Spinal dural closure without suture: Minimizing the risk of CSF leakage with a flat non-penetrating titanium U-clip

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Tumor in 67-year-old female patient with severe hearing loss (Gardner–Robertson IV). History of subtotal surgical resection of left VS one year earlier and ventriculoperitoneal shunt for post-surgical hydrocephalus. (A) Treatment with LINAC-RS in 2012 of the rest of the tumor after surgery (initial TV 3.2cc). (B) Post-RS control MRI after 9 months of treatment, compatible with pseudoprogression (TV 4.2cc). (C) Progressive regression in control MRI at 24 months (TV 3.2cc). (D) Control MRI at 36 months post-RS (TV 0.75cc). TV: tumor volume." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ángela Ros-Sanjuán, Sara Iglesias-Moroño, Marta Troya-Castilla, Bernarda Márquez-Márquez, Ismael Herruzo-Cabrera, Miguel Ángel Arráez-Sánchez" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Ángela" "apellidos" => "Ros-Sanjuán" ] 1 => array:2 [ "nombre" => "Sara" "apellidos" => "Iglesias-Moroño" ] 2 => array:2 [ "nombre" => "Marta" "apellidos" => "Troya-Castilla" ] 3 => array:2 [ "nombre" => "Bernarda" "apellidos" => "Márquez-Márquez" ] 4 => array:2 [ "nombre" => "Ismael" "apellidos" => "Herruzo-Cabrera" ] 5 => array:2 [ "nombre" => "Miguel Ángel" "apellidos" => "Arráez-Sánchez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147319300077?idApp=UINPBA00004B" "url" => "/11301473/0000003000000004/v1_201906220636/S1130147319300077/v1_201906220636/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S1130147319300259" "issn" => "11301473" "doi" => "10.1016/j.neucir.2019.03.001" "estado" => "S300" "fechaPublicacion" => "2019-07-01" "aid" => "373" "copyright" => "Sociedad Española de Neurocirugía" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Neurocirugia. 2019;30:167-72" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 13 "formatos" => array:2 [ "HTML" => 7 "PDF" => 6 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Clinical Research" "titulo" => "MRI-guided frame-based stereotactic brainstem biopsy procedure: A single-center experience" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "167" "paginaFinal" => "172" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Procedimiento de biopsia de tronco de cerebro estereotáctico guiado por marco de imágenes por resonancia magnética (IRM): Una experiencia en un solo centro" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 672 "Ancho" => 2000 "Tamanyo" => 122896 ] ] "descripcion" => array:1 [ "en" => "The MRIs performed on the patients having a Leksell head frame fixation to calculate the coordinates of the target. (a) Contrast-enhanced T1-weight MRI showing a midbrain posterior-paramedian located lesion. Transfrontal ipsilaterally trajectory was used, and the histopathological diagnosis was metastasis. (b) Non contrast-enhanced T2 weight MRI showing a diffuse lesion on cerebellar peduncle and lateral pons. Transfrontal contralaterally trajectory was used, and the histopathological diagnosis was anaplastic astrocytoma. (c) Non-contrast-enhanced T1-weight MRI showing a midbrain posterior-median located cystic lesion. Transfrontal ipsilaterally trajectory was used, and the histopathological diagnosis was neuroepithelial cyst." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ali Akay, Sertaç Işlekel" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Ali" "apellidos" => "Akay" ] 1 => array:2 [ "nombre" => "Sertaç" "apellidos" => "Işlekel" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147319300259?idApp=UINPBA00004B" "url" => "/11301473/0000003000000004/v1_201906220636/S1130147319300259/v1_201906220636/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Special article" "titulo" => "Spinal dural closure without suture: Minimizing the risk of CSF leakage with a flat non-penetrating titanium U-clip" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "173" "paginaFinal" => "178" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Francisco M. Marin Laut, Efraim A. Gómez Cárdenas, Jesús Riqué Dormido, Nicolás Moliz Molina, Jose A. López López" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Francisco M." "apellidos" => "Marin Laut" "email" => array:1 [ 0 => "miguel.laut@uca.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Efraim A." "apellidos" => "Gómez Cárdenas" ] 2 => array:2 [ "nombre" => "Jesús Riqué" "apellidos" => "Dormido" ] 3 => array:2 [ "nombre" => "Nicolás Moliz" "apellidos" => "Molina" ] 4 => array:2 [ "nombre" => "Jose A." "apellidos" => "López López" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Neurosurgery, University Hospital of Puerta de Mar, Cádiz, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cierre dural espinal sin sutura: minimizando el riesgo de fístula de LCR con U-Clip® de titanio no penetrante plano" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 600 "Ancho" => 805 "Tamanyo" => 59438 ] ] "descripcion" => array:1 [ "en" => "(A) postoperative Sagittal T2-weighted MRI revealing U-clip in the dorsal spine. (B) Sagittal T1-FE with contrast shows the U-clips in the cervical spine with signal changes by the clips (arrow), but without anatomical distortion." ] ] ] "textoCompleto" => "IntroductionPersistent cerebrospinal fluid (CSF) leakage is a common complication that follows durotomies.<a class="elsevierStyleCrossRefs" href="#bib0125">1,2</a> CSF leakage increases comorbidity and lengthens the hospital stay. The severe consequences of inadequate treatment of CSF leakage have been widely reported,<a class="elsevierStyleCrossRefs" href="#bib0135">3,4</a> and various surgical techniques have been proposed for spinal dural closure.<a class="elsevierStyleCrossRefs" href="#bib0145">5–8</a> CSF leakage could cause arachnoiditis, meningitis, pseudomeningocele, dural-cutaneous fistula, infections, and alterations in wound healing. The incidence of complications related to CSF after surgery on intradural tumours ranges from 5% to 18%.<a class="elsevierStyleCrossRef" href="#bib0130">2</a>The classic surgical spinal dural closure technique in surgery on intradural lesions is performed with continuous suture or loose stitches using 4-0 to 6-0 polypropylene monofilament or nylon suture.<a class="elsevierStyleCrossRefs" href="#bib0150">6,9</a> Generally, tissue glue substances are applied with or without a fat, fascia, or muscle graft to achieve a better dural seal and reduce CSF leakage after spinal dural closure. Dural closure with suture causes irritant damage to the dural/arachnoid interface.<a class="elsevierStyleCrossRef" href="#bib0170">10</a> The penetrating suture causes new dural holes. Even the needle of the suture can cause harm to the patient and the surgeon.<a class="elsevierStyleCrossRefs" href="#bib0175">11,12</a> For these reasons, other non-penetrating techniques for dural closure have been sought.The application of non-penetrating titanium U-clips for dural closure has previously been described. This dural closure technique is simple and decreases the impact of the surgeon's experience as a risk factor for CSF leakage.<a class="elsevierStyleCrossRef" href="#bib0185">13</a> This has been shown to be effective in preventing CSF leakage.<a class="elsevierStyleCrossRefs" href="#bib0190">14–18</a> Although randomized studies have not yet been reported,<a class="elsevierStyleCrossRef" href="#bib0190">14</a> the efficacy of the U-clips has been demonstrated, and no relevant artefacts have been observed in the post-operative magnetic resonance images (MRI).