treated from 2005 to 2010 at The Johns Hopkins Hospital. There were 163 patients who underwent cranial surgery with the use of PEG sealant as an adjunct to standard closure techniques. There were 92 males and 71 females with an average age of 10.2 years. The incidences of revision surgery, CSF leak, meningitis, and neurological deficit were recorded. RESULTS: In the cohort's 90-day postoperative clinical course, the authors found that 4 patients (2.5%) required revision surgery, 2 patients (1.2%) developed a CSF leak, 4 patients (2.5%) developed a superficial skin infection, and 1 patient developed meningitis (0.6%) with no deaths or neurological deficits observed. CONCLUSIONS: PEG sealant appears to be a safe adjunct to standard dural closure in pediatric cranial surgery patients to augment dural closure.

A review article on the diagnosis and treatment of cerebrospinal fluid fistulas and dural tears occurring during spinal surgery.

BACKGROUND: In spinal surgery, cerebrospinal fluid (CSF) fistulas attributed to deliberate dural opening (e.g., for tumors, shunts, marsupialization of cysts) or inadvertent/traumatic dural tears (DTs) need to be readily recognized, and appropriately treated. METHODS: During spinal surgery, the dura may be deliberately opened to resect intradural lesions/tumors, to perform shunts, or to open/marsupialize cysts. DTs, however, may inadvertently occur during primary, but are seen more frequently during revision spinal surgery often attributed to epidural scarring. Other etiologies of CSF fistulas/DTs include; epidural steroid injections, and resection of ossification of the posterior longitudinal ligament (OPLL) or ossification of the yellow ligament (OYL). Whatever the etiology of CSF fistulas or DTs, they must be diagnosed utilizing radioisotope cisternography (RIC), magnetic resonance imaging (MRI), computed axial tomography (CT) studies, and expeditiously repaired. RESULTS: DTs should be repaired utilizing interrupted 7-0 Gore-Tex (W.L. Gore and Associates Inc., Elkton, MD, USA) sutures, as the suture itself is larger than the needle; the larger suture occludes the dural puncture site. Closure may also include muscle patch grafts, dural patches/substitutes (bovine pericardium), microfibrillar collagen (Duragen: Integra Life Sciences Holdings Corporation, Plainsboro, NJ), and fibrin glues or dural sealants (Tisseel: Baxter Healthcare Corporation, Deerfield, IL, USA). Only rarely are lumbar drains and wound-peritoneal and/or lumboperitoneal shunts warranted. CONCLUSION: DTs or CSF fistulas attributed to primary/secondary spinal surgery, trauma, epidural injections, OPLL, OYL, and other factors, require timely diagnosis (MRI/CT/Cisternography), and appropriate reconstruction.