Management of acute intraoperative cerebrospinal fluid leaks

Incidental durotomy in spinal surgery has been reported with incidences varying between 1 and over 16%, depending on the type of surgery and the region of the spine. When a dural tear occurs, immediate and meticulous repair is advised in order to minimize the risk of complications secondary to persistent leakage of cerebrospinal fluid (CSF). These complications include intracranial hypotension, pseudomeningocele formation and the development of a CSF fistula with secondary wound infection and meningitis. Most dural tears are caused during biting actions by Kerrison rongeurs, and dural adhesions, dural redundancy and thinned dura are known risk factors. Accurate visualization and thorough preparation of the surgical field are key steps in dural tear repair. Those tears that are amenable to it should be carefully sutured. Large defects may require a patch of dural substitute to be sewed in. Autologous fat has proven to be useful as onlay or plugin graft. The use of fibrin glue has become a widespread practice and its effectiveness as an adjunct to primary suturing and graft constructions has been well demonstrated. Hydrogel sealants and collagen matrix onlay grafts have become available to the surgeon as additional tools in dural tear repair. However, primary suturing — if possible — is still considered to be the most effective way of reducing the chance of persistent CSF leakage. Tight closure of the fascial layer is imperative. After lumbar durotomy repair, bed rest is advised. Postoperative lumbar or ventricular CSF drainage can also help as an additional protective measure. While numerous measures and tools are available, the key message is that the surgeon confronted with a dural tear should take his time and apply all intraoperative and postoperative means required to secure watertight closure.     

Acinetobacter baumanii meningitis: a rare complication of incidental durotomy

Despite the frequency of dural tears in spinal surgery, meningitis is a rare complication reported to occur with a frequency of 0.18%. To the best of our knowledge, no case of Acinetobacter baumanii meningitis has been reported in the literature after a dural tear secondary to lumbar spine discectomy. This case highlights the importance of repairing all dural tears and commencing antibiotics that cover uncommon bacteria in those who develop symptoms of meningitis in this setting.     

Les plaies durales : à propos d’une série de 100 cas

IntroductionDural tears are a dreaded surgical incident because they are difficult to anticipate and may lead to serious complications.Materials and methodsThe French College of Neurosurgery analyzed 100 cases of dural tears declared on the physicians accreditation website from the Haute Autorité de santé (Regional Health Authority). A questionnaire on drainage, type of dural repair and bed rest duration was sent to 87 French neurosurgeons.ResultsThirty-six percent of patients with dural tears had a history of previous spinal surgery and the most common cause of tear was surgical fibrosis into the operative field for 30% of cases. Sixty-four percent had no history of spinal surgery and, in 33% of cases, the dural tear occurred during a surgery for herniated disc. Drainage was proposed case by case in 76% of cases, the patient was allowed to stand up at day 1 in 48% of cases. The treatment of dural tears combined different techniques including in situ injection of biological glue in 86% of cases. The most common complication was the need of wound repair procedure in 59.5% of cases, which was complicated by meningitis in 21.5% of cases.ConclusionThis study shows the lack of formal consensus about the procedure of repair, the method of drainage or the need to keep the patient bed ridden. This study highlights a relatively high frequency of dural tears, its potentially serious complications and stresses the need for prospective studies in order to define the appropriate action to undertake when faced with this type of incident.     

Symptomatic Epidural Hematoma after Elective Posterior Lumbar Decompression: Incidence,Timing, Risk Factors,and Associated Complications

Background

Symptomatic post-operative lumbar epidural hematoma (PLEH) is a complication of lumbar spine surgery that can cause permanent neurologic consequences through compression of the cauda equina and nerve roots.

Questions/Purposes

We sought to investigate the incidence, timing, and risk factors for symptomatic epidural hematomas following posterior lumbar decompression, as well as to identify additional post-operative complications associated with symptomatic lumbar epidural hematomas.

