Dural repairs (incidental durotomy) can increase morbidity, cost, and medicolegal issues. Not good. A team of researchers from the Harvard Combined Orthopaedic Residency Program and the Massachusetts General Hospital (MGH), decided to conduct a study which would compare two methods for dealing with dural repairs: open intraoperative epidural blood patches or hydrogel techniques. Their work, “Open epidural blood patch to augment durotomy repair in lumbar spine surgery: surgical technique and cohort study,” was published in the June 15, 2021 edition of The Spine Journal.
Dural Repair: Hydrogels or Epidural Blood Patch?
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Secondary#durotomyrepair#epiduralbloodpatch#hematoma
“Incidental durotomy is not uncommon,” said co-author Stuart Hershman, M.D., an orthopedic surgeon with MGH. “Despite its frequency, there is no ideal method of repair, and persistent leaks occur in spite of thorough and appropriate attempts to obtain a dural closure. Placing a sealant over the dura to obtain a watertight barrier has been described to help prevent persistent CSF [cerebrospinal fluid] leaks.”
“When surgeons perform an evacuation of an epidural hematoma, the hematoma is almost always firmly adherent to the thecal sac and requires significant manipulation in order to mobilize it. That fact made me wonder whether we could place a controlled epidural hematoma to act as a watertight barrier. The use of a controlled epidural blood patch is new to surgery but has been used in a percutaneous fashion in patients who have dural headaches secondary to lumbar punctures.”
The research team enrolled 48 patients in the study (25 in the hydrogel group and 23 in the epidural blood patch group). Two patients in the hydrogel group (8.0%) and two in the epidural blood patch group (8.7%) experienced mild positional headaches after surgery that resolved within 24 hours with no treatment needed. One patient in the latter group had positional headaches after initially experiencing no headache. While this individual was returned to the OR, no evidence of a persistent cerebrospinal fluid leak was found.
Dr. Hershman summarized the outcome of the study OTW: “An epidural blood patch was just as effective as commercially available sealants at preventing persistent leak that required a return to the operating room. Open epidural blood patching may be an efficacious, allergy free, and cost-effective method to augment durotomy repair.”
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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