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Thread: Torn Dura Repair

  1. #1
    Member
    Join Date
    May 2003
    Location
    Grand Rapids, MI, USA
    Posts
    61

    Torn Dura Repair

    Can anyone recommend a surgeon with experience in repairing a torn dura? The patient has had a spinal fluid leak for almost a year. A surgery in 10/06 led to a leak at L3 under the ventral surface and under the nerve root.
    Attempts have been made to repair it and failed. Time has not healed it. The pain and discomfort is very difficult to live with. Any suggestions?
    Dr. Young are you aware of a doctor who has experience with this?

  2. #2
    Any spine neurosurgeon should be able to repair this.
    You might want to try a major medical center with a neurosurgery department.

    CWO

  3. #3
    Quote Originally Posted by Redford
    Can anyone recommend a surgeon with experience in repairing a torn dura? The patient has had a spinal fluid leak for almost a year. A surgery in 10/06 led to a leak at L3 under the ventral surface and under the nerve root.
    Attempts have been made to repair it and failed. Time has not healed it. The pain and discomfort is very difficult to live with. Any suggestions?
    Dr. Young are you aware of a doctor who has experience with this?
    Redford, sorry that I did not see this earlier. Dural repair, in my opinion, is actually quite difficult when it has reached a chronic stage like what you are describing. You would think that this is a relatively simple problem to solve, that all that one needs to do is a tight dural closure, i.e. sew or glue it shut. The problem is that if scarring does not occur, the leak recurs.

    It is difficult to to think of a good neurosurgeon who has a lot of experience with dural leaks. A good neurosurgeon tries to do everything possible to avoid a dural leak. In 1981, Eismont, et al. recommended use of a fascial graft/tissue plug and reoperation to fix the leak; I think this remains very good advice. Often, the leakage site cannot be seen or localized in the operating room and use of fluorescein dye (a fluorescent dye) helps (Calcetera, 1980).

    Recently, Spetzler at Barrows Neurological (whom many consider to be one of the best neurosurgeons in the United States) published a paper using hydrogels seals in a dog craniotomy model. I would recommend a consultation with this group.

    Wise.

    Literature Cited
    1. Eismont FJ, Wiesel SW and Rothman RH (1981). Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am. 63: 1132-6. We reviewed the cases of five consecutive patients with tears of the spinal dura with postoperative leaks of cerebrospinal fluid. Problems in cluded the persistence of cerebrospinal-fluid fistulas in four patients and a late symptomatic pseudomeningocele in one, all requiring reoperation and meticulous closure of the dura. Dural tears should be repaired at the time of the original operation either directly or utilizing a fascial graft or a tissue-plug technique. When the leak is first noted in the postoperative period, reoperation for repair of the dura is recommended.
    2. Calcaterra TC (1980). Extracranial surgical repair of cerebrospinal rhinorrhea. Ann Otol Rhinol Laryngol. 89: 108-16. A spinal fluid leak from the intracranial space to the nasal respiratory tract is potentially very serious because of the risk of an ascending infection which could produce fulminant meningitis. Cerebrospinal rhinorrhea typically stems from a complication of head trauma, and fortunately these leaks tend to heal spontaneously. In a smaller percentage of cases, intracranial lesions or congenital osteomeningeal defects are harbored, allowing spinal fluid to enter the nasal cavity, and patients with this condition rarely heal without operative intervention. Succesful repair of a dural defect mandates precise anatomic localization of the leakage site. Although radioisotopes have been a popular method of documenting and localizing a spinal fluid leak, they do not provide the topographic accuracy of intrathecal dyes such as fluorescein. The author not only employs this dye during the preoperative localization of a leak but also uses it intraoperatively to improve visualization of the leakage site and to plan a method of repair. The operating microscope also seems to facilitate visualization of the leak and enables better manipulation of grafts and flaps.
    3. Preul MC, Campbell PK, Bichard WD and Spetzler RF (2007). Application of a hydrogel sealant improves watertight closures of duraplasty onlay grafts in a canine craniotomy model. J Neurosurg. 107: 642-50. Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA. mpreul@chw.edu. OBJECT: The authors evaluated whether a polyethylene glycol-based hydrogel sealant system improved dural closures with collagen-based duraplasty onlay grafts. METHODS: Dural defects 1.5 cm in diameter were created in 12 canines and repaired with one of two commercially available duraplasty onlay products. In six animals, hydrogel was applied onto the dural onlays, and the other six animals underwent duraplasty only. Before bone flap replacement, watertight closure was assessed. Before the animals were killed, the craniotomy was reopened, adhesions were rated by a neurosurgeon blinded to the treatment groups, and dural integrity was assessed using pressure testing. RESULTS: The animals that received the hydrogel sealant in addition to the duraplasty withstood intraoperative Valsalva maneuvers up to 20 cm H2O without cerebrospinal fluid (CSF) leakage. The duraplasty-only animals leaked CSF at spontaneous pressures (p = 0.0022). Postoperatively, all six duraplasty-only dogs developed CSF subcutaneous accumulations, compared with only one (16.7%) dog who underwent hydrogel application (p = 0.0152). At the time of harvesting (8 weeks after implantation), duraplasty-only dogs had extensive scarring between the bone flap and the dura mater (median adhesion score 4, range 3-4). The animals receiving hydrogel showed minimal scarring (median adhesion score 0.5, range 0-2). In hydrogel-treated dogs, the mean adhesion score was 82.6% lower than the scores in duraplasty-only animals (p = 0.0043). In animals receiving hydrogel, the mean dural leak pressure was 56.8 +/- 2.5 cm H2O compared with 9.8 +/- 3.8 cm H2O in duraplasty-only dogs (p = 0.0392). Application of the hydrogel was not associated with neurotoxicity, delayed healing, degenerative changes, or increased dura-cortex adhesions. CONCLUSIONS: The hydrogel sealant applied to collagen-based dural grafts significantly reduced CSF leakage and functioned as an adhesion barrier. Such technology could be an important tool for cranial surgery.