Methods

Elective lumbar spine procedures were identified in the National Surgical Quality Improvement Program (NSQIP) database between 2012 and 2016. Analyzed predictors of reoperation or readmission within 30 days for symptomatic PLEH included demographics, comorbidities, pre-operative laboratory values, peri-operative characteristics, and post-operative complications.

Results

There were 75,878 cases included in the analysis. The incidence rate of symptomatic PLEH was 0.27% (n = 206), 54.4% (n = 112) of which occurred within 5 days of the procedure. Increased age, obesity (body mass index of 35 or higher), peri-operative transfusion, multilevel surgery (two or more levels), dural tear repair, and microscope use were independently associated with PLEH. Post-operative complications associated with PLEH included surgical site infection and urinary tract infection.

Conclusions

Readmission or reoperation for symptomatic PLEH following elective lumbar spine surgery is rare and can occur many days or weeks after a procedure. There are modifiable risk factors for PLEH and associated additional post-operative complications that physicians should be suspicious of following posterior lumbar decompression.

     

Subdural hematoma after microdiscectomy: a case report and review of the literature

Background contextSubdural hematomas (SDHs) have been described as a rare complication from durotomy after lumbar spine surgery. In half of the reported cases, the durotomy was unnoticed intraoperatively. The most common presenting symptom was persistent headache.PurposeTo report a case of SDH after routine microdiscectomy and to review the literature.Study designCase report and review of the literature.MethodsRetrospective review of patient's history and imaging studies.ResultsA 39-year-old female underwent routine microdiscectomy for L5–S1 herniated disc. There were no complications, and no dural tear was noted. Approximately 1 week postoperatively, the patient complained of severe headaches. Imaging revealed a right intracranial chronic SDH and a lumbar pseudomeningocele. Operative exploration of her lumbar wound revealed a dural tear, which was closed primarily. The patient had subsequent resolution of her SDH.ConclusionsThe authors present a case of a routine microdiscectomy complicated by delayed cerebrospinal leak causing a chronic SDH. This report illustrates the need for a comprehensive evaluation of headaches after spine surgery.     

老年腰椎椎管狭窄症患者术中硬膜囊撕裂位置及术中术后处理对策

目的探讨老年腰椎椎管狭窄症患者手术发生硬膜囊撕裂的解剖学机制,比较撕裂位置及术中、术后处理对策。方法回顾性分析2012年01月~2014年01月本院行腰椎后路手术的216例〉70岁老年患者,记录患者一般资料、病程时间、术前诊断、手术方式和节段、术中硬膜囊撕裂的位置、术后脑脊液漏情况和处理方法以及并发症等。结果共计151例患者入选,其中男89例,女62例,年龄70~93岁,平均78.12岁。术中发生硬膜囊撕裂共计34例,术后出现脑脊液漏23例,硬膜囊撕裂位置发生率硬膜囊后外侧〉根袖〉硬膜囊外侧〉硬膜囊腹侧。术中采取硬膜囊缝合修补、明胶海绵压迫、生物蛋白胶粘合等处理,术后常规给予预防感染、神经根脱水、补液等治疗,均于术后3~10 d拔管,3~4周切口愈合,全部患者未出现严重并发症。结论 〉70岁老年腰椎椎管狭窄症患者术中硬膜囊撕裂及术后脑脊液漏的发生率高于整体人群,且多位于硬膜囊后外侧及根袖,术中及时发现并仔细缝合或修补破损的硬膜、术后间断夹闭引流管、延长拔管时间能获得良好的效果。     

