Abstract:

A variety of techniques have been used to stop venous bleeding from the cranial and spinal epidural space. These generally consist of packing with oxidized regenerated cellulose, fibrillar collagen, and so forth, and in cranial surgery, tack-up sutures. Bipolar coagulation may also be used to control bleeding from spinal venous plexus, but it may bear the risk of healthy nervous tissue injury: dissipation of heat from the tips of the bipolar forceps may induce thermal injury to adjacent neural structures. Quick and safe hemostasis reduces the duration of surgery. Efficient control of bleeding is also a prerequisite for the realization of the planned therapeutic procedure, that is, the result of surgery, and can thereby reduce perioperative morbidity. Fibrin sealant is safely used to increase hemostasis and to treat cerebrospinal leakage. Between January 2014 and March 2015, the authors used injection of fibrin sealant (EVICEL®, Johnson & Johnson Wound Management, Somerville, NJ) into the cranial and spinal epidural space to assist in hemostasis in 97 patients. EVICEL injection was used in 81 cases of cranial surgery and 16 cases of spinal surgery. When the venous bleeding continued from the epidural space after packing with classical hemostatic agents, fibrin sealant was used to stop venous bleeding. When arterial bleeding was present, fibrin sealant was not used. In all cases, the results were judged to be excellent with stoppage of epidural bleeding, or good with mild persistent oozing. During the 10-minute observation period, no patients treated with EVICEL required additional hemostatic measures. No complications related to the fibrin glue were encountered.

Authors:

Roberto Gazzeri, MD, Consultant Neurosurgeon, Department of Neurosurgery, San Giovanni Addolorata Hospital, Rome, Italy, Claudio Fiore, MD, Consultant Neurosurgeon, Department of Neurosurgery, San Giovanni Addolorata Hospital, Rome, Italy, Marcelo Galarza, MD, Consultant Neurosurgeon, Regional Service of Neurosurgery, Virgen de la Arrixaca University Hospital, Murcia, Spain

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Abstract:

Introduction: Surgical correction of spinal deformity in myelomeningocele is associated with high rates of pseudarthrosis and implant failure. The anterior fusion is traditionally a wide exposure from the thorax to the sacrum. We report minimally invasive lateral interbody fusion (MILIF) to address the issue of fusion between vertebrae with marginal posterior elements while minimizing the morbidity of an open approach. Materials and Methods: We performed a single-center, retrospective review of patients with myelomeningocele and severe scoliosis who underwent posterior spinal fusion (PSF) and staged MILIF for anterior fusion of the thoracolumbar/lumbar spine. We identified four patients with high risk of curve progression who met the following inclusion criteria: diagnosis of myelomeningocele, severe scoliosis (Cobb angle > 70°), PSF using greater than 80% pedicle screws, age greater than 10 years at time of surgery, and a minimum follow-up of two years. Radiographic, clinical, and complication data were reviewed. Results: All four patients achieved fusion (100%). The average age at index surgery was 12.8 years (range, 11–16) and follow-up was 3.2 years (range, 2–4.9). The average preoperative coronal Cobb angle measured 111° (range, 74–140°). The average postoperative Cobb angle at follow-up measured 37° (range, 23–42°). The MILIF procedure was performed an average of six months after the index procedure. After anterior fusion, all patients spent one day in the pediatric ICU and an average of 5.5 days in the hospital (range, 4–7). One patient (25%) developed a postoperative wound infection after PSF which required irrigation and debridement in the operating room. Conclusion: MILIF as an adjunct to posterior spinal fusion for severe scoliosis associated with myelomeningocele may provide acceptable fusion rates, curve correction, maintenance of correction at mid-term follow-up, and be associated with less morbidity than the traditional anterior approach.

Authors:

Justin A. Iorio, MD, Resident, Orthopedic Surgery, Temple University Hospital, Philadelphia, PA, Andre M. Jakoi, MD, Resident, Orthopedic Surgery, University Orthopedic Institute at Hahnemann, Philadelphia, PA, Craig D. Steiner, MD, Resident, Orthopedic Surgery, Temple University Hospital, Philadelphia, PA, Patrick J. Cahill, MD, Attending Physician, Orthopedic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, Amer Samdani, MD, Chief of Surgery, Neurological Surgery, Shriners Hospital for Children, Philadelphia, PA, Randal R. Betz, MD, Attending Physician, Orthopedic Surgery, Institute for Spine & Scoliosis, Lawrenceville, NH, Anuj Singla, MD, Attending Physician, Orthopedic Surgery, University of Virginia, Charlottesville, VA

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Abstract:

Hemostasis is extremely important in neurosurgical procedures to prevent major postoperative bleedings and their catastrophic consequences. Emoxicel TAF Retilight (Bioster, a.s., Czech Republic) is a sterile, resorbable, hemostatic reticulum, mainly used to stop capillary and venous bleeding. The textile form of the hemostatic material allows, in several cases, perfect adjustment to the varied shape of the surgical cavities and of the epidural space to which it adheres when wet. Hemostatic effect is rapid, and complete hemostasis can be achieved in several minutes after application. This topical hemostatic agent is biocompatible, biodegradable, and highly resorbable. It has a hemostatic and antimicrobic effect. The main aim of this study was to verify the efficacy, broadness of use, and safety of this topical hemostatic in neurosurgical procedures. A total of 43 cases were included, 18 cranial and 25 spinal, and in only one case a postoperative epidural bleeding was reported. A histopathologic study of the hemostatic was performed. No allergic reactions were reported. Emoxicel was useful not only in stopping minor bleeding, but also for bleeding prevention in the postoperative period.

Authors:

Roberto Gazzeri, MD, Consultant Neurosurgeon, Department of Neurosurgery, San Giovanni Addolorata Hospital, Rome, Italy, Massimiliano Neroni, MD, Consultant Neurosurgeon, Department of Neurosurgery, San Giovanni Addolorata Hospital, Rome, Italy, Mauro Pischedda, MD, Consultant, Department of Anesthesia, San Giovanni Addolorata Hospital, Rome, Italy, Mauro Martin, MD, Consultant, Department of Anesthesia, San Giovanni Addolorata Hospital, Rome, Italy, Marcelo Galarza, MD, Consultant Neurosurgeon, Department of Neurosurgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, Domenico Campagna, MD, Consultant, Department of Pathology, San Giovani Addolorata Hospital, Rome, Italy, Marco Giordano, MD, Consultant, Department of Pathology, San Giovanni Addolorata Hospital, Rome, Italy

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