The Role of Haemostatic Gel Matrix in Reducing Neurosurgical Complications

 Neurosurgical procedures demand exceptional precision and control, especially when performed in tight anatomical spaces using microscopic or endoscopic techniques. In such confined environments, even minor bleeding can significantly obscure the surgical field, increasing operative complexity and the risk of damaging critical neural structures [1]. Thus, achieving rapid and effective haemostasis is not merely desirable — it is vital to patient safety and surgical success.

Why Haemostasis Matters in Neurosurgery

Unlike many other surgical specialties, neurosurgery poses distinct challenges due to the proximity of vital neural structures and the potentially devastating consequences of even minor postoperative bleeding. Generalized oozing from the dura mater, spinal nerves, or bony surfaces may be deceptively persistent and difficult to control. Residual blood, even in small amounts, can compress delicate tissues, resulting in complications such as hematomas, infections, or neurological deficits [2].

Uncontrolled intraoperative bleeding can also lead to:

• Prolonged surgical duration
• Increased need for blood transfusions
• Extended ventilatory support and ICU stays
• Longer hospitalizations and elevated healthcare costs

For these reasons, effective haemostasis in neurosurgery is essential not only for surgical visibility but also for minimizing complications and optimizing patient outcomes [3].

Limitations of Conventional Haemostatic Techniques

Traditionally, bleeding in neurosurgery is managed using bipolar cautery or mechanical pressure. While effective in many cases, these techniques havenotable limitations:

• Bipolar coagulation carries a risk of damaging healthy nervous tissue, which can result in long-term neurological sequelae.
• Mechanical pressure may not conform well to the complex, irregular surfaces commonly encountered in cranial and spinal surgeries [2, 4].

These limitations have led to growing adoption of topical haemostatic agents (THAs), which offer a more controlled and targeted approach to intraoperative bleeding.

Topical Haemostatic Agents

Topical haemostatic agents (THAs) have emerged as valuable tools in neurosurgery, offering targeted bleeding control without compromising surrounding tissues. These agents function by either supporting the body’s natural clotting process or forming physical barriers at bleeding sites. They are classified based on their mechanism of action:

• Mechanical agents (e.g., gelatin sponges, oxidized regenerated cellulose)
• Active agents (e.g., thrombin)
• Flowable agents (e.g., gelatin-thrombin matrices)
• Fibrin sealants (containing both thrombin and fibrinogen)

Among these, flowable haemostatic agent gel matrices have gained significant attention in neurosurgical settings due to their ease of use, adaptability to irregular surfaces, and favorable safety profile [4].

Haemostatic agent Gel:

One of the leading products in this space is FLOGEL®, a flowable gelatin haemostatic matrix made from absorbable gelatin sponge. Packaged in a prefilled syringe, FLOGEL® is engineered for application in tight, irregular spaces — especially those that are difficult to access during minimally invasive or deep neuro-spinal procedures.

Fig. 1: FLOGEL® Flowable Gelatin Haemostatic Matrix

Key Benefits

• Uniform, flowable consistency for precise placement
• Quick and easy preparation
• Up to 8 hours of effective working time after preparation
• Conforms to the tissue & stays in place during active bleeding
• Delivers faster haemostasis where its intended
• Excess material can be gently irrigated away once bleeding stops
• Fully absorbable within ≤ 4 weeks when used in appropriate amount
• Promotes rapid haemostasis and stable clot formation

These features make FLOGEL® not just a bleeding control solution but an enabler of safer, faster, and more precise neurosurgical procedures.

Clinical Evidence Summary: Use of FLOSEAL® in Brain Tumor Resection

A prospective study evaluated the efficacy of FLOSEAL®, a thrombin-gelatin-based topical hemostatic agent, in 100 patients undergoing intracranial tumor resection. Hemostasis was scored from 1 (mild) to 4 (life-threatening) across 109 bleeding sites. The majority (95 sites) had mild bleeding (score 1), with FLOSEAL achieving hemostasis in 96% (91/95) on the first application. Of the 13 moderate bleeds (score 2), 62% responded to a single application, while subsequent application led to hemostasis in 4 out of 5 remaining cases. Overall, FLOSEAL achieved successful hemostasis in 94% (103/109) of bleeding sites.

Compared to controls, the FLOSEAL group exhibited a significant reduction in intraoperative and postoperative bleeding (confirmed by CT imaging one day post-op). Importantly, no adverse events were associated with FLOSEAL use [3].

Fig.2: (a) Moderate bleeding was observed from the cavernous sinus after tumor removal (yellow arrow), (b) FLOSEAL was applied to the bleeding, © FLOSEAL was washed by saline 2 min after its application, (d) complete hemostasis was achieved [3].

The Need for Standardized THA Guidelines in Neurosurgery

Despite their effectiveness, the use of THAs in neurosurgery has long lacked standardized application protocols. While expert bodies — like the 2022 Spine Expert Panel and the American Society of Anesthesiologists — have supported multimodal strategies, detailed algorithms for THA selection remain scarce [5].

To address this, a national expert panel recently released the first comprehensive guidelines for THA use in neuro-spine surgery. These evidence-based recommendations:

• Categorize THAs by mechanism of action and bleeding scenario
• Assist surgeons in selecting the right agent for specific challenges
• Aim to standardize intraoperative practice, enhance patient safety, and improve outcomes

A sample classification matrix helps align THA selection with bleeding severity and anatomical location (e.g., epidural spaces, sphenoid sinus, skull base procedures, AV malformations).

Fig.3: Recommended THA for different bleeding sites & situations in different procedures, THA: Topical: haemostat; ORC: Oxidized regenerated cellulose; AV: Arteriovenous [5]

Conclusion

In today’s neurosurgical landscape, the role of haemostatic agent gel matrices extends far beyond just controlling bleeding. They have become a cornerstone of safe, efficient, and outcomes-driven surgery. With growing clinical evidence and formal expert recommendations now available, these agents are poised to become a routine part of neuro-spine surgery protocols.

By embracing innovative yet proven technologies like gel matrix haemostats, neurosurgeons can ensure better visibility, reduced operative risk, and most importantlybetter care for their patients.