Reconstruction After Posterior Cranial Fossa Surgery—Case Report of Application of a Synthetic Tissue Sealant to Augment Dural Closure
Reconstruction After Posterior Cranial Fossa Surgery—Case Report of Application of a Synthetic Tissue Sealant to Augment Dural Closure
US Neurology, 2010;5(2):85-8
Abstract
Cerebrospinal fluid (CSF) leakage following cranial surgery is a well-described and potentially devastating complication, particularly in posterior cranial fossa surgery. If untreated, a persistent CSF leak can evolve into wound breakdown, a surgical-site infection, and meningitis. The morbidity of a complication following a cranial operation is harmful to the patient. Additionally, complications are a source of elevated medical costs. Numerous reconstruction strategies have been developed to thwart the ill effects of CSF leaks on patient outcomes and healthcare finances. This case report illustrates the method employed at our institution to repair posterior fossa defects following surgery in the cerebellopontine angle.
Keywords
Reconstruction, posterior fossa surgery, dural closure, dural repair, dural sealant, cerebrospinal fluid (CSF) leak
Disclosure: Nicholas D Coppa, MD, has no conflicts of interest to declare. Johnny B Delashaw Jr, MD, is a paid consultant to Covidien.
Received: August 4, 2009 Accepted: January 8, 2010
Correspondence: Nicholas D Coppa, MD, Department of Neurological Surgery, Mail code CH8N, Oregon Health & Science University, 3303 SW Bond Avenue, Portland, OR 97239. E: coppan@ohsu.edu
Post-operative cerebrospinal fluid (CFS) leakage can be a challenging and potentially hazardous problem following many complex cranial procedures.1–3 This is especially true for surgical approaches to the skull base because a watertight dural reconstruction is not always feasible and CSF pulsation waves are greatest in this location.1,3 CSF fistulas into the soft tissues at the base of the skull can cause pseudomeningoceles, which often become very painful and debilitating.1,2 In addition, drainage of spinal fluid from the skin increases the risk for surgical-site infections and meningitis.1,2
Techniques for dural reconstruction and closure include incorporationof autologous tissue, such as pericranium or fascia lata, to complete dural closure.4 This can be augmented with ‘muscle plugs’ to closeadditional small defects in the suture line. Even with these techniques, however, it is impossible to ensure a watertight dural closure because of the holes in the dura that are created by the surgical needle duringsuturing. Several commercially available synthetic grafting materials can also be used to augment dural closure.5–7 They are applied in either a ‘suturable’ or ‘onlay’ fashion depending on the anatomical location. Lastly, temporary CSF diversion can be employed via a lumbar or external ventricular drain to reduce the pressure gradient across the dural closure until it ‘seals.’8
At our institution, we have been using the DuraSealâ„¢ (Covidien) dural sealant system since its US Food and Drug Administration (FDA) approval for use in dural closure after cranial operations.9,10 It has been successfully incorporated into closures for supratentorial, posterior fossa, and lateral skull base procedures. It has been applied as a stand-alone sealant and as an adjunct over a piece of dural grafting material or adipose tissue without any complications specifically referable to its use.
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Reconstruction, posterior fossa surgery, dural closure, dural repair, dural sealant, cerebrospinal fluid (CSF) leak, posterior fossa decompression surgery, posterior fossa symptoms, subocciptal craniectomy, cerebellar mutism, cerebrospinal fluid proteins, leaking brain fluid symptoms, cerebrospinal fluid leak symptoms, cerebrospinal fluid rhinorrhea, cerebrospinal fluid fistula, dura spinal cord,
