Cauda Equina Syndrome After a TLIF Resulting From Postoperative Expansion of a Hydrogel Dural Sealant

Abstract

Background DuraSeal TM (Coviden, Waltham, MA, USA), a hydrogel sealant, is primarily used as an adjunct to a dural repair. Its use has also been described to seal off an annulotomy after a transforaminal lumbar interbody fusion when recombinant human bone morphogenetic protein-2 (rhBMP-2) is used. This aids in the reduction of postoperative radiculitis caused by rhBMP-2. However, as a result of its hydrophilic properties, DuraSeal TM has the potential to swell, which could lead to compression of the thecal sac. Case Description We report a 57-year-old woman who developed cauda equina after a transforaminal lumbar 47 interbody fusion (TLIF) procedure in which the expansion of the DuraSeal TM was believed to be the causative factor. The patient developed urinary retention, bowel incontinence, and paresthesias in the saddle region on postoperative Day 3. She underwent emergent exploration and decompression of the thecal sac. The gel-like DuraSeal TM material was causing significant compression of the thecal sac. Literature Review Multiple reports have documented that DuraSeal TM , used as an adjunct to dural repair, can swell leading to compression of the spinal cord and/or neural elements. Our case demonstrates the use of DuraSeal TM both over a site of a dural repair and over an annulotomy site, through which a TLIF was performed, is associated with the risk of developing postoperative cauda equina syndrome as a result of swelling of the DuraSeal TM . Clinical Relevance Those using DuraSeal TM to seal off the annulotomy after a TLIF procedure performed with rhBMP-2 should use the product with an understanding of the potential postoperative swelling of the product and resulting neurologic sequela, particularly if DuraSeal TM is used concomitantly at the site of dural repair.

Swelling, sealing, and hemostatic ability of a novel biomaterial: A polyethylene glycol-coated collagen pad

“…9 Similarly, the misuse of a PEG-based dural sealant to inhibit the migration of rhBMP-2 caused cauda equine syndrome secondary to spinal cord compression. 10 The mass effect complications are not limited to misuses of PEG nor limited to PEG-based biomaterials.…”

Injectable Hydrogels for Spinal Cord Repair: A Focus on Swelling and Intraspinal Pressure

“…Therefore, direct measurements of local spinal tissue pressure before and after hydrogel application in vivo are needed to confirm these ex vivo observations. Some researchers have examined the swelling properties of hydrogels in experimental settings (in preclinical models) for applications within the CNS [Baumann et Bjugstad et al, 2010;Kubinova et al, 2011;Neuman et al, 2012]. Indeed, Bjugstad et al [2010] implanted a strand of photocrosslinked PEG gel that was preformed, but not preswollen, into the ventral midbrain.…”

“…All measurements were acquired at room temperature. [Mulder et al, 2009;Neuman et al, 2012;Lee et al, 2013]. Swelling of the DuraSeal ® hydrogels at the site of application had adverse effects in the higher cervical level where there is less space between the bony vertebra and the spinal cord parenchyma [Lee et al, 2013], as well as in the cauda equina where there is a relatively larger space between the vertebra and the spinal cord [Mulder et al, 2009;Neuman et al, 2012].…”

“…[Mulder et al, 2009;Neuman et al, 2012;Lee et al, 2013]. Swelling of the DuraSeal ® hydrogels at the site of application had adverse effects in the higher cervical level where there is less space between the bony vertebra and the spinal cord parenchyma [Lee et al, 2013], as well as in the cauda equina where there is a relatively larger space between the vertebra and the spinal cord [Mulder et al, 2009;Neuman et al, 2012]. It is also important to consider that the application of hydrogel material within the subdural space (as mentioned above, the spinal cord is freely floating within the spinal column) can migrate away from the site of application, so that the adverse effects may be detected at distant sites [Mulder et al, 2009].…”

Duraseal thecal sac compression after lumbar discectomy causing radiculopathy

“…Duraseal causing spinal cord compression has been described in the literature and is usually caused by a progressive expansion after the operation [1][2][3][4][5]. It can take several months for spontaneous absorption of the dural sealant [6].…”