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Elhassan YH, Alhasan M, Abdulghani YS. A Rare Case of Post-lumbar Discectomy Pneumocephalus: An Anatomically Informed Case Report. Cureus 2025; 17:e81147. [PMID: 40276415 PMCID: PMC12020446 DOI: 10.7759/cureus.81147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2025] [Indexed: 04/26/2025] Open
Abstract
Pneumocephalus is an uncommon yet significant complication that can arise after lumbar discectomy and requires rapid diagnosis and intervention. Although cerebrospinal fluid (CSF) leakage is not frequently observed during these procedures, it can result from small, often inconspicuous dural defects that may be missed during surgery. This scenario underscores the importance of careful intraoperative inspection and vigilant postoperative monitoring to ensure timely recognition and management, thereby mitigating potential adverse outcomes. A 36-year-old male patient underwent an L5-S1 lumbar discectomy for disc herniation. Eight days postoperatively, he developed severe headache, neck pain, and nausea, accompanied by CSF leakage confirmed through beta-2 transferrin testing. Computed tomography revealed significant pneumocephalus, while high-resolution MRI demonstrated a subtle dural defect. Despite no macroscopically visible dural tear during re-exploration, applying an epidural blood patch successfully resolved both the CSF leak and pneumocephalus. This case underscores the value of advanced imaging, specifically high-resolution MRI, in identifying subtle dural defects that may not be apparent during surgery. Detecting the minor CSF leakage was essential for directing subsequent management and avoiding further complications. Early recognition of postoperative symptoms combined with comprehensive imaging assessment is crucial in the management of post-discectomy pneumocephalus. The rapid resolution observed after applying an epidural blood patch supports its role as a primary intervention strategy, even in cases where dural tears are not macroscopically evident.
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Anselmi L, Anania CD, Ubezio MC, Farinaro G, Creatura D, Ortolina A, Tomei M, Baram A, Fornari M. Cerebrospinal Fluid Leak Prevention in Intradural Spine Surgery: A Long Series Analysis of Closure with Non-Penetrating Titanium Clips. Brain Sci 2024; 14:1223. [PMID: 39766422 PMCID: PMC11727195 DOI: 10.3390/brainsci14121223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2024] [Revised: 11/21/2024] [Accepted: 11/30/2024] [Indexed: 01/15/2025] Open
Abstract
Background/Objectives: Postoperative cerebrospinal fluid (CSF) fistulas remain a significant concern in spinal neurosurgery, particularly following dural closure. The incidence of dural tears during spinal surgery is estimated between 1.6% and 10%. While direct suturing remains the gold standard, it has a failure rate of 5-10%. Various materials and techniques have been used to enhance dural closure. This study aims to assess the effectiveness of non-penetrating titanium clips (AnastoClip®) for dural closure in intradural spinal lesion surgeries. Methods: A prospective analysis was conducted on 272 patients who were operated on for intradural spinal lesions from August 2017 to December 2023. Dural closure was performed using non-penetrating titanium clips with sealant, and, in select cases, autologous grafts. Postoperative care included early mobilization and routine MRI to assess outcomes. A comparative analysis was performed with a cohort of 81 patients treated with traditional sutures. Results: Among the 272 patients, postoperative CSF leaks occurred in 32 cases (11.76%), requiring various management approaches. Thirteen cases required surgical revision, while others resolved with external lumbar drainage or fluid aspiration. Compared to the suture group, which had a fistula rate of 23.46%, the titanium clip group had a significantly lower fistula rate. Logistic regression analysis did not find statistically significant associations between fistula risk and clinical factors. Conclusions: Non-penetrating titanium clips provide an effective alternative to sutures for dural closure, reducing CSF leak rates. They preserve dural integrity, reduce operative time, and avoid imaging artifacts, making them a viable advancement in spinal surgery with outcomes comparable to, or better than, traditional techniques.
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Affiliation(s)
- Leonardo Anselmi
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (L.A.); (G.F.); (D.C.); (A.O.); (M.T.); (A.B.); (M.F.)
- Department of Biomedical Sciences, Humanitas University, Via R.L Montalcini 2, 20072 Pieve Emanuele, Italy;
| | - Carla Daniela Anania
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (L.A.); (G.F.); (D.C.); (A.O.); (M.T.); (A.B.); (M.F.)
| | - Maria Cleofe Ubezio
- Department of Biomedical Sciences, Humanitas University, Via R.L Montalcini 2, 20072 Pieve Emanuele, Italy;
| | - Generoso Farinaro
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (L.A.); (G.F.); (D.C.); (A.O.); (M.T.); (A.B.); (M.F.)
