Efficacy and safety of titanium clips for dural closure in spinal surgery: a systematic review and single-arm meta-analysis
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Published on: May 31, 2017
José Otávio D Tomé1,2, Guilherme P Pajanoti3, Fernando Bezerra4
1Department of Orthopedic Surgery, Spine Surgery section, Medical School of ABC, Santo André, Brazil. donadeli.otavio@gmail.com.
Study Design:
Systematic review and meta-analysis.
Purpose:
Incidental or intentional durotomies remain a relevant intraoperative challenge in spinal surgery, as inadequate dural closure may result in cerebrospinal fluid (CSF) leakage, wound complications, and the need for reoperation. Titanium clips have emerged as an alternative to conventional suturing, particularly in minimally invasive or technically constrained procedures. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of titanium clips for dural closure in spinal surgery.
Methods:
A systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials was conducted from inception to July 1, 2025. Studies reporting outcomes of dural closure using titanium clips in spinal surgery were included. The primary outcomes were postoperative CSF leakage, revision surgery, and overall postoperative complications. Random-effects meta-analysis was performed, and heterogeneity was assessed using the I² statistic. Baujat plots were used to explore sources of heterogeneity.
Results:
Six studies comprising 798 patients met the inclusion criteria. Postoperative CSF leakage occurred in 4.0% of patients (95% CI 3.0-7.0%; I² = 0%). The pooled incidence of overall postoperative complications was 6.0% (95% CI 1.0-21.0%; I² = 82.9%), and revision surgery was required in 5.0% of cases (95% CI 2.0-13.0%; I² = 69.8%). Complications included pseudomeningocele, infection, subdural hematoma, positional headache, and wound-related events. Heterogeneity in complications and revision outcomes was primarily driven by differences in patient populations, outcome definitions, and revision thresholds.
Conclusion:
Titanium clips provide effective dural closure in spinal surgery, with low CSF leak rates, acceptable complication profiles, and infrequent need for revision surgery. However, because most of the included studies were non-comparative, these pooled single-arm data should be interpreted with caution and cannot establish equivalence or superiority relative to conventional dural repair; they suggest that titanium clips may be a viable alternative that requires confirmation in comparative studies. Prospective comparative studies with standardized outcome definitions are warranted to further define their role in clinical practice.
