Name: Expansion Duroplasty For Severe Cervical Spinal Cord Swelling After Traumatic Injury: A Step-by-Step Surgical Protocol (Video) | JoVE Journal
Uploaded: 2026-05-26T13:10:00.000+00:00
Duration: 5 min 45 s
Description: Learn expansion duroplasty for severe cervical spinal cord swelling after traumatic injury. This protocol demonstrates surgical techniques to restore cerebrospinal fluid space and reduce dural constriction using an artificial dural substitute.

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5 minutes

The surgical nursing staff and postoperative rehabilitation teams at Chang Gung Memorial Hospital were acknowledged for their assistance in perioperative care. This work received no external funding.

This study was approved by the Institutional Review Board of Chang Gung Medical Foundation (IRB No. 2312250059). All procedures were conducted in accordance with institutional guidelines for human research. Written informed consent was obtained from patients or their legally authorized surrogates.
1. Patient preparation and positioning 
<ol>
	<li>Induce general anesthesia with endotracheal intubation and maintain standard intraoperative monitoring, including electrocardiography, pulse oximetry, and invasive arterial blood pressure monitoring.</li>
	<li>Position the patient prone on a radiolucent spinal table with the head secured in a rigid head holder, while maintaining neutral cervical alignment to avoid secondary cord compression.</li>
	<li>Prepare the posterior cervical region using standard antiseptic solution and apply sterile draping in the usual fashion.</li>
	<li>Make a midline posterior cervical skin incision centered over the planned decompression levels. Perform subperiosteal dissection of the paraspinal musculature to expose the laminae and lateral margins of the posterior elements while preserving the facet joint capsules whenever possible.</li>
</ol>
2. Determination of laminectomy levels
<ol>
	<li>Review preoperative sagittal T2-weighted magnetic resonance imaging to identify the rostrocaudal extent of spinal cord swelling.</li>
	<li>Define the involved segment according to the visible longitudinal extent of intramedullary T2 hyperintensity and associated obliteration of the pericord CSF space.</li>
	<li>Perform posterior decompression spanning one vertebral level above and one vertebral level below the segment demonstrating the clearest T2 hyperintensity.</li>
	<li>If T2 hyperintensity is faint or equivocal, determine decompression extent based on the segment of maximal spinal cord compression, cord expansion, and loss of surrounding CSF space.</li>
	<li>Confirm planned decompression levels intraoperatively using fluoroscopy. 
	NOTE: Adequate rostrocaudal extension of the laminectomy beyond the radiographic margins of cord swelling is critical to prevent residual dural constriction after dural expansion.</li>
</ol>
3. Laminectomy
<ol>
	<li>After exposure of the posterior cervical elements, place retractors to maintain visualization while avoiding excessive soft-tissue traction.</li>
	<li>Under microscopic visualization, thin the laminae as needed and remove them in a controlled cranial-to-caudal sequence using Kerrison rongeurs.</li>
	<li>Carefully detach and remove the ligamentum flavum after adequate bony decompression, avoiding abrupt instrument passage beneath the lamina.</li>
	<li>Keep all instruments tangential to the laminar surface and avoid downward force toward the swollen spinal cord.</li>
	<li>Preserve the facet joints whenever possible to minimize additional destabilization.</li>
	<li>Perform posterior instrumentation and fusion when instability is present or anticipated based on the underlying injury pattern.</li>
</ol>
4. Dural opening
<ol>
	<li>Perform a longitudinal midline durotomy under microscopic visualization using a microsurgical blade, beginning cranially and extending caudally along the decompressed segment (Figure 1).</li>
	<li>Open the dura gradually with a nerve hook oriented parallel to the dural surface while gently elevating the dura so as to control tension and avoid contact with the swollen spinal cord.</li>
	<li>Extend the durotomy to match the decompressed segment and visually swollen cord region.</li>
	<li>Selectively divide one or more dentate ligaments on each side, as needed, at the levels of maximal cord swelling to facilitate symmetric spinal cord relaxation. Adequate release is judged by reduction of asymmetric tethering and improved uniformity of cord expansion.</li>