- Department of Biomedical Sciences, Humanitas University, Via R.L Montalcini 2, 20072 Pieve Emanuele, Italy;
| | - Donato Creatura
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (L.A.); (G.F.); (D.C.); (A.O.); (M.T.); (A.B.); (M.F.)
- Department of Biomedical Sciences, Humanitas University, Via R.L Montalcini 2, 20072 Pieve Emanuele, Italy;
| | - Alessandro Ortolina
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (L.A.); (G.F.); (D.C.); (A.O.); (M.T.); (A.B.); (M.F.)
| | - Massimo Tomei
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (L.A.); (G.F.); (D.C.); (A.O.); (M.T.); (A.B.); (M.F.)
| | - Ali Baram
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (L.A.); (G.F.); (D.C.); (A.O.); (M.T.); (A.B.); (M.F.)
| | - Maurizio Fornari
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (L.A.); (G.F.); (D.C.); (A.O.); (M.T.); (A.B.); (M.F.)
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Encarnación-Santos D, Chmutin G, Bozkurt I, Chaurasia B, Umana GE, Nicoletti GF, Scalia G. Letter to the Editor Regarding "Minimally Invasive Spine Surgery: An Overview". World Neurosurg 2024; 184:353-354. [PMID: 38590064 DOI: 10.1016/j.wneu.2023.11.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 04/10/2024]
Affiliation(s)
| | - Gennady Chmutin
- Department of Neurosurgery, Peoples' Friendship University, Moscow, Russia
| | - Ismail Bozkurt
- Department of Neurosurgery, Medical Park Ankara Hospital, Ankara, Turkey; Department of Neurosurgery, School of Medicine, Yuksek Ihtisas University, Ankara, Turkey
| | - Bipin Chaurasia
- Department of Neurosurgery, Bhawani Hospital and Research Center, Birgunj, Nepal
| | | | | | - Gianluca Scalia
- Neurosurgery Unit, Department of Head and Neck Surgery, Garibaldi Hospital, Catania, Italy
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Alessa M, Ababneh F, Al Taimeh F, Haddad S, Al Rabadi J, Hjazeen A. Incidental Dural Tears During Lumbar Spine Surgery: Prevalence and Evaluation of Management Outcomes. Cureus 2024; 16:e54212. [PMID: 38362037 PMCID: PMC10868713 DOI: 10.7759/cureus.54212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Incidental dural tears (IDTs) are sometimes observed as an intraoperative complication associated with lumbar spine surgery. Commonly, this complication is recognized and repaired during surgery, but if it is undiagnosed or inadequately treated, a variety of consequences may occur. Many techniques have been developed to treat cerebrospinal fluid (CSF) leakage, and each has its limitations. Objectives: To assess the prevalence of incidental dural tears in lumbar spine surgeries and evaluate the outcomes of the sandwich technique in the management of this complication. METHODS A total of 92 patients who underwent lumbar spine surgery at the Royal Rehabilitation Center in Amman from January 2018 to December 2021 were retrospectively reviewed. Patients were divided into two groups: group A (patients without IDT) and group B (patients with IDT), where group B was repaired using the sandwich technique. The follow-up period was six months. Further, the sandwich technique involves repairing the dural defect with interlocking sutures, painting medical glue around the dural incision, covering this with gelatin sponge, and finally covering the gelatin sponge with medical glue again. RESULTS The overall prevalence of IDT in the study group was 14.1%. IDT was more common among elderly patients above the age of 60 (17.2%), females (16.7%), patients with multiple lumbar levels treated (66.7%), open approaches (21%), and those who had previous spinal surgery (72.7%). Most IDTs were diagnosed and managed intraoperatively (84.6%). Among those patients, only one complained of a surgical site infection. Patients in group B had a significantly higher postoperative length of hospital stay, amount of drainage, and operative time compared to group A (P<0.001). Regarding postoperative pain, patients in group B had significantly higher pain on the Numerical Pain Scale at day three post-operation compared to patients in group A (P<0.001). CONCLUSION Based on our results, the sandwich technique was effective in the management and prevention of CSF leakage. Further prospective studies with long-term follow-up are needed to confirm our findings.
