Quantitative evaluation of the regenerated dura mater in a decompressive skull trepanation model in rats / Evaluación cuantitativa de la duramadre regenerada en un modelo de perforación cranial descompresiva en ratas

SUMMARY: Regeneration of the dura mater following duraplasty using a collagen film, a chitosan film, or a combination of both with gelatin, was studied in a craniotomy and penetrating brain injury model in rats. Collagen autofluorescence in the regenerated dura mater was evaluated using confocal microscopy with excitation at λem = 488 nm and λem = 543 nm. An increase in regeneration of the extracellular matrix of connective tissue and an increase in matrix fluorescence were detected at 6 weeks after duraplasty. The major contributors to dura mater regeneration were collagen films, chitosan plus gelatin-based films, and, to a much lesser extent, chitosan-based films. By using autofluorescence densitometry of extracellular matrix, the authors were able to quantify the degree of connective tissue regeneration in the dura mater following duraplasty.

RESUMEN: Se estudió la regeneración de la duramadre después de una duraplastía utilizando una lámina de colágeno, una lamina de quitosano o una combinación de ambas con gelatina en un modelo de craneotomía y lesión cerebral en ratas. La autofluorescencia del colágeno en la duramadre regenerada se evaluó mediante microscopía confocal con excitación a λem = 488 nm y λem = 543 nm. Se observó un aumento en la regeneración de la matriz extracelular del tejido conectivo y un aumento en la fluorescencia de la matriz a las 6 semanas después de la duraplastía. Se observe un efecto significativo en la regeneración de la duramadre con las láminas de colágeno, las láminas en base de quitosano más gelatina y, en un menor grado, las láminas a base de quitosano. Mediante el uso de densitometría de autofluorescencia de la matriz extracelular, los autores lograron cuantificar el grado de regenera- ción del tejido conectivo en la duramadre después de la duraplastía.

Idiopathic Spinal Cord Herniation

STUDY DESIGN: Literature review. OBJECTIVES: The aim of this study was to provide insight into idiopathic spinal cord herniation (ISCH) in terms of clinical presentation, pathophysiology, diagnosis, classification, and treatment. SUMMARY OF LITERATURE REVIEW: ISCH is a rare disorder characterized by anterior displacement of the spinal cord through a ventral dural defect. It has increasingly been recognized and described over the past 10 years. MATERIALS AND METHODS: Review of the English-language literature on ISCH. RESULTS: ISCH occurs in middle-aged adults with a female preponderance. The most common clinical presentation is Brown-Sequard syndrome, which can progress to spastic paraparesis. Its pathophysiology is unknown. However, some authors proposed that inflammation may play an important role in the emergence of a dural defect. Magnetic resonance imaging typically shows an anterior kink of the thoracic spinal cord with an obliteration of the ventral subarachnoid space and the widened dorsal subarachnoid space. Surgery is generally recommended for patients with motor deficits or progressive neurological symptoms. The posterior approach has been used because it allows wide exposure of the spinal cord. The surgical treatment of ISCH consists of spinal cord reduction from the ventral dural defect, which can be managed with enlargement, direct repair, or duraplasty (dural repair with a patch). In recent years, duraplasty has been used more frequently than enlargement of the dural defect. CONCLUSIONS: ISCH causing thoracic myelopathy could be safely treated with surgical management. The possibility of this disease should be kept in mind when treating patients with progressive myelopathy.

Evaluation of Non-Watertight Dural Reconstruction with Collagen Matrix Onlay Graft in Posterior Fossa Surgery

