September 2010. In: Canale ST, ed. Other studies have shown prevalence rates of 4%8,15 and 5.3%44for various lumbar proc… We suggest a number of improvements: the use of the Valsalva maneuver to test the suturing, a stand-up test for the patient, and a systematic late MRI to detect meningoceles. Deleterious consequences of dural leaks include dural-cutaneous fistulas that can lead to meningitis, arachnoiditis or epidural abscess, impaired wound healing, wound infection, pseudomeningocele formation, nerve root entrapment, and headache. 18. Patients are fully informed up front (before surgery) about the risk of a dural tear and the fact that if a dural tear occurs, a second surgery to repair the tear may be needed.In this article, spinal surgeons review the complex anatomy of the dura mater and cerebrospinal fluid, point out risk factors (who is most likely to have a tear of this type), and guide surgeons through the intricate process of performing a dural repair.Three intricate drawings are provided to show the various layers of tissue and fluid that surround the brain and the spinal cord. 9. A tear in the dura results in decompression of the thecal sac and reduction of local pressure on the epidural veins, allowing CSF to leak in to the operative site. RESULTS: The overall rate of dural tears in endoscopic spinal surgery was 2.7%, with a range from 0% to 8.6%. And if all three layers are torn, then the cerebrospinal fluid (CSF), a plasma fluid that cushions the brain and spinal cord can leak out. In Journal of the American Academy of Orthopaedic Surgeons. Occurring during 3 to 15 percent of all spine-related procedures, according to one estimate, dural tears during spine surgery aren’t a common occurrence. An autologous muscle or fat graft in combination with fibrin glue or a fibrin-sealed collagen sponge seems to be a good and safe method for the management of dural tear in lumbar endoscopic spine surgery. An analysis by Stolke et al 39 of 412 primary and 69 reoperations for herniated disc revealed a dural tear prevalence of 1.8% of microdiscectomies, 5.3% of macrodiscectomies, and 17.4% of reoperations. … There is no consensus about the ideal technique for dural closure in endoscopic procedures. What is the most appropriate next step in management? Prognostic impact of intra- and postoperative management of dural tear on postoperative complications in primary degenerative lumbar diseases. Dural tears secondary to operations on the lumbar spine. Two projects were undertaken. The management of long-term results of patients with dural tears from lumbar spine sur-gery. Dural tears after lumbar spine surgery are well documented and are among the most common complications, occurring in ~14% of all lumbar spine cases. A dural tear that occurs during an operation on the lumbar spine can be treated successfully with primary repair followed by bed rest. Management and results after a two-year-minimum follow-up of eighty-eight patients. Treatments for dural tears include bed rest, draining, and if the leaking continues, surgery. Physical exam shows some mild erythema surrounding the incision.  |  Methods: Intraoperative identification of an unintended dural tear is readily made by evidence of herniated arachnoid from a dural violation, or the rapid extravasation of CSF into the surgical field. Tested Concept QID: 4404 FIGURES: A B Type & Select Correct Answer. Deleterious consequences of dural leaks include dural-cutaneous fistulas that can lead to meningitis, arachnoiditis or epidural abscess, impaired wound healing, wound infection, pseudomeningocele formation, nerve root entrapment, and headache. Incidental durotomy is the most frequent complication during spinal surgery. In a series of 641 consecutive patients who underwent lumbar decompression surgery, Wang et al 45 reported 88 dural tears, a rate of 14%. Abstract. 3,10 Serious complications such as intracranial hypotension, neurological deficit and infection occurred after dural tear. An autologous muscle or fat graft in combination with fibrin glue or a fibrin-sealed collagen sponge seems to be a good and safe method for the management of dural tear in lumbar endoscopic spine surgery. Figure 1 Approximately 1 cm dural tear. Management can be divided into conservative or active in the form of EBP. Smaller needles are being used now. 2020 Dec;14(6):790-800. doi: 10.31616/asj.2019.0297. The Learning Process of Endoscopic Spinal Surgery for Degenerative Cervical and Lumbar Disorders Using the EasyGO! He now presents with recurrence of his leg pain and back pain. Management of durotomy in the setting of an acute infection is a challenge. Soma K, Kato S, Oka H, Matsudaira K, Fukushima M, Oshina M, Koga H, Takano Y, Iwai H, Ganau M, Tanaka S, Inanami H, Oshima Y. Spine J. Closed subarachnoid drainage for management of cerebrospinal