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Affiliation(s)
- Monther Alessa
- Department of Orthopedics, Royal Medical Services, Amman, JOR
| | - Faris Ababneh
- Department of Orthopedics, Royal Medical Services, Amman, JOR
| | | | - Saad Haddad
- Department of Orthopedics, Royal Medical Services, Amman, JOR
| | | | - Anees Hjazeen
- Department of Biostatistics, Royal Medical Services, Amman, JOR
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Gomes FC, Larcipretti ALL, Elvir FAR, Diniz JBC, de Melo TMV, Santana LS, de Oliveira HM, Barroso DC, Polverini AD. Early ambulation versus prolonged bed rest for incidental durotomies in spine procedures: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:310. [PMID: 37989906 DOI: 10.1007/s10143-023-02201-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/09/2023] [Accepted: 10/25/2023] [Indexed: 11/23/2023]
Abstract
Incidental durotomies are frequent complications of spine surgery associated with cerebrospinal fluid (CSF) leak-related symptoms. Management typically involves prolonged bed rest to reduce CSF pressure at the durotomy site. However, early ambulation may be a safer, effective alternative. PubMed, Web of Science, Embase, Cochrane, and Scopus were systematically searched for studies comparing early ambulation (bed rest ≤ 24 h) with prolonged bed rest (> 24 h) for patients with incidental durotomies in spine surgeries. The outcomes of interest were CSF leak, hypotensive headache, additional surgical repair, pseudomeningocele, and pulmonary complications. Systematic reviews and meta-analysis were performed following the Cochrane Handbook for Systematic Reviews of Interventions. We included a total of 704 patients from 6 studies. There was a significant reduction in the incidence of pulmonary complications (RR 0.23; 95% CI 0.08-0.67; p = 0.007) in the early mobilization group. The incidence of CSF leak (RR 1.34; 95% CI 0.83-2.14; p = 0.23), hypotensive headache (RR 0.72; 95% CI 0.27-1.90; p = 0.50), additional repair surgery (RR 1.29; 95% CI 0.76-2.2; p = 0.35), and pseudomeningocele (RR 1.29; 95% CI 0.20-8.48; p = 0.79) did not differ significantly. In patients with incidental durotomy following spinal surgery, early mobilization was associated with a lower incidence of pulmonary complications as compared with prolonged bed rest. There was no significant difference between groups in terms of CSF leak, need for additional repair, pseudomeningocele, and hypotensive headache.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Allan Dias Polverini
- Neurosurgical Oncology Division, Hospital de Amor, Fundação Pio XII, Antenor Duarte Vilela, 1331 - Dr. Paulo Prata, Barretos, Sao Paulo, 14784-400, Brazil.
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杨 意, 张 扬, 雷 伟. [Research status of dural injury types and repair]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2023; 37:1177-1182. [PMID: 37718434 PMCID: PMC10505634 DOI: 10.7507/1002-1892.202306064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/31/2023] [Indexed: 09/19/2023]
Abstract
Objective To evaluate the current status of classification and repair methods for dural injury caused by spinal surgery or trauma, providing new strategies and ideas for the clinical repair of dural injury and the development of related materials. Methods The literature related to dural injury both at home and abroad in recent years was thoroughly reviewed and analyzed in order to draw meaningful conclusions. Results There have been numerous retrospective studies on dural injury, but there is a scarcity of prospective and multi-center studies, resulting in a low level of evidence-based research. The incidence and risk factors of dural injury have primarily been studied in relation to common degenerative spinal diseases of the cervical and lumbar spine, with insufficient research on thoracic spine-related diseases. Currently, a universally recognized method for grading and classifying dural injury has not been established, which hampers the development of clinical guidelines for their repair. Furthermore, although there are repair materials and surgical strategies available to address clinical issues such as suture leakage and surgical repair of dural injury in complex locations, there is a lack of comprehensive clinical research and evidence-based data to validate their scientificity and reliability. Conclusion Regardless of the classification of dural injury, suture remains the most important repair method. It is important to further develop new patches or sealants that can meet clinical needs and reduce the difficulty of repair.