OBJECTIVE: Many surgeons advocate for watertight dural reconstruction after posterior fossa surgery given the significant risk of cerebrospinal fluid (CSF) leak. Little evidence exists for posterior fossa dural reconstruction utilizing monolayer collagen matrix onlay graft in a non-watertight fashion. Our objective was to report the results of using collagen matrix in a non-watertight fashion for posterior fossa dural reconstruction. METHODS: We conducted a retrospective review of operations performed by the senior author from 2004-2011 identified collagen matrix (DuraGen) use in 84 posterior fossa operations. Wound complications such as CSF leak, infection, pseudomeningocele, and aseptic meningitis were noted. Fisher's exact test was performed to assess risk factor association with specific complications. RESULTS: Incisional CSF leak rate was 8.3% and non-incisional CSF leak rate was 3.6%. Incidence of aseptic meningitis was 7.1% and all cases resolved with steroids alone. Incidence of palpable and symptomatic pseudomeningocele in follow-up was 10.7% and 3.6% respectively. Postoperative infection rate was 4.8%. Previous surgery was associated with pseudomeningocele development (p<0.05). CONCLUSION: When primary dural closure after posterior fossa surgery is undesirable or not feasible, non-watertight dural reconstruction with collagen matrix resulted in incisional CSF leak in 8.3%. Incidence of pseudomeningocele, aseptic meningitis, and wound infection were within acceptable range. Data from this study may be used to compare alternative methods of dural reconstruction in posterior fossa surgery.

Foramen Magnum Decompression and Duraplasty is Superior to Only Foramen Magnum Decompression in Chiari Malformation Type 1 Associated with Syringomyelia in Adults

STUDY DESIGN: Retrospective cohort study. PURPOSE: To compare surgical results of foramen magnum decompression with and without duraplasty in Chiari malformation type 1 (CM-1) associated syringomyelia (SM). OVERVIEW OF LITERATURE: The optimal surgical treatment of CM-1 associated with SM is unclear. METHODS: Twenty-five cases of CM-1 with SM were included. There were 12 patients (48%) in the non-duraplasty group and 13 patients (52%) in the duraplasty group. The rate of improvement, state of postoperative SM size, amount of tonsillar herniation, preoperative symptom duration, complications and reoperation rates were analysed. RESULTS: The rate of clinical improvement was significantly higher with duraplasty (84.6%) than without (33.3%, p <0.05). The rate of postoperative syrinx regression was significantly higher in the duraplasty group (84.6%) than in the non-duraplasty group (33.3%, p <0.05). One case in the duraplasty group needed a reoperation compared with five cases in the non-duraplasty group (p =0.059). CONCLUSIONS: Duraplasty is superior to non-duraplasty in CM-1 associated with SM despite a slightly higher complication rate.

Clinical Features of Post-Traumatic Syringomyelia / 대한신경손상학회지

OBJECTIVE: The purpose of this study was to analyze the clinical manifestations, radiological findings, treatment results, and clinical significance of post-traumatic syringomyelia (PTS). METHODS: We retrospectively reviewed the medical charts of nine surgical patients with symptomatic PTS between 1992 and 2012. RESULTS: The most common clinical manifestation was development of new motor weakness. The mean interval between the initial injury and the onset of new symptoms 21.9 years. The mean length of the syringes observed on preoperative magnetic resonance images was 7.8 spinal levels. Shunting procedures were performed in five patients. Four patients underwent arachnoidolysis and duraplasty. Patients developed mechanical shunt failure. Postoperatively, one patient showed clinical improvement, four patients were stable, and four patients showed deterioration. CONCLUSION: PTS is a disabling sequelae of spinal cord injury, which develops months to years after spinal injury. We have to consider that patients with PTS may have poor long-term outcome.

Therapeutic effect analysis of small bone flap craniotomy decompression of posterior cranial fossa and duraplasty for 45 patients with Chiari malformation type Ⅰ / 中国医师进修杂志

Objective To evaluate the therapeutic effect of small bone flap craniotomy decompression of posterior cranial fossa and duraplasty in the treatment of Chiari malformation type Ⅰ.Methods The clinical data of 45 Chiari malformation type Ⅰ patients who were treated with small bone flap craniotomy decompression of posterior cranial fossa and duraplasty were retrospectively analyzed,31 cases among them with syringomyelia.Results According to Tator etc.standard,1 month after surgery,the excellent in 30 cases,good in 15 cases.Follow up from 6 months to 6 years,the excellent in 37 cases,good in 8 cases.Among 31 patients with syringomyelia,26 cases were syringomyelia subsided,5 cases were not obvious change.Conclusion The small bone flap craniotomy decompression of posterior cranial fossa and duraplasty can make the craniocervical decompression,and has obvious effect of treating syringomyelia,is safe and effective in treatment of Chiari malformation type Ⅰ.