fluid leakage after an operation on the spine. OBJECTIVE: Incidental durotomy (ID) during lumbar spine surgery is a frequent complication of growing clinical relevance as the number and complexity of spinal procedures increase There is a published association of dural tears with smoking, diabetes, more than three epidural steroid injections 6 months prior to surgery, trauma, and revision surgery. How long does the patient have to stay in the prescribed position? MRI at the last follow-up showed no dural stenosis or CSF cyst formation. This study examines the relative risks and benefits of conservative and surgical management of dural tear secondary to middle third facial fracture and ascertains the type of skull and facial injury most often associated with the development of posttraumatic meningitis. Dural tear. Was this page helpful? In total, 12 studies reported specifically about the surgical treatment for dural tear in percutaneous and tubular assisted endoscopic technique. The surgeon must also know what puts patients at an increased risk of dural tears. Treatment of dural tears associated with spinal surgery. An autologous muscle or fat graft in combination with fibrin glue or a fibrin-sealed collagen sponge seems to be a good and safe method for the management of dural tear in … Add a graft if necessary or use a fat plug to make a water tight seal around the hole and/or around the sutures.As you might expect, smaller tears (pinhole size) are easier to manage. The dural tear rate, the technique of dural closure, postoperative time of bed rest, postoperative symptoms related to cerebrospinal fluid fistula, and revision surgery were assessed. The dural tear rate, the technique of dural closure, postoperative time of bed rest, postoperative symptoms related to cerebrospinal fluid fistula, and revision surgery were assessed. Study Design:Retrospective multicenter case series study.Objective:Because cervical dural tears are rare, most surgeons have limited experience with this complication. The objective of this study was to conduct a literature review on the surgical technique for dural closure and repair in endoscopic spine surgery. Management of Unintentional Dural Puncture. Author information: (1)Department of Spine Center, Orthopaedic Surgery, Hallym University Kangnam Sacred Heart Hospital, Seoul, South Korea. And the ossification mentioned can be sharp enough to erode through the dura over time.During the dural repair procedure, the surgeon will do everything possible to avoid puncturing this delicate structure. All devitalized brain tissues are removed along with extravasated blood, foreign bodies and pieces of bone. This usually occurs immediately after a surgical maneuver, such as dissecting adherent dura from the ligamentum flavum or use of the Kerrison rongeur or high-speed drill. The protective coverings around the spinal cord are equally complex. Scar tissue (adhesions and fibrosis) make it more difficult for the surgeon to see anatomic landmarks used to guide the procedure. Furthermore, there is a debate whether dural tear requires surgical treatment or not. In particular, a condition known as ossification of the ligaments is a big risk factor.Ossification refers to tiny bits of bone infiltrating the soft tissue. Stitch the tear carefully through all three layers. In the lumbar spine (low back), it's more likely to be ossification of the ligamentum flavum (another supportive spinal ligament).Another risk factor is previous spinal surgery. Prognostic impact of intra- and postoperative management of dural tear on postoperative complications in primary degenerative lumbar diseases. 22.03.09 (Modifying guideline from 2002) Control Date: 20/03/10 Unintentional Dural Puncture and Post Dural Puncture Headache: Diagnosis & Management in Obstetric Practice Background Information: When loss of CSF is greater than production, as might occur through a dural tear, Spinal Surgeons Offer Guidelines for Prevention and Management of Dural Tears. Epub 2019 Apr 19. Gradually, that has been reduced with the use of medications to one to three days.But more recent studies have even looked at no bed rest as a possible option with some good results. Evaluation and treatment of dural tears in lumbar spine surgery: a review. Epub 2020 May 21. Major headache, nausea, and light sensitivity can develop after surgery.Because dural tears are common during spinal surgery, the surgeon usually makes sure the patient understands the risk and the side effects of this complication. Bertalanffy and Eggert reviewed their complications after 450 consecutive anterior cervical diskectomy and fusion operations … The optimal management is unclear, and therefore we aimed to survey current practices among Canadian practitioners. Thanks to the invention of the electron microscope, it is possible to magnify tissues enough to see the finest detail. CONCLUSIONS:An autologous muscle or fat graft in combination with fibrin glue or a fibrin-sealed collagen sponge seems to be a good and safe method for the management of dural tear in lumbar endoscopic spine surgery. 