Incidental durotomy in spine surgery: first aid in ten steps

• Published in: European spine journal Vol. 24; no. 9; pp. 2077 - 2084
• Main Authors: Papavero, Luca, Engler, Nils, Kothe, Ralph
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01-09-2015; Springer Nature B.V
• Subjects: Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Leak - epidemiology; Cerebrospinal Fluid Leak - surgery; Decompression, Surgical; Diskectomy; Dura Mater - injuries; Dura Mater - surgery; Female; First Aid; Humans; Intervertebral Disc Degeneration - surgery; Intraoperative Complications - epidemiology; Intraoperative Complications - surgery; Learning Curve; Lumbar Vertebrae - surgery; Male; Medicine; Medicine & Public Health; Middle Aged; Neurosurgery; Original Article; Reoperation; Retrospective Studies; Risk Factors; Surgical Orthopedics; Complications in spine surgery; Dural tear; Cerebrospinal fluid leak; Incidental durotomy; Surgical education
• ISSN: 0940-6719; 1432-0932
• DOI: 10.1007/s00586-015-3837-x

Introduction
Incidental durotomy (ID) is the most common complication of spine surgery. Revision procedures, ossification of the yellow ligament, or synovial cysts are well-known risk factors. The size, shape, and severity of ID are unpredictable, ranging from a pinpoint hole to a several centimeters large dural laceration with transected fibers following the slippage of a cutting burr. Furthermore, the occurrence of ID is always unexpected. Intra-operative management is often based on a steep learning curve rather than a structured scheme.
Purpose
To provide an intra-operative ten-step closure technique (10ST) for IDs of varying severity.
Methods
A database of 4020 consecutive surgeries for lumbar degenerative disease over the past 4 years was searched for ID. The records of 176 patients were analyzed. Two dural repair techniques were compared: the “individual” technique (InT) and the 10ST.
Results
The overall prevalence of ID was 4.4 %. The prevalence was lowest in virgin micro-discectomies (1.7 %) and ranged from 3.6 % in decompression for spinal canal stenosis up to 14.5 % in revision procedures. All surgeries were performed with the aid of a microscope. Among 107 primary surgeries, the InT achieved a single-stage closure of the ID in 96 procedures (89.7 %). Among 20 virgin surgeries, the 10ST was successful in all cases (
P
 = 0.21). Among 42 re-do procedures following failed attempts to stop cerebrospinal fluid (CSF) leakage, the InT achieved single-stage closure in 36 procedures (85.7 %). The 10ST was successful in all 26 cases (
P
 = 0.03). The follow-up was 1 year.
Conclusions
The 10ST should be considered for successful single-stage closure in primary repair of ID.