<a class="elsevierStyleCrossRef" href="#bib0215">19</a>We present a retrospective analysis of 50 cases of intradural lesions that underwent surgery at our institution between 2013 and 2018 in which a flat U-clip is used for the dural closure (Ligaclip-MCA of Ethicon Endo-Surgery, LLC, Medical GmbH, Norderstedt, Germany). The difference between our technique and the Non-penetrating Titanium Vessel Clip techniques described above was that the internal surfaces of the U-clips that we used were completely flat when closed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>MethodsWe conducted a retrospective analysis of a cohort of 50 patients who underwent surgery on their intradural spinal lesions in the department of neurosurgery of our institution between 2013 and 2018. Consultants from our institution performed all the procedures.The U-clips used were the Ligaclip® Multiple Clip Appliers of Ethicon Endo-Surgery, (Ligaclip-MCA of Ethicon Endo-Surgery, LLC, Medical GmbH, Norderstedt, Germany) with multiple applicators. Each clip had a closing height of 3.8mm. Surgeons have previously used these types of U-clips for vascular closure in brain surgeries. The U-clip application technique hardly varied with the surgeon. Moreover, between 6 and 9 clips were applied per centimetre.Follow-up with MRI was performed routinely at 6 weeks, at 12 months, and then once a year. Projections and standard sequences were used to evaluate the degree of tumour resection as well as possible recurrence/tumour growth. A database entry for each patient that included age, sex, and diagnosis was completed. This study was performed with the approval of our institutional review board. All patients or the authorized representative were informed of the nature of their pathology, as well as the different forms of dural closure and provided written informed consent for the surgery, approved by the appropriate institutional review board of the respective clinical site.U-clip application. Surgical techniqueAfter the laminectomy, dural opening, and removal of the lesion, dural closure is performed with U-clips. Dural opening is normally performed in the medial/posterior dural region (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Due to the loss of CSF during the extirpation of the lesion, there is no considerable intradural tension, so the dural margins can be approximated easily. While a neurosurgeon approximates and everts the dural margins, always observing that there no nearby nerve fascicles that the U-clip might trap, another neurosurgeon applies the U-clip at the dural borders. The application of the U-clip by a single neurosurgeon is complex and can lead to incorrect positioning, especially of the first U-clips. Due to the U-clips design, to facilitate their correct application, the dural margins must be brought completely together. Between 6 and 9 U-clips were used per centimetre (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). No additional tissue sealant was applied to the dura when U-clips were used.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>The dura of the thoracic and cervical spine (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>A and B) is thicker and less fragile than that of the lumbar spinal region. Its resistance to traction is greater, so the application of the U-clips is more complex than that in other spinal regions. For the correct use of the U-clips, the correct exposure and eversion of both dural edges must be performed. The number of U-clips applied for dural closure in the cervical region was higher than that in the thoracic and lumbar region to overcome the resistance of the dural approximation and prevent the opening and coming out of the U-clip. The resistance of this type of clip to open, due to its flat surface when closed, allows it to overcome the resistance in the cervical and thoracic regions, producing a completely hermetic closure The design of the applicator we used at our institution only allowed us to reach areas where the dural edges were widely exposed. After the dural closure, valsalva manoeuvre with 25–30cmH2O was performed. No leakage of CSF was observed. The use of this type of applicator and U-clip for the repair of dural damage in lateral regions is very complex. If there is no correct visualization of the intradural structures below the dural borders where the clip is applied, nerve structures could be damaged. It is also necessary to get a good eversion of the dural edges, and this is usually complicated in lateral regions of the dura. The application of the clip in the dural tear in minimally invasive spinal surgery of the herniated disc was not satisfactory. The dural tear was closed with interrupted suture, muscle, and tissue sealant. In surgeries where a duraplasty was performed, the U-clips were not used. The closure was carried out with suture and tissue sealant. The applicator of our Institution does not allow applying the U-clip with low angulation, so that the duraplasties cannot be closed satisfactorily. This applicator is not effective when it is not applied almost perpendicularly in the dorsal region.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>One patient was operated on for tumour recurrence 9 months later. It was possible to remove the U-clips without difficulty. When the U-clips were removed, the dural edges had healed on the inside without adhesions and no CSF leakage was observed. The dura could be opened again in the same place. The dural closure was performed again with U-clips. Typically, all the patients maintained bed rest for 24h then were mobilized as tolerated.U-clip and post-operative control with MRIAll patients underwent post-operative control with MRI. The first MRI control was performed routinely at 6 weeks. In cases in which there were clinical signs of CSF leakage or suspected tumour persistence, the MRI was performed during the same hospital admission. The U-clip caused a hypointense image in the T1 and T2 sequences of MRI: the figure of a small circle (ovoid/circular shape) in the axial image (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).<elsevierMultimedia ident="fig0025"></elsevierMultimedia>ResultsPatient dataDural closure was performed on the 50 using the non-penetrating titanium U-clip. 34/50 were men, and 16/50 were women. The mean age at surgery was 55 years (range, 34–77 years), and the length of the average follow-up period was 27 months (range, 4–56 months). Closure with U-clips was used in 7 patients who had lesions in the cervical region (7/50), 22 patients who had lesions in the thoracic spine (22/50), and 21 patients who had lesions in the lumbar spine (21/50). The pathologies subjected to intervention were meningioma (16/50), schwannoma (14/50), and ependymoma (10/50). A cavernous angioma (3/50), spinal subdural haematoma (2/50), spinal astrocytoma (3/50), and an inflammatory pseudotumor (2/50) were also operated on. The mean level of laminectomy (LC) was 2.6 in the cervical region (range, 2–4), 2.2 (range 2–3) in the thoracic region, and 2 in the lumbar region (range, 1–3) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). No patient presented with a post-operative CSF cutaneous-dural fistula. CSF leakage was not observed in the control MRIs at 6 weeks. No other complications were observed. A patient with ependymoma presented with tumour recurrence. The patient was reoperated on, and the dural closure was performed again with U-clips (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and B).