Incidental durotomy during spine surgery: …

1 ReviewIncidental durotomy during spine surgery : incidence , management andcomplications. A retrospective reviewPatrick Guerin*, Abdelkrim Benchikh El Fegoun, Ibrahim Obeid, Olivier Gille, Luc Lelong,Ste phane Luc, Anouar Bourghli, Jean Christophe Cursolle, Vincent Pointillart, Jean-Marc VitalDepartment of Orthopaedic surgery , University Hospital of Bordeaux, Spinal Unit, Place Ame lie Raba Le on, 33076 Bordeaux, FranceContentsIntroduction .. 000 Materials and methods .. 000 Results .. 000 Discussion .. 000 Conclusion .. 000 Conflict of interest statement .. 000 Acknowledgements .. 000 References .. 000 IntroductionAn Incidental dural tear is a frequent intraoperative complica-tion of spine surgery3,37epidural injections and , Int. J. Care Injured xxx (2011) xxx xxxARTICLE INFOA rticle history:Accepted 16 December 2010 Keywords:Dural tearIncidental durotomyComplication in spine surgeryCerebrospinal fluid leakABSTRACTS tudy design:Retrospective review of a series of patients who underwent spinal surgery at a single spineunit during a 1 year :To assess the incidence , treatment, clinical consequence, complications of incidentaldurotomy during spine surgery and results of 37 months clinical of background data: Incidental durotomy is an underestimated and relatively adverse eventduring spinal surgery .

2 Several consequences of inadequately treated dural tears have been :A retrospective review was conducted on 1326 consecutive patients who underwent spinalsurgery performed in one French spine unit from January 2005 to December 2005. We excluded from thisstudy patients treated for emergency spine :Fifty-one dural tears were identified ( ). Incidental durotomies were associated withanterior cervical approach in 1 case, with posterior cervical approach in 1 case, with anteriorretroperitoneal approach in 1 case and with posterior thoracolumbar approach in 48 cases. In addition,any clinically significant durotomy unrecognised during surgical procedure were included. Thirteenpatients presented postoperative complications including 7 cerebrospinal fluid leaks, 2 woundinfections, 2 postoperative haematomas, and 2 pseudomeningoceles. Nine of these 13 patients required arevision procedure.

3 A mean follow-up of 37 months showed good long-term clinical : Incidental durotomy is a common complication of spine surgery . All Incidental durotomiesmust be repaired primarily. Dural tears that were immediately recognised and treated accordingly didnot lead to any significant sequelae at a mean follow-up of 37 months. However, long-term follow-upstudies will be needed to confirm this finding. The risks associated with dural tears and cerebrospinalfluid leaks are serious and should be discussed with any patients undergoing spine surgery . 2010 Elsevier Ltd. All rights reserved.* Corresponding author. Tel.: +33 556798718; fax: +33 Guerin).G ModelJINJ-4522; No. of Pages 5 Please cite this article in press as: Guerin P, et al. Incidental durotomy during spine surgery : incidence , management and retrospective review. Injury (2011), lists available atScienceDirectInjuryjournal homepage: 1383/$ see front matter 2010 Elsevier Ltd.

4 All rights studies have reported incidences ranging from 1% to17%.5,21,31,32,36,39 spine surgeons tend to underestimate thefrequency of Incidental consequences ofinadequately treated dural tears have been ,3,20,38If thedural tear is not properly closed or unrecognised patients canpresent with postural headaches, vertigo, posterior neck pain, neckand/or stiffness, nausea, diplopia, photophobia, tinnitus, andblurred ,24,28 These symptoms are caused by a persistentcerebrospinal fluid leak from the subarachnoid space. The decreasein cerebrospinal fluid pressure leads to a loss of buoyancy andcaudal displacement of the intracranial et the biology of dural tear repair in a canine model. Theyfound that fibroblastic bridging of the dural defect starts on the 6thday and by the 10th day the defect is purpose of the current study is to evaluate incidentaldurotomies during one year in our practice.

5 We want to clarifyassociated surgical procedures, treatments, postoperative clinicaloutcomes, complications and revision and methodsAll patients who underwent degenerative spine and spinaltumour surgeries performed between January 2005 and December2005 in our spine unit were retrospectively reviewed. We excludedfrom this study patients treated for emergency spine cases. Wecollected information on demographics, diagnoses, prior spinesurgeries, details of the surgical procedure, details of the incidentaldurotomy, treatment, postoperative evaluation at a minimum 36months patients underwent degenerative spine surgery in oneyear. Of these, 240 underwent anterior cervical surgery , 14underwent posterior cervical surgery , 24 underwent anteriorthoracic surgery , 32 anterior lumbar surgery and 1048 underwentposterior thoracolumbar and/or lumbo-sacral surgery . We identi-fied 51 dural tears ( ) in the population.