Incidental durotomy in lumbar spine surgery: incidence and management

There is increasing awareness of the need to inform patients of common complications that occur during surgical procedures. During lumbar spine surgery, incidental tear of the dural sac and subsequent cerebrospinal fluid leak is possibly the most frequently occurring complication. There is no consensus in the literature about the rate of dural tears in spine surgery. We have undertaken this study to evaluate the incidence of dural tears among spine surgeons in the United Kingdom for commonly performed spinal procedures. Prospective data was gathered for 1,549 cases across 14 institutions in the United Kingdom. The results give us a baseline rate for the incidence of dural tears. The rate was 3.5% for primary discectomy, 8.5% for spinal stenosis surgery and 13.2% for revision discectomy. There was a wide variation in the actual and estimated rates of dural tears among the spine surgeons. The results confirm that prospective data collection by spine surgeons is the most efficient and accurate way to assess complication rates for spinal surgery.This research was carried out at the Leicester General Hospital, Leicester, UK.     

Dural injury following elective spine surgery – A prospective analysis of risk factors,management and complications

Incidental dural tears being a familiar complication in spine surgery could result in dreaded postoperative outcomes. Though the literature pertaining to their incidence and management is vast, it is limited by the retrospective study designs and smaller case series. Hence, we performed a prospective study in our institute to determine the incidence, surgical risk factors, complications and surgical outcomes in patients with unintended durotomy during spine surgery over a period of one year. The overall incidence in our study was 2.3% (44/1912). Revision spine surgeries in particular had a higher incidence of 16.6%. The average age of the study population was 51.6 years. The most common intraoperative surgical step associated with dural tear was removal of the lamina, and 50% of the injuries were during usage of kerrison rongeur. The most common location of the tear was paramedian location (20 patients) and the most common size of the tear was about 1 mm-5mm (31 patients). We observed that the dural repair techniques, placement of drain and prolonged post-operative bed rest didnot significantly affect the post-operative outcomes. One patient in our study developed persistent CSF leak, which was treated by subarachnoid lumbar drain placement. No patients developed pseudomeningocele or post-operative neurological worsening or re-exploration for dural repair. Wound complications were noted in 4 patients and treated by debridement and antibiotics. Based on our study, we have proposed a treatment algorithm for the management of dural tears in spine surgery.     

Incisional hernia after extreme lateral interbody fusion on the lumbar spine: A case report

IntroductionExtreme lateral interbody fusion is a minimally invasive lateral transpsoas approach for spine surgery. We herein report a case of an incisional hernia after an extreme lateral interbody fusion on the lumbar spine that was successfully treated by laparoscopic surgery with intraperitoneal onlay mesh repair.Presentation of caseA 78-year-old woman was referred to our hospital with a complaint of left abdominal bulge and pain. She had undergone an extreme lateral interbody fusion for a lumbar spinal canal stenosis from L1 to L4 a year prior. Abdominal computerized tomography showed a left lumbar incisional hernia, and laparoscopic surgery was performed. The hernia orifice was sutured closed and covered with mesh. The patient was discharged five days after the operation with no complications.DiscussionWhen performing XLIF for a spinal disorder, the muscles should be separated bluntly along their fibers to prevent muscle atrophy, and the incised fascia should be securely sutured closed. Abdominal wall incisional hernias can occur after spinal surgeries such as extreme lateral interbody fusion.ConclusionLaparoscopic repair for abdominal wall incisional hernia after spine surgery is safe and feasible.     

Effect of fibrin glue on the prevention of persistent cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery

