DOI: http://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20184388

Incidence and management of incidental durotomy during thoracic and lumbar spine surgeries: a retrospective review in a tertiary care centre

Prince Solomon, Yuvaraja Murugan, Justin Arockiyaraj, Rohit Amritanand, Venkatesh Krishnan, Gabriel D. Sundararaj

Abstract


Background: Incidental durotomy is among the most common complications of spine surgery with reported incidence ranging from 1.7% to 16%. Various management options including primary repair, fascial or fat graft, epidural blood patch, fibrin glue sealant, etc., have been proposed. The purpose of this study is to evaluate the incidence of incidental durotomy and the efficacy of different management options during a five year period at a tertiary care center.

Methods: All patients who underwent various surgical procedures in thoracic and lumbar spine from January 2006 - December 2010 in our centre were retrospectively reviewed. Data on demographics, primary diagnosis, associated co morbidities, details of surgical procedure, training level of the operating surgeon, details of the incidental durotomy, the treatment, complications and the postoperative stay were recorded.

Results: Of 2270 patients, 1401 patients were included in the study. The incidence of incidental durotomy was 3.49% (49 patients). We found a very high incidence of 33.33% incidental durotomies among patients who underwent revision procedures as compared to 3.23% for patients who underwent primary surgeries. 5.10% of incidental durotomies were caused by fellows under training, 4.27% by junior consultants and 2.92% by senior consultants. Of 49 durotomies, complication were 5 cases of intracranial hypotension, 5 postoperative neurological deficits, 2 deep wound infection, 2 pseudomeningocele and 1 meningitis.

Conclusions: The risk of incidental durotomy in thoracolumbar surgeries is high in revision surgeries and when performed by fellows in training. Intraoperative identification and primary repair with suturing or sealant reduces postoperative complications.


Keywords


Incidental durotomy, Incidence, Management, Complications, Pseudomeningocele

Full Text:

PDF

References


Zeidman SM. Intraoperative dural laceration, postoperative cerebrospinal fluid fistula and postoperative pseudomeningocele. In: Vaccaro R, ed. Complications of Pediatric and Adult Spinal Surgery. 1st ed. New York: Marcel Dekker; 2004: 55-62.

Bosacco SJ, Gardner MJ, Guille JT. Evaluation and treatment of dural tears in lumbar spine surgery: a review. Clin Orthop Relat Res. 2001;(389):238–47.

Tafazal SI, Sell PJ. Incidental durotomy in lumbar spine surgery: incidence and management. Eur Spine J. 2005;14(3):287–90.

Wang JC, Bohlman HH, Riew KD. Dural tears secondary to operations on the lumbar spine. Management and results after a two-year-minimum follow-up of eighty-eight patients. J Bone Joint Surg Am. 1998;80(12):1728–32.

Guerin P, El Fegoun AB, Obeid I, Gille O, Lelong L, Luc S, et al. Incidental durotomy during spine surgery: incidence, management and complications. A retrospective review. Injury. 2012;43(4):397–401.

Cammisa FP Jr, Girardi FP, Sangani PK, Parvataneni HK, Cadag S, Sandhu HS. Incidental durotomy in spine surgery. Spine. 2000;25(20):2663–7.

Saxler G, Krämer J, Barden B, Kurt A, Pförtner J, Bernsmann K. The long-term clinical sequelae of incidental durotomy in lumbar disc surgery. Spine. 2005;30(20):2298–302.

Sin AH, Caldito G, Smith D, Rashidi M, Willis B, Nanda A. Predictive factors for dural tear and cerebrospinal fluid leakage in patients undergoing lumbar surgery. J Neurosurg Spine. 2006;5(3):224–7.

Stolke D, Sollmann WP, Seifert V. Intra- and postoperative complications in lumbar disc surgery. Spine. 1989;14(1):56–9.

Mayfield FH, Kurokawa K. Watertight closure of spinal dura mater. Technical note. J Neurosurg. 1975;43(5):639–40.

McCormack BM, Taylor SL, Heath S, Scanlon J. Pseudomeningocele/CSF fistula in a patient with lumbar spinal implants treated with epidural blood patch and a brief course of closed subarachnoid drainage. A case report. Spine. 1996;21(19):2273–6.

Jones AA, Stambough JL, Balderston RA, Rothman RH, Booth RE Jr. Long-term results of lumbar spine surgery complicated by unintended incidental durotomy. Spine. 1989;14(4):443–6.

Epstein NE. The frequency and etiology of intraoperative dural tears in 110 predominantly geriatric patients undergoing multilevel laminectomy with noninstrumented fusions. J Spinal Disord Tech. 2007;20(5):380–6.

