Titanium clips and ligamentum flavum-epidural fat patch graft for midline lumbar durotomy closure in pediatric neurosurgery.

Abstract

Objective: CSF leaks are a significant source of patient morbidity following intradural spine surgeries. Watertight dural closure is crucial during these procedures to minimize the risk of a CSF leak. This study reports postoperative outcomes and changes in patient management after switching to penetrating titanium clips for dural closure in a large cohort of pediatric patients receiving a tethered cord release (TCR) or a selective dorsal rhizotomy (SDR).

Methods: An IRB-approved retrospective review was conducted of the medical charts of all patients who underwent thoracolumbar dorsal midline dural closure with the AnastoClip GC Closure System during the 7 years between May 22, 2017, and May 21, 2024. Selected data such as evidence of a CSF leak and postoperative length of stay were collected.

Results: A total of 290 patients were treated with AnastoClips GC for dural closure. Of these patients, 232 (80.0%) underwent a TCR only, 52 (17.9%) received an SDR, and 6 (2.1%) underwent a complex TCR. The mean duration between surgery and last follow-up was 7.96 months (range 0.27-54.57 months). One patient, who received a simple TCR, experienced a transient pseudomeningocele without headache, emesis, or visible leak that resolved without surgical intervention within 8 weeks. Three (1%) patients had positional headaches without other evidence of a CSF leak, all limited to the initial 2 weeks of postoperative care. Six (2%) patients had delayed wound healing, 2 of whom underwent operative wound revisions. As of January 1, 2021, patients no longer had to lie flat postoperatively. While 60.6% of TCR patients were discharged from the hospital on POD 1 (none on POD 0) prior to this date, 87.5% of patients were discharged from the hospital on either POD 0 (3.1%) or POD 1 (84.4%) afterward. Similarly, 50% of SDR patients were discharged on POD 2 or 3 after the need for lying flat postoperatively was removed versus 21% before the protocol change.

Conclusions: AnastoClip GC Closure System titanium clips are safe and effective for dural closure in both TCR and SDR, with rare complications. Their efficacy has prompted us to remove flat bed rest requirements for postoperative patients, significantly reducing the length of stay, and has opened the door to making simple TCRs a same-day surgery.