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

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>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.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>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.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>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.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>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.</jats:p></jats:sec>

Impact of surgical approach on complication rates after elective spinal fusion (≥3 levels) for adult spine deformity

“…In a retrospective study of 4,223 patients, Basques et al identified age >70 years, female sex, pulmonary disease, and preoperative hematocrit <36 as independent risk factors for intraoperative blood transfusion during lumbar fusion using a posterior approach (11). Similarly, in a retrospective study of 1,014 consecutive patients undergoing posterior lumbar fusion, Takahashi et al identified female sex, older age as well as underlying degenerative spondylolisthesis and juxtafacet cysts as risk factors for incidental durotomy (12). Given the higher risk of blood loss associated with posterior approaches by both our study and the literature (2,4,5), preoperative identification of these risk factors might sway surgical decision-making in favor of an anterior approach.…”

Incidental dural tear in spine surgery: analysis of a nationwide database

“…The risk increased with the age, and patients older than 84 years were 2.8 times more likely to have DT than those aged between 18 and 44 years. Age has been previously suggested to be a risk factor for DT [1,7,9]. Possible reasons for age as a risk factor include normal signs of DT group the patients with dural tear, nonDT group the patients without dural tear, WF weighted frequency aging such as narrowing the spinal canal, thicker ligamentum flavum, and osteophyte formation [22].…”

“…The reported incidence of DT for all spine surgeries is 1.6-10 % [1][2][3][4][5][6]. Previous studies have examined various risk factors for DT, which include age, patient gender, and experience level of the surgeon [1,2,[7][8][9][10][11][12]. DTs that cannot be closed, those that are not adequately closed, or those that are unrecognized may result in relevant cerebrospinal fluid leakage, which may cause postural headaches, vertigo, posterior neck pain, neck and/or stiffness, nausea, diplopia, photophobia, tinnitus, and blurred vision [13][14][15].…”

Safety of epidural triamcinolone acetonide use during lumbar decompression surgery in pediatric patients: an association with delayed pseudomeningocele formation

“…Although the occurrence of lumbar CSF leakage or pseudomeningocele following incidental durotomy is well described, 3,5,8,33,35,38 the senior author of the present study (A.J.) noted an alarming rate of symptomatic delayed lumbar spine pseudomeningoceles at our institution following lumbar decompression in the absence of intraoperative durotomy.…”