Or the patients ??? Dural Tears Incidence from 2 6 % all comers - - PowerPoint PPT Presentation

Non-stop headaches after leaving the operating room

ISADOR LIEBERMAN MD MBA FRCSC

ISADOR LIEBERMAN MD MBA FRCSC

disclosures October 2017

Consultant Research Support Royalties Stock Options Mazor Robotics

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Stryker Spine

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Globus

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Misonix

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Safe Orthopaedics

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Medtronic

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SI Bone

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AAOS; member CME Courses committee ISASS; member Public Policy committee SMISS; member Board of Directors Editorial board; Spine, JSD&T, European Spine J

My Headache???

Or the patient’s ???

Dural Tears

• Incidence from 2 – 6 % all comers to spine surgery
• Revision surgery incidence > 15%
• Risk factors = adhesions, ossification, surgeon experience
• Strategy

1) Prevention 2) Direct Primary Repair 3) Diversion Drainage

Prevention

Ultrasonic Bone Scalpel

• Blunt tip blade oscillates at 22.5khz with stroke amplitude of 100 micrometer
• Crystalline “non yielding” tissue pulverized
• Soft “yielding” tissue displaced
• Create osteotomies of .5 mm width up to 20 mm deep
• Minimal blood loss & Integrated irrigation/cooling system

Direct Primary Repair

• Exposure
• Control

(suction, protection of nerves)

• Watertight Suture Repair

(test repair with Valsalva)

• Reinforcement

(synthetic, allograft, muscle/fascia)

• Sealants

(fibrin glue, gel preps)

• Watertight muscle and skin closure
• Diversion subarachnoid drain

Diversion Draining

• Subarachnoid drain

inserted percutaneously at L2/3 or cervical

• Bedrest for 2 – 5 days
• Place bag level to drain

200 – 300 ml per day, 5 – 10 ml per hour,

• Titrate to headache

Symptoms

• Positional headache
• Nausea
• Photophobia
• Clear drainage from incision

Treatments

• Analgesics
• Antiemetics
• Caffiene/Theophylline

(to vasoconstrict)

• Epidural blood patch

Investigations

• Fluid analysis for

Beta 2 Transferrin

• MRI scan
• Radionucleotide

cisternography

Thank You

ISADOR LIEBERMAN MD MBA FRCSC