Intracranial subdural hematoma after unintended durotomy during spine surgery

Lu, Chueng-He; Ho, Shung‐Tai; Kong, Shang-Shung; Cherng, Chen‐Hwan; Wong, Chih‐Shung

doi:10.1007/bf03020428

Cited by 63 publications

(29 citation statements)

References 11 publications

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“…Failure to achieve watertight dural closure not only can increase the incidence of spinal headache, nausea, and vomiting immediately after surgery, 23,28,33 but may also predispose patients to more serious postoperative complications such as CSF leakage, CSF-cutaneous fistula, pseudomeningocele, wound infection, meningitis, and even intracranial hemorrhage. 1,14,17 Some methods of MIS dural closure have been described in the literature. Chou et al 4 reported a technique for MIS primary dural repair using a micropituitary rongeur as the needle holder in combination with a laparoscopic knot pusher commonly used in arthroscopy.…”

Section: Discussionmentioning

confidence: 99%

Management of intended durotomy in minimally invasive intradural spine surgery

Tan¹,

Takagi²,

Straus³

et al. 2014

SPI

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Object Minimally invasive surgery (MIS) has been increasingly used for the treatment of various intradural spinal pathologies in recent years. Although MIS techniques allow for successful treatment of intradural pathology, primary dural closure in MIS can be technically challenging due to a limited surgical corridor through the tubular retractor system. The authors describe their experience with 23 consecutive patients from a single institution who underwent MIS for intradural pathologies, along with a review of pertinent literature. Methods A retrospective review of a prospectively collected surgical database was performed to identify patients who underwent MIS for intradural spinal pathologies between November 2006 and July 2013. Patient demographics, preoperative records, operative notes, and postoperative records were reviewed. Primary outcomes include operative duration, estimated blood loss, length of bed rest, length of hospital stay, and postoperative complications, which were recorded prospectively. Results Twenty-three patients who had undergone MIS for intradural spinal pathologies during the study period were identified. Fifteen patients (65.2%) were female and 8 (34.8%) were male. The mean age at surgery was 54.4 years (range 30–74 years). Surgical pathologies included neoplastic (17 patients), congenital (3 patients), vascular (2 patients), and degenerative (1 patient). The most common spinal region treated was lumbar (11 patients), followed by thoracic (9 patients), cervical (2 patients), and sacral (1 patient). The mean operative time was 161.1 minutes, and the mean estimated blood loss was 107.2 ml. All patients were allowed full activity less than 24 hours after surgery. The median length of stay was 78.2 hours. Primary sutured dural closure was achieved using specialized MIS instruments with adjuvant fibrin sealant in all cases. The rate of postoperative headache, nausea, vomiting, and diplopia was 0%. No case of cutaneous CSF fistula or symptomatic pseudomeningocele was identified at follow-up, and no patient required revision surgery. Conclusions Primary dural closure with early mobilization is an effective strategy with excellent clinical outcomes in the use of MIS techniques for intradural spinal pathology. Prolonged bed rest after successful primary dural closure appears unnecessary, and the need for watertight dural closure should not prevent the use of MIS techniques in this specific patient population.

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Section: Discussionmentioning

confidence: 99%

Management of intended durotomy in minimally invasive intradural spine surgery

Tan¹,

Takagi²,

Straus³

et al. 2014

SPI

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“…4,8,9,19,39 However, serious complications, such as neurological deficit, pseudomeningocele, meningitis, and intracranial hemorrhage, have been reported. 4,5,7,11,14,20,[23][24][25][26][27][28]34,42 In addition, rates of persistent CSF wound leak and pseudomeningocele formation have been reported to be as high as 17.6%. 15 In our series of patients with a mean follow-up of 310 days, there were no complications referable to durotomy, which compares favorably with the current literature on durotomies after open cases.…”

