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Expansion duroplasty improves intraspinal pressure, spinal cord perfusion pressure, and vascular pressure reactivity index in patients with traumatic spinal cord injury: injured spinal cord pressure evaluation study.

Phang I, Werndle MC, Saadoun S, Varsos G, Czosnyka M, Zoumprouli A, Papadopoulos MC - J. Neurotrauma (2015)

Bottom Line: Compared with the laminectomy group, the laminectomy+duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord.In the laminectomy+duroplasty group, ISP was lower, SCPP higher, and sPRx lower, (i.e., improved vascular pressure reactivity), compared with the laminectomy group.Laminectomy+duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients.

View Article: PubMed Central - PubMed

Affiliation: 1 Academic Neurosurgery Unit, St. George's University of London , United Kingdom .

ABSTRACT
We recently showed that, after traumatic spinal cord injury (TSCI), laminectomy does not improve intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), or the vascular pressure reactivity index (sPRx) at the injury site sufficiently because of dural compression. This is an open label, prospective trial comparing combined bony and dural decompression versus laminectomy. Twenty-one patients with acute severe TSCI had re-alignment of the fracture and surgical fixation; 11 had laminectomy alone (laminectomy group) and 10 had laminectomy and duroplasty (laminectomy+duroplasty group). Primary outcomes were magnetic resonance imaging evidence of spinal cord decompression (increase in intradural space, cerebrospinal fluid around the injured cord) and spinal cord physiology (ISP, SCPP, sPRx). The laminectomy and laminectomy+duroplasty groups were well matched. Compared with the laminectomy group, the laminectomy+duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord. In the laminectomy+duroplasty group, ISP was lower, SCPP higher, and sPRx lower, (i.e., improved vascular pressure reactivity), compared with the laminectomy group. Laminectomy+duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients. We conclude that, after TSCI, laminectomy+duroplasty improves spinal cord radiological and physiological parameters more effectively than laminectomy alone.

No MeSH data available.


Related in: MedlinePlus

Duroplasty technique and computed tomography (CT)/magnetic resonance imaging (MRI). (A) Left: Exposed dura after laminectomy. Middle: Durotomy held open with forceps showing injured spinal cord and intraspinal pressure (ISP) probe. Right: Sutured dural patch. (B) Pre-operative T2 MRI showing high signal at site of traumatic spinal cord injury. (C) Post-operative (left) CT showing ISP probe and (right) T2 MRI showing duroplasty. Color image is available online at www.liebertpub.com/neu
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f1: Duroplasty technique and computed tomography (CT)/magnetic resonance imaging (MRI). (A) Left: Exposed dura after laminectomy. Middle: Durotomy held open with forceps showing injured spinal cord and intraspinal pressure (ISP) probe. Right: Sutured dural patch. (B) Pre-operative T2 MRI showing high signal at site of traumatic spinal cord injury. (C) Post-operative (left) CT showing ISP probe and (right) T2 MRI showing duroplasty. Color image is available online at www.liebertpub.com/neu

Mentions: All patients had a posterior approach to realign and stabilize the spine. Spinal stabilization involved lateral mass screws for cervical injuries and pedicle screws for thoracic injuries. The first 11 patients had laminectomy without opening the dura (termed the laminectomy group). The extent of laminectomy was based on the extent of cord edema seen on magnetic resonance imaging (MRI). Four patients in the laminectomy group also had anterior cervical fixation and fusion. The last 10 patients (termed the laminectomy+duroplasty group) had laminectomy, followed by incising the posterior aspect of the dura longitudinally in the midline under a microscope. The length of the laminectomy and dural incision was estimated from the length of the swollen spinal cord edema on the pre-operative MRI. No patients in the laminectomy+duroplasty group had anterior cervical fixation and fusion. After opening the dura in the laminectomy+duroplasty group, we could see the ISP probe. In each of the 10 patients, the ISP probe was in the subdural space, thus confirming that our insertion technique was safe and did not result in intraparenchymal placement of the ISP probe. We then sutured an elliptical patch of artificial dura (Durepair®; Medtronic, Hertfordshire, UK) to the dural edges to expand the intradural space. The duroplasty was supplemented with fibrin glue (Tisseel®; Baxter, Newbury, Berkshire, UK). The surgical procedure is summarized in Figure 1A.


