A CT-guided fibrin patch may be successful in treating postlaminec-tomy headache secondary to dural tear (Figure 17.2). MRI may be helpful to help identify and characterize the site of the tear and the extent of pseudomeningocele formation (Figure 17.3). CT guidance can then be used to drain the pseudomeningocele and patch the tear at the same time, thereby saving the patient from a major repeat surgery. Most spine surgeons dread such a complication and are grateful for this service. The fibrin patch can also be administered under fluoroscopic guidance by means of the same technique described for EBP.
If frozen cryoprecipitate is to be used, the blood bank will need 30 minutes' notice to allow time for thawing. Once thawed, the cryoprecipitate must be used within 4 hours. Thrombin comes in a powder form. Twenty thousand (20,000) units of thrombin is reconstituted in 10 mL of 10% calcium chloride solution and 0.5 mL of nonionic contrast. The thrombin solution and cryoprecipitate are drawn up into separate 3 mL Luer syringes. Equal volumes of thrombin and fibrinogen are then injected simultaneously by means of a three-way stopcock, through an 18-gauge spinal needle placed at the site of the suspected
Figure 17.2. CT-guided fibrin patch for treatment of postoperative CSF leak. Axial image after percutaneous aspiration of the pseudomeningocele through an 18-gauge needle and application of fibrin glue patch through the same needle. Contrast material is added to the fibrin glue to enhance visualization. This patient had complete relief of symptoms within 24 hours.
tear. The mixture forms a fibrin glue patch almost instantaneously. The glue is gelatin-like and rubbery in appearance. Administered volumes of 4 to 18 mL have been described.28,29 Postoperative CT, overnight bed rest, and intravenous hydration are then prescribed. Steroids may be helpful in temporarily alleviating CSF hypovolemia symptoms.
The commercial fibrin glue is usually stocked in hospital operating rooms, not in the hospital pharmacy. Tisseel and Hemaseel are actually the same product but packaged under the two different names by different distributors. The commercial glue is available in vials of 2 or 5 mL, both of which reconstitute to make a slightly larger volume. The commercial glue comes as a kit comprising sealer protein concentrate (the main component is pooled human cryoprecipitate), fibrinolysis inhibitor (bovine aprotinin) solution, thrombin (human), calcium chloride solution, and a double-barreled syringe with a common plunger. This plunger ensures that equal volumes of the two main components (fib-rinogen and thrombin) are drawn up separately but can be fed through a common needle for administration. Once the kit has been opened, the product must be used within 4 hours following reconstitution. The
sealant is reported to reach about 70% tensile strength in about 10 minutes and its ultimate strength about 2 hours after administration.
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