Is Placing Prophylactic Dural Tenting Sutures a Dogma?

Objective In this study, we investigated if and when dural tenting sutures are necessary during craniotomy. Methods Results from 437 patients aged 18 to 91 years (average, 43.5 years) who underwent supratentorial craniotomy between 2014 and 2019 were evaluated. The patients were categorized into 1 of 3 groups, patients who had at least 3 prophylactic dural tenting sutures placed before opening of the dura (group 1), at least 3 dural tenting sutures placed after surgery was completed, during closure (group 2), or no dural tenting sutures (group 3 [control]). All such sutures in groups 1 and 2 were placed in the circumference of the craniotomy and dural junction. No central dural tenting sutures were placed in any of the patients. Results Among the 437 patients, 344 underwent surgery for the first time and 93 were undergoing a second surgery. Cranial computed tomography imaging was performed for each patient 1 hour, 3 days, and 1 month after surgery. In group 1, 3 patients had a cerebral cortex contusion and 2 patients had acute subdural hematoma after the sutures were placed. In groups 2 and 3, none of the patients had a cerebral cortex contusion or acute subdural hematoma. Fewer complications were observed when dural tenting sutures were placed during postsurgical closure. Conclusion Placing dural tenting sutures is an important technique for ensuring hemostasis. However, when not needed, they seem to cause inadvertent complications. As our results suggest, knowing when and where to use them is equally important

Assessment for efficacy of vertebroplasty and kyphoplasty in the treatment of painful osteoporotic vertebral compression fractures in elderly patients

Amaç: Konservatif tedaviden fayda görmeyen ağrılı osteoporotik vertebra çökme kırıklı yaşlı hastaların vertebroplasti ve kifoplasti ile tedavi edilerek, beklenen morbidite ve mortaliteden korunmaları ve yaşam kalitelerinin arttırılması amaçlanmıştır. Gereç ve Yöntem: Ankara Üniversitesi Tıp Fakültesi Nöroşirürji Anabilim Dalında 2003-2004 yılları arasında, ağrılı osteoporotik vertebra çökme kırığı olan dokuz yaşlı hastaya (iki erkek, yedi kadın, 60 yaş üzeri) kifoplasti ve vertebroplasti uygulanmıştır. Yöntemlerin etkinliği, klinik ve radyografik olarak değerlendirilmiştir. Sonuçlar: Osteoporotik vertebra kırıkları, serimizde kadınlarda daha yüksek oranda bulunmuştur. Tüm hastalar osteopenik veya osteoporotiktir ve dirençli ağrı en belirgin semptomdur. İlaç tedavisine ve fizik tedaviye yanıt vermemişlerdir. Torakolomber vertebroplasti ve kifoplasti uygulanan dokuz hastadan sadece birinde klinik olarak önemsiz epidural kaçak gelişmiştir. Tüm hastaların şikayetlerinde akut düzelme izlenmiş, radyografik olarak da %88.8’inde postoperatif vertebra elevasyonu sağlanmıştır. Seride mortalite ve morbidite yoktur. Tüm hastalar aynı gün mobilize edilmiş ve ilk üç gün içinde taburcu edilmişlerdir. Tartışma: Osteoporotik vertebra kompresyon kırıkları, yaşlılarda önemli bozukluklara ve mortaliteye yol açar. Bu kırıkların cerrahi tedavisinde, hastanın ağrısını en aza indirmek, kifozu önlemek ve daha iyi yaşam koşullarını minimal invaziv bir yolla gerçekleştirmek hedeflenmelidir.Purpose: It is aimed to increase health-related quality of life and to avoid the clinical consequences of osteoporotic vertebral compression fractures in elderly patients by performing vertebroplasty and kyphoplasty. Material-Methods: Nine elderly patients (two men, seven women, aged over 60) with painful osteoporotic vertebral compression fractures were treated with vertebroplasty and kyphoplasty in University of Ankara Faculty of Medicine, Department of Neurosurgery between 2003-2004. The efficacy of the procedures was assessed clinically and radiographically. Results: Osteoporotic vertebrae fractures were slightly more common in females in our series. All the patients had low bone mineral density and intractable pain. Clinical outcomes were unchanged following medical and physical therapy. In one of the nine patients undergone thoracolomber vertebroplasty and kyphoplasty, the cement leaked into the epidural space after kyphoplasty causing no change in its therapeutic benefits. All the patients had good pain relief, improved function and vertebral body elevation at a rate of 88.8%. There was no mortality and morbidity. All the patients were mobilized the day after the procedures were performed and discharged within three days postoperatively. Conclusion: Osteoporotic vertebral compression fractures represent a significant cause of disability and mortality in the elderly. The surgical treatment of these fractures should address the need to reduce the fracture related pain and the kyphotic deformity and to provide better quality of life to the elderly patients in a minimally invasive fashion

Revisiting ligament-sparing lumbar microdiscectomy: When to preserve ligamentum flavum and how to evaluate radiological results for epidural fibrosis

WOS: 000432959600042PubMed ID: 29530695OBJECTIVE: Preserving the ligamentum flavum (LF) during lumbar spine surgery can help to limit the extent of postoperative epidural fibrosis (EF), which is a potential cause of persistent leg pain. We present a retrospective analysis of microdiscectomy with preservation of the LF to evaluate the effects of the two LF mobilizing techniques (reflecting inferiorly or medially vs. removing completely) on EF and clinical outcomes. METHODS: Microdiscectomy was performed through a unilateral laminotomy in 93 patients (52 male, 41 female; mean age, 46 years; range, 25-65 years) with L3-L4 (n = 3), L4-L5 (n = 40), and L5-S1 (n = 50) lumbar disc herniation. Patients whose LF was removed were assigned to group 1 (n = 42), and patients whose LF was preserved by mobilizing it medially (n = 31) or inferiorly (n = 20) were assigned to groups 2 and 3, respectively. Follow-up visual analog scale (VAS) scores and magnetic resonance images were evaluated. RESULTS: EF scores, particularly for the anterior quadrants, were significantly higher in group 1 than in groups 2 (P = 0.012) and 3 (P = 0.001). Likewise, postoperative VAS scores in group 1 were also significantly higher than in groups 2 (P = 0.009) and 3 (P = 0.044). CONCLUSIONS: Our results demonstrate that 1) preserving the LF during lumbar microdiscectomy reduces the formation of postoperative EF and improves clinical outcomes; 2) EF in the anterior, rather than the posterior epidural space, is correlated with clinical results; and 3) the ligament mobilizing technique used should be individually tailored on the basis of the features of disc herniation