management of spinal dural tear
TRANSCRIPT
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
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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
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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)