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Affiliation(s)
- 意鹏 杨
- 空军军医大学第一附属医院骨科（西安 710032）Department of Orthopedics, the First Affiliated Hospital of Air Force Medical University, Xi’an Shaanxi, 710032, P. R. China
| | - 扬 张
- 空军军医大学第一附属医院骨科（西安 710032）Department of Orthopedics, the First Affiliated Hospital of Air Force Medical University, Xi’an Shaanxi, 710032, P. R. China
| | - 伟 雷
- 空军军医大学第一附属医院骨科（西安 710032）Department of Orthopedics, the First Affiliated Hospital of Air Force Medical University, Xi’an Shaanxi, 710032, P. R. China
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Kumaar A, Ramachandraiah MK, Agarawal S, Shanthappa AH, Parmanantham M. Outcomes of Incidental Durotomy Repair in Thoracolumbar Spine Surgery: An Institutional Experience With Orthopedic Residents. Cureus 2023; 15:e41740. [PMID: 37575738 PMCID: PMC10415536 DOI: 10.7759/cureus.41740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/15/2023] Open
Abstract
Background The occurrence of incidental durotomies (IDs) following spinal operations is a widely recognized issue. Complications such as poor outcomes, extended hospitalization, prolonged immobilization, infections, and revision surgeries are all potential consequences of inadequate durotomy management during the initial surgery. This study aims to describe the outcomes of ID repair in thoracolumbar spine surgery in terms of the Oswestry Disability Index (ODI) score and visual analog scale (VAS) when performed with the active involvement of orthopedic residents in the surgical procedure. Methodology Between April 2021 and April 2023, a hospital-based observational study was conducted among 110 patients hospitalized in the orthopedic ward at R.L. Jalappa Hospital and Research Center in Kolar, Karnataka, who required IDs due to an accidental dural tear or a postoperative CSF fluid leak following thoracolumbar spine procedures. Patients with a previous history of thoracolumbar spine surgery, vertebral tumors, spinal metastasis, infections, e.g., spondylodiscitis, or Pott's spine were excluded. The ODI score and VAS score were calculated on the postoperative day, one month, and three months following surgery. Results The mean age of the study participants was 62.81 + 10.49 years, with a male preponderance of 67.2% among the study participants. The mean BMI of study participants was 23.77 kg/m2. Approximately 24.5% of participants had a prior history of spinal surgery. Among 110 patients, 32 had postoperative complications. Six patients reported experiencing urinary retention, followed by five with CSF leakage and one with a postural headache (five cases). Based on the ODI score, mild disability was seen in 32.7% of the study samples at three months of follow-up. Based on the VAS score, moderate pain was seen among all the study samples at three months of follow-up. The ANOVA test revealed statistically significant differences in ODI and VAS score reductions between the immediate postoperative period and the one-month and three-month follow-up periods (p = 0.001 and p = 0.0247, respectively). Conclusion Less than one-third of the samples had postoperative complications. At three months, ODI scores showed mild disability in one-third of the study samples. At three months, all study samples had moderate VAS pain. The improvement in ODI and VAS scores from the day after surgery through the one-month and three-month follow-up periods was statistically significant.
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Affiliation(s)
- Arun Kumaar
- Orthopedics, Sri Devaraj Urs Medical College, Kolar, IND
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Dong RP, Zhang Q, Yang LL, Cheng XL, Zhao JW. Clinical management of dural defects: A review. World J Clin Cases 2023; 11:2903-2915. [PMID: 37215425 PMCID: PMC10198091 DOI: 10.12998/wjcc.v11.i13.2903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/03/2023] [Accepted: 04/04/2023] [Indexed: 04/25/2023] Open
Abstract
Dural defects are common in spinal and cranial neurosurgery. A series of complications, such as cerebrospinal fluid leakage, occur after rupture of the dura. Therefore, treatment strategies are necessary to reduce or avoid complications. This review comprehensively summarizes the common causes, risk factors, clinical complications, and repair methods of dural defects. The latest research progress on dural repair methods and materials is summarized, including direct sutures, grafts, biomaterials, non-biomaterial materials, and composites formed by different materials. The characteristics and efficacy of these dural substitutes are reviewed, and these materials and methods are systematically evaluated. Finally, the best methods for dural repair and the challenges and future prospects of new dural repair materials are discussed.
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Affiliation(s)
- Rong-Peng Dong
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Qi Zhang
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Li-Li Yang
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Xue-Liang Cheng
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Jian-Wu Zhao
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
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Xu C, Dong RP, Cheng XL, Zhao JW. Late presentation of dural tears: Two case reports and review of literature. World J Clin Cases 2023; 11:2464-2473. [PMID: 37123324 PMCID: PMC10130997 DOI: 10.12998/wjcc.v11.i11.2464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/23/2023] [Accepted: 03/21/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND The late presentation of dural tears (LPDT) has a low incidence rate and hidden symptoms and is easily ignored in clinical practice. If the disease is not treated in time, a series of complications may occur, including low intracranial pressure headache, infection, pseudodural cyst formation, and sinus formation. Here, we describe two cases of LPDT. CASE SUMMARY Two patients had sudden fever 1 wk after lumbar surgery. Physical examination showed obvious tenderness in the operation area. The patients were confirmed as having LPDT by lumbar magnetic resonance imaging and surgical exploration. One case was caused by continuous negative pressure suction and malnutrition, and the other was caused by decreased dural ductility and low postoperative nutritional status. The first symptom of both patients was fever, with occasional headache. Both patients underwent secondary surgery to treat the LPDT. Dural defects were observed and dural sealants were used to seal the dural defects, then drainage tubes were retained for drainage. After the operation, the patients were treated with antibiotics and the patients' surgical incisions healed well, without fever or incision tenderness. Both recovered and were discharged 1 wk after the operation. CONCLUSION LPDT is a rare complication of spinal surgery or neurosurgery that has hidden symptoms and can easily be overlooked. Since it may cause a series of complications, LPDT needs to be actively addressed in clinical practice.
