Management of durotomy in spine surgery: a narrative review of current solutions and emerging materials

Introduction

The spinal dura is tough and water-resistant consisting of three layers: an outermost layer with loosely arranged fibroelastic tissue, a middle fibrous layer mainly composed of extracellular collagen, and an innermost cellular layer known as the “dural border cell layer”, which contains cells and is closely associated with the underlying brain or spinal cord (1). A surgical durotomy is often required during various spinal procedures, particularly for the resection of intradural tumors and extradural tumors that are adherent to the dura. Additionally, incidental durotomy, which refers to an unintended tear in the dura, is a recognized complication in spinal surgeries. Every spine surgeon will likely encounter such instances, and there will be a need to repair or reconstruct the dura in these cases. Despite advancements in surgical techniques and instrumentation, dural repair or duroplasty remains a challenge (2).

Pertaining to incidental durotomies, some are recognized intraoperatively and repaired immediately, while others may go unnoticed until postoperative complications arise (3). Understanding the incidence and prognosis of incidental durotomy is crucial for optimizing patient outcomes and guiding clinical decision-making. However, the incidence varies widely in the literature, ranging from as low as 1% to as high as 17%, depending on the surgical approach, pathology, and surgeon experience (4-6). Risk factors for unintended durotomies can be divided into modifiable and non-modifiable categories. The latter includes revision surgery, elderly patients, and the presence of pre-existing conditions, such as an ossified posterior longitudinal ligament (7,8). Other modifiable factors affecting the incidence rate include the surgical approach, for example, in cases of bilateral decompression using a unilateral approach, as well as the surgeon’s experience (9).

The prognosis of an unrepaired durotomy is multifactorial, influenced by various patient and surgical factors. While some of these durotomies may resolve without significant clinical sequelae, others can result in cerebrospinal fluid (CSF) leaks, pseudomeningocele formation, and potentially severe neurological complications (10-14). Treating these complications often requires prolonged bed rest, which is associated with additional risks such as pneumonia, deep venous thrombosis, pulmonary embolism, and bed sores (15,16). Hence, proper water-tight closure of the durotomy is imperative to avoid significant morbidity to patients.

Since the presence of underlying spinal pathologies, the location and size of the durotomy, and the effectiveness of repair techniques play significant roles in determining the clinical course and long-term outcomes for affected patients (17,18), it is important to understand the techniques and materials available to achieve a watertight closure. Therefore, this review aims to provide a summary of the existing literature on spinal durotomy repair from a user’s perspective, delving into various techniques utilized in these approaches while highlighting their advantages and limitations. It covers not only commercially available dural sealants, including their composition, effectiveness, and clinical applications, but also incorporate emerging preclinical insights to provide a more holistic understanding of current and evolving treatment options. We present this article in accordance with the Narrative Review reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-24-59/rc).

Methods

This narrative review examines the current evidence on durotomy repair techniques, materials, and outcomes to guide surgical decision-making. A literature search was conducted across PubMed, Web of Science, and Google Scholar for studies published from 2000 to 2024 (Table 1). The search employed a combination of Medical Subject Headings (MeSH) terms and keywords related to dural sealants, substitutes, and dural repair in various iterations. Boolean operators (AND/OR) refined results, and backward citation tracking identified additional relevant studies. Inclusion criteria focused on studies addressing material properties, surgical techniques, clinical outcomes, and complications related to dural repair. Both clinical studies (randomized trials, cohort studies, case series) and preclinical investigations (biomechanical testing, animal models) were considered if they provided meaningful insights. Review articles were consulted for synthesized evidence. Articles were excluded if they lacked sufficient methodological detail or were published in languages other than English without available translations. Selection was guided by relevance to the topic, narrative flow, and the key points the author aimed to highlight. Due to heterogeneity and the narrative nature, findings were synthesized thematically to identify trends and offer context for readers to critically assess and interpret the available evidence as detailed below.

