Incidental Durotomy During Lumbar Spine Surgery

Background Context: Dural tear causing a cerebrospinal fluid (CSF) leak is a well-known risk of lumbar spinal procedures. The incidence of a CSF leak is higher in cases involving repeated operations and when the surgeon is less experienced; however, the overall outcome of the patient would not be adversely affected by the presence of a dural tear. Purpose: The current study reports a wide variation in rates of dural tears in spine surgery. The purpose of the present study was to elucidate the incidence, risk factors, and effect on outcome of an incidental dural lesion in lumbar disk herniation (LDH) surgery. Study Design/Setting: A prospective evaluation was performed for all patients undergoing elective lumbar spine surgery. Patient Sample (Must be Included in Clinical Studies): Inclusion criteria to enter the study were a diagnosis of symptomatic, posterior LDH by spine specialists (orthopedic and neurosurgeons) in patients aged 18 to 65 years with pain and/or neurological signs in concordant distribution lasting at least over 6 weeks of appropriate conservative treatment consisting of systemic drugs for pain relief and/or epidural steroid administration. Outcome Measures (Must be Included in Clinical Studies): CSF leak and pseudomeningocele formation. Methods: A prospective evaluation was carried out for all patients undergoing elective lumbar spine surgery between July 2007 and March 2009. Inclusion criteria to enter the study were a diagnosis of symptomatic, posterior LDH by spine specialists (orthopedic and neurosurgeons) in patients aged 18 to 65 years with pain and/or neurological signs in concordant distribution lasting at least over 6 weeks of appropriate conservative treatment consisting of systemic drugs for pain relief and/or epidural steroid administration. The purpose of the present study was to elucidate the incidence, risk factors, and effect on outcome of an incidental dural lesion in LDH surgery. Results: In 1116 spinal procedures, 92 dural tears noted intraoperatively were repaired during the procedure using the fat-graft techniques described previously. There were 6 cases of postoperative CSF leak that was readily controlled by placement of additional skin sutures. A total of 1116 patients were prospectively entered in the study, of whom 567 were male (47.2%) and 549 were female (49.3%), with a mean age of 43.2 years (range, 22 to 65 y). In 4 cases, pseudomeningocele occurred as a complication of extradural surgery. Conclusions: This prospective study has shown an incidence rate of 8.24% for dural lesions in LDH surgery. For patients who have undergone operations previously, the risk is doubled. Patients with previous surgery have more back pain before surgery and a lower quality of life. A conclusion that can be drawn from this study is that a dural lesion is a technical problem that should be solved during surgery and, if so, it bears no negative implications on the 1-year postoperative outcome.