  4. #4

    Smile

    Quote Originally Posted by Redford View Post
    Can anyone recommend a surgeon with experience in repairing a torn dura? The patient has had a spinal fluid leak for almost a year. A surgery in 10/06 led to a leak at L3 under the ventral surface and under the nerve root.
    Attempts have been made to repair it and failed. Time has not healed it. The pain and discomfort is very difficult to live with. Any suggestions?
    Dr. Young are you aware of a doctor who has experience with this?
    Dr Schievink at Cedars Sinai in LA best. People go to him from all over USA Go to BrainTalk Communities on Internet and look up cerebral spinal leaks
    Hope, health & happiness,
    Berthabutt

  5. #5

    Little Tear...BIG PROBLEM.

    I would first like to offer my condolences regarding your condition. A torn dura; in my mind, is just a purely evil thing to deal with.

    I have; what my doctors think is a large torn dura around or adjacent to my T-11 space. It just so happens that; over one year ago in August 2009, I was operated on to receive a spinal cord stimulator implant. The IPG (implantable pulse generator...battery) is in my upper buttock and the lead wire was run subdermal to the area around my T-11 vertebrae. My Pain Management Specialist and Spinal Reconstructive Surgeon worked together on this one...they had to fully remove the laminae from two vertebrae in order to fit the paddle lead (end of the lead wiring from the IPG which is fused inside of a long ovular shaped plastic paddle) into my epidural space. To secure the paddle lead from movement; extremely small holes were drilled through the adjacent vertebrae and the lead wire was secured by tie through the vertebral holes.

    Over the past 4 weeks, I have suffered random weakness, numbness, loss of sensation, black outs, nausea, urinary retention difficulty, loss of right eye peripheral vision, and complete right body paralysis. Due to the fact that I have a spinal cord stimulator implant (actually...I have TWO in my body), I cannot receive an MRI. Nowadays; doctors rely all too heavily on MRI diagnostics for their process.

    Long story short...they think a sizable tear in my dura is causing a severe leak of CSF (cerebral spinal fluid); which makes some sense considering...I have been dealing with a THREE (3) week long headache from hell! I NEVER get headaches; coincidentally, my description of this headache is exactly like my fiance's description of the headache she endured the day our baby girl was born...AFTER an epidural was administered.

    The doctors who have worked on my case thus far (2 neurologists, 2 ER docs, 3 pain management specialists) cannot reach a solid conclusion. Multiple CT-Scans, X-Rays, CSF testing from lumbar puncture, labs...all normal. What is NOT normal; full right body paralysis...to the point where I cannot feel my eye, tongue, throat, scalp, all the way down to my foot.

    My recent pain mngt specialist told me that a torn dura is NOT something that doctors are "wild" about fixing; in fact, he said that the BODY must do the job on its own...form scar tissue. For a person like yourself who has been experiencing this disaster for an entire year...I really do not know what options you have.

    I am not a doctor...nor do I assume to provide perfect medical advice; however, I would recommend contacting a spinal reconstructive surgeon who works in the Sacramento Valley region of California. His name is Dr Philip J Orisek; his info follows below:

    2575 East Bidwell Street Suite 220
    Folsom, CA, 95630
    Phone Number:

    (916) 817-6390

    PLEASE let me know if you find success getting your back "back" in shape!! I wish you the best and always send a general prayer out to the people around the world suffering from chronic pain; the #1 worst condition.

  6. #6

    Torn dura

    I just want to say that I am really new to this, so..... Dr. Kim Kee, Neuro, UC Davis Medical Center Sacramento Ca. Just has performed the 3rd spine surgery in 4 years on my wife. Dura was opened every time. There are several options for problematic dura closures, ( dont hold me to the spelling or names exactly , I am not a dr. ) one is a bovine collagin? the other is a mesh type of stuff. I will look up the names tomorrow. There was some problems with the mesh in the cranium part of the dura, very low percentage though. I think the test I read were done in 07. We were asked to be a part of the one of the studies, however we don't know if they used it or not. They opened up quite a large amount of my wifes dura to strip cysts out. She didn't seem to have leaks from it. Just some thoughts from a newbie. The other surgen in the same place is Boegen (spelling?) Who is also one of the main specialist in that area.

    Jeff

  7. #7

    Recommendation on a doctor

    Dr. HrayrShahinian, Skull Base Institute, 8635 West 3rd Street, Suite 1170W,
    Los Angeles, CA 90048, is one of maybe two doctors who could perform the surgery you are talking about.

    Local Telephone 310-691-8888
    Facsimile 310-691-8877
    Toll-Free Hotline 866-266-9627


  8. #8
    I would image that 5 years later, this problem has already been addressed and resolved for this person. The last post is questionably spam.

    (KLD)

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