Do the gaps in the ligamentum flavum in the cervical spine translate into dural punctures? An analysis of 4,396 fluoroscopic interlaminar epidural injections

BACKGROUND

Cervical interlaminar epidural injections are performed frequently in managing chronic neck and upper extremity pain, although less commonly than lumbar interlaminar epidural injections. Recently, the US Food and Drug Administration warnings and safeguards to prevent neurologic complications. These were developed by the Multi-Society Pain Workgroup have taken center stage for all types of epidural injections, including cervical interlaminar epidural injections. The recommendations of safeguards to prevent neurologic complications after epidural steroid injections include that cervical interlaminar epidural injections must be performed utilizing fluoroscopy with anteroposterior, lateral, or oblique views with injection of contrast medium and that entry be limited to the C7-T1 epidural space or occasionally the C6-C7 with requirements for magnetic resonance imaging assessment of the epidural space.

OBJECTIVES

To assess the incidence of dural puncture associated with fluoroscopically directed cervical interlaminar epidural injections.

STUDY DESIGN

A retrospective assessment of patients undergoing cervical interlaminar epidural injections from January 2013 through February 2015.

SETTING

A private interventional pain management practice; a specialty referral center in the United States.

METHODS

The data were collected for 4,396 consecutive cervical interlaminar epidural injections performed from January 2013 through February 2015. The procedures were all performed under fluoroscopic visualization under posteroanterior view with contrast medium injection with lateral view confirmation when indicated. The procedures were performed by one of 2 physicians; the dural puncture and subsequent postoperative complications with level of epidural entry were determined.

OUTCOMES ASSESSMENT

The outcome was assessment of dural puncture.

RESULTS

A review of multiple manuscripts showed that defects in the ligamentum flavum may extend to as much as 100% of the population. However, it also has been shown that among the levels with a gap, the location of a gap in the caudal third of the ligamentum flavum was more frequent than in the middle or cephalic portion of the ligamentum flavum. Among the 4,396 epidural injections performed at C7-T1, C6-C7, and C5-C6, 1,227 were performed at C7-T1; 1,835 were performed at C6-C7; and 1,334 were performed at C5-C6. Dural punctures were observed in 1.8% (24 procedures) at the C5-C6 level entry; 0.87% (16 procedures) at the C6-C7 level entry; and 1.71% (21 procedures) at the C7-T1 level. There was no significant difference among the entry levels. No complications or spinal cord damage or postdural puncture headache were observed.

LIMITATIONS

The limitations of this report include that it is an assessment by only 2 well experienced physicians, even though it included a relatively large number of patients.

CONCLUSION

This study illustrates that dural puncture is equally prevalent, though very rare, irrespective of the needle entry level into the epidural space, with an overall dural puncture rate of 1.4%, with 1.8% at the C5-C6 level, 0.87% at the C6-C7 level, and 1.71% at the C7-T1 level. Based on the present literature, it appears that performing the procedure by inserting the needle into the cephalic portion of the intervertebral space rather than the caudal portion may be safer.

[Recurring post-traumatic growing skull fracture]

INTRODUCTION

Growing skull fracture, also known as post-traumatic bone absorption or leptomeningeal cyst, is a rare complication of traumatic brain injuries and occurs almost exclusively in children under 3 years of age.

CASE REPORT

We report the case of a 6-month-old child who presented, two months after an apparently unimportant traumatic skull injury, persistence of left temporoparietooccipital cephalohaematoma with no other signs. A transfontanellar ultrasonography scan revealed a bone defect with brain herniation, and computerised tomography and magnetic resonance imaging also confirmed the existence of a growing fracture. Excision of the leptomeningeal cyst, dural closure and repair of the bone defect with plates and lactate material were performed. Three months after the operation, the patient still presented collection of fluid and recurrence of the growing fracture was confirmed. Following the second operation, a baby helmet was fitted in order to prevent renewed recurrences. One year after the traumatic injury occurred, the patient remains asymptomatic.

