INTRODUCTION

The dura mater is the toughest and outermost layer of the three
meninges that surrounds the brain and spinal cord and covers and
supports the dural sinuses and carries blood from the brain toward
the heart. However, the dura mater can be damaged by trauma or
excising during intracranial or spinal surgery. As cerebrospinal fluid
(CSF) is an integral part of the central nervous system (CNS),
effective CSF containment following dural closure is imperative to
prevent CSF leakage and facilitate dura regeneration. Thus,
advances in surgical techniques and dura repair materials are critical
to improve the duration and functionality of artificial dura mater
repairs. Although the grading system used to evaluate dural healing.
The dura mater, the outermost layer of the meninges covering the
brain and spinal cord, is a collagenous connective tissue consisting of
numerous collagen fibres, fibroblasts, and few elastic fibres arranged
in a parallel form. The dura mater may be damaged by trauma or
excising during intracranial or spinal surgery. To date, cerebrospinal
fluid leakage followed by dura damage is still an intractable
complication due to its various secondary complications , dural
repair has recently garnered increased attention with the progress of
the spinal surgery and neurosurgery. In this review, we discuss
commonly used methods including the addition of sealants, the use
of substitutes, and other effective methods and materials. The dura
mater is the toughest and outermost layer of the three meninges that
surrounds the brain and spinal cord and covers and supports the
dural sinuses and carries blood from the brain toward the heart.
WHAT ARE DURAL RECONSTRUCTION
TECHNIQUES?
Surgical suture is a medical device used to hold body
tissues together after an injury or surgery. Application
generally involves using a needle with an attached length
of thread. A number of different shapes, sizes, and thread
materials have been developed over its millennia of history.
Surgeons, physicians, dentists, podiatrists, eye doctors,
registered nurses and other trained nursing personnel, medics,
and clinical pharmacists typically engage in suturing. Surgical
knots are used to secure the sutures.
Autologous Graft: - Taken
from a person’s own body.
The adipose tissue was
removed from the
paraumbilical abdominal
region and was transformed
into a thin foil. When
possible, a watertight suture
was made between the dural
or bone edge with a fat graft.
We always used fibrin glue to
reinforce the dural closure.
Autologous
graft (autoplastic graft) a graft taken from another area of
the patient's own body; called also autograft.
avascular graft a graft of tissue in which not even transient
vascularization is achieved. bone graft bone transplanted
from one site to another.
An allograft is a bone or tissue that is transplanted from one
person to another. They typically come from a donor, or
cadaver bone. The allograft is safe, ready to use and available
in large amounts. The main advantage of an allograft is that
it requires one less procedure than the autograft, which must
first be taken from the patient. Surgical time is minimized
and the recovery can be quicker. The allograft comes from a
reputable and reliable tissue bank.
Acellular dermal matrix (ADM) has been used as a soft tissue
replacement since its introduction in 1994. ADMs are soft
tissue matrix grafts created by a process that results in
decellularization but leaves the extracellular matrix intact.
Synthetic graft: Have rigid structure
Cause numerous inflammatory and foreign body reactions
Can cause cerebrospinal fluid bleeding and meningitis
graft rejection, scarring, delayed bleeding result in reoperations
increased risk of adhesion necessitating reoperations
Surgical Sealants: Fibrin sealants
indicated as an adjunct to
haemostats in surgeries, during
inaffective control of bleeding
Act as adjuvant to existing
treatment option for dural repair
Does not regenerate
Temperature required for storage
ranges between 2 and 8C
Possess risk of anaphylaxis reaction
Life threatening air or gas embolism risk associated with their
use.
 CEREBROSPINAL FLUID LEAK: A MAJOR
CONCERN DURING NEUROSURGICAL
PROCEDURES
Cerebrospinal fluid leak (CSF) is one of the most common complications
of neurosurgical procedures. The incidence CSF leak varies from 4% for
Trans sphenoidal procedures to 32 % for posterior fossa procedures. CSF
leak is associated with several complications and therefore it is
important to implement appropriate measures during the dural closure
procedure.
Complications of CSF leak following neurosurgical procedures
I. Formation of CSF fistula and pseudomeningocele
II. Low intracranial pressure due to CSF fistula
III. Wound infection and low healing due to persistence of
subcutaneous fluid
IV. Infection of CNS
V. Intracranial haemorrhage
VI. Herniation of cerebral or cerebellar component
VII. Nerve root entrapment
VIII. Abduces palsy- a rare complication after spine surgery