Clinical experience with a novel bovine collagen dura mater substitute / Experiência clínica com um novo substituto dural derivado de matriz de colágeno bovino

Dural substitutes are used to achieve watertight closure of the dura mater when adequate closure is not possible. The purpose of this study was to evaluate the efficacy and safety of a new collagen matrix dural substitute (Duradry, Technodry, Belo Horizonte MG) in the repair or expansion of cranial and spinal dura mater. METHOD: Thirty patients, operated on between March and September, 2008, were studied. Surgical records were reviewed for sex, age, location of graft, technique, and presence of fistula or infection. The patients were followed up for at least 3 months, and presence of complications, such as cerebrospinal fluid leakage, infection, asseptic meningitis hydrocephalus, pseudomeningocele, was analyzed. RESULTS: Only one patient presented cerebrospinal fluid fistula. No patients presented wound infections, hydrocephalus, pseudomenigocele, meningites, brain abscesses or signs of toxicity related to the dural substitute. CONCLUSION: The new dural substitute used in this study is effective and safe, and the initial results are similar to those of other dural substitutes reported in the literature.

Substitutos de dura máter são utilizados quando não conseguimos um fechamento dural hermético. O objetivo deste estudo foi avaliar a eficácia e segurança de um novo substituto dural derivado de matriz colágena bovina (Duradry, Tecnodry, Belo Horizonte MG) no reparo ou expansão da dura máter craniana ou espinhal. MÉTODO: Trinta pacientes operados entre março e setembro de 2008 foram estudados. Foram analisados sexo, idade, localização do enxerto, técnica e presença de fístula ou infecção. Os pacientes foram acompanhados por, pelo menos, 3 meses e a presença de complicações como fístula liquórica, infecção, meningite asséptica, hidrocefalia, pseudomeningocele foram analisadas. RESULTADOS: Apenas um paciente apresentou fístula liquórica. Nenhuma infecção de ferida cirúrgica foi observada. Também não ocorreram casos de hidrocefalia, pseudomeningocele, meningite, abscesso ou sinais de toxicidade relacionada ao implante. CONCLUSÃO: O novo substituto dural utilizado neste estudo é seguro e efetivo e os resultados iniciais são semelhantes aos de outros substitutos durais descritos na literatura.

Suboccipital craniectomy with or without duraplasty: what is the best choice in patients with Chiari type 1 malformation? / Craniectomia suboccipital com ou sem duroplastia: qual a melhor escolha em pacientes com malformação de Chiari tipo 1?

The best surgical treatment for Chiari malformation is unclear, especially in patients with syringomyelia. We reviewed the records of 16 patients who underwent suboccipital craniectomy at our institution between 2005 and 2008. Of the six patients who did not undergo duraplasty, four showed improvement postoperatively. Two patients without syringomyelia showed improvement postoperatively. Of the four patients with syringomyelia, three showed improvement, including two with a decrease in the cavity size. One patient showed improvement in symptoms but the syringomyelia was unchanged. The cavity size increased in the one patient who did not show improvement. Among the 10 patients who underwent duraplasty, improvements were noted in four of the five patients without syringomyelia and in all of the five with syringomyelia. There is a suggestion that patients with syringomyelia may have a higher likelihood of improvement after undergoing duraplasty.

A melhor opção de tratamento cirúrgico na malformação de Chiari é desconhecido, especialmente em paciente com siringomielia. Nós revisamos casos de 16 pacientes submetidos à craniectomia suboccipital em nossa instituição de 2005 à 2008. Dos 6 pacientes que não foram submetidos à duroplastia, quatro tiveram melhora pós operatória. Dois pacientes sem siringomielia tiveram melhora pós operatória. Dos quatro pacientes com siringomielia, três tiveram melhora, incluindo dois com diminuição do tamanho da cavidade. Um paciente teve melhora da sintomatologia mas a siringomielia não se modificou. Dez pacientes foram submetidos à duroplastia. Melhora foi observada em 4 de 5 pacientes sem siringomielia e 5 de 5 casos com siringomielia. Há uma sugestão de que pacientes com siringomielia possam ter uma maior taxa de melhora após serem submetidos à duroplastia.