Approximately one million spinal surgeries are performed in the United States each year. The risk of an incidental durotomy (ID) and resultant persistent cerebrospinal fluid (CSF) leakage is a significant concern for surgeons, as this complication has been associated with increased length of hospitalization, worse neurological outcome, and the development of CSF fistulae. Augmentation of standard dural suture repair with the application of fibrin glue has been suggested to reduce the frequency of these complications. This study examined unintended durotomies during lumbar spine surgery in a large surgical patient cohort and the impact of fibrin glue usage as part of the ID repair on the incidence of persistent CSF leakage. A retrospective analysis of 4,835 surgical procedures of the lumbar spine from a single institution over a 10-year period was performed to determine the rate of ID. The 90-day clinical course of these patients was evaluated. Clinical examination, B-2 transferrin assay, and radiographic imaging were utilized to determine the number of persistent CSF leaks after repair with or without fibrin glue. Five hundred forty-seven patients (11.3%) experienced a durotomy during surgery. Of this cohort, fibrin glue was used in the dural repair in 278 patients (50.8%). Logistic models evaluating age, sex, redo surgery, and the use of fibrin glue revealed that prior lumbar spinal surgery was the only univariate predictor of persistent CSF leak, conferring a 2.8-fold increase in risk. A persistent CSF leak, defined as continued drainage of CSF from the operative incision within 90 days of the surgery that required an intervention greater than simple bed rest or over-sewing of the wound, was noted in a total of 64 patients (11.7%). This persistent CSF leak rate was significantly higher (P < 0.001) in patients with prior lumbar surgery (21%) versus those undergoing their first spine surgery (9%). There was no statistical difference in persistent CSF leak between those cases in which fibrin glue was used at the time of surgery and those in which fibrin glue was not used. There were no complications associated with the use of fibrin glue. A history of prior surgery significantly increases the incidence of durotomy during elective lumbar spine surgery. In patients who experienced a durotomy during lumbar spine surgery, the use of fibrin glue for dural repair did not significantly decrease the incidence of a persistent CSF leak.     

Adverse effects of surgeon performance after a night shift on the incidence of perioperative complications in elective thoracolumbar spine surgery

BackgroundDecline in cognitive function after night shift has been well described. However, in the field of spine surgery, the effect of surgeons’ sleeplessness on patient outcome is unclear. The purpose of this study was to investigate whether the risk of perioperative complications in elective thoracolumbar spine surgery could be higher if the surgeon had been on a night shift prior to the day of surgery.MethodsWe performed a retrospective review of patients who underwent elective posterior thoracolumbar spine surgery, as indicated in medical records, between March 2015 and September 2018. In total, 1189 patients were included and divided into two groups: the post-nighttime (n = 110) and control groups (n = 1079). A post-nighttime case was defined when the operating surgeon was on nighttime duty on the previous night, and other cases were defined as controls. We evaluated the incidence of perioperative complications (surgical site infection, postoperative hematoma, postoperative paralysis, nerve root injury, and dural tear) in both groups.ResultsOverall, we found no significant difference in the major or minor perioperative complication rates between the two groups, but according to the type of complication, the incidence rate of dural tear tended to be higher in the post-nighttime group (13.6% vs 8.2%, P = 0.074). Multivariate analysis showed that post-nighttime status was an independent risk factor of dural tear (adjusted odds ratio, 2.02; 95% confidence interval [CI], 1.10–3.70; P = 0.023). After stratification by surgical complexity, post-nighttime status was an independent risk factor of dural tear only in the surgeries of 3 levels or more (adjusted odds ratio, 2.81; 95% CI, 1.18–6.67; P = 0.019).ConclusionsPost-nighttime status was generally not a risk factor of perioperative complications in elective posterior thoracolumbar spine surgeries, but was an independent risk factor of dural tear, especially in complex cases.     

Incidental durotomy during spine surgery: Incidence,management and complications. A retrospective review