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>DiscussionIn this case series, we report our initial experience with the use of the non-penetrating U-clip (Ligaclip® Multiple Clip Applier of Ethicon Endo-Surgery, LLC, Medical GmbH, Norderstedt, Germany) for spinal dural closure as well as classic dural closure with continuous suture. The literature does not offer many reported cases of this dural non-penetrating closure technique.In 1994, Levy and Sonntag<a class="elsevierStyleCrossRef" href="#bib0195">15</a> developed a clip for dural tear repair (Weck Hemoclip, Teleflex, Co Westmeath, Ireland), which was similar to the aneurysm clip, with a non-automatic applicator. However, they encountered problems with the design of the applicator and the clip and problems related to dural laceration by the clip. In 1999, Palm et al.<a class="elsevierStyleCrossRef" href="#bib0170">10</a> reported that, in their experimental study with animal models, there was a less inflammatory reaction to duraplasty in adjacent tissues in cases where the non-penetrating titanium clip was applied than in those where sutures were employed. They used the clip with an automatic applicator (DuraClose; Surgical Dynamics, Norwalk, USA). In 2007, Timothy et al.<a class="elsevierStyleCrossRef" href="#bib0190">14</a> reported a high incidence of CSF leakage (13.7%) from 1 to 34 days post-surgery (mean, 8 days) in a series of 58 adult patients on whom dural closure with the titanium clip had been performed. In 2010, Kaufman et al.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> described a series of 27 paediatric patients in whom the non-penetrating titanium clips had been applied (AnastoClip Vessel Closure System, LeMaitre Vascular, Inc. Burlington, USA). In 16 cases, additional tissue sealant was applied on the clips. No cases of CSF leak were reported. In 2015, using the same clips, Ito et al.<a class="elsevierStyleCrossRef" href="#bib0210">18</a> observed a leakage rate of 3.2% in a series of 31 cases.The CSF leakage with continuous suture or loose stitches using 4-0 to 6-0 polypropylene monofilament or nylon suture is about 8%.<a class="elsevierStyleCrossRefs" href="#bib0220">20–22</a> No CSF cutaneous-dural fistula was observed in the days after surgery. In the 6-week control MRI, no CSF leakage was observed. The U-clips were applied independently of the extension of the durotomy.U-clips produce hydrostatic resistance similar to that of an intact dura.<a class="elsevierStyleCrossRef" href="#bib0235">23</a> Such eversion necessarily causes a decreased diameter of the thecal sac. Although the intradural area is reduced after the placement of the U-clips, especially when considering the Ligamentous interfacet distance, and the anterior-posterior diameter of the dural sac; In the control MRI, no CSF absence was observed around the spinal cord in the U-clip placement regions (<a class="elsevierStyleCrossRefs" href="#fig0020">Figs. 4A and 5D</a>). No symptoms of spinal cord compression were observed during follow-up in any patient. We can say that although there is a reduction of the intradural area, this has not had a clinical effect. The intraoperative valsalva manoeuvre confirmed the hermetic closure without CSF leakage.The application of the U-clip presents more complexity if the dural edges are not in the dorsal dural region and if the dural edges cannot be approximated and everted, for example, in lateral dural damage in minimally invasive surgeries. Ferroli et al.<a class="elsevierStyleCrossRef" href="#bib0240">24</a> described the use of the U-clip for dural damage repair in minimally invasive disc herniation surgeries. Its use was attempted during two instances of surgery to repair dural damage in the lateral region, in front of the pedicle, in minimally invasive disc hernia surgery. However, this approach was abandoned as it was not possible to evert and approximate the dural edges. The placement of the U-clip parallel to the axial plane with our applicator was very complex in minimally invasive surgeries. The dural damage was closed with interrupted suture, 5.0.When the dural edges are close, the U-clips can be applied quickly, so they save surgical time. Their simple application reduces the surgical learning curve in dural closure and decreases the risk of CSF leakage when younger surgeons perform the procedure. In addition, removing them once they have been placed is not a problem. The dural edges can heal without the interposition of foreign material. We believe that the advantage of this type of clip is that when closed, its internal face is completely flat, this allows to overcome greater intradural resistances. The application of the U-clip in the cervical and thoracic spinal region, where the dural tension is greater and the edges are wider, is not a problem either.The clips are completely compatible with MRI. The U-clips produce a small artefact in the post-operative images. The quality of the radiological evaluation was not altered by the use of the U-clip.<a class="elsevierStyleCrossRef" href="#bib0215">19</a>The applicator and the U-clip were not designed for spinal dural closure. This gave rise to a disadvantage: a second neurosurgeon was needed to approximate the dural edges, and the U-clips had to be applied very close to each other, so many U-clips were needed for correct dural closure. Perhaps an improvement in their design could eliminate these characteristics and encourage more neurosurgeons to use them.The cost of the U-clip applicator is 60 times more expensive than 1 single suture. However, to evaluate the effectiveness in terms of cost, safety and complication of the suture dural closure compared to the application of U-clips, the cost of the U-Clip applicator or the number of sutures used must be considered; but also factors such as the dural closure time used with each technique, and the cost for the treatment of complications caused by cerebrospinal fluid fistula. For this, a prospective randomized, double blind study should be performed.ConclusionsBased on our limited observation, flat titanium non-penetrating U-clips of this type are useful and safe for spinal dural closure to prevent CSF leakage regardless of the number of levels and the spinal region in which they are applied. They are easy to use, especially if the surgical field is large, and they are used in the posterior dural region. Better adaptation of the applicator and the clip for use in spinal surgery after durotomies could increase the use of the clips, facilitating a multicentric study to corroborate their safety and the advantages of using them over the suture closure technique.Conflicts of interestNo personal, professional or financial conflicts of interest to report." