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Journal List > J Korean Soc Spine Surg > v.10(3) > 1035582

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Shin, Lee, Cho, Choi, Huh, Kim, and Kim: Incidental Dural Tear during Posterior Surgery of Degenerative Lumbar Disease
Original Article

Journal of Korean Spine Surg 2003;10(3):233-239.

Published online: 12 February 2003

DOI: https://doi.org/10.4184/jkss.2003.10.3.233

Incidental Dural Tear during Posterior Surgery of Degenerative Lumbar Disease

Byung-Joon Shin, M.D., Jae-Chul Lee, M.D., Young-Il Cho, M.D., Won-Kee Choi, M.D., Il Huh, M.D., Kyung-Je Kim, M.D., Yon-Il Kim, M.D.

Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Bucheon, Korea

Address reprint requests to Byung-Joon Shin, M.D. Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine #1174 Jung-dong, Wonmi-gu, Bucheon-si, Gyeonggi-do, 420-853, Korea Tel: 82-32-621-5259, Fax: 82-32-324-9577, E-mail: schsbj@schbc.ac.kr

Copyright © 2003 Korean Society of Spine Surgery

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Study Design

A retrospective study.

Objective

To analyze the clinical features and prognosis of intraoperative incidental durotomy during posterior surgery for degenerative lumbar disease. In addition, we tried to evaluate clinical outcome and safety of skillful neglect of pin point dural tear.

Summary of literature review

Incidental durotomy is one of the most common complications during the operation of degenerative lumbar disease. It may cause signs and symptoms of cerebrospinal fluid leakage and complications such as meningitis, wound infection, pseudomeningocele and fistula. From the literature review, primary repair is mandatory even in the case of pin point dural tear.

Materials and methods

Seven hundred fifty- five patients with degenerative lumbar disease, who were operated posteriorly from Jan. 1990 to Feb. 2002, were reviewed retrospectively. Primary operations were 378 cases of laminectomy without instrumentation and 377 cases of decompression and instrumented fusion. Of these patients, 44 (6 percent) sustained an incidental dural tear.
We analyzed the mechanisms of dural tear, intraoperative treatment, postoperative management and clinical outcome.

Results

Eight cases (2.1%) of dural tears occurred during discectomy, 36 (9.5%) during instrumentation and fusion, and 12 (20%) during revision surgery. Dural tears were treated intraoperatively by primary repair in 20 cases, by fascial graft in 2 and without repair (skillful neglect) in 22. There were no cases of persistent cerebrospinal fluid leakage or fistula formation, and the symptoms of cerebrospinal fluid leakage were transient. Of 36 patients followed for more than one year, 82% had good or excellent result.

Co nclusio n

Incidental durotomy occurred in 5.8 percent of lower back surgery patients, and more frequently in revision surgery. Very small dural tears did not have significant influence on the clinical outcome, whether they were repaired or not. Skillful neglect of pin point dural tear may be a reasonable treatment option.

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Keywords: Intraoperative incidental durotomy, Degenerative lumbar surgery

REFERENCES

1). Jones AAM, Stambough JL, Balderston RA, Rothman RH, Booth RE. Long-term results of lumbar spine surgery complicated by unintended incidental durotomy. Spine. 1989; 14:443–446.
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2). Stolke D, Sollmann W, Seifert V. Intra- and postoperative complications in lumbar disc surgery. Spine. 1989; 14:56–59.
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3). Waisman M, Schweppe Y. Postoperative cerebrospinal fluid leakage after lumbar spine operations;conservative treatment. Spine. 1991; 16:52–53.
4). Eismont FJ, Wiesel SW, Rothman RH. Treatment of dural tears associated with spinal surgery. J Bone Joint Surg. 1981; 63A:1132–1136.
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5). Kim NH, Lee WH. Clinical study on treatment of Spondylolisthesis. J Kor Orthop Assoc. 1992; 27:1263–1272.
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6). Stephen JB, Gardner MJ, Guille JT. Evaluation and treatment of dural tears in lumbar spine surgery. Clin Orthop. 2001; 389:238–247.
7). Wang JC, Bohlman HH, Riew KD. Dural tears sec -ondary to operations on the lumbar spine. J Bone Joint Surg. 1998; 80A:1728–1732.
8). Hagen R, Engesaeter LB. Unilateral and bilateral par -tial laminectomy in lumbar disc prolapse. A follow-up study of 156 patients. Acta Orthop Scand. 1977; 48:41–46.
9). Wiesel SW. The multiply-operated lumbar spine. Instructional Course Lecture. 34. St Louis: CV Mosby;p. 67–77. 1985.
10). Davne SH, Myers DL. Complications of lumbar spinal fusion with transpedicular instrumentation. Spine. 1992; 17(Suppl 6):S184–S189.
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11). Kadrie H, Driedger AA, McInnis W. Persistent dural cerebrospinal fluid leak shown by retrograde radionuclide myelography. A case report. J Nucl Med. 1976; 17:797–799.
12). Mayfield FH, Kurokawa K. Watertight closure of spinal dura mater: Technical note. J Neurosurg. 1975; 43:639–640.
13). Morris GF, Marshall LF. Cerebrospinal Fluid Leaks: Etiology and treatment. Rothman-Simeone , editor. The Spine. 2:4th ed. Philadelphia: WB Saunders Co;p. 1733–1739. 1999.
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Table 1.
Preoperative Diagnosis of Incidental Dural Tear
  Repaired(n=22) Not-repaired(n=22)
Spinal stenosis 12 18
Spondylolisthesis 7 1
HIVD∗ 3 2
Spondylolysis - 1

