Incidental durotomy after spinal surgery: a prospective study in an academic institution

Presented at the 2012 Joint Spine Section Meeting 

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Object

Incidental durotomies (IDs) are an unfortunate but anticipated potential complication of spinal surgery. The authors surveyed the frequency of IDs for a single spine surgeon and analyzed the major risk factors as well as the impact on long-term patient outcomes.

Methods

The authors conducted a prospective review of elective spinal surgeries performed over a 15-year period. Any surgery involving peripheral nerve only, intradural procedures, or dural tears due to trauma were excluded from analysis. The incidence of ID was categorized by surgery type including primary surgery, revision surgery, and so forth. Incidence of ID was also examined in the context of years of physician experience and training. Furthermore, the incidence and types of sequelae were examined in patients with an ID.

Results

Among 3000 elective spinal surgery cases, 3.5% (104) had an ID. The incidence of ID during minimally invasive procedures (3.3%) was similar, but no patients experienced long-term sequelae. The incidence of ID during revision surgery (6.5%) was higher. There was a marked difference in incidence between cervical (1.3%) and thoracolumbar (5.1%) cases. The incidence was lower for cases involving instrumentation (2.4%). When physician training was examined, residents were responsible for 49% of all IDs, whereas fellows were responsible for 26% and the attending for 25%. Among all of the cases that involved an ID, 7.7% of patients went on to experience a neurological deficit as compared with 1.5% of those without an ID. The overall failure rate of dural repair was 6.9%, and failure was almost 3 times higher (13%) in revision surgery as compared with a primary procedure (5%).

Conclusions

The authors established a reliable baseline incidence for durotomy after spine surgery: 3.5%. They also identified risk factors that can increase the likelihood of a durotomy, including location of the spinal procedure, type of procedure performed, and the implementation of a new procedure. The years of physician training or resident experience did not appear to be a major risk for ID.

Abbreviations used in this paper:ID = incidental durotomy; PGY = postgraduate year.

Article Information

Address correspondence to: Allan D. Levi, M.D., Ph.D., Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4–6), Miami, Florida 33136. email: alevi@med.miami.edu.

Please include this information when citing this paper: published online April 27, 2012; DOI: 10.3171/2012.3.SPINE11939.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Intraoperative photographs showing a dural rent and its repair. A: Intraoperative incidental durotomy with herniation of the dorsal rootlet (dotted circle). B: Repair with figure of 8 5-0 Prolene sutures in a watertight fashion. C: Durotomy covered with a DuraGen graft patch.

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    Bar graph demonstrating the number of dural tears during minimally invasive procedures by year of occurrence.

  • View in gallery

    Pie chart depicting the incidence of IDs by level of training.

  • View in gallery

    Bar graph demonstrating the number of IDs relative to residency neurosurgical training. # of IDs = total number of IDs per training level.

  • View in gallery

    Sagittal T2-weighted MR image (left) and early phase postmyelogram sagittal reconstructed CT (right) of postoperative lumbar spine demonstrating early filling of pseudomeningocele (arrow).

References

1

Aydinli UKaraeminogullari OTiskaya KOztürk C: Dural tears in lumbar burst fractures with greenstick lamina fractures. Spine (Phila Pa 1976) 26:E410E4152001

2

Belanger TARoh JSHanks SEKang JDEmery SEBohlman HH: Ossification of the posterior longitudinal ligament. Results of anterior cervical decompression and arthrodesis in sixty-one North American patients. J Bone Joint Surg Am 87:6106152005

3

Black P: Cerebrospinal fluid leaks following spinal surgery: use of fat grafts for prevention and repair. Technical note. J Neurosurg 96:2 Suppl2502522002

4

Cammisa FP JrGirardi FPSangani PKParvataneni HKCadag SSandhu HS: Incidental durotomy in spine surgery. Spine (Phila Pa 1976) 25:266326672000

5

Campbell PGHanna AHarrop JSSpinal dural injuries. Herkowitz HNGarfin SREismont FJ: Rothman-Simeone The Spine ed 6PhiladelphiaElsevier Saunders2011. 2:17201727

6

Desai ABall PABekelis KLurie JMirza SKTosteson TD: SPORT: does incidental durotomy affect long-term outcomes in cases of spinal stenosis?. Neurosurgery 69:38442011

7

Desai ABall PABekelis KLurie JDMirza SKTosteson TD: Outcomes after incidental durotomy during firsttime lumbar discectomy. Clinical article. J Neurosurg Spine 14:6476532011

8

Eismont FJWiesel SWRothman RH: Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am 63:113211361981

9

Farhat HIElhammady MSLevi ADAziz-Sultan MA: Cervical subarachnoid catheter placement for continuous cerebrospinal fluid drainage: a safe and efficacious alternative to the classic lumbar cistern drain. Neurosurgery 68:1 Suppl Operative52562011

10

Fessler RGKhoo LT: Minimally invasive cervical microendoscopic foraminotomy: an initial clinical experience. Neurosurgery 51:5 SupplS37S452002

11

Goodkin RLaska LL: Unintended “incidental” durotomy during surgery of the lumbar spine: medicolegal implications. Surg Neurol 43:4141995

12

Hadani MFindler GKnoler NTadmor RSahar AShacked I: Entrapped lumbar nerve root in pseudomeningocele after laminectomy: report of three cases. Neurosurgery 19:4054071986

13

Hannallah DLee JKhan MDonaldson WFKang JD: Cerebrospinal fluid leaks following cervical spine surgery. J Bone Joint Surg Am 90:110111052008

14

Hodges SDHumphreys SCEck JCCovington LA: Management of incidental durotomy without mandatory bed rest. A retrospective review of 20 cases. Spine (Phila Pa 1976) 24:206220641999