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1209848" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1126399" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1209849" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1126398" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "U-clip application. Surgical technique" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "U-clip and post-operative control with MRI" ] ] ] 6 => array:3 [ "identificador" => "sec0025" "titulo" => "Results" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Patient data" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack413462" "titulo" => "Acknowledgement" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-08-02" "fechaAceptado" => "2018-12-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1126399" "palabras" => array:4 [ 0 => "Spinal dural closure" 1 => "Non-penetrating titanium clips" 2 => "Postoperative cerebrospinal leakage" 3 => "Anastomotic clips" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1126398" "palabras" => array:4 [ 0 => "Cierre dural espinal" 1 => "Clips de titanio no penetrantes" 2 => "Fístula postoperatoria del líquido cefalorraquídeo" 3 => "Clip de anastomosis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundThe classic surgical spinal dural closure technique in surgery on intradural lesions is performed with continuous suture or loose stitches using 4-0 to 6-0 polypropylene monofilament or nylon suture. Dural closure with suture causes irritant damage to the dural/arachnoid interface. The penetrating suture causes new dural holes. Even the needle of the suture can cause harm to the patient and the surgeon. For these reasons, other non-penetrating techniques for dural closure have been sought. ObjectiveThe purpose of this review was to show the efficacy of using the titanium clip (U-clip) (Ligaclip-MCA of Ethicon Endo-Surgery, LLC, Medical GmbH, Norderstedt, Germany) with a flat internal surface in spinal neurosurgical procedures, and to evaluate the effects of its use on post-operative magnetic resonance imaging (MRI). MethodsWe performed a retrospective analysis of a cohort of 50 consecutive patients who underwent intradural spinal surgeries for intradural spinal lesions in the neurosurgery department of our institution between 2013 and 2018. ResultsThe mean follow-up period was 27 months. No patient developed a post-operative cerebrospinal fluid (CSF) dural-cutaneous fistula. CSF leakage was not observed in the control MRIs at 6 weeks. ConclusionsWe describe, for the first time, the use of this type of U-clip with a flat inner side. The non-penetrating titanium U-clip facilitates effective and rapid dural closure at all spinal levels due to its flat internal face when closed. The U-clips did not cause significant artefacts or distortions on the magnetic resonance imaging." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa técnica quirúrgica clásica de cierre de la duramadre espinal en cirugía en lesiones intradurales se realiza con sutura continua o puntos sueltos usando monofilamento de polipropileno 4-0 a 6-0 o sutura de nylon. El cierre dural con sutura causa daño irritante a la interfaz dural/aracnoidea. La sutura penetrante causa nuevos agujeros durales. Incluso la aguja de la sutura puede causar daño al paciente y al cirujano. Por estas razones, se han buscado otras técnicas no penetrantes para el cierre de la duramadre. ObjetivoEl propósito de esta revisión fue mostrar la eficacia del uso del clip de titanio (U-Clip®) (Ligaclip MCA de Ethicon Endo-Surgery, LLC, Medical GmbH, Norderstedt, Alemania) con una superficie interna plana en procedimientos neuroquirúrgicos espinales, y para evaluar los efectos de su uso en los controles de resonancia magnética (RM) postoperatoria. MétodosSe realizó un análisis retrospectivo de una cohorte de 50 pacientes consecutivos que se sometieron a cirugías intradurales espinales en el departamento de neurocirugía de nuestra institución entre 2013 y 2018. ResultadosEl período medio de seguimiento fue de 27 meses. Ningún paciente desarrolló fístula dural-cutánea del líquido cefalorraquídeo (LCR) postoperatoria. No se observó fuga del LCR en las RM de control a las 6 semanas. ConclusionesDescribimos, por primera vez, el uso de este tipo U-Clip® con un lado interior plano. El U-Clip® de titanio no penetrante facilita el cierre dural efectivo y rápido en todos los niveles espinales debido a su cara interna plana cuando está cerrado. Los U-Clip® no causaron artefactos o distorsiones significativas en la RM." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 597 "Ancho" => 805 "Tamanyo" => 36829 ] ] "descripcion" => array:1 [ "en" => "(A) The image shows how the U-clip is applied when the dural margins have been everted. Since the inside of the clip is flat, most of the inner surface of the clip comes into contact with the dura. (B) The image shows the non-penetrating titanium Vessel Clip, as well as a representation of its closure once the dural edges have been everted. The inner side is not flat. Only the lower edge of the clip comes in contact with the dura." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 874 "Ancho" => 805 "Tamanyo" => 88549 ] ] "descripcion" => array:1 [ "en" => "(A) Postoperative sagittal T2-weighted MRI obtained in a patient who underwent a 3-level laminectomy for ependymoma. The image shows signal changes by the clips (arrow). (B) Sagittal T1 SPRI-weighted with contrast in 6 weeks MRI after the second surgery. Image revealing an increase in the durotomy and the number of U-clip (arrow), but no interference with intradural space." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 605 "Ancho" => 805 "Tamanyo" => 104390 ] ] "descripcion" => array:1 [ "en" => "Intraoperative image where the U-clips are shown (arrow). A surgical patty protects nerve fascicles (triangle)." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 600 "Ancho" => 805 "Tamanyo" => 59438 ] ] "descripcion" => array:1 [ "en" => "(A) postoperative Sagittal T2-weighted MRI revealing U-clip in the dorsal spine. (B) Sagittal T1-FE with contrast shows the U-clips in the cervical spine with signal changes by the clips (arrow), but without anatomical distortion." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1228 "Ancho" => 1523 "Tamanyo" => 189567 ] ] "descripcion" => array:1 [ "en" => "Axial images of MRI in different sequences show the defect of the U-clip (arrow) with ovoid/circular shape; the interferences allow a correct evaluation of the intradural structures." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cervical region \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LC (range) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Thoracic region \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LC (range) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lumbar region \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LC (range) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total pathology \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Schwannoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ependymoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cavernous angioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inflammatory pseudotumor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subdural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spinal astrocytoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="8" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6 (2–4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.2 (2–3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1–3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2065537.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Etiological distribution by regions with laminectomy rate." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The surgical treatment for spinal intradural extramedullary tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.K. 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Special article

Spinal dural closure without suture: Minimizing the risk of CSF leakage with a flat non-penetrating titanium U-clip

Cierre dural espinal sin sutura: minimizando el riesgo de fístula de LCR con U-Clip® de titanio no penetrante plano

Francisco M. Marin Laut

Autor para correspondencia

miguel.laut@uca.es

Corresponding author.

