Expansion Duroplasty For Severe Cervical Spinal Cord Swelling After Traumatic Injury: A Step-by-Step Surgical Protocol

This research is aimed at standardizing the steps of expansion duraplasty for traumatic cervical spinal cord injury with persistent cord swelling. This approach is useful when posterior decompression may not fully relieve intradural pressure after traumatic cervical spinal cord injury. To begin, position the patient prone on a radiolucent spinal table, secure the head in a rigid head holder while maintaining neutral cervical alignment to avoid secondary cord compression.

After disinfecting the posterior cervical region, apply sterile draping in the usual fashion and mark the incision line. Make a midline posterior cervical skin incision centered over the planned decompression levels. Perform subperiosteal dissection of the paraspinal musculature.

Expose the lamina and lateral margins of the posterior elements while preserving the facet joint capsules whenever possible. Review preoperative sagittal T-two weighted magnetic resonance image to define the extent of spinal cord swelling. Decompress one level above and below the segment with maximal T-two hyperintensity.

After exposure of the posterior cervical elements, place retractors to maintain visualization while avoiding excessive soft tissue traction. Under microscopic visualization, thin the lamina as needed and remove them in a controlled coddle-to-cranial sequence using Kerrison rongeurs. Now carefully detach the ligamentum flavum after adequate bony decompression, and remove it while avoiding abrupt instrument passage beneath the lamina.

Keep all instruments tangential to the laminar surface and avoid downward force toward the swollen spinal cord. Preserve the facet joints whenever possible to minimize additional destabilization. Perform a longitudinal midline durotomy under microscopic visualization using a microsurgical blade.

Begin cranially and extend coddly along the decompressed segment. Open the dura gradually with a nerve hook oriented parallel to the dural surface, while gently elevating the dura to control tension and avoid contact with the swollen spinal cord. Then, extend the durotomy to match the decompressed segment and the visually swollen cord region.

Selectively divide one or more dentate ligaments on each side as needed at the levels of maximal cord swelling. Judge adequate release by reduction of asymmetric tethering and improved uniformity of cord expansion. Preserve arachnoid integrity during all steps of dural opening.

Secure the artificial dural substitute using interrupted 5-O polypropylene sutures along the dural edges. Next, place sutures at regular intervals with shallow bites to maintain a watertight seal. Finally, inspect the closure line under the microscope for focal gaping, persistent tension or visible cerebral spinal fluid leakage, particularly at the superior and inferior junctions, and cover the closure site with a waterproof adhesive film dressing.

Representative sagittal T-two weighted magnetic resonance images were obtained from a patient with severe cervical traumatic spinal cord injury, who underwent posterior decompression and expansion duraplasty. Preoperative imaging showed near complete effacement of the dorsal cerebrospinal fluid space at the level of maximal cord compression. Postoperative day seven imaging demonstrated restoration of the dorsal cerebral spinal fluid space with maximal thickness measuring approximately 2.2 millimeters.

On postoperative day 14, the dorsal cerebrospinal fluid space remained preserved with maximal thickness measuring approximately 2.6 millimeters. The longitudinal extent of the restored visible pericordal cerebrospinal fluid space measured approximately 18 millimeters. This protocol allows researchers to study persistent cord swelling after bony decompression.

The key challenge is preserving the arachnoid membrane during durotomy. This helps reduce CSF leakage and pseudomeningocele formation. Future studies can compare laminectomy alone with laminectomy plus expansion duraplasty, and clarify which patients benefit the most from dural expansion.