CONCLUSIONS

Any child under 3 years of age with a post-traumatic cephalohaematoma should be checked periodically until the full resolution of the collection of fluid, especially if they present a fractured skull. The presence of a cephalohaematoma that remains more than two weeks after traumatic brain injury must make us suspect a growing fracture and reparation of the dura mater and a cranioplasty will be needed to treat it. The use of resorbable material allows it to be remodelled as the patient's skull grows, but its fragility increases the risk of recurrence. The use of a baby helmet after the operation could prevent complications.

The intra- and postoperative management of accidental durotomy in lumbar spine surgery: results of a German survey

BACKGROUND

The intra- and postoperative management of accidental durotomy in operations of the lumbar spine is not standardized. It is the aim of our survey to obtain an overview on the current practice in neurosurgical departments in Germany.

METHODS

The used questionnaire consisted of three questions and could be answered within a few minutes by checking boxes. In September 2012, the questionnaire was sent to 149 German neurosurgical departments. In the following 4 weeks 109 replies (73.2 %) were received.

RESULTS

Seventy-one neurosurgical departments (65.1 %) treat dural tears by a combination of methods, 28 (25.7 %) with suture alone, 7 (6.4 %) with fibrin-coated fleeces alone, 2 (1.8 %) with muscle patch alone and 1 (0.9 %) with fibrin glue alone. Sixty-six neurosurgical departments (60.5 %) decide on postoperative bed rest depending on the quality of the dural closure. Forty-three (39.5 %) neurosurgical departments do not rely on the quality of the dural closure for their postoperative management. In total, 72.5 % of the neurosurgical departments prescribe bed rest for 1-3 days, 1.8 % for more than 3 days, whereas 25.7 % allow immediate mobilization.

CONCLUSIONS

Among German neurosurgeons, no consensus exists concerning the intra- and postoperative management of accidental durotomies in lumbar spine surgery. Despite not being proved to reduce the rate of cerebrospinal fluid fistulas, bed rest is frequently used. As bed rest prolongs the hospital stay with additional costs and has the potential of a higher rate of medical complications, a prospective multicenter trial is warranted.

Dural tear of unusual cause

Epidural analgesia is highly recommended in cancer anorectal surgery. In addition to the fight against pain it provides some benefit in allowing early rehabilitation of patients. One of the risks of this practice is the dural tear creating a cerebrospinal fluid leak (CSF) in the epidural space (EPD). Clinical features the typical positional headache, a procession of various more or less severe symptoms: nausea, vomiting, dizziness, visual or hearing impairment or radicular pain. We report a dural of unusual cause secondary of the obstruction of tuohy catheter by vertebral cartilage.

Prospective comparison of simple suturing and elevation debridement in compound depressed fractures with no significant mass effect

BACKGROUND

Compound depressed fractures have conventionally been managed surgically with elevation and debridement to avoid infection, especially when there is dural penetration, nonetheless with little evidence. This study was to prospectively compare outcomes after simple suturing and elevation debridement in patients with compound depressed fractures.

METHODS

Patients of compound depressed fracture with GCS of five or more, no serious systemic injury, and no significant mass effect were prospectively studied for various factors in relation to infection, hospital stay, survival, and late post-traumatic seizures. Univariate and multivariate analyses were performed using SPSS21.

RESULTS

Of the total 232 patients with complete clinico-radiological and follow-up data, 183 underwent simple cleansing and suturing, and 49 underwent surgical elevation debridement. The surgical group at baseline had significantly lower GCS, greater dural violation, and brain matter herniation compared to the conservative arm. Univariate analysis showed simple suturing group to have significantly shorter hospital stay (2.4 vs. 10.3 days) (p < 0.001), lesser infection among survivors (4 vs. 21 %) (p = 0.001), and greater 'survival with no infection' (85 vs. 69 %) (p = 0.01). Multivariate analysis adjusting for age, sex, GCS, dural penetration, and surgical intervention confirmed significantly shorter hospital stay (p < 0.001) and lesser infection among survivors (p = 0.02) in the simple suturing group. Overall, there was no benefit offered by surgical debridement. Simple suturing had a better outcome in most subgroups, except in those with brain matter herniation and GCS 5-8, which showed non-significant benefit with surgical intervention.