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Affiliation(s)
- Chang Xu
- Department of Orthopedics, Jilin Provincial Armed Police Corps Hospital, Changchun 130000, Jilin Province, China
| | - Rong-Peng Dong
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130012, Jilin Province, China
| | - Xue-Liang Cheng
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130012, Jilin Province, China
| | - Jian-Wu Zhao
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130012, Jilin Province, China
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Verma K, Freelin AH, Atkinson KA, Graham RS, Broaddus WC. Early mobilization versus bed rest for incidental durotomy: an institutional cohort study. J Neurosurg Spine 2022; 37:460-465. [PMID: 35303709 DOI: 10.3171/2022.1.spine211208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 01/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to assess whether flat bed rest for > 24 hours after an incidental durotomy improves patient outcome or is a risk factor for medical and wound complications and longer hospital stay. METHODS Medical records of consecutive patients undergoing thoracic and lumbar decompression procedures from 2010 to 2020 were reviewed. Operative notes and progress notes were reviewed and searched to identify patients in whom incidental durotomies occurred. The need for revision surgery related to CSF leak or wound infection was recorded. The duration of bed rest, length of hospital stay, and complications (pulmonary, gastrointestinal, urinary, and wound) were recorded. The rates of complications were compared with regard to the duration of bed rest (≤ 24 hours vs > 24 hours). RESULTS A total of 420 incidental durotomies were identified, indicating a rate of 6.7% in the patient population. Of the 420 patients, 361 underwent primary repair of the dura; 254 patients were prescribed bed rest ≤ 24 hours, and 107 patients were prescribed bed rest > 24 hours. There was no statistically significant difference in the need for revision surgery (7.87% vs 8.41%, p = 0.86) between the two groups, but wound complications were increased in the prolonged bed rest group (8.66% vs 15.89%, p = 0.043). The average length of stay for patients with bed rest ≤ 24 hours was 4.47 ± 3.64 days versus 7.24 ± 4.23 days for patients with bed rest > 24 hours (p < 0.0001). There was a statistically significant increase in the frequency of ileus, urinary retention, urinary tract infections, pulmonary issues, and altered mental status in the group with prolonged bed rest after an incidental durotomy. The relative risk of complications in the group with bed rest ≤ 24 hours was 50% less than the group with > 24 hours of bed rest (RR 0.5, 95% CI 0.39-0.62; p < 0.0001). CONCLUSIONS In this retrospective study, the rate of revision surgery was not higher in patients with durotomy who underwent immediate mobilization, and medical complications were significantly decreased. Flat bed rest > 24 hours following incidental durotomy was associated with increased length of stay and increased rate of medical complications. After primary repair of an incidental durotomy, flat bed rest may not be necessary and appears to be associated with higher costs and complications.
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Anterior Dural Tear in Thoracic and Lumbar Spinal Fractures: Single-Center Experience with Coating Technique and Literature Review of the Available Strategies. Life (Basel) 2021; 11:life11090875. [PMID: 34575024 PMCID: PMC8465010 DOI: 10.3390/life11090875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/20/2021] [Accepted: 08/24/2021] [Indexed: 11/24/2022] Open
Abstract
Differently from the posterior, the anterior dural tears associated with spinal fractures are rarely reported and debated. We document our experience with a coating technique for repairing ventral dural lacerations, providing an associated literature review on the available strategies to seal off such dural defects. A PubMed search on watertight repair techniques of anterior dural lacerations focused on their association with spinal fractures was performed. Studies on animal or cadaveric models, on cervical spine, or based on seal/gelfoam or “not suturing” strategies were excluded. 10 studies were finally selected and our experience of three patients with thoracic/lumbar spinal fractures with associated ventral dural tear was integrated into the analysis of the surgical techniques. Among the described repair techniques for ventral dural lacerations a preference for primary suturing, mostly trans-dural, was noted (n = 6/10 papers). Other documented strategies were the plugging of the dural opening with a fat graft sutured to its margins, or stitched to the dura adjacent to the defect, and the closure of the dural tear with two patches, both trans-dural and epidural. Our coating techniques of the whole dural sac with the heterologous patch were revealed as safe and effective alternatives strategies, even when patch flaps wrapping nerve roots have to be cut and a fat graft has to be stitched in the patch respectively for sealing off antero-lateral and wide anterior dural tears. Compared to all the documented strategies for obtaining a watertight closure of an anterior dural laceration, the coating techniques revealed advantages of preserving neural structures, being adaptable to anterior and antero-lateral dural tears of any size.