Eismont FJ, Wiesel SW, Rothman RH. Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am. 1981;63(7):1132–6.

Black P. Cerebrospinal fluid leaks following spinal surgery: use of fat grafts for prevention and repair. Technical note. J. Neurosurg. 2002;96(2 Suppl):250–2.

Jankowitz BT, Atteberry DS, Gerszten PC, Karausky P, Cheng BC, Faught R, et al. Effect of fibrin glue on the prevention of persistent cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery. Eur Spine J. 2009;18(8):1169–74.

Khan MH, Rihn J, Steele G, Davis R, Donaldson WF 3rd, Kang JD, et al. Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery: a review of 3,183 consecutive degenerative lumbar cases. Spine. 2006;31(22):2609–13.

Hodges SD, Humphreys SC, Eck JC, Covington LA. Management of incidental durotomy without mandatory bed rest: a retrospective review of 20 cases. Spine 1999;24:2062–4.

Gerardi FD, Cammisa FP, Sangani PK. Frequency and sequelae of incidental durotomy. Presented at The 14th annual meeting of the North American Spine Society. 1999.

Kitchel SH, Eismont FJ, Green BA. Closed subarachnoid drainage for management of cerebrospinal fluid leakage after an operation on the spine. J Bone Joint Surg Am. 1989;71(7):984–7.

McMahon P, Dididze M, Levi AD. Incidental durotomy after spinal surgery: a prospective study in an academic institution. J Neurosurg Spine. 2012;17(1):30–6.

Weinstein MA, McCabe JP, Cammisa FP Jr. Postoperative Spinal Wound Infection: A Review of 2,391 Consecutive index procedures. J Spinal Disord. 2000;13(5):422-6.

Elbiaadi-Aziz N, Benzon HT, Russell EJ, Mirkovic S. Cerebrospinal fluid leak treated by aspiration and epidural blood patch under computed tomography guidance. Reg Anesth Pain Med. 2001;26(4):363-7.

Jones AA, Stambough JL, Balderston RA, Rothman RH, Booth RE Jr. Long-term results of lumbar spine surgery complicated by unintended incidental durotomy. Spine. 1989;14(4):443–6.

Tosun B, Ilbay K, Kim MSM, Selek O. Management of Persistent Cerebrospinal Fluid Leakage Following Thoraco-lumbar Surgery. Asian Spine J. 2012;6(3):157–62.

Weng YJ, Cheng CC, Li YY, Huang TJ, Hsu RWW. Management of giant pseudomeningoceles after spinal surgery. BMC Musculoskelet Disord. 2010;11:53.

Coplin WM, Avellino AM, Kim DK, Winn HR, Grady MS. Bacterial meningitis associated with lumbar drains: a retrospective cohort study. J. Neurol Neurosurg Psychiatr. 1999;67(4):468–73.

Lanska DJ, Lanska MJ, Selman WR. Meningitis following spinal puncture in a patient with a CSF leak. Neurology. 1989;39(2):306–7.

Kothe R, Quante M, Engler N, Heider F, Kneibl J, Pirschner S, Siepe C. The effect of incidental durai lesions on outcome after decompression surgery for lumbar spinal stenosis: results of a multi-center study with 800 patients. Eur Spine J. 2017;26(10):2504-11.

Desai A, Ball PA, Bekelis K, Lurie J, Mirza SK, Tosteson TD, et al. SPORT: Does incidental durotomy affect long-term outcomes in cases of spinal stenosis? Neurosurgery. 2015;76(01):57-63.

Ishikura H, Ogihara S, Oka H, Maruyama T, Inanami H, Miyoshi K, et al. Risk factors for incidental durotomy during posterior open spine surgery for degenerative diseases in adults: A multicenter observational study. PLoS One. 2017;12(11):e0188038.

Wolff S, Kheirredine W, Riouallon G. Surgical dural tears: Prevalence and updated management protocol based on 1359 lumbar vertebra interventions. Orthop Traumatol: Surg Res. 2012;98(8):879-86.

Kalevski S, Peev N, Haritonov D. Incidental Dural Tears in lumbar decompressive surgery: Incidence, causes, treatment, results. Asian J Neurosurg. 2010;5(1):54-9.

Thomsen FB, Amtoft O, Andersen M, Bøge-Rasmussen T, Jensen TT, Jensen LE, et al. [Iatrogenic dural lesions in lumbar neural decompressive surgery]. Ugeskrift for laeger. 2010;172:688-91.