CONCLUSIONS

Simple suturing seems to be an equally good option in patients with compound depressed fracture with no significant mass effect or brain matter herniation.

Incidental durotomy in lumbar spine surgery--a three-nation survey to evaluate its management

BACKGROUND

Although it is generally accepted that incidental durotomies (ID) should be primarily repaired, the current literature shows no consensus regarding the peri- and postoperative management in case of ID during lumbar spine surgery. Because ID is a rather frequent complication and may be associated with significant disability, we were interested to analyze the current handling of ID in three European countries.

METHODS

In March 2014, members of the Swiss, German, and Austrian neurosurgical and spine societies were asked to complete an online questionnaire regarding the management of ID during and after lumbar spine surgery. Two, respectively 4 weeks after the first invitation, reminder requests were sent to all invitees, who had not already responded at that time.

RESULTS

There were 175 responses from 397 requests (44.1 %). Responders were predominantly neurosurgeons (89.7 %; 10.3 % were orthopedic surgeons), of which 45.7, 40.0, and 17.8 % work in a non-university hospital, university hospital, and private clinic, respectively. As for the perioperative management of ID, 19.4 % of the responders suggest only bed rest, while, depending on the extent of the ID, 84.0 % suggest additional actions, TachoSil/Spongostan with fibrin glue or a similar product and single suture repair being the most mentioned. Concerning epidural wound drainage in case of ID, 37.2 % desist from placing an epidural wound drainage with or without aspiration, 30.9 % place it sometimes, and 33.7 % place it regularly, but only without aspiration. Most responders prescribe bed rest for 24 (34.9 %) or 48 h (28.0 %), with much fewer prescribing bed rest for 72 h (6.3 %) and none more than 72 h, and 14.9 % of participants never prescribe bed rest. The vast majority of physicians (82.9 %, n = 145) always inform their patients after the operation in case of ID.

CONCLUSIONS

There is substantial heterogeneity in the management of incidental durotomies. The majority of spine surgeons today aim at complete/sufficient primary repair of the ID with varying recommendations concerning postoperative bed rest. Still, there is a trend towards early mobilization if the incidental durotomy has been closed completely/sufficiently with no participant favoring bed rest for more than 72 h.

The use of surgical sealants in the repair of dural tears during non-instrumented spinal surgery

PURPOSE

To compare the success in repair of dural tears (DTs) using two different surgical sealants in non-instrumented lumbar spinal surgery and evaluate the incidence of associated short- and long-term complications.

METHODS

Twenty-three patients undergoing non-instrumented spinal surgery with intraoperative DTs were included both retrospectively and prospectively in this study. External signs of CSF leakage, neurological deficits, and infection-related complications were investigated postoperatively. The persistence of low-back pain was also evaluated and postoperative MRI was performed in all patients. DTs were repaired intraoperatively using suture with or without a dural patch. Eleven patients received an application of fibrin glue (Tissucol(®); Baxter, Inc., IL, USA) and 12 patients received an application of bovine serum albumin glutaraldehyde surgical adhesive (BioGlue(®) Surgical Adhesive; CryoLife, GA, USA). These patients were followed up at 3 months and 1 year postoperatively.

RESULTS

Successful intraoperative DT repair was obtained in all cases. Three patients in the Tissucol group presented with CSF leakage in the early postoperative period. There were no complications observed in the patients treated with BioGlue. At 3-month follow-up, no incidences of neurological or infection-related complications were observed in either group. There was no statistically significant difference in VAS between the two treatment groups.

CONCLUSIONS

Intraoperative DTs can be easily repaired by many effective techniques. However, in our experience, the use of BioGlue is an effective adjunct to immediate dural repair, being comparable in terms of efficacy and safety to the use of fibrin glue, potentially decreasing the incidence of associated short- and long-term complications.