6 Incidental durotomieswere associated with anterior cervical approach in 1 case, withposterior cervical approach in 1 case, with anterior retroperitonealapproach in 1 case and with posterior thoracolumbar approach in48 cases. The mean age of patients with Incidental durotomies years (range 28 84). There were 32 men and 19 women (sexratio). Thirteen patients ( ) had previous spine surgery . Noneof them had previously documented dural tears. All incidentaldurotomies were diagnosed in the perioperative period. Theincidence of durotomies according to the specific procedureperformed is shown inTable 1. The most common cause of duraltears was decompression procedures for lumbar Incidental durotomies were recognised during theperioperative magnetic resonance images. Sequence T1 (A), T2 (B), Spir with gadolinium enhancement (C). The cerebrospinal fluid leak of this pseudomeningocele wascompletely contained.

7 There was no leakage from the incision axial magnetic resonance image. Guerin et al. / Injury, Int. J. Care Injured xxx (2011) xxx xxx2G ModelJINJ-4522; No. of Pages 5 Please cite this article in press as: Guerin P, et al. Incidental durotomy during spine surgery : incidence , management and retrospective review. Injury (2011), Incidental durotomies were treatedprimarily (Table 2). Seventeen cases were not sewn. Of these 11patients were treated with fibrin glue only. The remaining 6 weretreated with Surgicel1(Ethicon, Inc., Somerville, NJ) and fibringlue. In the remainder (33 patients), the repair consisted ofsuturing the defect with a running locked technique. Fibrin gluewas used in 29 of these patients and fibrin glue and Surgicel1(Ethicon, Inc., Somerville, NJ) in 1 patient. We do not use musclegraft, fat graft or fibrin patches for the primary repair ofdurotomies.

8 The Tredelenburg position (for thoracolumbar repair)or reverse Tredelenburg position (for cervical repair) was used inthe all cases. Upon completion of the repair we proceeded toperform the Valsalva manoeuvre. Muscular fascial closure wasachieved with Vicryl1sutures (Ethicon, Inc., Johnson & Johnson,Skillman, NJ) and skin closure was achieved with either staples,running suture, or interrupted sutures. Subfascial drains were usedfor 45 patients ( ) and were kept in place for 2 days in allpatients. For these patients, we did not use wound bed average postoperative bed rest days (range 0 10 days). The length of bed rest required wasdetermined by the surgical procedure, the size of durotomy , thequality of primary repair and postoperative the dural tear is recognised and treated,broad spectrum antibiotic prophylaxis (cefuroxime) is initiatedbefore surgery during 24 h.

9 This protocol is used routinely in ourSpine patients ( ) presented with apostoperative complication (Table 2). These resulted in 9 revisionprocedures. Two patients presented with a deep wound underwent surgical debridement (10 and 14 days afterprimary surgery ) and antibiotic therapy. Two patients presentedwith postoperative epidural haematoma and required surgicalevacuation. Seven patients presented with a persistent cerebrospinalfluid leak. Four of these cases were treated conservatively with bedrest. The remaining three patients required a revision procedure. Onepatient was treated with primary closure via suture, the other with amuscular graft and fibrin glue, and the last with suture and a lumbarsubarachnoid drain. Two patients developed a pseudomeningocele(Figs. 1 and 2) (Fig 1a/b/c and Fig 2). They also underwent a revisionprocedure. Both of them were repaired with suture and Surgicel1(Ethicon, Inc.)

10 , Somerville, NJ). Fibrin glue was used additionally in oneof these patients. All 13 patients with complications achievedsatisfactory outcomes. There were no long-term sequelea at anaverage of 37 months follow-up (range 36 48).DiscussionThere is wide variation in rates of Incidental durotomy in theliterature. The prevalence of Incidental durotomy is 1 ,5,8,18,36,39 The incidence of dural tears is variable accordingto the indications, to the type of procedures and to the differentstudies. The incidence of Incidental durotomies in different studiesis shown inTable 3. Dural tears are commonly associated withcomplex spinal surgery25,35and revision ,5,39 Themorbidity is lower for younger patients and for surgeries ofherniated discs. The rate was increased with age and withprocedures for spinal ,7,8,16,36,39 The incidence increaseswith complexity of et not demonstratedeleterious effects from the use of spinal and Laska12reviewed 146 malpractice cases in a studylooking into the medicolegal aspects of spine surgery .