Uso de pericardio humano en neurocirugía / Use of human pericardium in neurosurgical practice

Objetivo. Describir y analizar una serie de pacientes operados en nuestro servicio por diferentes patologías, en los cuales se utilizó pericardio de donante no vivo para la realización de la duroplastía, obtenido del Banco de Tejidos de nuestro Hospital. Material y método. Se realizó un análisis retrospectivo de las historias clínicas de 33 pacientes en los cuales se utilizó pericardio humano, operados entre los años 2006 y 2008. Resultados. La edad de los pacientes fue entre 1 mes y 19 años (promedio: 6,6 años). 17 masculinos, 16 femeninos. Las cirugías en las cuales se utilizó, por diferentes motivos, pericardio humano para el cierre de la duramadre fueron: 7 cirugías por tumores de fosa posterior, 6 por tumores supratentoriales, 5 por traumatismos encefalocraneanos, 3 por malformación de Arnold-Chiari, 3 por hematomas espontáneos, 2 por malformaciones arteriovenosas, 2 por lipomas lumbosacros, 2 por encefaloceles, 1 por cirugía de la epilepsia, 1 por tumor espinal, y 1 por tumor de tronco. Las complicaciones encontradas fueron: 2 pseudomeningoceles y 1 fístula de líquido cefalorraquídeo, las que se resolvieron sin necesidad de nueva intervención quirúrgica. No se presentaron infecciones de la herida quirúrgica ni rechazo del injerto. Follow up: 18,6 meses. Conclusión. Consideramos que este material se comporta en forma excelente como sustituto de la duramadre, presentando ventajas tales como: ser impermeable, fácil de suturar y manejar, proporcionando un sellado hermético, baja antigenicidad y no inducir reacciones a cuerpo extraño.

Objective. To describe and to analyze a series of patients operated in our service by different pathologies, in which we used pericardium of alive donor for dural closure, stored at 80°Cbelow cero in our hospital. Method. A retrospective analysis was designed to evaluate the medical records of 33 patients in which human pericardiumwere used, in a period of time between 2006 and 2008. Results. The age of the patients ranged from 1 month to 19years old (average age: 6.6). 17 were male and 16 female. The surgeries in which we used, by different reasons, human pericardium for dural closure were: 7 posterior fossa tumors, 6supratentorial tumors, 5 traumatic brain injury (intracranial hypertension), 3 Arnold-Chiari malformations, 3 spontaneous haematomas, 2 arterio-venous malformations, 2 lumbo-sacrallipomas, 2 encephaloceles, 1 surgery for epilepsy, 1 spinal cord tumor, and 1 brainstem tumor. The complications found were: 2 pseudomeningoceles and 1 CSF fistula. There were no systemicallergic reactions or local skin changes or infections. Follow up: 18.6 months.Conclusion. We considered that human pericardium is an excellent, effective and safe cranial and spinal dural substitute, presenting advantages such as: to be impermeable, easy tosuture and to handle, providing hermetic sealing, low antigenicidadand not to induce reactions to strange body.

Amigdalopexia cerebelosa en el manejo de la malformación de chiari de tipo I / Cerebellar amygdalopexy in the management of Chiari I malformation

Antecedentes. El tratamiento de la malformación de Chiari de tipo I asociada a siringomielia es controvertido. En este trabajo se presenta un análisis clínico, quirúrgico y radiológico de los pacientes con esta afección que fueron manejados durante un periodo de doce años. Material y métodos. Se incluyeron 48 pacientes, donde se encontró un discreto predominio en el sexo femenino. El cuadro clínico estuvo dominado por cefalea, dolor cervical, signos y síntomas cerebelosos, afección de nervios craneales bajos y lesión de la vía piramidal. Resultados. Tanto el grado de descenso amigdalino como el tamaño de la siringomielia fueron muy variables, sin encontrar correlación entre ambos. La cirugía consistió en una craniectomía occipital, laminectomía de C1, ascenso de amígdalas cerebelosas mediante coagulación bipolar y plastía de duramadre. Los mejores resultados clínicos se obtuvieron en el dolor y los síntomas cerebelosos, mientras que los peores fueron en la afección de los nervios craneales bajos y de la vía piramidal, sin embargo, en la gran mayoría de los pacientes se logró detener la progresión de los síntomas. No se presentaron complicaciones serias en el presente estudio. Conclusión. El procedimiento propuesto ofrece una alternativa segura, efectiva y comparable con otros métodos más riesgosos para el manejo de esta malformación.

