Cauda equina syndrome after a TLIF resulting from postoperative expansion of a hydrogel dural sealant

Background DuraSeal™ (Coviden, Waltham, MA, USA), a hydrogel sealant, is primarily used as an adjunct to a dural repair. Its use has also been described to seal off an annulotomy after a transforaminal lumbar interbody fusion when recombinant human bone morphogenetic protein-2 (rhBMP-2) is used. This aids in the reduction of postoperative radiculitis caused by rhBMP-2. However, as a result of its hydrophilic properties, DuraSeal™ has the potential to swell, which could lead to compression of the thecal sac. Case Description We report a 57-year-old woman who developed cauda equina after a transforaminal lumbar 47 interbody fusion (TLIF) procedure in which the expansion of the DuraSeal™ was believed to be the causative factor. The patient developed urinary retention, bowel incontinence, and paresthesias in the saddle region on postoperative Day 3. She underwent emergent exploration and decompression of the thecal sac. The gel-like DuraSeal™ material was causing significant compression of the thecal sac. Literature Review Multiple reports have documented that DuraSeal™, used as an adjunct to dural repair, can swell leading to compression of the spinal cord and/or neural elements. Our case demonstrates the use of DuraSeal™ both over a site of a dural repair and over an annulotomy site, through which a TLIF was performed, is associated with the risk of developing postoperative cauda equina syndrome as a result of swelling of the DuraSeal™. Clinical Relevance Those using DuraSeal™ to seal off the annulotomy after a TLIF procedure performed with rhBMP-2 should use the product with an understanding of the potential postoperative swelling of the product and resulting neurologic sequela, particularly if DuraSeal™ is used concomitantly at the site of dural repair.