, Efraim A. Gómez Cárdenas, Jesús Riqué Dormido, Nicolás Moliz Molina, Jose A. López López

Department of Neurosurgery, University Hospital of Puerta de Mar, Cádiz, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Persistent cerebrospinal fluid &#40;CSF&#41; leakage is a common complication that follows durotomies&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;2</span></a> CSF leakage increases comorbidity and lengthens the hospital stay&#46; The severe consequences of inadequate treatment of CSF leakage have been widely reported&#44;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;4</span></a> and various surgical techniques have been proposed for spinal dural closure&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">5&#8211;8</span></a> CSF leakage could cause arachnoiditis&#44; meningitis&#44; pseudomeningocele&#44; dural-cutaneous fistula&#44; infections&#44; and alterations in wound healing&#46; The incidence of complications related to CSF after surgery on intradural tumours ranges from 5&#37; to 18&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The classic surgical spinal dural closure technique in surgery on intradural lesions is performed with continuous suture or loose stitches using 4-0 to 6-0 polypropylene monofilament or nylon suture&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">6&#44;9</span></a> Generally&#44; tissue glue substances are applied with or without a fat&#44; fascia&#44; or muscle graft to achieve a better dural seal and reduce CSF leakage after spinal dural closure&#46; Dural closure with suture causes irritant damage to the dural&#47;arachnoid interface&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> The penetrating suture causes new dural holes&#46; Even the needle of the suture can cause harm to the patient and the surgeon&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">11&#44;12</span></a> For these reasons&#44; other non-penetrating techniques for dural closure have been sought&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The application of non-penetrating titanium U-clips for dural closure has previously been described&#46; This dural closure technique is simple and decreases the impact of the surgeon&#39;s experience as a risk factor for CSF leakage&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> This has been shown to be effective in preventing CSF leakage&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">14&#8211;18</span></a> Although randomized studies have not yet been reported&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> the efficacy of the U-clips has been demonstrated&#44; and no relevant artefacts have been observed in the post-operative magnetic resonance images &#40;MRI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We present a retrospective analysis of 50 cases of intradural lesions that underwent surgery at our institution between 2013 and 2018 in which a flat U-clip is used for the dural closure &#40;Ligaclip-MCA of Ethicon Endo-Surgery&#44; LLC&#44; Medical GmbH&#44; Norderstedt&#44; Germany&#41;&#46; The difference between our technique and the Non-penetrating Titanium Vessel Clip techniques described above was that the internal surfaces of the U-clips that we used were completely flat when closed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We conducted a retrospective analysis of a cohort of 50 patients who underwent surgery on their intradural spinal lesions in the department of neurosurgery of our institution between 2013 and 2018&#46; Consultants from our institution performed all the procedures&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The U-clips used were the Ligaclip<span class="elsevierStyleSup">&#174;</span> Multiple Clip Appliers of Ethicon Endo-Surgery&#44; &#40;Ligaclip-MCA of Ethicon Endo-Surgery&#44; LLC&#44; Medical GmbH&#44; Norderstedt&#44; Germany&#41; with multiple applicators&#46; Each clip had a closing height of 3&#46;8<span class="elsevierStyleHsp" style=""></span>mm&#46; Surgeons have previously used these types of U-clips for vascular closure in brain surgeries&#46; The U-clip application technique hardly varied with the surgeon&#46; Moreover&#44; between 6 and 9 clips were applied per centimetre&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Follow-up with MRI was performed routinely at 6 weeks&#44; at 12 months&#44; and then once a year&#46; Projections and standard sequences were used to evaluate the degree of tumour resection as well as possible recurrence&#47;tumour growth&#46; A database entry for each patient that included age&#44; sex&#44; and diagnosis was completed&#46; This study was performed with the approval of our institutional review board&#46; All patients or the authorized representative were informed of the nature of their pathology&#44; as well as the different forms of dural closure and provided written informed consent for the surgery&#44; approved by the appropriate institutional review board of the respective clinical site&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">U-clip application&#46; Surgical technique</span><p id="par0040" class="elsevierStylePara elsevierViewall">After the laminectomy&#44; dural opening&#44; and removal of the lesion&#44; dural closure is performed with U-clips&#46; Dural opening is normally performed in the medial&#47;posterior dural region &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Due to the loss of CSF during the extirpation of the lesion&#44; there is no considerable intradural tension&#44; so the dural margins can be approximated easily&#46; While a neurosurgeon approximates and everts the dural margins&#44; always observing that there no nearby nerve fascicles that the U-clip might trap&#44; another neurosurgeon applies the U-clip at the dural borders&#46; The application of the U-clip by a single neurosurgeon is complex and can lead to incorrect positioning&#44; especially of the first U-clips&#46; Due to the U-clips design&#44; to facilitate their correct application&#44; the dural margins must be brought completely together&#46; Between 6 and 9 U-clips were used per centimetre &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; No additional tissue sealant was applied to the dura when U-clips were used&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The dura of the thoracic and cervical spine &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A and B&#41; is thicker and less fragile than that of the lumbar spinal region&#46; Its resistance to traction is greater&#44; so the application of the U-clips is more complex than that in other spinal regions&#46; For the correct use of the U-clips&#44; the correct exposure and eversion of both dural edges must be performed&#46; The number of U-clips applied for dural closure in the cervical region was higher than that in the thoracic and lumbar region to overcome the