BACKGROUND: The treatment of Chiari I malformation associated with syringomyelia is controversial. OBJECTIVE: We describe a series of patients with this disease treated during a twelve-year period. We also present clinical, surgical and radiological findings. MATERIAL AND METHODS: Forty eight patients were included; a non significant female predominance was found. Clinical course was characterized by headache, cerebellar signs and symptoms, neck pain and involvement of lower cranial nerves and pyramidal tract. The degree of tonsillar descent and syringomyelia size varied and a correlation between them was not found. Surgery consisted in an occipital craniectomy, C1 laminectomy and tonsillar elevation through bipolar coagulation and duraplasty. RESULTS: The best results were observed in pain and cerebellar symptoms, while a deficit of lower cranial nerves and pyramidal tract were observed. However, in most patients we were able to slow symptom progression. No adverse effects were documented. CONCLUSIONS: The surgicalprocedureproposed herein is an effective and safe treatment alternative for this malformation, and its results are comparable to other riskier procedures.

Operative Treatments in Syringomyelia Caused by Trauma or Arachnoiditis

OBJECTIVE: Most cases of syringomyelia with arachnoid scarring were related to spinal trauma or inflammatory reaction. The aim of this study is to analyze the influence of arachnoid scarring on the altered dynamics of cerebrospinal fluid(CSF) and determine the proper treatment. METHODS: Between Jan 1991 and Dec 2001, We have operated on 15 patients with progressive neurological deficits associated with syringomyelia. We analyze the clinical presentations, radiographic and magnetic resonance images. RESULTS: As to cause of syringomyelia, 11 patients were related with trauma and 4 patients were tuberculous meningitis. Shunting procedures underwent in 11 patients and 5 showed clinical improvement. Subarachnoid adhesiolysis and expansile duraplasty were performed in 4 patients and 3 experienced clinical improvement. The 6 patients with shunting procedures were neurologically deteriorated and 4 were reoperated. CONCLUSION: The arachnoid scarring interferes with CSF flow and causes syringomyelia. Successful long-term outcome in the surgical treatment of syringomyelia caused by focal arachnoid scar appeared to require microsurgical dissection of scar and expansile duroplasty. For extensive arachnoid scarring over multiple spinal levels or after previous surgery, shunting procedure may be indicated only.

Early Decompressive Craniectomy for Cerebral Edema

OBJECTIVE: The aim of this study is the determination the value of early decompressive craniectomy in patients with severe cerebral edema. METHODS: We prospectively studied 23 consecutive patients with severe cerebral edema received decompressive craniectomy from July 1999 to March 2001. The indication for decompression was the progressive therapy-resistant intracranial hypertension and edema in patients with clinically and radiologically poor condition. We analyzed the results(GCS score, GOS score) with the variables such as cause(trauma, aneurysmal rupture, infarction), dominant edema side, midline shift on CT scan(<10mm), dilating of pupils, preoperative GCS score(<8). RESULTS: The overall rate of good recovery(GOS score 4 or 5) who underwent craniectomy was 48%(11 of 23 patients), poor recovery(GOS score 2 or 3) was 30%(7 of 23 patients), and mortality rate was 22%(5 of 23 patients). All of survived patients had improved GCS score(mean 12.61) compared with the preoperative GCS score(mean 7.89). The pupilary dilatation was the only statistically significant factor (p<0.05). CONCLUSION: Our results provide favorable evidence that early decompressive craniectomy with duraplasty is effective in patients with progressive therapy-resistant cerebral edema. Early decompression may have an effect in preventing this secondary adverse effect, thus is considered in early cerebral edema.