Management of Incidental Dural Tear during Lumbar Spine Surgery. To Suture or Not To Suture?

Aim: Incidental durotomy (ID) during lumbar spine surgery is a frequent complication of growing clinical relevance as the number and complexity of spinal procedures increases. Yet, there is still a lack of guidelines for the treatment of ID with a large heterogeneity of established surgical techniques. The aim of this study was to investigate the efficacy of dural suturing in patients having ID during lumbar spine surgery, compared with other dural closure techniques. Methods: Patients undergoing decompressive lumbar spine surgery with fusion, experiencing intraoperative ID, were retrospectively reviewed. The patients were divided into three groups depending on the dural closure technique used. Group A: sole dural suture; group B: dural suture in combination with TachoSil^®, muscle, and/or fat patch; group C: TachoSil^®, muscle, and/or fat patch only. The primary end point was revision operation due to complications of liquor leakage after 6 weeks. The secondary end points were hospitalization time, operative time, clinical outcome, surgical morbidity, and mortality, at 6 weeks. Results: Out of 105 consecutive patients undergoing decompressive lumbar spine surgery with fusion in 13 patients (12.4%, 6 females) ID was caused. The mean age at the time of surgery was 70.2 ( ±  9.1) years. Group A included five patients (38.5%), group B and C four patients (30.8%) each. Revision surgery, due to wound infection, was indicated in two patients (15.4%), one out of group A and the other out of group C. All patients from groups A and B showed clinical improvement on follow-up, while in group C in 50% of the cases (n = 2) no clinical improvement was seen. The mean hospitalization and per segment operation time was 13 days and 123 minutes in group A, 9 days and 114.4 minute in group B, and 21.5 days and 100.9 minute in group C. Surgical morbidity occurred in one patient (7.7%, group B), where a revision surgery due to an epidural hematoma was concluded, while mortality rate was 0%. Conclusion: The preliminary data might suggest that dural repair should not be done using solely dural suture or solely a patch, but rather combine these methods. However, conclusions cannot be drawn yet, due to the small number of patients. A larger cohort of patients will be acquired and the statistical results presented.