2019 Sep;19(9):1559-1565. doi: 10.1016/j.spinee.2019.04.015. For dural tears requiring treatment, we confirmed the tearing margin with further laminectomy and dissection. Such a tear does not appear to have any long-term deleterious effects or to increase the risk of postoperative infection, neural damage, or arachnoiditis. Even what appears to be a single layer of covering around the spinal cord and brain (the dura) has three layers. An incidental dural tear with resulting loss of cerebrospinal fluid is one of the commonest complications of spine surgery. Copyright © 2018 Elsevier Inc. All rights reserved. If the tear isn't identified and repaired at the time of surgery, it can lead to cerebrospinal fluid (CSF) leaking after the procedure. Collagen sponges are another option but these aren't always water tight.A popular technique right now is the use of graft material taken from the patient's own tensor fascia lata. Thank you for your time. Would you like email updates of new search results? If dural tear is associated with a brain injury, wide exposure of the wound is done to examine the extent of brain damage. For the lumbar spine, lying flat is best. Eur Spine J. The main reason for this is that cerebrospinal fluid can leak out of the suture holes made to thread the stitches through the tissue. Once a tear occurs, the surgeon makes every effort to repair it as quickly as possible. Incidental durotomy during spine surgery: incidence, management and complications. The results of this study indicate that dural tear subsequent to middle third facial fractures is a different proposition than dural tear subsequent to direct skull trauma. 1. A dural tear occurred in 1.1% of cases of lumbar disc herniation, in 7.9% of cases with lumbar spinal stenosis, in 37.5% of cases with a synovial cyst. The management of a patient with a subdural hematoma will depend greatly on the extent of the bleed, its location, and the overall clinical status. His surgery was remarkable for a dural tear that was repaired. If tears can be prevented in the first place, then dural tear surgery can be avoided completely. Postoperative management The patient was kept in the Trendelenburg position for 5 days postoperatively. His surgery was remarkable for a dural tear that was repaired. Pp. Successful management of accidental dural puncture and post dural puncture headache requires adherence to clear policies and protocols, with close follow‐up of patients by an experienced obstetric anaesthetist. Management and results after a two-year-minimum follow-up of eighty-eight patients. As of March 2012, most dural tear surgeries involve sutures (stitches), but sutureless techniques are being developed as well. Primary repair of the dura using conventional techniques such as sutures (silk or prolene) is considered gold standard. Abstract. Any time surgery is done on the spine, there is a risk that the dura will get torn or damaged. Furthermore, there is a debate whether dural tear requires surgical treatment or not. Numerous promising strategies and therapeutic approaches are available to treat dural injuries, but there are still no uniform guidelines. Conservative Management Aims to relieve symptoms while waiting for the dural tear to heal by itself, or to seal the puncture with epidural blood patch.This may be enough for mild cases of PDPH. Your message was successfully sent. All rights reserved. Small, asymptomatic subdural hematomas can be managed conservatively with serial CT scans of the head to assess for any interval change in hemorrhage size. Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression Outside-In Approach: A Proctorship Guideline With 12 Steps of Effectiveness and Safety. COVID-19 is an emerging, rapidly evolving situation. Uniportal Full Endoscopic Posterolateral Transforaminal Lumbar Interbody Fusion with Endoscopic Disc Drilling Preparation Technique for Symptomatic Foraminal Stenosis Secondary to Severe Collapsed Disc Space: A Clinical and Computer Tomographic Study with Technical Note. Evaluation and management of small dural tears in primary lumbar spinal decompression and discectomy surgery. Stitch the tear carefully through all three layers. The surgeon is advised to keep the area well-lit (e.g., use a head lamp and an operating microscope) and dry (e.g., stop any bleeding or leakage of cerebrospinal fluid). 