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Watertight Sealing Without Lumbar Drainage for Incidental Ventral Dural Defect in Transthoracic Spine Surgery: A Retrospective Review of 53 Cases

Jeon, Sang-Hyeop MD*; Lee, Sang-Ho MD, PhD; Tsang, Yi Sheng MD; Jung, Tag-Geun MD§; Moon, Ki-Hyoung MD§; Choi, Gun§; Dilip, Ketan D. MD§

doi: 10.1097/BSD.0000000000000249

Study Design: A retrospective review.

Objectives: To evaluate the therapeutic efficacy of the triple layer closure technique to establish watertight sealing without diversion of lumbar drainage, in preventing persistent incidental subarachnoid-pleural fistula and other neurological complications related to excessive drainage of cerebrospinal fluid (CSF) after dural defect in transthoracic ossified posterior longitudinal ligament (OPLL) surgery.

Summary of Background Data: CSF leakage into the pleural cavity leads to unfavorable conditions for natural healing of incidental durotomy due to the negative pressure environment of the pleural space and lack of wound healing around the bony cavity near the decompressed spinal cord. This often leads to a persistent incidental subarachnoid-pleural fistula. In addition, diversion of lumbar drainage may lead to excessive CSF drainage resulting in intracranial hypotension. To avoid this, we studied the efficacy of a modified sealing method to establish a more watertight covering at the ventral dural defect without lumbar CSF drainage.

Methods: Fifty-three patients who had CSF leakage from the ventral aspect of the spinal cord during transthoracic spine surgery for thoracic OPLL between 2004 and 2013 were retrospectively reviewed. Patients were divided into 2 groups: a conventional group (group A) and a triple layer closure group (group B). In group A (n=33 patients), the dural defect was covered with fibrin glue (Beriplast P) mixed with gelfoam (Spongostan Standard) with subsequent subarachnoid lumbar drainage. In group B (n=20 patients), the dural defect was sealed using the triple layer technique with 2 layers of fibrin glue and gelatin sponge plus a third layer of synthetic hydrogel (Duraseal, Dural Sealant System) without subsequent subarachnoid lumbar drainage. Both groups had chest tubes that drained through an underwater seal. Clinical data including duration and total amount of drainage (chest tube and lumbar drainage), related complications, and duration of hospital stay were compared between the 2 groups.

Results: Compared with the patients in group A, group B had a significantly smaller total volume of drainage and shorter chest tube drainage time (P<0.05) during their hospital stay. In group A, complications occurred in 6 cases (18.2%), including 3 cases of intracranial hypotension combined with transient mental status alteration, postural headache, and dizziness, 1 case of regional atelectasis with pneumonia, and 2 cases of revision thoracotomy. Revision thoracotomy was performed to treat persistent subarachnoid-pleural fistula due to significant and prolonged CSF leakage. In group B, there were no complications and no revision thoracotomy was needed. The mean duration of hospital stay was shorter in group B (15.6 d) compared with group A (22.4 d).

Conclusions: The established watertight closure of the dural defect using the triple layer sealing method without lumbar drainage was more effective and safe.

*Department of Cardiothoracic Surgery, Seoul Gimpo Airport Wooridul Spine Hospital

Department of Neurosurgery, Seoul Spine Hospital

Department of Neurosurgery, Pohang Wooridul Spine Hospital

§Department of Neurosurgery, Seoul Gimpo Airport Wooridul Spine Hospital, Seoul, Korea

The authors declare no conflict of interest.

Reprints: Sang-Ho Lee, MD, PhD, Department of Neurosurgery, Seoul Wooridul Spine Hospital, 445Hakdong-ro, Gangnam-gu, Seoul 135-951, Korea (e-mail:

Received August 27, 2014

Accepted January 6, 2015

© 2017 by Lippincott Williams & Wilkins, Inc.