	<li>Preserve arachnoid integrity during all steps of dural opening (Figure 2). 
	CAUTION: The dura should be opened gradually under microscopic visualization. Abrupt dural release may result in sudden cord bulging and increased risk of neural or venous injury. Careful division of the dentate ligaments facilitates symmetric spinal cord relaxation and minimizes asymmetric cord displacement during intradural expansion.</li>
</ol>
5. Determination of duroplasty dimensions
<ol>
	<li>Trim the artificial dural substitute (Onlay Dura Patch, Aesculap) with sterile Metzenbaum scissors into an elliptical (&#8220;fish-mouth&#8221;) configuration.</li>
	<li>Orient the long axis of the dural substitute parallel to the durotomy and prepare it to extend approximately 1 cm beyond the superior and inferior ends of the dural opening.</li>
	<li>Maximize the width of the central portion of the patch so that the widest region overlies the segment of maximal cord swelling.</li>
	<li>Avoid excessive patch width to reduce the risk of postoperative cord drift or adhesion formation.</li>
	<li>Prepare the dural edges for patch placement under microscopic visualization (Figure 3). 
	NOTE: The elliptical (fish-mouth) configuration allows gradual intradural expansion while minimizing focal stress. Excessive artificial dural substitute width may increase the risk of postoperative cord drift or adhesion formation.</li>
</ol>
6. Artificial dural substitute suturing technique
<ol>
	<li>Secure the artificial dural substitute using interrupted 5-0 polypropylene sutures (Prolene, Ethicon) along the dural edges.</li>
	<li>Place sutures at regular intervals with shallow bites to maintain a watertight seal (Figure 4).</li>
	<li>Reinforce sutures at the superior and inferior junctions to minimize cerebrospinal fluid (CSF) leakage. 
	NOTE: CSF leakage at closure sites is commonly due to insufficient fixation or tension at junction points. Reinforce these areas with additional sutures to achieve a watertight seal.</li>
	<li>Gently elevate the artificial dural substitute during suturing to prevent direct contact with the edematous spinal cord.</li>
	<li>Confirm the final elliptical (fish-mouth) configuration after completion of expansion duroplasty (Figure 5). 
	NOTE: Interrupted sutures with evenly spaced, shallow dural bites are essential for achieving a watertight closure. Particular attention should be given to the superior and inferior junction points, which are common sites of cerebrospinal fluid leakage.</li>
</ol>
7. CSF leak mitigation
<ol>
	<li>Inspect the closure line under the microscope for focal gaping, persistent tension, or visible CSF leakage, particularly at the superior and inferior junctions.</li>
	<li>Add additional interrupted reinforcing sutures at these sites as needed, typically one to several sutures depending on closure tension.</li>
	<li>Cover the closure site with a waterproof adhesive film dressing. 
	NOTE: Regions of high dural tension should be identified intraoperatively and reinforced with additional sutures rather than relying on external measures.</li>
</ol>
8. Drain placement
<ol>
	<li>Place a wound drain in the posterior surgical wound superficial to the dural repair and deep to the muscle/fascial closure, avoiding direct compression of the duroplasty site.</li>
	<li>Maintain gravity-dependent drainage without suction.</li>
	<li>Secure the drain exit site with nylon sutures to prevent CSF leakage along the tract. 
	NOTE: Postoperative drainage should be maintained under gravity without suction. Negative pressure drainage may compromise the dural repair and increase the risk of cerebrospinal fluid leakage.</li>
</ol>
9. Wound closure
<ol>
	<li>Close muscle and fascial layers using absorbable sutures in a layered fashion.</li>
	<li>Close the skin using nylon sutures to enhance watertight sealing.</li>
</ol>
10. Postoperative management
<ol>
	<li>Maintain head elevation greater than 30&#176; for 7 days postoperatively. 
	NOTE: Head elevation greater than 30&#176; reduces hydrostatic pressure at the dural repair site and supports dural healing during the early postoperative period.</li>
	<li>Remove the wound drain after 7 days if no evidence of CSF leakage is present. 
	NOTE: Persistent postoperative CSF leakage should be managed with continued gravity drainage, strict head elevation, and avoidance of suction systems. Progressive wound leakage or failure of conservative measures may require revision of dural repair.</li>
</ol>

