Bruce A. Kaufman, Anne E. Matthews, Marike Zwienenberg-Lee and Sean M. Lew
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.
Paul Klimo Jr., Anne Matthews, Sean M. Lew, Marike Zwienenberg-Lee and Bruce A. Kaufman
Various surgical interventions have been described to evacuate chronic subdural collections (CSCs) of infancy. These include transfontanel percutaneous aspiration, subdural drains, placement of bur hole(s) with or without a subdural drain, and shunting. Shunt placement typically provides good long-term success (resolution of the subdural fluid), but comes with well-known early and late complications. Recently, the authors have used a mini–osteoplastic craniotomy technique with the goal of definitively treating these children with a single surgery while avoiding the many issues associated with a shunt. They describe their procedure and compare it with the traditional bur hole technique.
In this single-institution retrospective study, the authors evaluated 26 cases involving patients who underwent treatment for CSC. Preoperative, intraoperative, and postoperative data were reviewed, including radiographic findings (density of the subdural fluid and ventricular and subarachnoid space size), neurological examination findings, and intraoperative fluid description. The primary outcome was treatment failure, defined as the patient requiring any subsequent surgical intervention after the index procedure (minicraniotomy or bur hole placement).
Fifteen patients (10 male and 5 female; median age 5.1 months) collectively underwent 27 minicraniotomy procedures (each procedure representing a hemisphere that was treated). In the bur hole group, there were 11 patients (6 male and 5 female; median age 4.6 months) with 18 hemispheres treated. Both groups had subdural drains placed. The average follow-up for each treatment group was just over 7 months. Treatment failure occurred in 2 patients (13%) in the minicraniotomy group compared with 5 patients (45%) in the bur hole group (p = 0.09). Furthermore, the 2 patients who had treatment failure in the minicraniotomy group required 1 subsequent surgery each, whereas the 5 in the bur hole group needed a total of 9 subsequent surgeries. Eventually, 80% of the patients in the minicraniotomy group and 70% of those in the bur hole group had resolution of the subdural collections on the last imaging study.
The minicraniotomy technique may be a superior technique for the treatment of CSCs in infants compared with bur hole evacuation. The minicraniotomy provides greater visualization of the subdural space and allows more aggressive evacuation of the fluid, better irrigation of the space, the ability to fenestrate any accessible membranes safely, and continued egress of fluid into the subgaleal space. Although this preliminary report has obvious limitations, evaluation of this technique may be worthy of a prospective, multiinstitutional collaborative effort.