Study designRetrospective review of a series of patients who underwent spinal surgery at a single spine unit during a 1 year period.ObjectivesTo assess the incidence, treatment, clinical consequence, complications of incidental durotomy during spine surgery and results of 37 months clinical follow-up.Summary of background dataIncidental durotomy is an underestimated and relatively adverse event during spinal surgery. Several consequences of inadequately treated dural tears have been reported.MethodsA retrospective review was conducted on 1326 consecutive patients who underwent spinal surgery performed in one French spine unit from January 2005 to December 2005. We excluded from this study patients treated for emergency spine cases.ResultsFifty-one dural tears were identified (3.84%). Incidental durotomies were associated with anterior cervical approach in 1 case, with posterior cervical approach in 1 case, with anterior retroperitoneal approach in 1 case and with posterior thoracolumbar approach in 48 cases. In addition, any clinically significant durotomy unrecognised during surgical procedure were included. Thirteen patients presented postoperative complications including 7 cerebrospinal fluid leaks, 2 wound infections, 2 postoperative haematomas, and 2 pseudomeningoceles. Nine of these 13 patients required a revision procedure. A mean follow-up of 37 months showed good long-term clinical results.ConclusionsIncidental durotomy is a common complication of spine surgery. All incidental durotomies must be repaired primarily. Dural tears that were immediately recognised and treated accordingly did not lead to any significant sequelae at a mean follow-up of 37 months. However, long-term follow-up studies will be needed to confirm this finding. The risks associated with dural tears and cerebrospinal fluid leaks are serious and should be discussed with any patients undergoing spine surgery.     

Influence of lumbar spine pathology on the incidence of paresthesia during spinal anesthesia

Background and Objectives. Paresthesia occasionally occurs during dural puncture or injection of local anesthetic for spinal anesthesia. Although the incidence of neurologic complications after spinal anesthesia is extremely low, the significance of paresthesia is unknown. The influence of known lumbar spine pathology on the incidence of paresthesia during spinal anesthesia is studied. Methods. Incidence of paresthesia with dural puncture (PP) or injection (PI) was studied in two groups of patients. Group 1 included patients for elective total joint replacement without known spine pathology or complaints. Group 2 included patients for elective lumbar spine surgery who received spinal anesthesia. Results. Significantly more PP (20% vs 9%) and PI (16% vs 6%) occurred in the spine surgery group. There were no neurologic sequelae of spinal anesthesia. Conclusions. This information suggests that the incidence of paresthesia during the conduct of spinal anesthesia is higher in patients with lumbar spine pathology. Although there were no neurologic complications, the sample size is too small to exclude an increase in the neurologic risk of spinal anesthesia in patients with known intraspinal pathology.     

Intravertebral pseudomeningocele: an unusual complication after disc surgery

Background contextPseudomeningoceles are most commonly the result of dural tear during spine surgery. They may sometimes slowly enlarge but they generally develop inside the spinal canal, toward the foramina or toward the surgical incision.PurposeTo describe a late and exceptional complication of a surgical discectomy.Study designA case report.MethodsWe report a unique case of a large asymptomatic pseudomeningocele strictly developed in the L5 vertebra, discovered incidentally in a 38-year-old woman. Computed tomography and magnetic resonance imaging showed a large cystic lesion involving the vertebral body and the left pedicle of L5 without contrast enhancement. There was neither extension of the cyst toward the vertebral lamina nor toward the spinal canal. Consent to publish the data was obtained from our patient.ResultsDiagnosis was performed during transpedicular image-guided puncture, when opacification of the cyst revealed dural communication. Biochemical analysis and cytology confirmed the presence of cerebrospinal fluid and absence of tumoral cells.ConclusionsDural tear was considered as a neglected complication after surgical discectomy at the same level performed 18 years ago. Differential diagnoses of cystic spinal lesions are discussed.     

Evaluation and treatment of dural tears in lumbar spine surgery: a review

Incidental durotomy is a frequent complication of lumbar spinal surgery. The number and complexity of spinal procedures is increasing, leading to a greater prevalence of dural tears; therefore, it is imperative that spine surgeons be familiar with safe and effective closure techniques. Occasionally, a tear may not be recognized during the procedure, so that one must recognize the signs and symptoms of a cerebrospinal fluid leak postoperatively. Several newer treatment concepts show promise. The current study represents an extensive review of the recent literature on the prevalence, mechanism, diagnosis, treatment, and outcomes of dural tears. The authors provide an overview of the problem, an update on current treatment strategies, and describe the senior author's technique of repair, which is easy to do and is effective in stopping additional leakage of cerebrospinal fluid.     