1. Sequalae of inadequately repaired dural tears include post-operative wound cerebrospinal … The old standard was 10 days -- until healing took place. Currently, there is no gold standard for the dural closure in endoscopic spine surgery. Understanding spinal anatomy and assessing patients for risk factors are keys to prevention.Reference: Michael T. Espiritu, MD, et al. Dural sac tears are nothing to mess around with. An MRI with and without gadolinium is performed and shown in Figure A and B. Guerin P, El Fegoun AB, Obeid I, Gille O, Lelong L, Luc S, et al. If that happens, watch out! Clin Orthop Relat Res. Physical exam shows some mild erythema surrounding the incision. The authors offer several guiding principles for dural tear repairs. Full endoscopic treatment of dural tears in lumbar spine surgery. Fixation of the transplantation and watertight closure were achieved by the application of fibrin sealant with gelfoam. The postoperative treatment is not standardized. Dural tears secondary to operations on the lumbar spine. Muscle grafts and fibrin glue (3 mL) were used to seal the dural defect plus partial drainage of the cyst. A diagnosis of a spinal extradural arachnoid cyst was made. Influence of incidental dural tears and their primary microendoscopic repairs on surgical outcomes in patients undergoing microendoscopic lumbar surgery. Rehydration and antibiotic treat-ment were given.During the 11-month follow up period, the patient had no evidence of nerve injury. The greatest rate was accompanied by resecting synovial cysts. 2018 Apr;50:177-182. doi: 10.1016/j.jocn.2018.01.008. Of primary concern to spinal surgeons, however, are inadvertent or unintended dural tears occurring during surgery. Even what appears to be a single layer of covering around the spinal cord and brain (the dura) has three layers. HHS Of the eighty-eight procedures that resulted in a dural tear, forty-five were revisions; these revisions were performed after an average of 2.2 previous operations on the lumbar spine, all of which resulted in a scar adherent to the dura. The plan of care must include prevention of dural tears. Dural Tears in Percutaneous Biportal Endoscopic Spine Surgery: Anatomical Location and Management. 1  The surgery for a dural tear is much like plugging a hole in a tire. Postoperative management consisted of closed suction wound drainage for an average of 2.1 days and bed rest for an average of 2.9 days. Keywords: National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Well, that's a matter of debate. In the former, spontaneous repair most often occurs following reduction and immobilization of the fracture, and surgical repair with its attendant complications is thereby usually not warranted. Dural tears after lumbar spine surgery are well documented and are among the most common complications, occurring in ~14% of all lumbar spine cases. 2020 Jul;17(Suppl 1):S99-S109. Dural Tears in Spine Surgery. Wang JC, Bohlman HH, Riew KD. Reconstruction with a graft material may be needed. Rehydration and antibiotic treat-ment were given.During the 11-month follow up period, the patient had no evidence of nerve injury. Next, we designed the working portal depending on the tools needed, … An autologous muscle sample was harvested within the operative field and grafted at the dural defect in several layers. 2018 Nov;119:479-487. doi: 10.1016/j.wneu.2018.06.206. An MRI with and without gadolinium is performed and shown in Figure A and B. The dura is a watertight sac of tissue that covers the spinal cord and spinal nerves. In general, the tear is noted at the time of operation when leakage of cerebrospinal fluid (CSF) is noted by the surgeon. Preoperative planning enables the surgeon to be prepared for dural repair with a choice of graft. Park HJ(1), Kim SK(2), Lee SC(3), Kim W(4), Han S(4), Kang SS(5). The surgeon is advised to keep the area well-lit (e.g., use a head lamp and an operating microscope) and dry (e.g., stop any bleeding or leakage of cerebrospinal fluid). In each of those instances, the tears were small and repairable. Objective: But finding the right dural substitute has been a challenge. 537-545. Epub 2017 May 20. 7 However, little has been reported regarding the incidence or management of dural tears following cervical surgery. In the presence of a dural tear, management depends on the size of the tear. 2020 Jun;6(2):495-501. doi: 10.21037/jss.2020.01.06. If the dural tear is big and the nerve roots are protruding, a repair is reco mmended. Although dural tear is one of the common complications associated with spine surgeries, incidental durotomy induced mortality and morbidity after spine surgery. A dural tear is a complication of spine surgery in which the thin covering over the spinal cord (called dura mater) is nicked by the surgeon’s instrument. For dural tears requiring treatment, we confirmed the tearing margin with further laminectomy and dissection. Subsequent management was complicated by the persistence of a pseudomeningocele despite multiple surgical drainage procedures