Adjuncts used for dural closure and their role

in reducing CSF leakage:
Several dural reconstruction techniques, such as
autografts, xenografts, synthetic grafts, are used
for dural closure. Fibrin glue and collagen matrix
are adhesive substances used as adjuncts to dural
repair. Reinforcement of dural repair with
adjuvants is important to reduce the incidence of
CSF leakage.
Collagen matrix vs Fibrin sealants as adjunct
in dural reinforcement:
Fibrin sealants are commercially available products that contains active
ingredients, fibrinogen and thrombin. It can be used only adjuvant and has a
resorption time of 2-4 days. The fibrin sealant should be carefully handled as
improper handling increases risk of air embolism and should be stored at the
temperature range of 2 to 25 degrees. Clinical safety of fibrin sealants has not
been well established in neurosurgical procedures.

DISADVANTAGES OF AUTOGRAFT:
Autologous graft as mentioned above is used to repair the dura. Though the
epidermal graft is from the patient’s body moreover it needs to be sutured.
Sometimes while suturing pores or defects may be induced onto the skin graft
and this causes CSF leak after surgery. This would lead to many complications
and may require a second surgery or may take the life of the patient.
Sometimes the patient’s own skin might not be sufficient to close and heal the
dura as in case of minors. It causes inconvenience as we have to suture the
cranium or the spine as well as dress the area from where the autologous graft
was extracted. This way matrix helps to heal the dura matter without any
inconvenience to the patient’s body and autoimmunity as well.

COLLAGEN MATRIX: DESIGNED FOR

CORRECTION OF DURAL DEFECTS
Collagen matrix is an onlay graft that does
not require additional fixation when the
overlap between the graft and dura
adequate
Sutureless repair reduces surgery time
Facilitates application of small patches in
anatomically difficult locations
Collagen matrix has a uniform pore
structure, facilitates cell ingrowth and enables uniform tissue repair. The
collagen matrix aids in the regeneration of the dural tissue and is completely
degraded after 2-3 months of placement, thereby preventing any tissue
reactions. The collagen matrix initiates fibrin clot formation forming a
biological water tight seal and further facilitates new dura formation.

FEATURES OF COLLAGEN MATRIX

Precisely engineered porosity:

Platelets infiltrate the brain and initiate fibrin

clot formation, forming an effective layer that
prevents CSF leakage and initiates the dural
repair process.
The pore size is optimized to allow fibroblasts
to rapidly enter the matrix and lay down
natural collagen fibres.
The optimized 99 % porosity, even distribution
and pore interconnectivity promote uniform
tissue regeneration throughout the matrix.
Excellent conformability and handling:

Offers optimal conformability and ease of handling

DuraGen matrix is quickly and easily hydrated prior to implantation or
in situ
Upon hydration DuraGen matrix becomes pliable membrane that
conforms to the existing dura and remains in place through surface
tension and fibrin clot formation, eliminating the need of sutures.
Scientific superiority:-
I. Excellent Conformability and Adherence
The hydrated graft conforms closely to the complex surfaces of the
exposed brain or spinal cord.
Matrix rapidly fills with the patient’s blood and plasma exudate.

II. Rapid CSF Leak Prevention

Type 1 collagen matrix rapidly initiates platelet aggregation.