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Aljoghaiman M, Ellenbogen Y, Takroni R, Yang K, Farrokhyar F, Reddy K. Safety of Early Mobilization in Patients With Intraoperative Cerebrospinal Fluid Leak in Minimally Invasive Spine Surgery: A Case Series. Oper Neurosurg (Hagerstown) 2021; 21:1-5. [PMID: 33609122 DOI: 10.1093/ons/opab041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/03/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leak is a common complication in spine surgery. Repairing durotomy is more difficult in the setting of minimally invasive spine surgery (MISS). Efficacy of postoperative bed rest in case of dural tear in MISS is not clear. OBJECTIVE To assess the safety and efficacy of our protocol of dura closure without changing access, early mobilization, and discharge in cases of intraoperative CSF leak in MISS. METHODS A retrospective review from 2006 to 2018 of patients who underwent MISS for degenerative and neoplastic diseases with documented accidental or intentional durotomy was conducted. The primary outcome of interest was readmission rate for repair of persistent CSF leak. Secondary outcomes captured included development of pseudomeningocele, positional headache, and subdural hematoma. RESULTS A total of 80 patients were identified out of 527 patients. Of these, intentional durotomy was performed in 28 patients and unintentional durotomy occurred in 52 patients. Mean follow-up period was 80.6 mo. Most of the patients were discharged on postoperative day 0 (within 4 h of surgery) without activity restrictions. A total of 2 (2.5%) patients required readmission and dural repair for continuous CSF leak and 3 patients (3.75%) developed pseudomeningocele. No lumbar drain insertion, meningitis, or subdural hematoma was reported. CONCLUSION Early mobilization and discharge in cases of intraoperative CSF leak in MISS appear to be safe and not associated with higher rate of complications than that of reported literature.
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Affiliation(s)
- Majid Aljoghaiman
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada.,Division of Neurosurgery, Department of Surgery, King Faisal University, Alahsa, Saudi Arabia
| | - Yosef Ellenbogen
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Radwan Takroni
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Kaiyun Yang
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Forough Farrokhyar
- Department of Surgery, Department of Health, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Kesava Reddy
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada
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Choi EH, Chan AY, Brown NJ, Lien BV, Sahyouni R, Chan AK, Roufail J, Oh MY. Effectiveness of Repair Techniques for Spinal Dural Tears: A Systematic Review. World Neurosurg 2021; 149:140-147. [PMID: 33640528 DOI: 10.1016/j.wneu.2021.02.079] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Incidental or intentional durotomy in spine surgery is associated with a risk of cerebrospinal fluid (CSF) leakage and reoperation. Several strategies have been introduced, but the incomplete closure is still relatively frequent and troublesome. In this study, we review current evidence on spinal dural repair strategies and evaluate their efficacy. METHODS PubMed, Web of Science, and Scopus were used to search primary studies about the repair of the spinal dura with different techniques. Of 265 articles found, 11 studies, which specified repair techniques and postoperative outcomes, were included for qualitative and quantitative analysis. The primary outcomes were CSF leakage and postoperative infection. RESULTS The outcomes of different dural repair techniques were available in 776 cases. Pooled analysis of 11 studies demonstrated that the most commonly used technique was a combination of primary closure, patch or graft, and sealant (22.7%, 176/776). A combination of primary closure and patch or graft resulted in the lowest rate of CSF leakage (5.5%, 7/128). In this study, sealants as an adjunct to primary closure (13.7%, 18/131) did not significantly reduce the rate of CSF leakage compared with primary closure alone (17.6%, 18/102). The rates of infection and postoperative neurologic deficit were similar regardless of the repair techniques. CONCLUSIONS Although the use of sealants has become prevalent, available sealants as an adjunct to primary closure did not reduce the rate of CSF leakage compared with primary closure. The combination of primary closure and patches or grafts could be effective in decreasing postoperative CSF leakage.
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Affiliation(s)
- Elliot H Choi
- Department of Neurological Surgery, University of California, Irvine, California, USA; Medical Scientist Training Program, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Alvin Y Chan
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Nolan J Brown
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Brian V Lien
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Ronald Sahyouni
- Department of Neurological Surgery, University of California, San Diego, California, USA
| | - Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - John Roufail
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Michael Y Oh
- Department of Neurological Surgery, University of California, Irvine, California, USA.