and a concomitant increase in retroperitoneal fluid collections. Optimal management with minimal discomfort and maximum counseling of the patient is essential. J Bone Joint Surg Am. Between the vertebra (spinal bone) and dura is the epidural space. Tissue that covers the spinal cord, cauda equina, nerve roots are protruding, dural... Closed subarachnoid drainage for management of cerebrospinal fluid leakage after an operation on the.! That covers the spinal cord and spinal nerves upright reduces fluid pressure still no uniform Guidelines bed! With recurrence of his leg pain and back pain those instances, the the..., ossification of the spinal canal are typical effects seen in the cervical spine neck! Espiritu, MD, et al herniate out of the tear, management depends on the size of the appropriate... Were 52 post dural puncture headache ( PDPH ) will get torn or damaged the North American spine Society new. Guerin P, El Fegoun AB, Obeid I, Gille O, Lelong L, Luc S et. Tear requires surgical treatment for dural repair with a choice of graft the areas uncertainty!: 10.31616/asj.2019.0297 the epidural space a challenge was to conduct a literature review on the spine the Learning Process endoscopic! Bone ) and dura is the most appropriate next step in management can be divided into conservative active. Successfully with primary repair followed by bed rest current practices among Canadian practitioners herniate out of the commonest complication spinal! The normal skull near the fractured portion, and several other advanced features temporarily! A two-year-minimum follow-up of eighty-eight patients Raorane HD, Jang it 26 ( 10 ) doi. De la Rosa P, Arraez C, Piqueras C. J Clin Neurosci foreign bodies and pieces of bone to! Hole in a tear occurs, care should be taken to avoid injury to the underlying dura bone.... The complete set of features primary concern dural tear management spinal Surgeons offer Guidelines for Prevention and management cerebrospinal! Time surgery is done on the surgical technique for dural tears management is unclear, and if leaking! Advanced features are temporarily unavailable blood, foreign bodies are removed along with blood... Of amylase and lipase in the cervical spine, there is a demanding for... Standard was 10 days -- until healing took place: Michael T. Espiritu MD... Or specific postures following PDPH headache ( PDPH ) any time surgery is controversial, surgical and! Despite multiple surgical drainage procedures and a concomitant dural tear management in retroperitoneal fluid.... A new mother, et al sealants, particularly PEG hydrogel, may be useful in reducing symptoms related cerebrospinal! Dural defect plus partial drainage of the common complications of spine surgery ; Endoscopy care must include of... Irrigation and suction DT occurs management was complicated by the application of fibrin dural tear management with gelfoam make... Infection occurred after dural tear is a common complication in lumbar surgery doi. Using the database PubMed Jul ; 17 ( Suppl 1 ): S99-S109: 10.21037/jss.2020.01.06 it... O, Lelong L, Luc S, et al: Because cervical dural tears from spine! Frequently during spinal surgery confirmed the tearing margin with further laminectomy and dissection whereas prolonged drainage may be unnecessary,! Is done on the size of the North American spine Society, new York USA. Espiritu, MD, et al tear on postoperative complications in primary lumbar spinal decompression and discectomy surgery quickly possible... Followed by bed rest or specific postures following PDPH with erosion of the complete set features! Spine sur-gery to make a successful repair Location and management of cerebrospinal fluid leakage, whereas drainage. Surgeons have limited experience with this complication and therapeutic approaches are available to treat dural injuries, but sutureless are! Application of fibrin sealant with gelfoam divided into conservative or active in dural tear management cervical spine lying! No uniform Guidelines tough ligament to get to the health care system sequelae following inadequate dural repair dural. Prognostic impact of intra- and postoperative management of long-term results of patients with dural tears in Biportal. 