values are number of patients

∗ herniation of intervertebral disc

Table 2.
Etiology of Dural Tear
  Repaired(n=22) Not-repaired(n=22)
Adhesiolysis 7 7
Bony spicule 3 10
Instrument 8 2
Pedicle screw 4 0
Unknown - 3

values are number of patients

Table 3.
Patient Profile who was repaired Dural Tear
CASE Sex/age Mechanism Diagnosis Operation F/U1)(month) Symptom Result2)
Headache Nausea Vomiting
1 M/62 Bovie stenosis revision fusion 3 none none none ∗
2 M/59 Rongeur stenosis fusion 16 yes yes yes excellent
3 M/51 set screw stenosis revision fusion 6 yes none none good
4 M/52 Kerrison punch stenosis fusion 14 yes none none excellent
5 F/60 adhesion listhesis fusion 13   ∗   good
6 F/48 adhesion stenosis fusion 80 yes yes yes fair
7 M/71 bony spiculae listhesis fusion 48 none none none fair
8 M/53 adhesion listhesis fusion 44 none none none good
9 F/43 Kerrison punch stenosis fusion 60 yes none none excellent
10 F/66 Pituitary forcep HIVD3) discectomy 12   ∗   good
11 M/42 bony spiculae listhesis fusion 78   ∗   good
12 F/65 Kerrison punch stenosis revision decompression 36 yes none yes good
13 F/74 adhesion stenosis revision fusion 3   ∗   excellent
14 M/38 screw tip listhesis fusion 60 none none none excellent
15 F/58 screw tip stenosis fusion 18 none none none good
16 F/63 screw tip listhesis fusion 12 yes none none excellent
17 F/48 adhesion stenosis revision fusion 25 none none none good
18 F/46 Kerrison punch listhesis fusion 88 yes none none good
19 M/35 Pituitary forcep HIVD discectomy 31 none none none excellent
20 M/53 bony spiculae HIVD discectomy 47 none none none good
21 M/69 adhesion stenosis revision fusion 12 yes none none good
22 M/71 adhesion stenosis fusion 3 none yes none ∗

∗ loss of record 1) period of follow-up 2) clinical result are determined by K im’s criteria 3) Herniation of intervertebral disc

Table 4.
Patient Profile who was not Repaired Dural Tear
CASE Sex/age Mechanism Diagnosis Operation F/U1)(month) Symptom Result2)
Headache Nausea Vomiting
1 M/32 Kerrison punch HIVD revision discectomy 3 none none none good
2 M/29 adhesion HIVD revision discectomy 6 none none none good
3 F/32 adhesion stenosis revision fusion 18 none yes yes excellent
4 M/37 bony spiculae lysis fusion 12 yes none none good
5 M/66 Kerrison punch stenosis fusion 18 yes none none fair
6 F/61 bony spiculae listhesis fusion 18   ∗   excellent
7 M/54 bony spiculae stenosis decompression 51 none none none excellent
8 F/48 OYL3) stenosis decompression 8   ∗   ∗
9 F/48 adhesion stenosis revision fusion 36   ∗   good
10 F/51 adhesion stenosis fusion 68 yes none none fair
11 F/46 bony spiculae stenosis fusion 24 none none none excellent
12 F/64 bony spiculae stenosis fusion 30 yes none none good
13 F/58 ∗ stenosis fusion 18 yes none yes good
14 F/59 bony spiculae stenosis fusion 78 none none none excellent
15 F/51 bony spiculae stenosis fusion 26 none none none fair
16 F/46 adhesion stenosis decompression 48 yes none none excellent
17 M/60 bony spiculae stenosis fusion 12 none none none fair
18 F/53 bony spiculae stenosis fusion 32 none none none excellent
19 F/53 bony spiculae stenosis fusion 18 none none none good
20 F/62 myelo-needle stenosis fusion 24 yes none none good
21 M/65 adhesion stenosis fusion 9   ∗   expired
22 M/61 adhesion stenosis fusion 12   ∗   poor

∗ loss of record 1) period of follow-up 2) clinical result are determined by Kim’s criteria 3) Ossification of yellow ligament

Table 5.
Postoperative Symptoms of Patients who was repaired or not for Incidental Dural Tear
  Repaired Not-repaired
No. of cases Average duration of symptoms No. of cases Average duration of symptoms
Headache 9 4.1 days 7 4.3 days
Nausea 3 1.7 days 1 1 days
Vomiting 3 5.3 days 2 3 days
Table 6.
Drainage Amount via Hemovac
  Repaired Not-Repaired
Total amount(ml/person) 796.1 933.2
Daily amount(ml/day) 283.1 281.2
Indwelling period(day) 2.8 3.3
Table 7.
Result by Kim’s Criteria
  Repaired (n=22) Not-repaired (n=22) Total (n=44)
Excellent 7 7 14
Good 11 10 21
Fair 3 4 7
Poor 1 1 2

values are number of patients

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