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14
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Aljoghaiman M, Martyniuk A, Farrokhyar F, Cenic A, Kachur E. Survey of lumbar discectomy practices: 10 years in the making. JOURNAL OF SPINE SURGERY 2020; 6:572-580. [PMID: 33102894 DOI: 10.21037/jss-20-519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Lumbar discectomy is a common spinal procedure. The purpose of this survey is to ascertain neurosurgeons' practices in the surgical management of one-level lumbar discectomies in the Canadian adult population and to determine changes over a 10-year period. Methods One-page questionnaire distributed electronically to neurosurgeons in Canada and results were compared with similarly completed survey from 2007. Results A total of 109 completed surveys were returned representing 43.8% response rate. This is compared to 112 completed surveys in 2007 reaching 64.4% response rate. Statistically significant differences between the two points in time were noted. There was an increase in spine fellowship training [26 (33.3%) 2017 vs. 15 (15.3%) 2007 (P=0.007)], use of pre-operative magnetic resonance imaging (MRI) [65 (83.3%) 2017 vs. 27 (27.6%) 2007] (P<0.001), use of intramuscular injection [58 (74.4%) 2017 vs. 43 (43.9%) 2007 (P<0.001)], use of both microscope and loupes [20 (25.6%) 2017 vs. 3 (3.1%) 2007 (P<0.001)], use of tubular retraction [26 (33.3%) 2017 vs. 12 (12.2%) 2007 (P=0.001)], use of fibrin glue for a durotomy [72 (92.3%) 2017 vs. 75 (76.5%) 2007 (P=0.007)]. There was an increased rate of same-day discharge in 2017 [46 (59.0%) vs. 18 (18.4%) 2007 (P<0.001)], and quicker return to work [62.8% in 6 weeks or less vs. 39.7% (P=0.003)]. No statistical differences were noted with pre-incision localization, pre-op antibiotics, pre-incision local anesthetic use, use of fat graft or epidural steroids. In either survey the majority would not perform lumbar discectomy on a patient whose primary complaint is back pain. Conclusions Our survey identified changes in practice patterns amongst Canadian neurosurgeons with respect to performing one-level lumbar discectomy over the past 10 years. These changes include increased preference for minimally invasive surgical technique, same-day discharge and sooner return to work. Randomized trials would be helpful to provide evidence regarding which practices are associated with better outcomes.
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Affiliation(s)
- Majid Aljoghaiman
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, King Faisal University, Alahsa, Saudi Arabia
| | - Amanda Martyniuk
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- Department of Epidemiology and Biostatistics, Office of Surgical Research Services, Surgical Research Methodology, McMaster University, Hamilton, Ontario, Canada
| | - Aleksa Cenic
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Edward Kachur
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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15
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d'Astorg H, Szadkowski M, Vieira TD, Dauzac C, Lonjon N, Bougeard R, Litrico S, Dupuy M. Management of Incidental Durotomy: Results from a Nationwide Survey Conducted by the French Society of Spine Surgery. World Neurosurg 2020; 143:e188-e192. [PMID: 32711151 DOI: 10.1016/j.wneu.2020.07.121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/15/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To obtain real-life data on the most common practices used for management of incidental durotomy (ID) in France. METHODS Data were collected from spinal surgeons using a practice-based online questionnaire. The survey comprised 31 questions on the current management of ID in France. The primary outcome was the identification of areas of consensus and uncertainty on ID follow-up. RESULTS A total of 217 surgeons (mainly orthopaedic surgeons and neurosurgeons) completed the questionnaire and were included in the analysis. There was a consensus on ID repair with 94.5% of the surgeons considering that an ID should always be repaired, if repairable, and 97.2% performing a repair if an ID occurred. The most popular techniques were simple suture or locked continuous suture (48.3% vs. 57.8% of surgeons). Nonrepairable IDs were more likely to be treated with surgical sealants than with an endogenous graft (84.9% vs. 75.5%). Almost two thirds of surgeons (71.6%) who adapted their standard postoperative protocol after an ID recommended bed rest in the supine position. Among these, 48.8% recommended 24 hours of bed rest, while 53.5% recommended 48 hours of bed rest. The surgeons considered that the main risk factors for ID were revision surgery (98.6%), patient's age (46.8%), surgeon's exhaustion (46.3%), and patient's weight (21.3%). CONCLUSIONS This nationwide survey reflects the lack of a standardized management protocol for ID. Practices among surgeons remain very heterogeneous. Further consensus studies are required to develop a standard management protocol for ID.
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Affiliation(s)
- Henri d'Astorg
- Centre Orthopédique Santy, Lyon, France; Hopital Privé Jean, Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Marc Szadkowski
- Centre Orthopédique Santy, Lyon, France; Hopital Privé Jean, Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, Lyon, France; Hopital Privé Jean, Mermoz, Ramsay-Générale de Santé, Lyon, France.
