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DOI: 10.1055/s-0043-1770781
Importance of Multimodal Spinal Cord Monitoring and Hemodynamic Augmentation during High Thoracic Ventral Dural Tear Repair Using the Posterior Approach
Abstract
Cerebrospinal fluid (CSF) leakage due to large ventral dural tears (VDT) often requires surgical intervention. Surgical closure of a high thoracic VDT is challenging and associated with high morbidity, especially if it is performed after multiple epidural blood patch (EBP)/fibrin glue injections. A 44-year-old woman was diagnosed with spontaneous intracranial hypotension due to VDT at T1-T2, causing CSF leakage. Multiple EBP and fibrin glue injections failed to treat her symptoms; hence, the patient underwent surgical closure using the posterior approach. The patient was anesthetized using standard anesthetic drugs and was maintained under total intravenous anesthesia to facilitate continuous motor-evoked potential (MEP) monitoring. The surgical course was complicated by bleeding, hypotension, and MEP loss. Continuous MEP monitoring, effective team communication, quick restoration of blood pressure(BP) and BP augmentation with fluid, blood, and vasopressor helped to restore the MEP back to baseline. Hence, the patient recovered without neurological morbidity. This case report highlights the importance of adequate vascular access, multimodal spinal cord monitoring, and BP augmentation during a high thoracic VDT repair.
Keywords
cerebrospinal fluid leakage - hemodynamic management - intracranial hypotension - multimodal spinal cord monitoring - ventral dural tearPublication History
Article published online:
19 February 2024
© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
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References
- 1 Schievink WI. Spontaneous intracranial hypotension. N Engl J Med 2021; 385 (23) 2173-2178
- 2 Shin HY. Recent update on epidural blood patch. Anesth Pain Med 2022; 17 (01) 12-23
- 3 Barber SM, Sofoluke N, Reardon T. et al. Full endoscopic repair of spontaneous ventral cerebrospinal fluid leaks in the spine: systematic review of surgical treatment options and illustrative case. World Neurosurg 2022; 168: e578-e586
- 4 Smith KA. Spontaneous intracranial hypotension: targeted or blind blood patch. J Clin Neurosci 2016; 25: 10-12
- 5 Wong K, Monroe BR. Successful treatment of post-dural puncture headache using epidural fibrin glue patch after the persistent failure of epidural blood patches. Pain Pract 2017; 17 (07) 956-960
- 6 Lee DH, Kim KT, Park JI, Park KS, Cho DC, Sung JK. Repair of inaccessible ventral dural defect in thoracic spine: double layered duraplasty. Korean J Spine 2016; 13 (02) 87-90
- 7 Häni L, Fung C, Jesse CM. et al. Outcome after surgical treatment of cerebrospinal fluid leaks in spontaneous intracranial hypotension-a matter of time. J Neurol 2022; 269 (03) 1439-1446
- 8 Collier CB. Blood patches may cause scarring in the epidural space: two case reports. Int J Obstet Anesth 2011; 20 (04) 347-351
- 9 Veeravagu A, Gupta G, Jiang B, Berta SC, Mindea SA, Chang SD. Spontaneous intracranial hypotension secondary to anterior thoracic osteophyte: resolution after primary dural repair via posterior approach. Int J Surg Case Rep 2013; 4 (01) 26-29
- 10 Dash D, Jalali A, Harsh V, Omeis I. Transpedicular surgical approach for the management of thoracic osteophyte-induced intracranial hypotension refractory to non-operative modalities: case report and review of literature. Eur Spine J 2016; 25 (1, Suppl 1): 209-215
- 11 Bhagat S, Durst A, Grover H. et al. An evaluation of multimodal spinal cord monitoring in scoliosis surgery: a single centre experience of 354 operations. Eur Spine J 2015; 24 (07) 1399-1407
- 12 Fletcher ND, Ghag R, Hedequist DJ, Imrie MN, Bennett JT, Glotzbecker MP. POSNA QSVI Spine Committee. Perioperative blood pressure management for patients undergoing spinal fusion for pediatric spinal deformity. J POSNA 2023; 5 (01) DOI: 10.55275/JPOSNA-2023-602.
- 13 Lee YS, Kim KT, Kwon BK. Hemodynamic management of acute spinal cord injury: a literature review. Neurospine 2021; 18 (01) 7-14
- 14 Menacho ST, Floyd C. Current practices and goals for mean arterial pressure and spinal cord perfusion pressure in acute traumatic spinal cord injury: defining the gaps in knowledge. J Spinal Cord Med 2021; 44 (03) 350-356
- 15 Walters BC, Hadley MN, Hurlbert RJ. et al; American Association of Neurological Surgeons, Congress of Neurological Surgeons. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery 2013; 60 (CN_suppl_1): 82-91
- 16 Squair JW, Bélanger LM, Tsang A. et al. Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury. Neurology 2017; 89 (16) 1660-1667
- 17 Saadoun S, Chen S, Papadopoulos MC. Intraspinal pressure and spinal cord perfusion pressure predict neurological outcome after traumatic spinal cord injury. J Neurol Neurosurg Psychiatry 2017; 88 (05) 452-453
- 18 Vitale MG, Skaggs DL, Pace GI. et al. Best practices in intraoperative neuromonitoring in spine deformity surgery: development of an intraoperative checklist to optimize response. Spine Deform 2014; 2 (05) 333-339