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<li>Wagner, F. C., Van Gilder, J. C. Jr, Dohrmann, G. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+development+of+intramedullary+cavitation+following+spinal+cord+injury%3A+An+experimental+pathological+study%5BTitle%5D)+AND+%22Paraplegia%22%5BJournal%5D)">The development of intramedullary cavitation following spinal cord injury: An experimental pathological study.</a> Paraplegia. 14 (4), 245-250 (1977).</li>
<li>Simpson, L. A., Eng, J. J., Hsieh, J. T., Wolfe, D. L. Spinal Cord Injury Rehabilitation Evidence Scire Research Team. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+health+and+life+priorities+of+individuals+with+spinal+cord+injury%3A+A+systematic+review%5BTitle%5D)+AND+%22J+Neurotrauma%22%5BJournal%5D)">The health and life priorities of individuals with spinal cord injury: A systematic review.</a> J Neurotrauma. 29 (8), 1548-1555 (2012).</li>
<li>Ganau, M., Syrmos, N., Martin, A. R., Jiang, F., Fehlings, M. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraoperative+ultrasound+in+spine+surgery%3A+History%2C+current+applications%2C+future+developments%5BTitle%5D)+AND+%22Quant+Imaging+Med+Surg%22%5BJournal%5D)">Intraoperative ultrasound in spine surgery: History, current applications, future developments.</a> Quant Imaging Med Surg. 8 (3), 261-267 (2018).</li>
<li>Le, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Predictors+of+intramedullary+lesion+expansion+rate+on+MR+images+of+patients+with+subaxial+spinal+cord+injury%5BTitle%5D)+AND+%22J+Neurosurg+Spine%22%5BJournal%5D)">Predictors of intramedullary lesion expansion rate on MR images of patients with subaxial spinal cord injury.</a> J Neurosurg Spine. 22 (6), 611-621 (2015).</li>
<li>Archavlis, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pathophysiologic+mechanisms+of+severe+spinal+cord+injury+and+neuroplasticity+following+decompressive+laminectomy+and+expansive+duraplasty%3A+A+systematic+review%5BTitle%5D)+AND+%22Neurol+Int%22%5BJournal%5D)">Pathophysiologic mechanisms of severe spinal cord injury and neuroplasticity following decompressive laminectomy and expansive duraplasty: A systematic review.</a> Neurol Int. 17 (4), (2025).</li>
<li>Aarabi, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intramedullary+lesion+expansion+on+magnetic+resonance+imaging+in+patients+with+motor+complete+cervical+spinal+cord+injury%5BTitle%5D)+AND+%22J+Neurosurg+Spine%22%5BJournal%5D)">Intramedullary lesion expansion on magnetic resonance imaging in patients with motor complete cervical spinal cord injury.</a> J Neurosurg Spine. 17 (3), 243-250 (2012).</li>
<li>Hubertus, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((AO+spine+clinical+practice+recommendations+for+the+surgical+management+of+acute+traumatic+spinal+cord+injury%3A+Contemporary+concepts%5BTitle%5D)+AND+%22Global+Spine+J%22%5BJournal%5D)">AO spine clinical practice recommendations for the surgical management of acute traumatic spinal cord injury: Contemporary concepts.</a> Global Spine J. 15 (8), 3572-3579 (2025).</li>
<li>Phang, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Expansion+duroplasty+improves+intraspinal+pressure%2C+spinal+cord+perfusion+pressure%2C+and+vascular+pressure+reactivity+index+in+patients+with+traumatic+spinal+cord+injury%3A+Injured+spinal+cord+pressure+evaluation+study%5BTitle%5D)+AND+%22J+Neurotrauma%22%5BJournal%5D)">Expansion duroplasty improves intraspinal pressure, spinal cord perfusion pressure, and vascular pressure reactivity index in patients with traumatic spinal cord injury: Injured spinal cord pressure evaluation study.</a> J Neurotrauma. 32 (12), 865-874 (2015).</li>
