Incidental durotomy during lumbar spine surgery: risk factors and anatomic locations

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Object

Incidental durotomy (dural tear) is a common complication of lumbar spine surgery. The purpose of this study was to clarify the anatomical location of and the specific causative factors for incidental durotomy during primary lumbar spine surgery.

Methods

The authors retrospectively reviewed 1014 consecutive cases involving patients (412 women and 602 men; mean age 57 years; age range 11–97 years) who underwent a surgical procedure for treatment of degenerative lumbar spinal disease at their institution between 2002 and 2008. In total, 1261 disc levels were treated surgically. Disease at the treated levels included 544 disc herniations, 453 instances of spinal canal stenosis without spondylolisthesis, 188 instances of lumbar spinal canal stenosis with spondylolisthesis (degenerative spondylolisthesis), 49 instances of combined stenosis (stenosis with disc herniation), and 22 juxtafacet cysts. In 5 of the treated levels, the condition was classified as “other” disease. Treatment included fenestration with discectomy in 547 levels, fenestration alone in 626, fenestration with resection of juxtafacet cysts in 22, unilateral recapping laminoplasty in 20, posterolateral spinal fusion or posterior lumbar interbody fusion in 17, microscopic discectomy with tubular retractor in 14, and “other” in 15.

Results

Unintended durotomy occurred in 4% of cases and in 3.3% of disc levels. The incidence of dural tear was significantly higher in women (5.6%) than in men (3%). The incidence of dural tear was 2% in disc levels with lumbar disc herniation, 1.8% with lumbar spinal canal stenosis without spondylolisthesis, 9% with degenerative spondylolisthesis, and 18.2% with juxtafacet cysts; the incidence was significantly higher in levels with degenerative spondylolisthesis or levels with juxtafacet cysts, than in those with other diseases. Incidental durotomy occurred in 4 critical anatomical zones, namely, the caudal margin of the cranial lamina, cranial margin of the caudal lamina, herniated disc level, and medial aspect of the facet joint adjacent to the insertion of the hypertrophic ligamentum flavum.

Conclusions

Risk factors for unintended durotomy were female sex, older age, degenerative spondylolisthesis, and juxtafacet cysts. In this study, the authors identified 4 high-risk anatomical zones that spine surgeons should be aware of to avoid dural tears.

Abbreviation used in this paper:JOA = Japanese Orthopaedic Association.

Article Information

Address correspondence to: Yoshimasa Takahashi, M.D., 24 Aza Higashi-dori, Izai, Wakabayashi-ku, Sendai, Miyagi 984-0038, Japan. email: ta-yoshi@sendaiseikei.or.jp.

Please include this information when citing this paper: published online November 30, 2012; DOI: 10.3171/2012.10.SPINE12271.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Incidence of dural tear stratified by disc level. There was no significant difference between disc levels.

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    Incidence of dural tear stratified by disease or condition being treated. The incidence of dural tear in levels with juxtafacet cysts or degenerative spondylolisthesis was significantly higher than that in levels with other diseases. LDH = lumbar disc herniation; LCS = degenerative spinal stenosis without spondylolisthesis; DS = degenerative spondylolisthesis; CS = combined stenosis (stenosis with disc herniation); Cyst = juxtafacet cyst. *p < 0.05.

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    Incidence of dural tear stratified by surgical procedure. The incidence of dural tear during fenestration with resection of juxtafacet cysts was significantly higher than that during other operations. F = fenestration; F+Cyst = fenestration with resection of juxtafacet cyst. *p < 0.05.

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    Schematic drawings showing the anatomical location of dural tears (indicated by X) according to the condition being treated. A: In patients with lumbar disc herniation, tears occurred mainly near the herniated disc. B: In patients with degenerative spondylolisthesis, dural tears occurred primarily around the medial aspect of the facet joint. C: In patients with lumbar spinal canal stenosis (without spondylolisthesis), dural tears occurred around the medial aspect of the facet joint. D: In patients with juxtafacet cysts, dural tears occurred where adhesive lesions contacted the dura mater. D = disc; FJ = facet joint; LF = ligamentum flavum.

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    Critical zones of unintended durotomy. There are 4 critical anatomical zones in lumbar fenestration where dural tears can occur: Zone 1, cranial margin of fenestration; Zone 2, medial aspect of the facet joint; Zone 3, intervertebral disc; and Zone 4, caudal margin of fenestration.

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