Upon contact with the collagen matrix, platelets degranulate and
release clotting factors that initiate fibrin clot formation
III. Rapid Fibroblast Infiltration

UltraPureCollagen Technology, in
combination with the open pore structures,
promotes fibroblast activity and acts as a
scaffold for cells to
The graft structure features pores of 50 to
150 microns, within the optimal size for
rapid fibroblast infiltration.
Fibroblasts begin to migrate into the
matrix 2 to 3 days after implantation and
start the process of lying down new collagen.

IV. Uniform Tissue formation

Within 2 weeks of implantation, a neodural layer has been formed

between the dural margins to permanently close the dural defect.
After 6-8 weeks, the implant is resorbed and replaced by dura.
After 1 year, the neodura has developed into mature dura.
SAFETY PROFILE:

Better safety profile than synthetic dural substitute- minimization of

postoperative complications
Infection rate comparable to other methods of dural closure
Effectiveness provided against CSF leakage
Inhibition of fibrosis and prevention of adhesion
Clinical outcomes of efficacy of collagen matrix in dural repair:
Reduction in operative time: Average 36 minutes time savings reported with
collagen matrix
100%CSF containment, infections seen in 3 patients; no delayed subdural
hematomas
0.4 % CSF leak rate, 0% reoperation rate
Low CSF leakage rates and no complications
ADVANTAGES OF COLLAGEN MATRIX
Inert, elastic and easily handled adhesive
material
Can be used both as adjuvant and dural
substitute
Does not cause inflammatory or foreign body
reaction
Aids in repair and regeneration of dural tissue
Completely degrades after 2-3 months of
placement and thereby prevents any tissue
reactions
Can be stored at room temperature
Does not require any preparation time
Efficacy and safety has been established with 1.8 million implantation.

SOME UNIQUE FEATURES OF DURAL

REGENERATION MATRIX:
1. The collagen matrix
provides a low pressure
absorptive surface to
diffuse CSF and attaches to
the dural surface via
surface tension.
2. Facilitates fibrin formation
by allowing clot formation
3. Fibrin holds the graft in
place until fibroblasts,
associated with the blood
vessels, proliferate into the
graft
4. Fibroblast infiltration starts by 3-4 days and becomes established in 10-14
days. The fibroblasts use the pores on the matrix to lay down endogenous
collagen.
5. By 6-8 weeks, the collagen matrix is resorbed and is integrated to the
endogenous dura.
6. The collagen matrix gets incorporated into the endogenous tissue in a
relatively short period of time and in 24 weeks becomes hardly
distinguishable from the endogenous dura.

LIMITATIONS OF CONTEMPORARY DURAL

SUBSTITUTES
Autografts require a second incision, thereby introducing another source
for potential morbidity. Availability becomes a concern for other
autografts that are accessible through same incision, such as the
pericranium and temporalis fascia, especially when a large extent of graft
is required.
Allografts have immunogenic reactions and have the risk of transmitting
related diseases. They become encapsulated in a connective tissue layer.

WHAT DOES THE DURAGEN MATRIX DO?

1. The hydrated graft conforms closely to the complex surfaces of the
exposed brain and spinal cord.
2. Matrix rapidly fills with the patient’s blood and plasma exudate.
3. The collagen imitates platelet aggretion.
4. Upon contact with collagen matrix, platelets degranulate and release
clotting factors that initiate fibrin clot formation.
5. Upon contact with the collagen matrix, platelets degranulate and
release clotting factors that initiate fibrin clot formation.
6. The fibrin clot creates a watertight barrier and binds the implanted
matrix to the patients dura.
7. The open pores in the matrix promotes fibroblast activity and cells
deposit into new collagen. The pores of 50 to 150 microns within the
optimal size for rapid fibroblast production.
8. The fibroblasts begin to migrate into the matrix after 2 to 3 days and
start lying down the new collagen.
9. Within two weeks a neodural membrane has formed between the dural
margins to permanently close the dural defect.
10. After 6 to 8 weeks the implant is resorbed and replaced by matrix.
11. After 1 year the neodura has developed into mature dura.