Utility of nonpenetrating titanium clips for dural closure during spinal surgery to prevent postoperative cerebrospinal fluid leakage

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>The nonpenetrating titanium clip has been successfully used in peripheral arterial bypass surgery. The purpose of this study was to evaluate the leakage pressures and patterns of nonpenetrating titanium clips using a simple model that mimicked spinal surgery. In addition, the authors describe their surgical experience with these clips and the follow-up results in 31 consecutive patients.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>The authors compared nonpenetrating titanium clips and expanded polytetrafluoroethylene (ePTFE) sutures in relation to the water pressure that could be tolerated by sutured ePTFE sheets, and the leakage pressure patterns were determined. The changes in leakage pressures at 5 minutes, 30 minutes, and 12 hours were examined when the clips and sutures were used in combination with the mesh-and-glue technique in an in vitro study. Thirty-one patients underwent spinal intradural procedures using nonpenetrating titanium clips to suture the dura maters using the meshand-glue technique, involving fibrin glue and polyglycolic acid-fibrin sheets.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>A significant difference was apparent between the ePTFE suture group and the nonpenetrating titanium clip group, with the latter showing a leakage pressure that could be sustained and was 1508% higher than that of the former (p = 0.001). In relation to leakage patterns, the nonpenetrating titanium clips did not make any suture holes in the ePTFE sheet and fluid leakage occurred between the clips, whereas fluid leakage was associated with the pressure elevation that occurred at the suture holes made by the ePTFE sutures. Of the 31 patients who underwent spinal intradural procedures using nonpenetrating titanium clips, 1 (3.2%) experienced cerebrospinal fluid (CSF) leakage postoperatively. No other complications—for example, allergic reactions, adhesions, or infections—were encountered.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>The interrupted placement of nonpenetrating titanium clips enables dural closure without creating any holes. These clips facilitate improvements in the initial leakage pressure and reduce postoperative CSF leakage following spinal surgery. The authors conclude that it is very beneficial to suture the spinal dura mater using nonpenetrating titanium clips given the anatomical characteristics of the spinal dura mater and the fact that the clips do not create suture holes.</jats:p></jats:sec>

Novel dural incision and closure procedure for preventing postoperative cerebrospinal fluid leakage during the surgical removal of dumbbell-shaped spinal tumors: technical note

“…Therefore, nonpenetrating titanium vascular clips, which do not create any suture holes, are ideal for closing dural incisions. 5,7 Surgeons should be aware that the interval between the 2 incisions can potentially interfere with tumor visualization. However, the present method utilizes 2 simple incisions that enable the surgeon to perform reliable closure to reduce postoperative CSF leakage and yield a good surgical result.…”

“…5,11 Additionally, during intradural procedures, the dura mater often becomes dry and shrinks, making it difficult to suture the T-shaped incision precisely without defect or CSF leakage. For this reason, watertight dural suturing is more difficult in spinal intradural procedures than in intracranial procedures.…”

“…In contrast, the spinal dura mater is composed of a single meningeal layer, with collagen fibers oriented in a longitudinal direction. 5 Because the collagen fibers of the spinal dura mater are oriented in the same direction, the dura mater can tear easily during surgical suturing with a needle and thread. Furthermore, the delicate structure of the spinal dura mater increases the possibility of lacerations proximal to the needle holes.…”

Letter to the Editor: Nonpenetrating titanium clips for dural closure during spinal surgery

“…TO THE EDITOR: We enjoyed the recent article by Ito et al 1 (Ito K, Aoyama T, Horiuchi T, et al: Utility of nonpenetrating titanium clips for dural closure during spinal surgery to prevent postoperative cerebrospinal fluid leakage. J Neurosurg Spine 23:812-819, December 2015).…”

“…Some have questioned even the routine use of postoperative radiographs in postanterior cervical fusion patients whose clinical course is unremarkable. 1 To spare patients unnecessary radiation exposure, CT or flexion-extension radiographs have been utilized only if clinical symptoms or radiographs were suggestive of pseudarthrosis.…”