<li>Pim, J., Mcdonnell, J. M., Darwish, S., Butler, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Traumatic+cervical+spinal+cord+injuries%3A+Is+there+a+clinical+benefit+of+added+duroplasty+alongside+bony+decompression%5BTitle%5D)+AND+%22Clin+Spine+Surg%22%5BJournal%5D)">Traumatic cervical spinal cord injuries: Is there a clinical benefit of added duroplasty alongside bony decompression.</a> Clin Spine Surg. , (2025).</li>
<li>Li, Y. C., Chen, K. H., Li, C. Y., Lu, Y. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+outcome+of+injured+cervical+spinal+cord+with+uncontrolled+swelling+under+duraplasty%3A+Protocol+of+the+iscud+randomized+controlled+trial%5BTitle%5D)+AND+%22Trials%22%5BJournal%5D)">The outcome of injured cervical spinal cord with uncontrolled swelling under duraplasty: Protocol of the iscud randomized controlled trial.</a> Trials. 26 (1), 559(2025).</li>
<li>Greil, M. E., Hunt, E. R., Torres Espin, A., Saigal, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retrospective+analysis+of+expansile+duraplasty+as+surgical+adjunct+after+acute+traumatic+spinal+cord+injury%5BTitle%5D)+AND+%22Global+Spine+J%22%5BJournal%5D)">Retrospective analysis of expansile duraplasty as surgical adjunct after acute traumatic spinal cord injury.</a> Global Spine J. , (2025).</li>
<li>Joaquim, A. F., Tan, L., Riew, K. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Posterior+screw+fixation+in+the+subaxial+cervical+spine%3A+A+technique+and+literature+review%5BTitle%5D)+AND+%22J+Spine+Surg%22%5BJournal%5D)">Posterior screw fixation in the subaxial cervical spine: A technique and literature review.</a> J Spine Surg. 6 (1), 252-261 (2020).</li>
<li>Yang, J. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((When+is+the+circumferential+stabilization+necessary+for+subaxial+cervical+fracture+dislocations%3F+The+posterior+ligament-bone+injury+classification+and+severity+score%3A+A+novel+treatment+algorithm%5BTitle%5D)+AND+%22Eur+Spine+J%22%5BJournal%5D)">When is the circumferential stabilization necessary for subaxial cervical fracture dislocations? The posterior ligament-bone injury classification and severity score: A novel treatment algorithm.</a> Eur Spine J. 30 (2), 524-533 (2021).</li>
<li>Lee, D. Y., Park, Y. J., Song, M. G., Kim, K. T., Kim, D. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+anterior-only+versus+combined+anterior+and+posterior+fusion+for+unstable+subaxial+cervical+injuries%3A+A+meta-analysis+of+biomechanical+and+clinical+studies%5BTitle%5D)+AND+%22Eur+Spine+J%22%5BJournal%5D)">Comparison of anterior-only versus combined anterior and posterior fusion for unstable subaxial cervical injuries: A meta-analysis of biomechanical and clinical studies.</a> Eur Spine J. 30 (6), 1460-1473 (2021).</li>
<li>Achinger, K. G., Williams, L. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Trends+in+CSF+leakage+associated+with+duraplasty+in+infratentorial+procedures+over+the+last+20+years%3A+A+systematic+review%5BTitle%5D)+AND+%22Crit+Rev+Biomed+Eng%22%5BJournal%5D)">Trends in CSF leakage associated with duraplasty in infratentorial procedures over the last 20 years: A systematic review.</a> Crit Rev Biomed Eng. 51 (2), 33-44 (2023).</li>
<li>Saadoun, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Duroplasty+for+injured+cervical+spinal+cord+with+uncontrolled+swelling%3A+Protocol+of+the+discus+randomized+controlled+trial%5BTitle%5D)+AND+%22Trials%22%5BJournal%5D)">Duroplasty for injured cervical spinal cord with uncontrolled swelling: Protocol of the discus randomized controlled trial.</a> Trials. 24 (1), 497(2023).</li>
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The authors declare no conflicts of interest.