Bacterial cellulose membranes used as artificial substitutes for dural defection in rabbits

To improve the efficacy and safety of dural repair in neurosurgical procedures, a new dural material derived from bacterial cellulose (BC) was evaluated in a rabbit model with dural defects. We prepared artificial dura mater using bacterial cellulose which was incubated and fermented from Acetobacter xylinum. The dural defects of the rabbit model were repaired with BC membranes. All surgeries were performed under sodium pentobarbital anesthesia, and all efforts were made to minimize suffering. All animals were humanely euthanized by intravenous injection of phenobarbitone, at each time point, after the operation. Then, the histocompatibility and inflammatory effects of BC were examined by histological examination, real-time fluorescent quantitative polymerase chain reaction (PCR) and Western Blot. BC membranes evenly covered the surface of brain without adhesion. There were seldom inflammatory cells surrounding the membrane during the early postoperative period. The expression of inflammatory cytokines IL-1β, IL-6 and TNF-α as well as iNOS and COX-2 were lower in the BC group compared to the control group at 7, 14 and 21 days after implantation. BC can repair dural defects in rabbit and has a decreased inflammatory response compared to traditional materials. However, the long-term effects need to be validated in larger animals.

Dural tears in primary decompressive lumbar surgery. Is primary repair necessary for a good outcome?

STUDY DESIGN

Case control series with prospective data collection.

OBJECTIVE

To establish whether incidental durotomy treated without primary suture repair adversely affects the outcome following lumbar surgery in the longer term.

METHOD

Outcome scores from a prospective database were used for an audit of dural tears in primary lumbar decompressive surgery. Outcome data collected includes the Short Form 36 General Health Questionnaire (SF36), the Oswestry Disability Index (ODI) and Visual Analogue Scores for leg pain (VAL) and back pain (VAB).

RESULTS

Out of 200 consecutive procedures, a dural tear occurred in 19 (9.5%) patients. Of 19 patients with a dural tear, data was incomplete in 4 patients, and 1 further patient who had their dural tear sutured was excluded, leaving 14 patients to be studied. There were seven males and seven females, with an average age of 50.8 years (31-69). These 14 patients (group 1) were compared to a matched group (age, sex, surgical diagnosis and duration of follow-up) of 14 patients (group 2) with no tear. Both groups had similar pre-operative scores. At 6-month follow-up, both groups had significant improvements in all outcomes measures except for the general health domain of the SF-36. At final follow-up, patients with dural tears appeared to have better improvements in outcome measures amongst the VAB, VAL and ODI with similar scores in the SF-36 domains.

CONCLUSION

Our study demonstrates that incidental durotomy in primary lumbar decompressive surgery can be successfully managed without primary suture repair with no adverse effect on surgical outcome in the longer term.

Incidental dural tear in spine surgery: analysis of a nationwide database

PURPOSE

The purpose of this study was to report the incidence of dural tear (DT) in spine surgery, risk factors, and patient outcomes on a national level.

METHODS

Clinical data were obtained from the Nationwide Inpatient Sample for 2009. Patients who underwent spine surgery were identified and, among them, patients who had DT were identified, according to the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes. Patient and hospital demographic data were retrieved. The incidence of DT and in-hospital patient outcomes were analyzed. Multivariate logistic regression analysis was performed to identify the risk factors for DT.

RESULTS

The incidence of DT was 2.7 % (17,932/665,818). Multivariate analysis revealed that older age, female gender, increased Elixhauser comorbidity score, and high hospital caseload were the significant risk factors for DT. Comparison between patients with and without DT showed that those with DT had significantly higher overall in-hospital complications (18.8 vs. 10.2 %), higher in-hospital mortality rate (0.4 vs. 0.3 %), longer hospital stays (5.1 vs. 3.7 days), lower proportion discharged home routinely (61.0 vs. 76.8 %), and increased total hospital charges ($85,138 vs. $71,808), respectively.

CONCLUSIONS

The reported incidence of DT in spine surgery was 2.7 % in the US. Risk factors included older age, female gender, increased comorbidities, and high hospital caseload. DT increased the rate of in-hospital complications and mortality and health care burdens.

Can the incidence of accidental dural puncture in laboring women be reduced? A systematic review and meta-analysis

BACKGROUND

Accidental dural puncture (ADP) after epidural analgesia (EDA) for labor pain may cause severe postdural puncture headache (PDPH) and may prolong hospital stay. We aimed to identify techniques that reduce the incidence of ADP.

