Postoperative Management of Incidental Durotomy in Minimally Invasive Lumbar Spinal Surgery

Abstract

Unintended durotomy is a relatively common complication in spine surgery, with a reported incidence up to 14%. Traditional management has been mandatory bed rest for at least 48 h following repair, with or without placement of a drain. With the muscle-splitting approach and decreased potential (dead) space created during minimally invasive spinal surgery (MISS), there is less potential likelihood of symptoms such as spinal headaches or cerebrospinal fluid fistulas. We reviewed the cases of 5 patients undergoing lumbar MISS complicated by an incidental dural tear. Surgical treatment consisted of primary repair and/or use of DuraGen followed by application of either DuraSeal or Tisseel. Although the duration of bed rest varied, postoperative management involved early mobilization less than 48 h after surgery without the use of a drain. One patient was mobilized early on the second postoperative day, 2 patients were mobilized the morning after surgery, and 2 patients were mobilized immediately upon recovery from anesthesia. None of the patients developed symptoms related to durotomy. Although this represents a small series, early postoperative mobilization appears to be a reasonable option and results in shorter hospitalization.

minimally invasive technique - cerebrospinal fluid leak - dural tear - spinal surgery

References

• 1 Wang JC, Bohlman HH, Riew KD. Dural tears secondary to operations on the lumbar spine. Management and results after a two-year-minimum follow-up of eighty-eight patients.  J Bone Joint Surg [Am]. 1998;  80 1728-1732
• 2 Goodkin R, Laska LL. Unintended “incidental” durotomy during surgery of the lumbar spine: medicolegal implications.  Surg Neurol. 1995;  43 4-14
• 3 Perez-Cruet MJ, Foley KT, Isaacs RE. et al . Microendoscopic lumbar discectomy: technical note.  Neurosurgery. 2002;  51 S129-S136
• 4 Khoo LT, Fessler RG. Microendoscopic decompressive laminotomy for the treatment of lumbar stenosis.  Neurosurgery. 2002;  51 S146-S154
• 5 Holly LT, Schwender JD, Rouben DP. et al . Minimally invasive transforaminal lumbar interbody fusion: indications, technique, and complications.  Neurosurg Focus. 2006;  20 E6
• 6 Cammisa Jr FP, Girardi FP, Sangani PK. et al . Incidental durotomy in spine surgery.  Spine. 2000;  25 2663-2667
• 7 Jones AA, Stambough JL, Balderston RA. et al . Long-term results of lumbar spine surgery complicated by unintended incidental durotomy.  Spine. 1989;  14 443-446
• 8 Khan MH, Rihn J, Steele G. et al . Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery: a review of 3,183 consecutive degenerative lumbar cases.  Spine. 2006;  31 2609-2613
• 9 Saxler G, Kramer J, Barden B. et al . The long-term clinical sequelae of incidental durotomy in lumbar disc surgery.  Spine. 2005;  30 2298-2302
• 10 Sin AH, Caldito G, Smith D. et al . Predictive factors for dural tear and cerebrospinal fluid leakage in patients undergoing lumbar surgery.  J Neurosurg Spine. 2006;  5 224-227
• 11 Hughes SA, Ozgur BM, German M. et al . Prolonged Jackson-Pratt drainage in the management of lumbar cerebrospinal fluid leaks.  Surg Neurol. 2006;  65 410-415
• 12 Hodges SD, Humphreys SC, Eck JC. et al . Management of incidental durotomy without mandatory bed rest. A retrospective review of 20 cases.  Spine. 1999;  24 2062-2064
• 13 Eismont FJ, Wiesel SW, Rothman RH. Treatment of dural tears associated with spinal surgery.  J Bone Joint Surg [Am]. 1981;  63 1132-1136
• 14 Kitchel SH, Eismont FJ, Green BA. Closed subarachnoid drainage for management of cerebrospinal fluid leakage after an operation on the spine.  J Bone Joint Surg [Am]. 1989;  71 984-987
• 15 Patel MR, Caruso PA, Yousuf N. et al . CT-guided percutaneous fibrin glue therapy of cerebrospinal fluid leaks in the spine after surgery.  AJR Am J Roentgenol. 2000;  175 443-446
• 16 Rosen DS, O'Toole JE, Eichholz KM. et al . Minimally invasive lumbar spinal decompression in the elderly: outcomes of 50 patients aged 75 years and older.  Neurosurgery. 2007;  60 503-510
• 17 Palmer S. Use of a tubular retractor system in microscopic lumbar discectomy: 1 year prospective results in 135 patients.  Neurosurg Focus. 2002;  13 E5
• 18 Le H, Sandhu FA, Fessler RG. Clinical outcomes after minimal-access surgery for recurrent lumbar disc herniation.  Neurosurg Focus. 2003;  15 E12

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