resistance of the dural approximation and prevent the opening and coming out of the U-clip&#46; The resistance of this type of clip to open&#44; due to its flat surface when closed&#44; allows it to overcome the resistance in the cervical and thoracic regions&#44; producing a completely hermetic closure The design of the applicator we used at our institution only allowed us to reach areas where the dural edges were widely exposed&#46; After the dural closure&#44; valsalva manoeuvre with 25&#8211;30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O was performed&#46; No leakage of CSF was observed&#46; The use of this type of applicator and U-clip for the repair of dural damage in lateral regions is very complex&#46; If there is no correct visualization of the intradural structures below the dural borders where the clip is applied&#44; nerve structures could be damaged&#46; It is also necessary to get a good eversion of the dural edges&#44; and this is usually complicated in lateral regions of the dura&#46; The application of the clip in the dural tear in minimally invasive spinal surgery of the herniated disc was not satisfactory&#46; The dural tear was closed with interrupted suture&#44; muscle&#44; and tissue sealant&#46; In surgeries where a duraplasty was performed&#44; the U-clips were not used&#46; The closure was carried out with suture and tissue sealant&#46; The applicator of our Institution does not allow applying the U-clip with low angulation&#44; so that the duraplasties cannot be closed satisfactorily&#46; This applicator is not effective when it is not applied almost perpendicularly in the dorsal region&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">One patient was operated on for tumour recurrence 9 months later&#46; It was possible to remove the U-clips without difficulty&#46; When the U-clips were removed&#44; the dural edges had healed on the inside without adhesions and no CSF leakage was observed&#46; The dura could be opened again in the same place&#46; The dural closure was performed again with U-clips&#46; Typically&#44; all the patients maintained bed rest for 24<span class="elsevierStyleHsp" style=""></span>h then were mobilized as tolerated&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">U-clip and post-operative control with MRI</span><p id="par0060" class="elsevierStylePara elsevierViewall">All patients underwent post-operative control with MRI&#46; The first MRI control was performed routinely at 6 weeks&#46; In cases in which there were clinical signs of CSF leakage or suspected tumour persistence&#44; the MRI was performed during the same hospital admission&#46; The U-clip caused a hypointense image in the T1 and T2 sequences of MRI&#58; the figure of a small circle &#40;ovoid&#47;circular shape&#41; in the axial image &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Patient data</span><p id="par0065" class="elsevierStylePara elsevierViewall">Dural closure was performed on the 50 using the non-penetrating titanium U-clip&#46; 34&#47;50 were men&#44; and 16&#47;50 were women&#46; The mean age at surgery was 55 years &#40;range&#44; 34&#8211;77 years&#41;&#44; and the length of the average follow-up period was 27 months &#40;range&#44; 4&#8211;56 months&#41;&#46; Closure with U-clips was used in 7 patients who had lesions in the cervical region &#40;7&#47;50&#41;&#44; 22 patients who had lesions in the thoracic spine &#40;22&#47;50&#41;&#44; and 21 patients who had lesions in the lumbar spine &#40;21&#47;50&#41;&#46; The pathologies subjected to intervention were meningioma &#40;16&#47;50&#41;&#44; schwannoma &#40;14&#47;50&#41;&#44; and ependymoma &#40;10&#47;50&#41;&#46; A cavernous angioma &#40;3&#47;50&#41;&#44; spinal subdural haematoma &#40;2&#47;50&#41;&#44; spinal astrocytoma &#40;3&#47;50&#41;&#44; and an inflammatory pseudotumor &#40;2&#47;50&#41; were also operated on&#46; The mean level of laminectomy &#40;LC&#41; was 2&#46;6 in the cervical region &#40;range&#44; 2&#8211;4&#41;&#44; 2&#46;2 &#40;range 2&#8211;3&#41; in the thoracic region&#44; and 2 in the lumbar region &#40;range&#44; 1&#8211;3&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; No patient presented with a post-operative CSF cutaneous-dural fistula&#46; CSF leakage was not observed in the control MRIs at 6 weeks&#46; No other complications were observed&#46; A patient with ependymoma presented with tumour recurrence&#46; The patient was reoperated on&#44; and the dural closure was performed again with U-clips &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">In this case series&#44; we report our initial experience with the use of the non-penetrating U-clip &#40;Ligaclip<span class="elsevierStyleSup">&#174;</span> Multiple Clip Applier of Ethicon Endo-Surgery&#44; LLC&#44; Medical GmbH&#44; Norderstedt&#44; Germany&#41; for spinal dural closure as well as classic dural closure with continuous suture&#46; The literature does not offer many reported cases of this dural non-penetrating closure technique&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In 1994&#44; Levy and Sonntag<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> developed a clip for dural tear repair &#40;Weck Hemoclip&#44; Teleflex&#44; Co Westmeath&#44; Ireland&#41;&#44; which was similar to the aneurysm clip&#44; with a non-automatic applicator&#46; However&#44; they encountered problems with the design of the applicator and the clip and problems related to dural laceration by the clip&#46; In 1999&#44; Palm et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> reported that&#44; in their experimental study with animal models&#44; there was a less inflammatory reaction to duraplasty in adjacent tissues in cases where the non-penetrating titanium clip was applied than in those where sutures were employed&#46; They used the clip with an automatic applicator &#40;DuraClose&#59; Surgical Dynamics&#44; Norwalk&#44; USA&#41;&#46; In 2007&#44; Timothy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> reported a high incidence of CSF leakage &#40;13&#46;7&#37;&#41; from 1 to 34 days post-surgery &#40;mean&#44; 8 days&#41; in a series of 58 adult patients on whom dural closure with the titanium clip had been performed&#46; In 2010&#44; Kaufman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> described a series of 27 paediatric patients in whom the non-penetrating titanium clips had been applied &#40;AnastoClip Vessel Closure System&#44; LeMaitre Vascular&#44; Inc&#46; Burlington&#44; USA&#41;&#46; In 16 cases&#44; additional tissue sealant was applied on the clips&#46; No cases of CSF leak were reported&#46; In 2015&#44; using the same clips&#44; Ito et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a> observed a leakage rate of 3&#46;2&#37; in a series of 31 cases&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The CSF leakage with continuous suture or loose