Primary repair

Primary repair of a durotomy involves suturing the dural defect as soon as it is identified intraoperatively (18). It is strongly advised to perform primary dural repair regardless of the size of the dural defect, as even small defects have been shown to cause severe complications. Suture techniques such as running, locked continuous, or interrupted can be used, depending on the surgeon’s preference (19). However, suture repair itself may be limited by the anatomical location of the dural tear and the type of spinal surgery being performed.

An alternative to sutures, although not commonly used in this context is non-penetrating titanium clips (20,21). The fact that these clips do not create suture holes, are easy to use, especially in anatomically restricted spaces, and are rapid in their application makes them a valuable alternative (21). However, there could be CSF leakage between the clips, similar to what occurs with sutures (20). Moreover, there are limitations, including the inability to reposition or reuse clips after they have been removed from the applier, as well as a higher risk of dural laceration and dislodgement, and increased costs (22).

Reinforcement of primary repair

While primary repair techniques may not always achieve a watertight closure, various materials are available to reinforce the repair, commonly referred to as dural sealants or substitutes. The latter specifically refers to filling a non-suturable gap with a substitute material. These materials or sealants should replicate the properties of the dura, including toughness and water resistance, while also being non-toxic, low in antigenicity, highly biocompatible, and capable of maintaining adequate tension over extended periods. Options include autologous or allogenic grafts, bio- or synthetic polymer-based sheets or patches, and fibrin- or hydrogel-based liquid adhesives, all of which have been used to enhance primary suture repair, as well as serve as alternatives to sutures for small tears or in situations where suturing is challenging or impractical (23). The effectiveness of these materials for durotomy repair remains a topic of ongoing research and discussion, as addressed in this review.

Grafts

Grafts are especially beneficial when the defect is large and primary repair is not feasible, both in cranial and spinal surgeries. Autografts commonly used to repair dural defects include fat, muscle tissue, and fascia, with fascia lata being preferred due to its strength and suitability for suturing (24). In addition to its use as a primary material for defects, Nakano et al. demonstrated that free thigh fascia lata transplantation can effectively treat postoperative infections of artificial dura mater, leading to favourable outcomes (25). However, while autologous tissue reduces the chances of reaction, rejection, or infection, it requires an additional procedure at the donor site, which can increase operation time and the risk of adhesion. Alternatively, allogeneic materials, including cadaveric dura, have been used for dural repair in the past. For example, preserved human cadaveric-derived dural grafts (Tutoplast-dura), processed through a multi-stage chemical procedure, were successfully used for many years, with various studies reporting their benefits (26,27). While both autografts and allografts have demonstrated effectiveness, their use in current clinical practice has declined, largely due to the widespread availability of commercially developed biological, synthetic polymer, and fibrin-based sealants. These modern materials offer enhanced, purpose-designed properties that better align with the demands of contemporary surgical techniques.

Biopolymers

Biopolymers, derived from animals, plants, humans, or microorganisms, are primarily composed of proteins or polysaccharides. Collagen-based protein substitutes are particularly favored for their dynamic nature and flexibility. They are biocompatible, exhibit low antigenicity, and therefore support tissue regeneration while undergoing remodeling. These substitutes closely resemble human tissue and can promote direct clot formation with the underlying tissue, which is crucial for hemostasis. Additionally, they are chemo-attractive to fibroblasts and have been used for many years as either sutureless or sutured onlay dural grafts. DuraGen (Integra Neurosciences, Plainsboro, NJ, USA), made from bovine Achilles tendon, TissuDura (Baxter Healthcare, Vienna, Austria), consisting of pure naturally cross-linked collagen from equine Achilles tendon, Dura-Guard (Synovis Surgical, St. Paul, MN, USA), processed from bovine pericardium, DuraMatrix (Collagen Matrix, Inc., Oakland, New Jersey, USA), derived from purified intact bovine dermis tissue, and Durepair Medtronic (TEI Biosciences, Boston, MA, USA), derived from fetal bovine skin, are some commonly available collagen-based substitutes.