The effectiveness and safety of expansion duroplasty depend on meticulous execution of several critical technical steps. Adequate rostrocaudal laminectomy is essential to prevent persistent dural constriction following decompression. The durotomy should be performed in a controlled, stepwise manner under microscopic visualization, allowing gradual release of intradural pressure while minimizing the risk of abrupt cord expansion and mechanical stress on the injured spinal cord. Preservation of arachnoid integrity is parti...

Early surgical decompression is currently recommended as the standard management for acute traumatic spinal cord injury (aTSCI). Contemporary clinical practice guidelines from AO Spine recommend decompressive surgery within 24 hours after injury when feasible, as early decompression is associated with improved neurological outcomes1. Despite early decompression, many patients with severe cervical spinal cord injury develop progressive spinal cord swelling and intramedullary edema, which increase intraspinal pressure (ISP), compromise spinal cord perfusion pressure (SCPP), and contribute to secondary neurological injury2,3,4.
Posterior decompression through laminectomy effectively relieves osseous compression; however, it may not fully address the circumferential constraint imposed by the dura mater. Intraoperative ultrasound (IoUS) has increasingly been used to assess the adequacy of decompression by demonstrating restoration of cerebrospinal fluid flow around the spinal cord following laminectomy or corpectomy5. However, because the spinal dura is relatively non-elastic, the edematous spinal cord may remain compressed despite adequate bony decompression, limiting restoration of cerebrospinal fluid (CSF) dynamics and spinal cord perfusion6,7.
Expansion duroplasty is a surgical strategy designed to overcome this limitation by longitudinal dural opening and placement of an artificial dural substitute to enlarge the intradural compartment7. By increasing the available intradural volume, this approach aims to reduce dural constriction, restore CSF buffering capacity, and allow controlled expansion of swollen cord tissue. Experimental and clinical studies incorporating invasive ISP monitoring have demonstrated reductions in ISP and corresponding increases in SCPP following dural expansion, supporting the physiological rationale of this technique8.
Despite increasing interest in expansion duroplasty, standardized surgical protocols and reproducible technical guidance remain limited. Variations in dural opening length, preparation of artificial dural substitutes, suturing technique, and postoperative CSF management may influence both safety and effectiveness. Furthermore, concerns about CSF-related complications have hindered the broader adoption of the technique in many spine centers.
These evolving concepts have increased interest in strategies to optimize decompression and perfusion in acute traumatic spinal cord injury. Recent AO Spine recommendations highlight the need to evaluate surgical approaches that address persistent intradural compression, including consideration of expansion duroplasty in selected patients with severe spinal cord swelling9. The present protocol provides a detailed, step-by-step demonstration of expansion duroplasty for severe cervical spinal cord swelling following acute traumatic injury. Key procedural elements include patient positioning, selection of decompression levels based on preoperative imaging, dural opening technique, preparation and suturing of the artificial dural substitute, and postoperative strategies to minimize CSF leakage and infection risk. This visualized protocol is intended to facilitate reproducibility and safe implementation in centers equipped with microsurgical spine expertise. The protocol standardizes key operative steps&#8212;including the extent of the laminectomy, dural opening technique, configuration of the artificial dural substitute, and postoperative CSF management&#8212;thereby improving reproducibility compared with previously reported techniques that lack detailed technical guidance.
Expansion duroplasty may be particularly relevant when preoperative magnetic resonance imaging demonstrates near-complete obliteration of the pericord CSF space across multiple vertebral levels, suggesting persistent intradural constraint after standard decompression. While the technique requires additional operative time and advanced microsurgical skill, it offers a structured approach to achieving intradural decompression in cases where bony decompression alone may be insufficient10,11.

<table><tbody><tr><td>Microsurgical dural scissors</td><td>Aesculap</td><td>N/A</td><td>For precise dural opening</td></tr><tr><td>Microsurgical dural scissors</td><td>Aesculap</td><td>N/A</td><td>For precise dural opening</td></tr><tr><td>Non-absorbable suture (5-0 Prolene)</td><td>Ethicon</td><td>8705H</td><td>For watertight dural closure</td></tr><tr><td>Non-absorbable suture (5-0 Prolene)</td><td>Ethicon</td><td>8705H</td><td>For watertight dural closure</td></tr><tr><td>Onlay Dura Patch</td><td>Aesculap</td><td>N/A</td><td>Used for expansion duroplasty to enlarge intradural space</td></tr><tr><td>Onlay Dura Patch</td><td>Aesculap</td><td>N/A</td><td>Used for expansion duroplasty to enlarge intradural space</td></tr><tr><td>Operative Microscope</td><td>Leica Microsystems</td><td>N/A</td><td>For microsurgical visualization during duroplasty</td></tr><tr><td>Operative Microscope</td><td>Leica Microsystems</td><td>N/A</td><td>For microsurgical visualization during duroplasty</td></tr></tbody></table>

expansion duroplasty for severe cervical spinal cord swelling after traumatic injury: a step-by-step surgical protocol