| | - Cyril Dauzac
- Centre du Rachis, Clinique du Dos, Neuilly sur Seine, France
| | - Nicolas Lonjon
- Department of Neurosurgery, Gui de Chauliac Hospital Montpellier, Montpellier, France; Mécanismes Moléculaires dans les Démences Neurodégénératives, University of Montpellier, Montpellier, France; Ecole Pratique des Hautes Études, Institut National de la Santé et de la Recherche Médicale U1198, Montpellier, France
| | - Renaud Bougeard
- Service de Neurochirurgie, Clinique du Val d'Ouest, Ecully, France
| | - Stephane Litrico
- Service de Neurochirurgie, Centre Hospitalier Universitaire de Nice, Hôpital Pasteur, Nice, France
| | - Martin Dupuy
- Service de Neurochirurgie, Clinique de l'Union, Saint-Jean, France
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Alshameeri ZAF, El-Mubarak A, Kim E, Jasani V. A systematic review and meta-analysis on the management of accidental dural tears in spinal surgery: drowning in information but thirsty for a clear message. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1671-1685. [DOI: 10.1007/s00586-020-06401-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/21/2020] [Accepted: 03/28/2020] [Indexed: 12/29/2022]
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17
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Minimizing CSF Leak and Wound Complications in Tethered Cord Surgery with Prone Positioning: Outcomes in 350 Patients. World Neurosurg 2020; 137:e610-e617. [PMID: 32088374 DOI: 10.1016/j.wneu.2020.02.073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND We document the results of a protocol to reduce the incidence of cerebrospinal fluid (CSF) leak and other wound complications in patients undergoing tethered cord surgery (TCS). METHODS Data from all patients undergoing TCS between January 2009 and April 2019 were reviewed retrospectively. Diagnosis (high risk or low risk; based on the presence of fascial and dural defects at surgery), type of graft used for dural or fascial repair, and CSF leak and other wound complications in the postoperative period were noted. All patients were nursed in the prone position with elevation of the foot end of the bed (Trendelenburg position) for at least 5 days after surgery with a subfascial drain in place. RESULTS Of a total of 350 patients (191 high risk; 159 low risk), CSF leak from the wound was noted in 16 (4.5%). All but 4 of these patients were managed with wound suturing with or without insertion of a subcutaneous drain with continued nursing in the prone and Trendelenburg position. Two patients had meningitis and 3 patients had wound infection. Multivariate analysis revealed that the use of synthetic grafts (P < 0.000) and inability to close the dura (P = 0.02) were the only significant risk factors for CSF wound leak. Wound infections and/or dehiscence were noted in 17 (4.8%) other patients. CONCLUSION Postoperative prone nursing with Trendelenburg position minimizes the incidence of CSF leak and other wound complications.
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18
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d’Avella E, Fazzolari B, Schiariti M, Delitala A, Ferroli P, Cappabianca P, Servadei F. Common Practice in the Management of Dural Closure: An Italian Questionnaire. World Neurosurg 2019; 129:e255-e263. [DOI: 10.1016/j.wneu.2019.05.125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/14/2019] [Accepted: 05/15/2019] [Indexed: 10/26/2022]
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Brazdzionis J, Ogunlade J, Elia C, Wacker MR, Menoni R, Miulli DE. Effectiveness of Method of Repair of Incidental Thoracic and Lumbar Durotomies: A Comparison of Direct Versus Indirect Repair. Cureus 2019; 11:e5224. [PMID: 31565626 PMCID: PMC6758957 DOI: 10.7759/cureus.5224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Introduction Incidental durotomy (ID) is a well-known complication in spine surgery. Surveys have not identified a consensus for repair method among neurosurgeons. IDs may lead to complications such as cerebrospinal fluid (CSF) fistula, which may predispose patients to infection, additional procedures, increased length of stay and morbidity. This study aims to compare durotomy repair methods with clinical outcomes. Methods The neurosurgery database at a single institution, Arrowhead Regional Medical Center, was screened for all patients who underwent thoracic and lumbar spine surgery from 2007-2017. Retrospective chart review of operative reports identified patients with an ID. Data collection included: length of stay, infection, additional procedures, time lying flat, CSF fistula formation (primary endpoint) with analysis using t-tests. Results A total of 384 patients underwent initial analysis. Of the 384 patients, 25 had an incidental durotomy based on operative reports. Four patients were excluded from this subset: two were repaired with muscle graft (low N), two were excluded for unclear repair method. The remaining 21 were stratified into two groups, those repaired directly with suture with or without adjunct (N=9) and those repaired indirectly with sealant (N=12). No patients developed a CSF fistula. The indirect group had a length of stay of six days, while the direct group had a length of stay of four days, p=0.184. Two of the nine patients in the direct group and two of the twelve patients in the indirect group developed an infection, p=0.586. Conclusion No patients developed CSF fistulas. Secondary endpoints of length of stay and infection rate did not differ. This study was unable to determine if direct versus indirect repair was a more effective repair method for ID. It is possible that if an incidental durotomy is identified and repaired with a water-tight seal, the repair method does not affect the outcome. It is up to the surgeon to individualize repair based on ability and circumstances.
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Affiliation(s)
- James Brazdzionis
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - John Ogunlade
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Christopher Elia
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | | | - Rosalinda Menoni
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
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