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 singlestage 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.
The results of this study reveal that an incidental durotomy was associated with a significant increase in the patient's length of stay, and risk for re-intervention for the treatment of persisting CSF leakage. In contrast to previous reports which have investigated the effects of incidental durotomies on the clinical outcome after lumbar decompression surgery, our data further suggest a possible inferior outcome in terms of low back pain improvement in the Dura+ cohort, which became clinically apparent at the 12-month follow-up period. Future studies should investigate whether a more pronounced decompression required for adequate exposure and repair of a dural laceration may, ultimately, result in increased segmental instability and in clinically undesirable low back pain.
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