Section: Discussionmentioning

confidence: 99%

Management of incidental durotomy in minimally invasive spine surgery

Ruban

O’Toole²

2011

FOC

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Object Unintended durotomy is one of the most common complications in spine surgery that may lead to serious complications if not recognized or treated properly. There are few reports on the management of durotomies incurred during minimally invasive spine surgery (MISS). The authors describe their experience in a series of consecutive MISS patients with unintended durotomies. Methods All patients who underwent MISS by the senior author between August 2006 and February 2011 were retrospectively reviewed, and cases with unintended durotomies were identified. A case-control study was carried out comparing patient demographics and perioperative data between patients with and without durotomy. Surgical technique, including a proposed algorithm for management of durotomies, is described. Results Unintended durotomy occurred in 53 (9.4%) of 563 patients. The mean age at surgery was 60.7 years (range 30–85 years). Previous surgery at the same level was performed in 5 patients (9.4%). Two patients underwent posterior cervical surgery, and 51 patients underwent posterior lumbar surgery. Decompression alone was performed in 32 patients (60.4%), and fusion was performed in 21 patients (39.6%). The mean operative time was 105 minutes in the decompression group and 310 minutes in the fusion group (p < 0.001). Estimated blood loss was 60 ml in the decompression group and 381 ml in the fusion group (p < 0.001). The hospital length of stay was 52 hours in the decompression group and 106 hours in the fusion group (p < 0.001). The mean follow-up was 310 days, and there were no cases of cutaneous CSF fistula, pseudomeningocele, or other complications referable to durotomy in either group. Risk factors identified for durotomy included previous operation at the same level (p = 0.019) and operation in the lumbar spine region (p = 0.001). Conclusions In the authors' consecutive series of patients undergoing MISS, an unintended durotomy was associated with fewer complications than previously reported for open spinal surgery. The authors propose a simple management algorithm that includes early mobilization and results in excellent clinical outcomes with no incidence of postoperative cutaneous CSF fistula or other complications.

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“…The result is a SSDH due to intracranial hemorrhage and migration of blood into the spinal subdural space, facilitated by CSF hypovolemia and gravity [20][21][22][23][24][25][26][27][28][29][30][31][32]. This pathophysiology is also cited for SSDH, after incidental durotomy associated with CSF leak [33][34][35].…”

Section: Discussionmentioning

confidence: 99%

Acute Spinal Subdural Hematoma Subsequent To Posterior Lumbar Fusion

Ali

Barkley²,

Malhotra³

2013

J Osteopor Phys Act

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of arthrodesis is exceedingly rare [6][7][8][9]. We present a case of acute SSDH, presenting with cauda equina after surgical decompression and reconstruction, as well as summarize the current literature on SSDH. Case ReportA 72 year old man presented with lower back pain extending down the left anterior thigh, one year after an uncomplicated L2-5 laminectomy for lumbar spinal stenosis. AbstractObjective: To report a rare case of post-operative cauda equina syndrome subsequent to lumbar decompression and reconstruction, and review the relevant anatomical causes of spinal subdural hematoma. We present a case report of an acute spinal subdural hematoma, following surgical decompression and fusion. The etiology of spinal subdural hematoma after spinal surgery is controversial. We propose that violation of the dural-arachnoid interface is a likely mechanism of this complication. Summary of background data:Spinal subdural hematoma (SSDH) is a very rare postoperative complication of surgical decompression. We report the presentation of acute SSDH presenting with acute cauda equine, following lumbar decompression and reconstruction in a patient lacking risk factors for this rare complication. Methods:A 72 year old man with a history of prior L2-5 laminectomy presented with persistent lower back and left lower extremity radicular pain, due to lumbar spondylosis with foraminal stenosis due to synovial cyst, and lumbar disc herniation. He underwent a revision L2-5 laminectomy with foramintomies, L3-4 synovial cyst resection, and L3-4 posterolateral instrumented fusion. Small incidental duratomy without arachnoid fenestration and without cerebrospinal fluid extravasation, was noted and repaired intraoperatively. On post-operative day four, the patient presented with acute cauda equina syndrome, found to be associated with an acute dorsal lumbar subdural hematoma.Results: After emergent evacuation of the hematoma, patient had immediate resolution of symptoms, and continued to demonstrate dramatic improvement after 1-year follow-up. Conclusions:Despite its low incidence, SSDH should be considered in the setting of acute cauda equina syndrome, following surgical decompression. Prompt evacuation of hematoma is associated with good prognosis. The etiology of SSDH post spinal surgery is controversial. Violation of the dural-arachnoid interface and destruction of local neurothelial cells is the suspected etiology of this very rare complication. Key Points* SSDH is a very rare complication of surgical decompression, with coagulopathy conferring an increased risk.* Although rare, acute SSDH should be considered in the setting of acute cauda equina syndrome, following lumbar decompression associated with intraoperative durotomy, without spinal fluid leak.* Emergent evacuation of SSDH provides greatest chance of good prognosis and reversal of symptoms.* Our case demonstrates that violation of the dural-arachnoid interface is a plausible etiology for postoperative SSDH.

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Intracranial subdural hematoma after unintended durotomy during spine surgery

Abstract: Purpose: To report a case of intracranial subdural hematoma occurring after a spinal dural tear that was made unintentionally during the course of a posterior laminectomy and spinal fusion at the L 5 -S 1 level. The possible physiopathological mechanisms are discussed.

Cited by 63 publications

References 11 publications

Management of intended durotomy in minimally invasive intradural spine surgery

Management of intended durotomy in minimally invasive intradural spine surgery

Management of incidental durotomy in minimally invasive spine surgery

Acute Spinal Subdural Hematoma Subsequent To Posterior Lumbar Fusion

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