Iatrogenic dural tears

A dural tear, or durotomy, is a well-known complication of spine surgery and is among the most common reported complications in spinal surgery with an incidence of 0.5-5%. This text will provide a general review of the relevant anatomy, diagnosis, treatment, and outcomes.     

Symptomatic pneumorachis associated with incidental durotomy during microscopic lumbar disc surgery. Case report

Unintended incidental durotomy is not a rare complication of lumbar microsurgery and is usually recognized and treated immediately. The reconstruction process can be complicated further by unpredictable factors. To their knowledge, the authors report the first case of a symptomatic pneumorachis associated with the accidental awakening of a patient during reconstruction of an incidental durotomy following lumbar microdiscectomy. Incomplete cauda equina syndrome developed in the patient on awakening from surgery after reconstruction of an unintended incidental dural tear that occurred during lumbar microdiscectomy. Symptomatic pneumorachis was revealed on an emergency computed tomography scan, and the patient underwent immediate repeated operation to remove air and decompress the spinal canal. The increasing number and complexity of surgical procedures in the lumbar spine contribute to the growing incidence of unintended durotomy. The surgeon should be aware of rare complications that may arise. Development of a vacuum phenomenon in conjunction with a ball-valve mechanism may lead to pneumorachis during durotomy repair. If this rare complication is promptly recognized and confronted, the outcome will not be associated with long-term sequelae.     

Lag screw fixation of remote bilateral pedicle fractures of the fourth and fifth lumbar vertebrae after a single gunshot wound: a case report and technical pearl

Background contextOf the injuries involving the lumbar spine, pedicle fractures are among the least common; those involving bilateral pedicles are rare.PurposeThe aims of the study were to provide the first documentation of bilateral pedicle fractures at two consecutive levels after a gunshot, to review the mechanism of injury, and to evaluate a nonfusion treatment option for pedicle fractures.Study designThis is a technical note and case report.Outcome measureThe outcome measures were lumbar range of motion, return of motor and sensory functions, and return to normal activities.MethodsA 20-year-old male sustained bilateral pedicle fractures at L4 and L5 with a massive dural tear, progressive neurologic deficits, and urinary incontinence. He underwent repair of the dural tear and lag screw fixation of the pedicle fractures without fusion.ResultsThe patient had full range of motion of his lumbar spine, full strength in his lower extremities, and bladder control.ConclusionsThis is the first report of bilateral multilevel lumbar pedicle fractures after a single penetrating gunshot wound. The case documents this injury pattern after a gunshot, reviews the mechanism of injury, and presents the successful application of a nonfusion treatment option.     

The pathological changes in the spinal cord after dural tear with and without autologous fascia repair

Purpose

Dural tear is one of the common complications of spinal surgery leading to cerebrospinal fluid leakage followed by serial secondary symptoms. However, little is known about pathological changes of the spinal cord after dural tear. In the present study, we aimed to study the pathological changes in the spinal cord after dural tear with and without autologous fascia repair.

Methods

Sixty Sprague–Dawley rats were used for dural tear and autologous fascia graft repair models. Three days and 1 week after surgery, the pathological changes in the spinal cord were analyzed by immunohistochemistry, Western blot, enzyme-linked immunosorbent assay and spinal somatosensory evoked potentials test.

Results

Neuroinflammation was found in the parenchyma of the spinal cord characterized by gliosis, increased expression of inflammatory factors and infiltration of exogenesis immunocells in the rats without repair, which impaired the sensory conduction function of the spinal cord at the early stage of injury. Repairing with autologous fascia could attenuate neuroinflammation and help to maintain normal sensory conduction function of the spinal cord.

Conclusion

Dural tear could cause a series of inflammatory reactions in the spinal cord and further impair its sensory conduction function at the early stage of injury. Repairing with autologous fascia was a necessary and effective way to prevent the neuroinflammation and to maintain the normal function of the spinal cord.