Various studies have proven the efficacy of these materials in terms of tissue regeneration and preventing CSF leakage in various cranial and spinal procedures (28,29). For instance, a retrospective review of 110 patients undergoing spinal dural repair using DuraGen showed successful CSF containment in >95% of patients (30). It was also found suitable for large dural defects (31). Similarly, the other commonly available substitute, TissuDura, has demonstrated elasticity, non-reactivity, and good adaptability (32). While these properties are common to most collagen-based preparations, immunogenicity and enzymatic degradation rates may vary. Furthermore, protein-based biopolymers may require strict conditions for successful polymerization, such as dry surfaces or specific fluid contact (with blood, water, or CSF); otherwise, the sealant properties may be compromised.

Gelatin is another biopolymer that is inherently biocompatible and biodegradable. It is typically derived from collagen through acid/alkali or heat-based hydrolysis and is classified as GRAS (Generally Recognized As Safe) by the US Food and Drug Administration (FDA) (33). Chemically, it has a repetition of a triplet sequence with predominant glycine and proline/hydroxyproline amino acids. They have good visco-elastic properties enabling them to mold to the appropriate shapes and sizes. It is also said to have regenerative properties (34). Gelatin is widely used in hemostatic agents like Gelform (Pfizer, NY, USA) and Floseal (Baxter Healthcare Corporation, Fremont, CA, USA), which are commonly used in spinal procedures (35). Although gelatin preparations are currently being explored as stand-alone sealants, as discussed in the future directions section, they are still often used in combination with fibrin glue for dural tears. For example, gelatin sponge (e.g., Gelfoam) and fibrin glue (e.g., Tisseel) are commonly used together. In this context, gelatin acts as a scaffold matrix, stabilizing the fibrin clot and enabling its localized and delayed formation in a controlled manner (36).

Polysaccharide-based biopolymers are sugar-derived polymers obtained from natural sources that are biocompatible and non-immunogenic. Among these, chitosan, a glycosaminoglycan polymer derived from chitin, has gained considerable interest due to its biomimetic properties, antimicrobial effects, and non-toxic biodegradability. It enhances macrophage activity, attracts neutrophils to the site of injury, and facilitates healing by promoting cellular regeneration (37-39). Although commercial preparations are limited, chitosan-based sealants have been the subject of extensive research. In an earlier in vivo animal study by Sandoval-Sánchez et al., a bilayer chitosan scaffold was used, achieving an effective watertight closure of the dura (40). Recently, an injectable and biocompatible catechol-functionalized chitosan (CCS) and dibenzaldehyde-terminated polyethylene glycol (PEG) hydrogel was developed by Ying et al. and applied to seal dural defects in rabbits, achieving a successful suture-less seal (41). Similarly, a bioactive patch composed of an alginate and polyacrylamide hydrogel matrix cross-linked by calcium ions, along with a chitosan adhesive, was found to be exhibiting anti-inflammatory and antibacterial properties (42,43). These developments have yet to be translated for human use. Similar to protein-based biopolymers, these polysaccharide-based polymers are also degraded enzymatically with the rate of degradation being affected by site of implantation and concentration of enzymes (44,45).

Synthetic polymers

Synthetic polymers are the result of research and exhibit distinct properties that support cell seeding, migration, growth, tissue regeneration, and controlled degeneration (46). Their morphological characteristics, such as pore size, shape, and surface area, can be precisely designed and customized for optimal application in cranial and spinal surgeries. They can be broadly categorized into hydrogel- and non-hydrogel-based compounds. PEG hydrogel sealants are commonly used due to their biocompatibility and non-immunogenic properties. These agents have been previously utilized in ocular, vascular, and gynecological procedures (47-49). Their use as a dural sealant has gained attention recently, for reinforcing and stabilizing primary dural repairs, with a dry surgical field being ideal for optimal effectiveness (50). Their polymerization time ranges from several seconds to minutes, and upon application, they effectively seal small gaps between suture stitches and pinholes.