15

Hughes SAOzgur BMGerman MTaylor WR: Prolonged Jackson-Pratt drainage in the management of lumbar cerebrospinal fluid leaks. Surg Neuro1 65:4104152006

16

Jankowitz BTAtteberry DSGerszten PCKarausky PCheng BCFaught R: Effect of fibrin glue on the prevention of persistent cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery. Eur Spine J 18:116911742009

17

Jones AAStambough JLBalderston RARothman RHBooth RE Jr: Long-term results of lumbar spine surgery complicated by unintended incidental durotomy. Spine (Phila Pa 1976) 14:4434461989

18

Khan MHRihn JSteele GDavis RDonaldson WF IIIKang JD: Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery: a review of 3,183 consecutive degenerative lumbar cases. Spine (Phila Pa 1976) 31:260926132006

19

Kitchel SHEismont FJGreen BA: Closed subarachnoid drainage for management of cerebrospinal fluid leakage after an operation on the spine. J Bone Joint Surg Am 71:9849871989

20

Lauer KKHaddox JD: Epidural blood patch as treatment for a surgical durocutaneous fistula. J Clin Anesth 4:45471992

21

Leung PC: Complications in the first 40 cases of microdiscectomy. J Spinal Disord 1:3063101988

22

Lu CHHo STKong SSCherng CHWong CS: Intracranial subdural hematoma after unintended durotomy during spine surgery. Can J Anaesth 49:1001022002

23

Maycock NFvan Essen IPfitzner I: Post-laminectomy cerebrospinal fluid fistula treated with epidural blood patch. Spine (Phila Pa 1976) 19:222322251994

24

Miller PRElder FW Jr: Meningeal pseudocysts (meningocele spurius) following laminectomy. Report of ten cases. J Bone Joint Surg Am 50:2682761968

25

Narotam PKJosé SNathoo NTaylon CVora Y: Collagen matrix (DuraGen) in dural repair: analysis of a new modified technique. Spine (Phila Pa 1976) 29:286128692004

26

O'Connor DMaskery NGriffiths WE: Pseudomeningocele nerve root entrapment after lumbar discectomy. Spine (Phila Pa 1976) 23:150115021998

27

Park PLeveque JCLa Marca FSullivan SE: Dural closure using the U-clip in minimally invasive spinal tumor resection. J Spinal Disord Tech 23:4864892010

28

Patel MRLouie WRachlin J: Postoperative cerebrospinal fluid leaks of the lumbosacral spine: management with percutaneous fibrin glue. AJNR Am J Neuroradiol 17:4955001996

29

Rampersaud YRMoro ERNeary MAWhite KLewis SJMassicotte EM: Intra-operative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. Spine (Phila Pa 1976) 31:150315102006

30

Saxler GKrämer JBarden BKurt APförtner JBernsmann K: The long-term clinical sequelae of incidental durotomy in lumbar disc surgery. Spine (Phila Pa 1976) 30:229823022005

31

Scarrow AMZusman EBall PAWehby M: Review of closed-claim malpractice litigation in neurosurgery. AANS Neurosurgeon 20:32372011

32

Sciubba DMKretzer RMWang PP: Acute intracranial subdural hematoma following a lumbar CSF leak caused by spine surgery. Spine (Phila Pa 1976) 30:E730E7322005

33

Shaffrey CISpotnitz WDShaffrey MEJane JA: Neurosurgical applications of fibrin glue: augmentation of dural closure in 134 patients. Neurosurgery 26:2072101990

34

Shapiro SAScully T: Closed continuous drainage of cerebrospinal fluid via a lumbar subarachnoid catheter for treatment or prevention of cranial/spinal cerebrospinal fluid fistula. Neurosurgery 30:2412451992

35

Silvers HRLewis PJAsch HL: Decompressive lumbar laminectomy for spinal stenosis. J Neurosurg 78:6957011993

36

Sin AHCaldito GSmith DRashidi MWillis BNanda A: Predictive factors for dural tear and cerebrospinal fluid leakage in patients undergoing lumbar surgery. J Neurosurg Spine 5:2242272006

37

Tafazal SISell PJ: Incidental durotomy in lumbar spine surgery: incidence and management. Eur Spine J 14:2872902005

38

Tatsui CEMartinez GLi XPattany PLevi AD: Evaluation of DuraGen in preventing peridural fibrosis in rabbits. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2005. J Neurosurg Spine 4:51592006

39

Than KDWang ACEtame ABLa Marca FPark P: Postoperative management of incidental durotomy in minimally invasive lumbar spinal surgery. Minim Invasive Neurosurg 51:2632662008

40

Vakharia SBThomas PSRosenbaum AEWasenko JJFellows DG: Magnetic resonance imaging of cerebrospinal fluid leak and tamponade effect of blood patch in postdural puncture headache. Anesth Analg 84:5855901997

41

Wang JCBohlman HHRiew 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 80:172817321998

42

Wiese MKrämer JBernsmann KErnst Willburger R: The related outcome and complication rate in primary lumbar microscopic disc surgery depending on the surgeon's experience: comparative studies. Spine J 4:5505562004

43

Williams BJSansur CASmith JSBerven SHBroadstone PAChoma TJ: Incidence of unintended durotomy in spine surgery based on 108,478 cases. Neurosurgery 68:1171242011

44

Woodrow SIBernstein MWallace MC: Safety of intracranial aneurysm surgery performed in a postgraduate training program: implications for training. J Neurosurg 102:6166212005

45

Zimmerman RMKebaish KM: Intracranial hemorrhage following incidental durotomy during spinal surgery. A report of four patients. J Bone Joint Surg Am 89:227522792007

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