stitches using 4-0 to 6-0 polypropylene monofilament or nylon suture is about 8&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">20&#8211;22</span></a> No CSF cutaneous-dural fistula was observed in the days after surgery&#46; In the 6-week control MRI&#44; no CSF leakage was observed&#46; The U-clips were applied independently of the extension of the durotomy&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">U-clips produce hydrostatic resistance similar to that of an intact dura&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> Such eversion necessarily causes a decreased diameter of the thecal sac&#46; Although the intradural area is reduced after the placement of the U-clips&#44; especially when considering the Ligamentous interfacet distance&#44; and the anterior-posterior diameter of the dural sac&#59; In the control MRI&#44; no CSF absence was observed around the spinal cord in the U-clip placement regions &#40;<a class="elsevierStyleCrossRefs" href="#fig0020">Figs&#46; 4A and 5D</a>&#41;&#46; No symptoms of spinal cord compression were observed during follow-up in any patient&#46; We can say that although there is a reduction of the intradural area&#44; this has not had a clinical effect&#46; The intraoperative valsalva manoeuvre confirmed the hermetic closure without CSF leakage&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The application of the U-clip presents more complexity if the dural edges are not in the dorsal dural region and if the dural edges cannot be approximated and everted&#44; for example&#44; in lateral dural damage in minimally invasive surgeries&#46; Ferroli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a> described the use of the U-clip for dural damage repair in minimally invasive disc herniation surgeries&#46; Its use was attempted during two instances of surgery to repair dural damage in the lateral region&#44; in front of the pedicle&#44; in minimally invasive disc hernia surgery&#46; However&#44; this approach was abandoned as it was not possible to evert and approximate the dural edges&#46; The placement of the U-clip parallel to the axial plane with our applicator was very complex in minimally invasive surgeries&#46; The dural damage was closed with interrupted suture&#44; 5&#46;0&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">When the dural edges are close&#44; the U-clips can be applied quickly&#44; so they save surgical time&#46; Their simple application reduces the surgical learning curve in dural closure and decreases the risk of CSF leakage when younger surgeons perform the procedure&#46; In addition&#44; removing them once they have been placed is not a problem&#46; The dural edges can heal without the interposition of foreign material&#46; We believe that the advantage of this type of clip is that when closed&#44; its internal face is completely flat&#44; this allows to overcome greater intradural resistances&#46; The application of the U-clip in the cervical and thoracic spinal region&#44; where the dural tension is greater and the edges are wider&#44; is not a problem either&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The clips are completely compatible with MRI&#46; The U-clips produce a small artefact in the post-operative images&#46; The quality of the radiological evaluation was not altered by the use of the U-clip&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The applicator and the U-clip were not designed for spinal dural closure&#46; This gave rise to a disadvantage&#58; a second neurosurgeon was needed to approximate the dural edges&#44; and the U-clips had to be applied very close to each other&#44; so many U-clips were needed for correct dural closure&#46; Perhaps an improvement in their design could eliminate these characteristics and encourage more neurosurgeons to use them&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The cost of the U-clip applicator is 60 times more expensive than 1 single suture&#46; However&#44; to evaluate the effectiveness in terms of cost&#44; safety and complication of the suture dural closure compared to the application of U-clips&#44; the cost of the U-Clip applicator or the number of sutures used must be considered&#59; but also factors such as the dural closure time used with each technique&#44; and the cost for the treatment of complications caused by cerebrospinal fluid fistula&#46; For this&#44; a prospective randomized&#44; double blind study should be performed&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusions</span><p id="par0115" class="elsevierStylePara elsevierViewall">Based on our limited observation&#44; flat titanium non-penetrating U-clips of this type are useful and safe for spinal dural closure to prevent CSF leakage regardless of the number of levels and the spinal region in which they are applied&#46; They are easy to use&#44; especially if the surgical field is large&#44; and they are used in the posterior dural region&#46; Better adaptation of the applicator and the clip for use in spinal surgery after durotomies could increase the use of the clips&#44; facilitating a multicentric study to corroborate their safety and the advantages of using them over the suture closure technique&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">No personal&#44; professional or financial conflicts of interest to report&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The classic surgical spinal dural closure technique in surgery on intradural lesions is performed with continuous suture or loose stitches using 4-0 to 6-0 polypropylene monofilament or nylon suture&#46; Dural closure with suture causes irritant damage to the dural&#47;arachnoid interface&#46; The penetrating suture causes new dural holes&#46; Even the needle of the suture can cause harm to the patient and the surgeon&#46; For these reasons&#44; other non-penetrating techniques for dural closure have been sought&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The purpose of this review was to show the efficacy of using the titanium clip &#40;U-clip&#41; &#40;Ligaclip-MCA of Ethicon Endo-Surgery&#44; LLC&#44; Medical GmbH&#44; Norderstedt&#44; Germany&#41; with a flat internal surface in spinal neurosurgical procedures&#44; and to evaluate the effects of its use on post-operative magnetic resonance imaging &#40;MRI&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective analysis of a cohort of 50 consecutive patients who underwent intradural spinal surgeries for intradural spinal lesions in the neurosurgery department of our institution between 2013 and 2018&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The mean follow-up period was 27 months&#46; No patient developed a post-operative cerebrospinal fluid &#40;CSF&#41; dural-cutaneous fistula&#46; CSF leakage was not observed in the control MRIs at 6 weeks&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We describe&#44; for the first time&#44; the use of this type of U-clip with a flat inner side&#46; The non-penetrating titanium U-clip facilitates effective and rapid dural closure at all spinal levels due to its flat internal face when closed&#46; The U-clips did not cause significant artefacts or distortions on the magnetic resonance imaging&#46;</p></span>"
