Circumferential Patching of the Dura Mater in the Setting of Dural Fistula after En Bloc Spondylectomy and High Dose Radiation Therapy

A rare neoplasm derived from notochordal remnants, chordoma has a wellcharacterized tendency to recur following an intralesional resection. Margin-free total en bloc spondylectomy (TES) is the only surgical approach associated with no tumor recurrence at follow-up longer than 5 years. Incidental durotomy is a common complication of TES. We report a novel technique to repair incidental durotomies in two patients who underwent TES for thoracic/thoracolumbar chordoma – a 76-year-old male who presents with an L1 chordoma and a 65-year-old female who presents with acute spinal cord compression from recurrence of a T9-T11 chordoma. Both patients underwent high dose pre-operative radiation therapy and TES for resection of their respective tumors. Both patients developed incidental durotomies that were initially repaired by primary suture. As we were concerned with the irradiated dura’s ability to heal and hold sutures, we supplemented primary repair with collagen matrix grafts. For each patient, the graft was passed in front of the thecal sac and wrapped circumferentially around the thecal sac, forming a seal. After repair, the patients recovered without complications. Here we describe two patients who presented with chordoma of the thoracic/ thoracolumbar spine and have undergone TES for tumor resection. Due to preoperative radiation therapy, this population may have friable dura that are not amenable to repair by primary suture alone in the event of incidental durotomy. We thus augmented our primary repair by passing a collagen matrix graft circumferentially around the thecal sac. These procedures were greatly aided by the maximum accessibility provided by the initial TES procedures. Central Shah et al. (2015) Email: Ann Orthop Rheumatol 3(1): 1044 (2015) 2/5 stage, we perform a posterior laminectomy with posterior spinal instrumentation. In the second stage, we perform an en bloc corpectomy with anterior spinal fusion and instrumentation. Here we discuss two patients who presented with chordomas of the thoracic and thoracolumbar spine. Commonly occurring in the skull base and vertebral column, chordomas have a wellcharacterized tendency to recur following intralesional resection [5,6]. Indeed, uncontrolled growth of this tumor after surgery is a common cause of death in patients with chordoma. A review of the largest series of chordoma in the mobile spine has shown that margin-free TES is the only treatment associated with no recurrence at follow-up longer than 5 years [5]. A common complication of TES is incidental durotomy [6]. If left unmanaged, an incidental durotomy with concomitant CSF leakage may result in adverse sequelae such as sepsis and meningocele [7]. The current report describes a novel technique to repair incidental durotomies in two patients treated with high dose pre-operative radiation therapy who underwent TES for chordoma of the thoracic and thoracolumbar spine. To our knowledge, such an approach has not been previously reported.