Expansion duroplasty improves intraspinal pressure, spinal cord perfusion pressure, and vascular pressure reactivity index in patients with traumatic spinal cord injury: injured spinal cord pressure evaluation study.

Phang I, Werndle MC, Saadoun S, Varsos G, Czosnyka M, Zoumprouli A, Papadopoulos MC - J. Neurotrauma (2015)

Duroplasty technique and computed tomography (CT)/magnetic resonance imaging (MRI). (A) Left: Exposed dura after laminectomy. Middle: Durotomy held open with forceps showing injured spinal cord and intraspinal pressure (ISP) probe. Right: Sutured dural patch. (B) Pre-operative T2 MRI showing high signal at site of traumatic spinal cord injury. (C) Post-operative (left) CT showing ISP probe and (right) T2 MRI showing duroplasty. Color image is available online at www.liebertpub.com/neu
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4492612&req=5

f1: Duroplasty technique and computed tomography (CT)/magnetic resonance imaging (MRI). (A) Left: Exposed dura after laminectomy. Middle: Durotomy held open with forceps showing injured spinal cord and intraspinal pressure (ISP) probe. Right: Sutured dural patch. (B) Pre-operative T2 MRI showing high signal at site of traumatic spinal cord injury. (C) Post-operative (left) CT showing ISP probe and (right) T2 MRI showing duroplasty. Color image is available online at www.liebertpub.com/neu
Mentions: All patients had a posterior approach to realign and stabilize the spine. Spinal stabilization involved lateral mass screws for cervical injuries and pedicle screws for thoracic injuries. The first 11 patients had laminectomy without opening the dura (termed the laminectomy group). The extent of laminectomy was based on the extent of cord edema seen on magnetic resonance imaging (MRI). Four patients in the laminectomy group also had anterior cervical fixation and fusion. The last 10 patients (termed the laminectomy+duroplasty group) had laminectomy, followed by incising the posterior aspect of the dura longitudinally in the midline under a microscope. The length of the laminectomy and dural incision was estimated from the length of the swollen spinal cord edema on the pre-operative MRI. No patients in the laminectomy+duroplasty group had anterior cervical fixation and fusion. After opening the dura in the laminectomy+duroplasty group, we could see the ISP probe. In each of the 10 patients, the ISP probe was in the subdural space, thus confirming that our insertion technique was safe and did not result in intraparenchymal placement of the ISP probe. We then sutured an elliptical patch of artificial dura (Durepair®; Medtronic, Hertfordshire, UK) to the dural edges to expand the intradural space. The duroplasty was supplemented with fibrin glue (Tisseel®; Baxter, Newbury, Berkshire, UK). The surgical procedure is summarized in Figure 1A.

Bottom Line: Compared with the laminectomy group, the laminectomy+duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord.In the laminectomy+duroplasty group, ISP was lower, SCPP higher, and sPRx lower, (i.e., improved vascular pressure reactivity), compared with the laminectomy group.Laminectomy+duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients.

View Article: PubMed Central - PubMed

Affiliation: 1 Academic Neurosurgery Unit, St. George's University of London , United Kingdom .

ABSTRACT
We recently showed that, after traumatic spinal cord injury (TSCI), laminectomy does not improve intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), or the vascular pressure reactivity index (sPRx) at the injury site sufficiently because of dural compression. This is an open label, prospective trial comparing combined bony and dural decompression versus laminectomy. Twenty-one patients with acute severe TSCI had re-alignment of the fracture and surgical fixation; 11 had laminectomy alone (laminectomy group) and 10 had laminectomy and duroplasty (laminectomy+duroplasty group). Primary outcomes were magnetic resonance imaging evidence of spinal cord decompression (increase in intradural space, cerebrospinal fluid around the injured cord) and spinal cord physiology (ISP, SCPP, sPRx). The laminectomy and laminectomy+duroplasty groups were well matched. Compared with the laminectomy group, the laminectomy+duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord. In the laminectomy+duroplasty group, ISP was lower, SCPP higher, and sPRx lower, (i.e., improved vascular pressure reactivity), compared with the laminectomy group. Laminectomy+duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients. We conclude that, after TSCI, laminectomy+duroplasty improves spinal cord radiological and physiological parameters more effectively than laminectomy alone.

No MeSH data available.


Related in: MedlinePlus