DuraSeal (Integra LifeScience, Plainsboro, USA) and Adherus (Hyperbranch Medical Technology, Durham, USA) are examples of FDA-approved commercial liquid PEG-based sealants for spine surgery. These compounds remain in the body for approximately 4–8 weeks before being fully resorbed (51). A prospective, multi-center randomized study involving 158 patients found that adding PEG hydrogel (DuraSeal) significantly (P<0.001) improved the water-tightness of dural closure, with the authors concluding it to be a superior method for preventing CSF leakage (50). Similarly, another study involving 98 subjects, 74 of whom were treated with DuraSeal, showed that it was superior to other standard care technologies for achieving safe and effective dural closure (52). A study by Strong et al. comparing Adherus to DuraSeal found that the primary composite endpoint at the 120-day follow-up was achieved in over 90% of both the Adherus (104/114) and DuraSeal (106/117) groups, with both groups performing well (53). Although the safety profile of hydrogel sealants is well-studied, there is a potential for these substitutes to swell due to water uptake (54). As a result, they should be used with caution, as this swelling may lead to compression of neural structures. To overcome this limitation, low swelling hydrogels are being developed (55).

Among synthetic polymers, non-hydrogel-based substitutes include non-degradable materials such as polytetrafluoroethylene and polyurethane, as well as degradable materials like polyglycolic acid (PGA), polycaprolactone, and poly(L-lactic acid) (PLLA) (17). These polymers can be cut to shape and are frequently used to fill dural defects in both cranial and spinal surgeries. Cerafix Dura (Acera Surgical, St. Louis, MO, USA), a synthetic porous polymer matrix made of spun poly(lactic acid-glycolic acid) and poly(p-dioxane); Neuro-Patch (Aesculap Inc., Center Valley, PA, USA), a fine-fibered microporous fleece manufactured from highly purified polyesterurethane; and Ethisorb (Codman, Raynham, MA, USA), a similar matrix consisting of polyglactin 910 and polydioxanone, have all been clinically proven to be effective (56-59). Other composite preparations include a three-dimensional nanofiber membrane based on enantiomeric polylactic acid and poly(d-lactic acid)-grafted tetracalcium phosphate (60); Liqoseal, a dural sealant patch composed of a watertight polyester urethane layer and an adhesive layer made of poly(DL-lactide-co-ε-caprolactone) copolymer and multi-armed N-hydroxysuccinimide-functionalized PEG (61); and a bilayer oxidized regenerated cellulose/poly-ε-caprolactone knitted fabric-reinforced composite (62).

Most often, materials such as PGA sheets are used in combination with fibrin sealants following primary repair. In a study by Masuda et al., dural tears in 75 patients were repaired using sutures or non-penetrating titanium clips, followed by reinforcement with a PGA mesh and fibrin glue (63). The study found that only one patient developed a persistent CSF leak that required reoperation. Also, Hida et al. in their cohort of 160 patients, noted there were no allergic reactions, infection, or adhesion with PGA use (64). However, complications like foreign body reaction and granuloma formation have been reported necessitating careful monitoring (65).

Fibrin-based sealants

Fibrin sealants typically contain blood coagulation factors such as fibrinogen, factor XIII, and thrombin, along with the antifibrinolytic agent aprotinin and calcium chloride (66). It is primarily used to control bleeding from surfaces or cavities that are difficult to suture. However, its sealing, tissue adhesion, and bio-absorption properties also make it highly suitable for use as a dural sealant. Tisseel (Baxter Healthcare, Norfolk, United Kingdom) and EVICEL (Johnson & Johnson Wound Management, Ethicon Inc., Somerville, NJ, USA) are pooled human plasma-based fibrin sealants, while Bioseal (Guangzhou Bioseal Biotech Co., Ltd., Guangzhou, China) is a porcine-derived fibrin sealant available commercially. While not evaluated and approved by the FDA as a dural sealant, studies have shown that fibrin sealants are effective as adjunct sealants in spine surgeries to enhance dural repair by direct sutures and/or polymer sheets (67-70).

