Incidental durotomy in the pediatric spine population

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Spine surgery is less common in children than adults. These surgeries, like all others, are subject to complications such as bleeding, infection, and CSF leak. The rate of incidental durotomy in the pediatric population, and its associated complications, has scarcely been reported in the literature.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>This is a retrospective chart review of all pediatric patients operated on at Wake Forest Baptist Health from 2012 to 2017 who underwent spine surgeries. The authors excluded any procedures with intended durotomy, such as tethered cord release or spinal cord tumor resection.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>From 2012 to 2017, 318 pediatric patients underwent surgery for a variety of indications, including adolescent idiopathic scoliosis (51.9%), neuromuscular scoliosis (27.4%), thoracolumbar fracture (2.83%), and other non–fusion-related indications (3.77%). Of these patients, the average age was 14.1 years, and 71.0% were female. There were 6 total incidental durotomies, resulting in an overall incidence of 1.9%. The incidence was 18.5% in revision operations, compared to 0.34% for index surgeries. Comparison of the revision cohort to the durotomy cohort revealed a trend toward increased length of stay, operative time, and blood loss; however, the trends were not statistically significant. The pedicle probe was implicated in 3 cases and the exact cause was not ascertained in the remaining 3 cases. The 3 durotomies caused by pedicle probe were treated with bone wax; 1 was treated with dry Gelfoam application and 2 were treated with primary repair. Only 1 patient had a persistent leak postoperatively that eventually required wound revision.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Incidental durotomy is an uncommon occurrence in the pediatric spinal surgery population. The majority occurred during placement of pedicle screws, and they were easily treated with bone wax at the time of surgery. Awareness of the incidence, predisposing factors, and treatment options is important in preventing complications and disability.</jats:p></jats:sec>

Paediatric Spinal Deformity Surgery: Complications and Their Management

“…The surgical strategy should, therefore, include moderate corrective manoeuvres to prevent progression of deformity and decompression to permit neurological recovery. Dural tear may occur during osteotomies, decompression or directly due to the placement of pedicle screw instrumentation; repair should include watertight closure with sutures or clips with or without supplemental fibrin glue and/or overlying patch sealant [ 31 , 32 ]. Traction may be utilised to perform gradual correction of spinal deformity, which may increase the tolerance of the spinal cord to subsequent corrective manoeuvres and definitive surgery [ 33 , 34 ].…”

Surgical treatment of spinal stenosis in achondroplasia: Literature review comparing results in adults and paediatrics

“…In comparison, the incidence of dural tear in general non-achondroplasia patients with spinal stenosis appear to be lower, with incidental durotomy rates in the published literature ranging from 3.5% for primary discectomy and 13.2% for revision discectomy in adult populations, 32 with 0.34% in index procedures and up to 18.5% in revision operations in paediatric populations. 33 The reason for this increased risk of dural tear in Achondroplasia might be secondary to intrinsic, non-modifiable risk factors. These include anatomic sequelae of the underlying dysplasia, such as severity or chronicity of congenital stenosis, increased lumbar lordosis, horizontal positioning of the sacrum, and increased thoracolumbar kyphosis, which may predispose this unique group of patients to this complication.…”

Dural Repair Simulation Model

“…The incidence of ID varies depending on the procedure, with incidence reported as low as 0.34% for primary surgery and as high as 18.5% for revision surgery. 1 Postoperative complications after ID include the need for revision surgery, durocutaneous fistula, pseudomeningocele, and arachnoiditis. Pediatric patients with an ID have 2.7 times greater odds of being readmitted within 30 days of surgery.…”