Long-term results of lumbar spine surgery complicated by unintended incidental durotomy

Unintended incidental durotomy is not an infrequent complication of spinal surgery (incidence, 0.3-13% reported). Although prompt repair is advocated, little has been written regarding any consequences of primarily repaired durotomies on long-term patient outcome. A retrospective review of 450 patients undergoing lumbar spine surgery revealed 17 cases (4%) of incidental durotomy, recognized intraoperatively and repaired primarily. These patients were evaluated at long-term follow-up (mean, 25.1 months); and their results were compared with controls matched for age, diagnosis, procedure, and length of follow-up. No differences of statistical significance could be identified in comparing the outcomes of the two groups. Incidental durotomy, when recognized and repaired intraoperatively, does not increase perioperative morbidity or compromise final result.     

Incidental durotomy in spine surgery

STUDY DESIGN: Retrospective review of a large series of patients who underwent spinal surgery at a single institution during a 10-year period. OBJECTIVES: To further clarify the frequency of incidental durotomy during spine surgery, its treatment, associated complications, and results of long-term clinical follow-up. SUMMARY OF BACKGROUND DATA: Incidental durotomy is a relatively common occurrence during spinal surgery. There remains significant concern about it despite reports of good associated clinical outcomes. There have been few large clinical series on the subject. METHODS: A retrospective review was conducted of clinical and surgical records and radiographic data for consecutive patients who underwent spinal surgery performed by the two senior surgeons from January 1989 through December 1998. RESULTS: A total of 2144 patients were reviewed, and 74 were found to have dural tears occurring during or before surgery. Incidental durotomy occurred at the time of surgery in 66 patients (3.1% overall incidence). Incidence varied according to the specific procedure performed but was highest in the group that underwent revision surgery. The incidence of clinically significant durotomies occurring during surgery but not identified at the time was 0.28%. All dural tears that occurred during surgery and were recognized (60 of 66) were repaired primarily. Pseudomeningoceles developed in five of the remaining six patients. All six patients had subsequent surgical repair of dural defects because of failure of conservative therapy. A mean follow-up of 22.4 months was available and showed good long-term clinical results for all patients. CONCLUSIONS: Incidental durotomy, if recognized and treated appropriately, does not lead to long-term sequelae.     

Intracranial subdural hematoma after unintended durotomy during spine surgery

PURPOSE: To report a case of intracranial subdural hematoma occurring after a spinal dural tear that was made unintentionally during the course of a posterior laminectomy and spinal fusion at the L(5)-S(1) level. The possible physiopathological mechanisms are discussed. Clinical features: On the fourth postoperative day, a 59-yr-old woman displayed persistent headache following unintended durotomy during spine implant revision. Perioperative blood loss was 2840 mL and intravascular replacement was about 3000 mL. She was hydrated with iv fluids and treated with non-steroidal anti-inflammatory drugs. The symptoms improved but persisted. With the aggravation of the headache complicated with unconsciousness and the appearance of focal neurological signs on the eighth day, a computed tomography was obtained and revealed a right subdural hematoma. Following surgical drainage, the patient made an uneventful recovery. CONCLUSION: This case reminds us that subdural hematoma formation can complicate durotomy during spine surgery. Neurological deterioration in the postoperative period should prompt clinicians to rule out the diagnosis and intervene rapidly as appropriate.     

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.     

Risk factors for unintended durotomy during spine surgery: a multivariate analysis

Background contextIncidental durotomy during spine surgery is a common occurrence, with a reported incidence ranging from 3% to 16%. Risk factors identified by prior studies include age, type of procedure, revision surgery, ossification of the posterior longitudinal ligament, gender, osteoporosis, and arthritis. However, these studies are largely univariate analyses using retrospectively recorded data.PurposeTo identify and quantify statistically significant risk factors for inadvertent durotomy during spine surgery.Study designMultivariate analysis of prospectively collected registry data. The University of Washington Spine End Results Registry 2003 and 2004 is a compilation of prospectively collected detailed data on 1,745 patients who underwent spine surgery during 2003 to 2004.Patient sampleOne thousand seven hundred forty-five patients underwent spine surgery from 2003 to 2004 at our two institutions.Outcome measuresCardiac, pulmonary, gastrointestinal, neurologic, renal, and urologic complications defined a priori data collection.MethodsUsing these data, univariate and multivariate statistical analyses were performed to identify and quantify risk factors for incidental durotomy during spine surgery. Relative risk (RR) values with valid confidence intervals and p values were determined using these data.ResultsOur multivariate analysis demonstrated that age, lumbar surgery, revision surgery, and elevated surgical invasiveness are significant risk factors for unintended durotomy. Of these, revision surgery was the strongest risk factor for dural tear (RR, 2.21). Diabetes was a significant risk factor in the univariate analysis but not in the multivariate analysis.ConclusionsRevision surgery, age, lumbar surgery, degenerative disease, and elevated surgical invasiveness are significant risk factors for unintended durotomy during spine surgery. These data can be useful to surgeons and patients when considering surgical treatment.     