Fibrin sealants have a unique formulation of fibrinogen and thrombin, which generate a crosslinked fibrin clot through a process that mimics the final stage of the physiological coagulation system (71). The aprotinin in the complex enhances the resistance of the fibrin sealant clots to degradation in a fibrinolytic environment, helping to maintain integrity and water-tightness in dural closure (70,72). In addition to liquid formulations, fibrinogen molecules (combined with thrombin) are also applied to collagen sheets, enabling a polymerization reaction upon contact with body fluids. Examples of fibrin-coated collagen sheets include TachoSil (Baxter, Westlake Village, CA, USA), which utilizes human thrombin, and Tachocomb (Nycomed, Ismaning, Germany), which employs bovine thrombin (73,74). In this process, the fibrin coating polymerizes into a fibrin clot, securing the collagen sponge tightly to the dural surface and forming a mechanically stable network (75). Below, we present a case where TachoSil was used to reinforce primary repair with sutures, followed by the application of Tisseel fibrin sealant, in the management of a dural tear during open surgery (Figure 1). The selection of these materials was based on availability and surgeon preference, which may vary between practitioners. While various studies report the advantages and safety profile of fibrin sealants in spine surgery, it is important to note the potential for allergic reactions, as well as local and systemic toxicity (76,77).

Figure 1 Representative images of a dural defect repair and reinforcement during an open surgery. (A) Primary repair using Proline sutures (arrow). (B) Reinforcement of primary repair using TachoSil (arrow). (C) Additional reinforcement by applying Tisseel fibrin sealant (arrows) over TachoSil.

Application of dural sealants in endoscopic spine surgery

In endoscopic spine surgery, the incidence of dural tears is reportedly lower (78). However, two key considerations arise regarding dural tears and repair strategies. Unlike open spine surgery, the anatomical dead space at the surgical site is smaller, and the surgical field is wet due to the constant flow of saline. This has led to ongoing debate about the most effective approach for dural repair in these procedures (79). A survey conducted among 93 spine surgeons regarding dural tears in endoscopic spine surgeries revealed some interesting findings. Over half of the surgeons (52.2%) did not attempt any repair or closure, while fewer than 10% attempted an endoscopic repair. Additionally, 40% of the surgeons used sealants, with DuraSeal being the most frequently mentioned commercially available brand (42.7%) (80).

While management strategies may depend on the size of the dural tear, primary repair is always recommended if the tear is significant (81,82). Apart from sutures, non-penetrating vascular clips have also been used in the endoscopic management of dural tears (83). Moreover, it is important to be aware of the substitutes that are suitable for use in the endoscopic scenario. Collagen-based patch or fibrin-sealed collagen have been generally reported to be good choices in endoscopic surgeries (79,84). They can be placed either as an onlay or inlay, with the inlay patch positioned inside the rent, where the hydrostatic pressure of the CSF helps effectively seal the patch to the torn dural edges (85). Derman et al. reported a series of cases where DuraGen, cut slightly larger than the size of the dural tear, was introduced into the surgical field and used to seal the tear using an inlay technique. Postoperatively, none of the patients showed signs or symptoms of CSF leakage at any follow-up timepoint (85). Our technique is similar to that of Derman et al., and in Figure 2, we demonstrate the use of DuraGen as an inlay endoscopic dural repair substitute (Figure 2). Furthermore, a table reporting findings from studies on incidental or surgical durotomy, and duroplasty using sealants or substitutes is provided (Table 2).

