In Reply: The Role of Watertight Dural Closure in Supratentorial Craniotomy: A Systematic Review and Meta-Analysis
Bibliographic record
Abstract
To the Editor: We thank the editor for the opportunity to respond to the letter from Dr Ioannis Mavridis. We would also like to thank the authors for their valuable and insightful comments on our paper.1 We read his comments enthusiastically and were pleased to see that our work has generated such relevant discussions within the community. The idea for our systematic review and meta-analysis arose from pertinent doubts in our daily practice of dural closure, where we often encountered the impossibility of achieving a watertight closure.2 We realized that only a small percentage of patients had any clinical consequences, even though most of our closures were not watertight. Our study was therefore a search for all the available evidence in the literature. Unsurprisingly, our findings confirm that there appears to be no significant difference between watertight dural closure (WTDC) and non-WTDC in patients undergoing supratentorial craniotomy regarding outcomes of cerebrospinal fluid (CSF) leak, subgaleal fluid collection, and infection. We argue that this is not surprising as it is the most common scenario we observe in clinical practice when WTDC is not possible. The idea that the supratentorial compartment functions differently from the infratentorial compartment and the spine comes from clinical practice, where we tend to see more complications related to dural closure with these approaches. On that account, our study investigated only supratentorial craniotomy, and none of the studies included in our meta-analysis showed a significant difference between one method and the other regarding CSF leak and subgaleal collection (ie, pseudomeningocele).3 Regarding pseudomeningocele, we certainly agree that it is a serious condition and can be associated with serious complications. However, it still seems to be a poorly understood condition from our perspective. Its nomenclature is confusingly used in the literature. It is treated in a variety of ways. In other words, it is a disease that is difficult to homogenize. From the viewpoint of dural closure, we have not identified any study that proves a clear relationship between non-WTDC and a higher risk of complications associated with pseudomeningocele. Roth et al4 showed a cohort of pediatric patients and evaluated the impact of WDTC. The author found in the univariate analysis that only the infratentorial approach was associated with a higher risk of pseudomeningocele and CSF shunt, whereas WDTC was not associated with pseudomeningocele. Furthermore, the study by Norrdahl et al cited by the author showed that duroplasty (supra- and infratentorial) and race were the only factors associated with the need for treatment of pseudomeningocele.5 Perhaps this occurs because sometimes it is not possible to achieve WTDC, no matter how much effort is made. This supports that the performance of the WTDC does not seem to be the main issue in the development of postoperative pseudomeningocele because the vast majority of these patients will improve spontaneously and will not require major intervention. Our study intends not to claim that non-WTDC closure is a better or superior method of closure than WTDC. In fact, we believe that WTDC is the best and safest method of dural closure based on basic surgical principles. However, primary WTDC is often not possible for several reasons. Therefore, the idea of our study is to show that in cases where WTDC is not possible, the strongest literature available supports non-WTDC as a relatively safe dural closure method, and it does not seem to be the main cause of CSF leak, subgaleal collection, or infection. Once again, we would like to thank the author for his pertinent comments on our study. We hope that this discussion will further enrich the field.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.032 | 0.201 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.005 | 0.004 |
| Bibliometrics | 0.003 | 0.003 |
| Science and technology studies | 0.002 | 0.002 |
| Scholarly communication | 0.004 | 0.005 |
| Open science | 0.004 | 0.002 |
| Research integrity | 0.015 | 0.014 |
| Insufficient payload (model declined to judge) | 0.009 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".