脊柱手术硬脊膜破裂的诊断及治疗进展

<正>硬脊膜破裂(incidental durotomy,ID)是脊柱手术中最常见的并发症之一。脊柱手术硬脊膜破裂的整体发生率为1%~17%[1]。其中腰椎手术硬脊膜破裂发生率最高,Kalevski等[2]报道其发生率为12.66%。早期、准确的诊断是成功处理的关键。在硬脊膜破裂的治疗方面缺乏系统的治疗原则,从而导致并发症的增多[3]。笔者就脊柱手术硬脊膜     

Postoperative management of incidental durotomy in minimally invasive lumbar spinal surgery

Unintended durotomy is a relatively common complication in spine surgery, with a reported incidence up to 14%. Traditional management has been mandatory bed rest for at least 48 h following repair, with or without placement of a drain. With the muscle-splitting approach and decreased potential (dead) space created during minimally invasive spinal surgery (MISS), there is less potential likelihood of symptoms such as spinal headaches or cerebrospinal fluid fistulas. We reviewed the cases of 5 patients undergoing lumbar MISS complicated by an incidental dural tear. Surgical treatment consisted of primary repair and/or use of DuraGen followed by application of either DuraSeal or Tisseel. Although the duration of bed rest varied, postoperative management involved early mobilization less than 48 h after surgery without the use of a drain. One patient was mobilized early on the second postoperative day, 2 patients were mobilized the morning after surgery, and 2 patients were mobilized immediately upon recovery from anesthesia. None of the patients developed symptoms related to durotomy. Although this represents a small series, early postoperative mobilization appears to be a reasonable option and results in shorter hospitalization.     

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.     

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.     

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.     

Natural language processing for automated detection of incidental durotomy

BACKGROUNDIncidental durotomy is a common intraoperative complication during spine surgery with potential implications for postoperative recovery, patient-reported outcomes, length of stay, and costs. To our knowledge, there are no processes available for automated surveillance of incidental durotomy.PURPOSEThe purpose of this study was to develop natural language processing (NLP) algorithms for automated detection of incidental durotomies in free-text operative notes of patients undergoing lumbar spine surgery.PATIENT SAMPLEAdult patients 18 years or older undergoing lumbar spine surgery between January 1, 2000 and June 31, 2018 at two academic and three community medical centers.OUTCOME MEASURESThe primary outcome was defined as intraoperative durotomy recorded in free-text operative notes.METHODSAn 80:20 stratified split was undertaken to create training and testing populations. An extreme gradient-boosting NLP algorithm was developed to detect incidental durotomy. Discrimination was assessed via area under receiver-operating curve (AUC-ROC), precision-recall curve, and Brier score. Performance of this algorithm was compared with current procedural terminology (CPT) and international classification of diseases (ICD) codes for durotomy.RESULTSOverall, 1,000 patients were included in the study and 93 (9.3%) had a recorded incidental durotomy in the free-text operative report. In the independent testing set (n=200) not used for model development, the NLP algorithm achieved AUC-ROC of 0.99 for detection of durotomy. In comparison, the CPT/ICD codes had AUC-ROC of 0.64. In the testing set, the NLP algorithm detected 16 of 18 patients with incidental durotomy (sensitivity 0.89) whereas the CPT and ICD codes detected 5 of 18 (sensitivity 0.28). At a threshold of 0.05, the NLP algorithm had specificity of 0.99, positive predictive value of 0.89, and negative predictive value of 0.99.CONCLUSIONSInternal validation of the NLP algorithm developed in this study indicates promising results for future NLP applications in spine surgery. Pending external validation, the NLP algorithm developed in this study may be used by entities including national spine registries or hospital quality and safety departments to automate tracking of incidental durotomies.     

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.     

Incidental durotomy in degenerative lumbar spine surgery – a register study of 64,431 operations

BACKGROUND

Incidental durotomy (ID) is one of the most common intraoperative complications seen in spine surgery. Conflicting evidence has been presented regarding whether or not outcomes are affected by the presence of an ID.