Figure 2 Representative images of a dural defect repair during an endoscopic decompression surgery. (A) Dural tear (arrow) as visualized through the endoscope. (B,C) Maneuvering the DuraGen patch (star) to position it within the dural defect (arrow). (D) Inlaid DuraGen patch (star) in place.

Suggested clinical care plan for durotomies

While the choice of dural sealants and substitute materials is extensive, the underlying principle remains straightforward: if a durotomy is accessible, it should be primarily sutured. In such cases, sealants and substitutes play a critical role, either by reinforcing the primary repair or by sealing defects that cannot be directly sutured. These materials are designed to be versatile, making them suitable for use across a broad spectrum of dural defect sizes, both small punctures and large durotomies. Clinical care strategies have evolved to reflect commonly adopted practices in both these scenarios, with current protocols increasingly integrating available evidence alongside surgical experience (101). In our practice, we generally follow the approach outlined by Milton et al. (86). Accessible durotomies are repaired with primary intraoperative suturing, often reinforced with dural sealants or substitutes. Following repair, closed suction negative pressure drainage may be used for up to 72 hours to reduce CSF leakage while minimizing the risk of infection. In contrast, complex or anatomically difficult durotomies such as those along nerve root sleeves, very small defects, or tears with irregular margins are typically managed without suturing, using dural sealants or substitutes alone, and without postoperative drainage. In all cases, watertight wound closure is essential. Postoperatively, patients are placed in the semi-Fowler position on postoperative day one and monitored closely for CSF leak or wound complications. If no symptoms (such as postural headache, nausea, dizziness, or diplopia), mobilization is initiated. However, if symptoms emerge, MRI imaging is considered, and early intervention is pursued. In some cases, this may involve continued bed rest, while in others, re-exploration and surgical repair may be required.

Future directions

Since dural tears and CSF leaks continue to be persistent issues in spine surgeries, further research is essential to improve management strategies. Recent advancements have led to the development of new materials that are currently being tested in vitro and in vivo in animal studies, showing promising results and potential for translation to human use. Among biopolymers, a new fish gelatin-based absorbable dural sealant has gained attention. This preparation involves gelatin derived from the marine fish Alaska pollock (ApGltn), modified with α-linolenic acid (ALA), an omega-3 fatty acid known for its anti-inflammatory properties, and cross-linked with a poly(ethylene glycol)-based cross-linker to create the ALA-ApGltn sealant (ALA-Seal) (116). It has a low swelling ratio, comparable burst strength to DuraSeal, and enhanced anti-inflammatory properties.

Another injectable, low-swelling hydrogel sealant, containing gelatin and o-phthalaldehyde (OPA)-terminated 4-armed poly(ethylene glycol) (4aPEG-OPA), was developed through the OPA/amine condensation reaction (55). The OPA groups of 4aPEG-OPA react with the amine groups on gelatin to form phthalimidine linkages, creating a stable cross-linked network with low-swelling properties under physiological conditions. In vitro sealing performance, evaluated through burst pressure testing, showed that it outperforms fibrin glue. In rat and rabbit models of lumbar and cerebral dural defects, the 4aPEG-OPA/gelatin hydrogel demonstrated effective sealing, reduced local inflammation, epidural fibrosis, and postoperative adhesion (55). Its low swelling property proved advantageous by preventing detectable compression on neural structures.

Most hydrogel preparations rely on reactive chemistry for crosslinking; alternatively, a new biodegradable hyaluronic acid (HA)-based dural sealant, called HA photosealant, has been designed (117). HA was chosen because it facilitates the simultaneous regeneration of both dural and bone tissue, which is particularly important in cases involving bone defects during neurosurgery. The key feature of this sealant is its ability to cure rapidly under low-energy visible light, forming a watertight multi-network hydrogel. A burst pressure test was performed to assess its adhesive performance, and the HA photosealant demonstrated adequate adhesion compared to commercially available tissue adhesives. In vitro, a scratch wound healing assay showed that the presence of HA photosealant promoted osteoblast recovery, indicating osteoconductive efficacy. In a rabbit craniectomy and durotomy model, after creating an 8-mm dural incision, 150 µL of the dural sealant was applied. The HA photosealant demonstrated rapid sealing after just 5 seconds of light exposure, compared to chemical sealants, which required 30 seconds. No significant changes or inflammatory cell infiltration were observed in the rabbit-treated HA photosealant areas, suggesting superior biocompatibility compared to commercial tissue glues.