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

Acute traumatic cervical spinal cord injury frequently leads to severe cord edema, elevated intraspinal pressure, reduced spinal cord perfusion, and progressive neurological deterioration. Conventional bony decompression via laminectomy may provide limited relief, as the non-elastic dura mater can continue to constrain the swollen spinal cord. Expansion duroplasty is designed to address this limitation by enlarging the intradural space using an artificial dural substitute, allowing controlled expansion of the injured spinal cord. This protocol describes patient positioning, selection of laminectomy levels based on preoperative magnetic resonance imaging, dural opening technique, preparation of an artificial dural substitute, suturing sequence, and postoperative strategies to mitigate cerebrospinal fluid leakage. Critical steps are highlighted to ensure a watertight closure, minimize infection risk, and optimize gravity-dependent wound drainage. Representative results include postoperative imaging demonstrating restoration of the cerebrospinal fluid space, reduced dural constriction, and absence of significant pseudomeningocele formation. This method is intended for patients with severe cervical spinal cord swelling within 72 hours of injury and can be implemented in centers with microsurgical spine expertise as an adjunct to standard decompression procedures.

Representative images are shown from a patient with severe cervical traumatic spinal cord injury (AIS A at presentation) who underwent posterior decompression and expansion duroplasty. Preoperative sagittal T2-weighted MRI demonstrated extensive cord swelling with near-complete effacement of the pericord CSF space. Postoperative MRI obtained on postoperative day 7 demonstrated interval restoration of the dorsal CSF space, with an increase in maximal dorsal CSF thickness from approximately 0–0.5 mm preoperatively to appro...

This protocol demonstrates expansion duroplasty as a surgical approach to address uncontrolled cervical spinal cord swelling following acute traumatic injury. By enlarging the intradural space with an artificial dural substitute, the technique aims to reduce intraspinal pressure, enhance perfusion, minimize postoperative cord tethering, and achieve watertight dural closure.

Acute traumatic cervical spinal cord injury frequently leads to severe cord edema, elevated intraspinal pressure, reduced spinal cord perfusion, and ...

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.

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Research

JoVE Journal

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Synergetic Use of Neural Precursor Cells and Self-assembling Peptides in Experimental Cervical Spinal Cord Injury

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The sagittal adjusting screw (SAS) system has been widely used for thoracolumbar (TL) spinal trauma. Percutaneous options and specialized trauma reduction devices are also available for the SAS system. We describe a technique for reducing TL burst fractures using an SAS system and a newly introduced trauma reduction device.

Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device

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Spinal Hernia Repair and Cauda Equina Repositioning After Lumbar Decompression under Three-Dimensional Microscopy: A Case Report and Literature Review

Lateral-PLIF is an advanced posterior lumbar interbody fusion technique allowing safer cage insertion with minimal neural manipulation. This article outlines the step-by-step procedure, highlighting the benefits of the bilateral approach, optimal cage orientation, high fusion rates, and low complication risks, offering a promising alternative to traditional PLIF.

Lateral-PLIF for Lumbar Spinal Arthrodesis: A Detailed Step-By-Step Surgical Technique

This surgical protocol is a step-by-step guide to insert an intrathecal catheter into the spinal subdural space of a rodent to deliver targeted treatment.

Accessing the Subdural Space of the Rodent Spinal Cord for Treatment Delivery

We describe two tactile sensory testing methods for acute or chronic periods of spinal cord injury in rats.  These validated procedures can detect the development and maintenance of allodynia-like sensations.

Acute and Chronic Tactile Sensory Testing after Spinal Cord Injury in Rats

A reliable and repeatable way to produce a cervical unilateral spinal cord injury using the Infinite Horizon impactor is described. The method takes advantage of a custom designed frame and clamp to stabilize the spine.  The standardized procedure and biomechanical injury parameters result in sufficient and sustained injuries.

A Contusive Model of Unilateral Cervical Spinal Cord Injury Using the Infinite Horizon Impactor

A novel technique to create a reproducible in vivo model of cervical spinal cord laceration injury in the mouse is described.  This technique is based on spine stabilization by fixation of the cervical facets and laceration of the spinal cord using an oscillating blade with an accuracy of ±0.01 mm.

Controlled Cervical Laceration Injury in Mice

Learn expansion duroplasty for severe cervical spinal cord swelling after traumatic injury. This protocol demonstrates surgical techniques to restore cerebrospinal fluid space and reduce dural constriction using an artificial dural substitute.

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

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