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            "titulo" => "Results"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La t&#233;cnica quir&#250;rgica cl&#225;sica de cierre de la duramadre espinal en cirug&#237;a en lesiones intradurales se realiza con sutura continua o puntos sueltos usando monofilamento de polipropileno 4-0 a 6-0 o sutura de <span class="elsevierStyleItalic">nylon</span>&#46; El cierre dural con sutura causa da&#241;o irritante a la interfaz dural&#47;aracnoidea&#46; La sutura penetrante causa nuevos agujeros durales&#46; Incluso la aguja de la sutura puede causar da&#241;o al paciente y al cirujano&#46; Por estas razones&#44; se han buscado otras t&#233;cnicas no penetrantes para el cierre de la duramadre&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El prop&#243;sito de esta revisi&#243;n fue mostrar la eficacia del uso del clip de titanio &#40;U-Clip<span class="elsevierStyleSup">&#174;</span>&#41; &#40;Ligaclip MCA de Ethicon Endo-Surgery&#44; LLC&#44; Medical GmbH&#44; Norderstedt&#44; Alemania&#41; con una superficie interna plana en procedimientos neuroquir&#250;rgicos espinales&#44; y para evaluar los efectos de su uso en los controles de resonancia magn&#233;tica &#40;RM&#41; postoperatoria&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un an&#225;lisis retrospectivo de una cohorte de 50 pacientes consecutivos que se sometieron a cirug&#237;as intradurales espinales en el departamento de neurocirug&#237;a de nuestra instituci&#243;n entre 2013 y 2018&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El per&#237;odo medio de seguimiento fue de 27 meses&#46; Ning&#250;n paciente desarroll&#243; f&#237;stula dural-cut&#225;nea del l&#237;quido cefalorraqu&#237;deo &#40;LCR&#41; postoperatoria&#46; No se observ&#243; fuga del LCR en las RM de control a las 6 semanas&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Describimos&#44; por primera vez&#44; el uso de este tipo U-Clip<span class="elsevierStyleSup">&#174;</span> con un lado interior plano&#46; El U-Clip<span class="elsevierStyleSup">&#174;</span> de titanio no penetrante facilita el cierre dural efectivo y r&#225;pido en todos los niveles espinales debido a su cara interna plana cuando est&#225; cerrado&#46; Los U-Clip<span class="elsevierStyleSup">&#174;</span> no causaron artefactos o distorsiones significativas en la RM&#46;</p></span>"
        "secciones" => array:5 [
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        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; The image shows how the U-clip is applied when the dural margins have been everted&#46; Since the inside of the clip is flat&#44; most of the inner surface of the clip comes into contact with the dura&#46; &#40;B&#41; The image shows the non-penetrating titanium Vessel Clip&#44; as well as a representation of its closure once the dural edges have been everted&#46; The inner side is not flat&#46; Only the lower edge of the clip comes in contact with the dura&#46;</p>"
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      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Postoperative sagittal T2-weighted MRI obtained in a patient who underwent a 3-level laminectomy for ependymoma&#46; The image shows signal changes by the clips &#40;<span class="elsevierStyleItalic">arrow</span>&#41;&#46; &#40;B&#41; Sagittal T1 SPRI-weighted with contrast in 6 weeks MRI after the second surgery&#46; Image revealing an increase in the durotomy and the number of U-clip &#40;<span class="elsevierStyleItalic">arrow</span>&#41;&#44; but no interference with intradural space&#46;</p>"
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      ]
      2 => array:7 [
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        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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            "Alto" => 605
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            "Tamanyo" => 104390
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Intraoperative image where the U-clips are shown &#40;<span class="elsevierStyleItalic">arrow</span>&#41;&#46; A surgical patty protects nerve fascicles &#40;<span class="elsevierStyleItalic">triangle</span>&#41;&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Fig&#46; 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 600
            "Ancho" => 805
            "Tamanyo" => 59438
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; postoperative Sagittal T2-weighted MRI revealing U-clip in the dorsal spine&#46; &#40;B&#41; Sagittal T1-FE with contrast shows the U-clips in the cervical spine with signal changes by the clips &#40;<span class="elsevierStyleItalic">arrow</span>&#41;&#44; but without anatomical distortion&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Fig&#46; 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 1228
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Axial images of MRI in different sequences show the defect of the U-clip &#40;arrow&#41; with ovoid&#47;circular shape&#59; the interferences allow a correct evaluation of the intradural structures&#46;</p>"
        ]
      ]
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cervical region&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LC &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Thoracic region&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LC &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lumbar region&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LC &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total pathology&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Meningioma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Schwannoma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ependymoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cavernous angioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inflammatory pseudotumor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Subdural haematoma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Spinal astrocytoma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;6 &#40;2&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;2 &#40;2&#8211;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;1&#8211;3&#41;&nbsp;\t\t\t\t\t\t\n
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Información del artículo

ISSN: 11301473
Idioma original: Inglés

DOI:10.1016/j.neucir.2018.12.002

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