Spinal dural closure with nonpenetrating titanium clips in pediatric neurosurgery

Clinical article

Restricted access


The authors report a retrospective review of their experience using nonpenetrating titanium anastomotic clips for dural closure in 27 pediatric cases (26 patients) of spinal surgery for a variety of diagnoses. The goal of this review was to define the utility of these clips in pediatric neurosurgical spinal procedures, identify complications of their use, and assess the effects on postoperative imaging because of their use.


Institutional review board approval was obtained for a retrospective chart review of all patients in whom titanium dural clips had been utilized. Patients were identified over a 2-year period using hospital and clinic records, and data were collected on the patient demographics, surgical diagnosis and procedure, durotomy location and length, and adjunctive closure methods. Postoperative complications were assessed. When available, postoperative imaging data were reviewed.


Twenty-six patients underwent 27 operations over a 20-month period. They ranged in age from 2.5 months to 18.5 years, with a median age of 3.2 years and an average age of 5.8 years. The operative diagnosis was some form of spinal dysraphism in 19 patients, with a syrinx or dural tear in 2 patients each, and an arachnoid cyst in 3 cases; 1 patient had a tumor resected. Operative levels included lumbosacral (19), thoracic (7), and cervical (1). Dural exposure was limited to 1 laminar level in 16 cases, 2 levels in 8, and 3 levels in 1; 2 cases involved focal dural tears. A combination of additional hemostatic and tissue sealant materials was applied over the clips in 16 cases. One patient required reoperation 13 months after clip placement. Prior clip use did not make subsequent exposure and opening more complicated. No significant complications were identified in the follow-up period ranging from 1 to 24 months. There were no documented CSF leaks. The clips are not easily seen on plain radiographs and did not cause artifacts or distortion on either CT or MR imaging.


Nonpenetrating titanium anastomotic clips afford an effective means of closure while limiting the exposure needed, and thus allowing more minimally invasive approaches. In tight spaces, dural closure is accomplished more easily and faster with the clips as compared with conventional suturing. No significant complications were seen from clip use, and the clips did not interfere with postoperative imaging.

Article Information

Address correspondence to: Bruce A. Kaufman, M.D., Pediatric Neurosurgery, Children's Hospital of Wisconsin, 999 North 92nd Street, Suite 310, Milwaukee, Wisconsin 53226. email: bkaufman@mcw.edu.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Images obtained in a 17-year-old with traumatic injury to C-5 who suffered a dural tear during corpectomy. Left: Axial CT revealing the clip dorsal to the vertebral body (arrow). Note that there is no obvious artifact. Right: Lateral radiograph showing barely visible staples immediately dorsal to the vertebral body (circle).

  • View in gallery

    Eight-month postoperative images obtained in a 15-year-old who underwent a 2-level hemilaminectomy for intradural tumor. A: Sagittal T2-weighted MR image demonstrating minor signal changes by the clips (arrow), but no anatomical distortion. B: Axial T2-weighted MR image revealing a small signal void at the clip site (arrow), but no interference with the ability to define the adjacent nerve roots. C: Axial T1-weighted MR image showing no image degradation due to the clips.

  • View in gallery

    Clips used in a limited laminectomy (1.0 × 0.5 cm) in an infant undergoing sectioning of the filum terminale.


  • 1

    Kirsch WMZhu YHHardesty RAWebster MHCBoukouvalas ZFurnas DThe non-penetrating arcuate-legged clip: clinical applications. Lee S: Color Atlas of Microsurgery St. LouisIEA Publishers1993. 89101

    • Search Google Scholar
    • Export Citation
  • 2

    Kirsch WMZhu YHWahlstrom EWang ZGHardesty ROberg KVascular reconstructions with nonpenetrating arcuate-legged clips. Yao JSTPearce WH: Techniques in Vascular and Endovascular Surgery Stamford, CTAppleton & Lange1998. 6790

    • Search Google Scholar
    • Export Citation
  • 3

    Levy DISonntag VKH: Titanium dural clip testing. Technical note. J Neurosurg 81:9479491994

  • 4

    Marks PKoskuba D: Use of a non-penetrating staple device for spinal dural closure. Br J Neurosurg 14:4682000

  • 5

    Palm SJKirsch WMZhu YHPeckham NKihara SIAnton R: Dural closure with nonpenetrating clips prevents meningoneural adhesions: an experimental study in dogs. Neurosurgery 45:8758821999

    • Search Google Scholar
    • Export Citation
  • 6

    Timothy JHanna SJFurtado NShanmuganathan MTyagi A: The use of titanium non-penetrating clips to close the spinal dura. Br J Neurosurg 21:2682712007

    • Search Google Scholar
    • Export Citation
  • 7

    Zeebregts CJKirsch WMReijnen MMZhu YHvan den Dungen JJ: Expanding use of nonpenetrating clips in various surgical specialities. Surg Technol Int 14:85952005

    • Search Google Scholar
    • Export Citation



All Time Past Year Past 30 Days
Abstract Views 114 114 11
Full Text Views 68 68 0
PDF Downloads 105 105 0
EPUB Downloads 0 0 0


Google Scholar