Common Practice in the Management of Dural Closure: An Italian Questionnaire

Objective: The optimal management of dural closure is unclear; therefore, we aimed to survey current common practices among Italian practitioners. Methods: The Delphi method was used to achieve a consensus on dura mater closing techniques in Italy. A steering committee decided 3 major topics to be investigated: pre- and postoperative conditions associated with cerebrospinal fluid (CSF) leak, indications to perform watertight dural closure, and dural closure technique. A questionnaire containing 12 statements was then submitted to Italian neurosurgeons. Results: The response rate was 60%. Among 60 items, 36 reached a positive consensus, 5 reached a negative consensus, and 19 did not reach consensus. Intrathecal hypertension, arachnoid opening, previous treatments, spinal incidental durotomy, wide size of osteo-dural defect, and lack of nasoseptal flap were considered major risk factors for CSF leak. Early mobilization, avoidance of stress maneuvers, and use of CSF external drainage were considered to reduce CSF leak rate. Italian neurosurgeons always attempt watertight dural closure, ideally with monofilament nonabsorbable sutures. Both autologous and heterologous dural grafts are used. Among dural sealants, fibrin glues are preferred, which are used most commonly in transsphenoidal surgery. Conclusions: This study elucidates the areas of consensus and uncertainty on dural closure management among a group of Italian neurosurgeons. It provides reliable and comparable data for the investigation of the departments' daily practice in dural closure. Given the lack of solid evidence, there is a need for further comparative studies of dural repair strategies.