Another recent innovation is the Dural Tough Adhesive (DTA), which consists of two interwoven polymer networks: polyacrylamide (crosslinked for high elasticity) and alginate (reversibly crosslinked to redistribute energy from mechanical forces in adjacent tissues) (118). It also features a chitosan-based adhesive surface. Its pliability, combined with its time-dependent adhesive properties, allows for easy manipulation and adjustments during placement, while also enabling removal if necessary. It is fracture-resistant, highly stretchable, exhibits superior adhesive properties even on fluid-covered surfaces, and demonstrates strong mechanical strength. These characteristics were identified through tensile testing, ex vivo burst pressure testing on porcine dura with a punch biopsy injury, and in a simulated surgical context with a CSF leak in postmortem human dural tissue (118). Some areas to explore, as mentioned by Wu et al., include determining whether a thicker gel or the integration of a semirigid backing, which has been shown to enhance peak burst pressures, would improve the mechanical properties of DTA. Also, the optimal balance between adhesive strength, mechanical performance, and degradation rate is to be studied before clinical translation.

Advancements in research have led to promising developments in various composite materials. By combining the strengths of both natural and synthetic polymers, composite polymeric grafts offer a potential solution for improving dural repair. These grafts can provide enhanced biocompatibility, mechanical properties, cell adhesion, and tissue regeneration. However, further research and clinical studies are needed to fully assess the performance and safety of these composite substitutes. An intriguing approach that could be applied to planned durotomies is 3D printing, which allows for the creation of customizable scaffolds and personalized dural substitutes with complex shapes. This is a new and exciting area that remains to be explored (119).

Limitations

This narrative review has certain inherent limitations that should be considered when interpreting the findings. Article selection was guided by relevance to the topic, the intended narrative flow, and the key points the author aimed to convey. The included studies vary in type, sample size, and methodological rigor, which can influence the generalizability and reliability of the results. Some studies referenced provide limited detail on specific indications and procedures, while others do not report prognostic information, both of which may affect interpretation. Additionally, although biological superiority of materials is often assessed in laboratory settings, many of the included studies do not directly compare compounds head-to-head in surgical contexts, nor provide a cost-effectiveness analysis, making it difficult to draw firm conclusions about the clinical utility of one material over another. A more robust comparison of compounds within similar indications would offer a clearer understanding of their relative advantages and disadvantages. As a narrative review, this article aims to provide an overview of the current literature and contextual insights for readers to critically assess and interpret the available evidence.

Conclusions

Dural sealants or substitute materials are essential components in a spine surgeon’s repertoire, offering substantial value, particularly in cases involving complex, irreparable dural tears or those in difficult-to-reach areas. These materials not only enhance primary suture repairs but also create a watertight seal, ensuring effective closure of dural defects. While numerous options exist, as highlighted in this review, having an injectable and patch variant at hand can be invaluable for addressing unforeseen challenges during surgeries. Although the results from various sealants are promising, it is important to remain aware of their chemical compositions and potential complications when selecting the most appropriate option. With ongoing advancements, the future of dural sealants looks promising, with new materials supported by encouraging in vitro and in vivo studies demonstrating notable advantages. However, the need for more robust clinical data and long-term studies is evident to fully assess their safety, efficacy, and potential for widespread use.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-24-59/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-24-59/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-24-59/coif). A.K.K.P. serves as an unpaid editorial board member of AME Surgical Journal from November 2024 to December 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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