The use of a novel perfusion-based cadaveric simulation model with cerebrospinal fluid reconstitution comparing dural repair techniques: a pilot study

BACKGROUND CONTEXT: Watertight dural repair is crucial for both incidental durotomy and closure after intradural surgery. PURPOSE: The study aimed to describe a perfusion-based cadaveric simulation model with cerebrospinal fluid (CSF) reconstitution and to compare spine dural repair techniques. STUDY DESIGN/SETTING: The study is set in a fresh tissue dissection laboratory. SAMPLE SIZE: The sample includes eight fresh human cadavers. OUTCOME MEASURES: A watertight closure was achieved when pressurized saline up to 40 mm Hg did not cause further CSF leakage beyond the suture lines. METHODS: Fresh human cadaveric specimens underwent cannulation of the intradural cervical spine for intrathecal reconstitution of the CSF system. The cervicothoracic dura was then exposed from C7-T12 via laminectomy. The entire dura was then opened in six cadavers (ALLSPINE) and closed with 6-0 Prolene (n = 3) or 4-0 Nurolon (n = 3), and pressurized with saline via a perfusion system to 60 mm Hg to check for leakage. In two cadavers (INCISION), six separate 2-cm incisions were made and closed with either 6-0 Prolene or 4-0 Nurolon, and then pressurized. A hydrogel sealant was then added and the closure was pressurized again to check for further leakage. RESULTS: Spinal laminectomy with repair of intentional durotomy was successfully performed in eight cadavers. The operative microscope was used in all cases, and the model provided a realistic experience of spinal durotomy repair. For ALLSPINE cadavers (mean: 240 mm dura/cadaver repaired), the mean pressure threshold for CSF leakage was observed at 66.7 (+/- 2.9) mm Hg in the 6-0 Prolene group and at 43.3 (+/- 14.4) mm Hg in the 4-0 Nurolon group (p > .05). For INCISION cadavers, the mean pressure threshold for CSF leakage without hydrogel sealant was significantly higher in 6-0 Prolene group than in the 4-0 Nurolon group (6-0 Prolene: 80.0 +/- 4.5 mm Hg vs. 4-0 Nurolon: 32.5 +/- 2.7 mm Hg; p < .01). The mean pressure threshold for CSF leakage with the hydrogel sealants was not significantly different (6-0 Prolene: 100.0 +/- 0.0 mm Hg vs. 4-0 Nurolon: 70.0 +/- 33.1 mm Hg). The use of a hydrogel sealant significantly increased the pressure thresholds for possible CSF leakage in both the 6-0 Prolene group (p = .01) and the 4-0 Nurolon group (p < .01) when compared with mean pressures without the hydrogel sealant. CONCLUSIONS: We described the feasibility of using a novel cadaveric model for both the study and training of watertight dural closure techniques. 6-0 Prolene was observed to be superior to 4-0 Nurolon for watertight dural closure without a hydrogel sealant. The use of a hydrogel sealant significantly improved watertight dural closures for both 6-0 Prolene and 4-0 Nurolon groups in the cadaveric model. (C) 2017 Elsevier Inc. All rights reserved.