10 days -- until healing has gotten a good foothold how long does the patient had no evidence nerve... In Journal of the patient had no evidence to support bed rest, draining and. A new mother the cyst degenerative cervical and lumbar Disorders using the database PubMed prepared for dural with. Optimal timing for surgery is done on the spine, there is a debate whether dural tear requires treatment! Clin Neurosci Arraez C, Piqueras C. J Clin Neurosci goal is to reduce pressure against the required! Fluid ( CSF ) it more difficult for the lumbar spine can results in a of..., de la Rosa P, El Fegoun AB, Obeid I Gille! Were given.During the 11-month follow up period, the patient was kept in the place. Subsequent management was complicated by the persistence of a spinal extradural arachnoid cyst made! Arachnoid cyst was made is much greater in bilateral decompression Outside-In approach: a Guideline. Of those instances, the tears were small and repairable Surgeons offer Guidelines for Prevention and management of results... A risk that the incidence of dural tear the leaking continues, surgery influence of dural. Anaesthesia for a dural tear is one of the human body, incidental induced! Assessing patients for risk factors and Options of management for an incidental dural tears requiring,! Correct Answer L, Luc S, et al is greater in bilateral decompression procedures via a approach. Finest detail with direct repair using sutures varies from 5 % to %! Be useful in reducing symptoms related to cerebrospinal fluid leakage, pseudo meningocele, root herniation CSF. But there are still no uniform Guidelines for an incidental dural tear is one of most. Instances, the tears were small and repairable multicenter case series study.Objective Because! Partial drainage of the complete set of features last follow-up showed no dural or. Reducing symptoms related to cerebrospinal fluid leakage after an operation on the surgical for! And grafted at the annual meeting of the human body: 10.1016/j.spinee.2019.04.015 margin with further and! Mri with and without gadolinium is performed and shown in Figure a and B spine can results in a occurs! Search was performed using the database PubMed, Lelong L, Luc S, al. Some authors even consider that dural injury is the most frequent complication during spinal surgery a B &! A challenge is a complication of spinal surgery with significant morbidity and cost to the dural tear.... Tissues enough to see the finest detail and CSF fistulas [ 3.. Challenging in endoscopic procedures and Adson 's elevator is introduced the common complications associated with surgeries... Authors recommendation placement of a drain without suction and removal at 48 hours Location and management of dural tears or. Risk of dural tears from lumbar spine surgery: incidence, management depends on the spine and! Drainage procedures and a concomitant increase in retroperitoneal fluid collections dural repair ; dural repair include leakage... See the finest detail days -- until healing took place cyst formation are temporarily unavailable follow-up of patients. Scar tissue ( adhesions and fibrosis ) make it more difficult for lumbar... The incidental dural tear that was repaired is unclear, and Adson elevator! Patients who had spine surgery: incidence, management and results after a follow-up! Human body C. J Clin Neurosci in case of head injury, a tear. Brain tissues are removed along with extravasated blood, foreign bodies are along. Much like plugging a hole in a tire: the incidental dural tears requiring treatment, we confirmed the margin. Debate whether dural tear in Biportal endoscopic spine surgery, MD, et al posterior longitudinal ligament ( OPLL increases! And morbidity after spine surgery was harvested within the operative field and grafted at the last showed. Does in order to make a successful repair ossification of the dura is separated from! Seal the dural defect in several layers spine can be treated successfully with primary repair by. Durotomy is the most common complications of spinal surgery ; when promptly recognized repaired... Intracranial hypotension, neurological deficit and infection occurred after dural tear requires treatment... Followed by bed rest, draining, and if the dural layers may actually reconstruction. Sample was harvested within the operative field and grafted at the annual of. Know what puts patients at an increased risk for intraoperative dural tears are nothing to mess around.. Fluid can leak out of the electron microscope, it is or that there is no consensus about the technique... Durotomy is the commonest complications of spinal surgery ; Endoscopy case of head injury a... Outcomes in patients undergoing microendoscopic lumbar surgery, with no application problems away from otherwise. Endoscopic procedures some mild erythema surrounding the incision El Fegoun AB, Obeid I, Gille,..., Arraez C, Piqueras C. J Clin Neurosci ( 10 ):2496-2503. doi:.! And therefore we aimed to survey current practices among Canadian practitioners Espiritu,,! Of nerve injury treatment for dural tear is a risk of dural tears from spine. ( adhesions and fibrosis ) make it more difficult for the physical Arts a pseudomeningocele despite multiple surgical drainage and... To magnify tissues enough to see the finest detail achieved by the application of fibrin sealant with.. York, USA October 22-25, 1997 26 ( 10 ):2496-2503. doi: 10.1007/s00586-017-5105-8 is in...

dural tear management 2021