METHODS

A systematic literature search was performed. Data on the occurrence of ADP and PDPH were extracted and subjected to meta-analysis. The random effects model was applied. Risk ratios (RR) and 95% confidence intervals (CI) were calculated.

RESULTS

We identified 54 articles, 13 non-randomized controlled trials and 41 randomized controlled trials (RCTs), reporting on a total of 98,869 patients. In non-RCTs, the use of liquid for the identification of the epidural space was associated with a reduced risk of ADP compared to the use of air (RR 0.55, 95% CI 0.39 to 0.79, P=0.001). In our analysis of RCTs this comparison did not produce a significant difference. No effect was found for combined spinal-epidural analgesia, maternal position, type of the catheter, needle size, bevel direction, operator experience, or use of ultrasound.

CONCLUSION

A reduction of the risk of ADP was found for liquid use for the loss of resistance, but only in lower quality studies. Based on current evidence, we cannot make a recommendation regarding any of the techniques under study. Therefore, clinicians should focus on measures to prevent or treat PDPH once ADP has occurred.

[Unknown intracerebral tumour presenting as brainstem compression following unintentional dural puncture]

A 36-year old primigravid of 41 weeks gestation was admitted to the labour ward. Her past medical history included hyperemesis gravidarum and migraine. An accidental dural puncture occurred during labour epidural analgesia. In the postpartum period she presented with continuous headache, and was treated with oral analgesics, oral caffeine, fluid therapy, and tetracosactide. She refused an epidural blood patch. On the seventh day postpartum, the patient was re-admitted to the Emergency Department with decreased level of consciousness and signs of brainstem compression. Cranial computed tomography and magnetic resonance imaging showed a posterior fossa tumour. An emergency craniotomy was performed with complete neurological recovery. This case emphasises the need to consider the differential diagnoses of post-dural puncture headache and to highlight the warning signs in patients who do not respond despite treatment with conventional therapy.

Repair of lumbar dural tears with a suture patch: retrospective single-surgeon case series

Dural tears traditionally have been treated with repair and then flat bed rest of variable duration. We conducted a study to evaluate the outcome of treating dural tears with a suture patch and immediate mobilization. Fifty patients (28 male, 22 female) had a lumbar dural tear repaired with suture patch and immediate mobilization. Mean age was 58.9 years (range, 31-81 years). Medical records were reviewed to determine the rate of signs and symptoms: headache, photophobia, tinnitus, neck pain, incisional fluctuance, wound drainage, and return to operating room. No patients reported postoperative headache, photophobia, tinnitus, or neck pain. No patients developed wound fluctuance or drainage. One patient was treated medically for a superficial wound infection. No patients required return to the operating room. Dural repair with suture patch appears to be effective and allows early mobilization.

Application of PLGA/type I collagen/chitosan artificial composite dura mater in the treatment of dural injury

To improve the safety of dura repair in neurological surgeries, a new poly (glycolide-co-lactide)/type I collagen/chitosan artificial composite dura mater was evaluated in a rabbit model with dura mater injury. Eighteen rabbits were randomized to 3 groups: rabbits with unclosed dura mater; rabbits with dura mater repaired by fascia and rabbits with dura mater repaired by the composite membrane. Modified combine behavior score were given at a series of time points and several cytokines were also determined to reflect the inflammatory conditions. Rabbits whose dura mater was repaired by composite membrane showed a similar recovery rate of neurological function and inflammatory condition compared with the rabbits whose dura mater was repaired by fascia. In addition, the rabbits with closed dura mater were better than ones with unclosed dura mater in the restore rate of neurological function as well as inflammatory reactions according to the statistical analysis. The new artificial membrane appears to be safe and efficient in the treatment of dura mater defect.

Dural tear and myelomalacia caused by an airgun pellet in a cat

An 8-year-old cat was presented with severe neurological deficits secondary to a traumatic cervical spinal cord injury caused by an airgun pellet. This report describes, for the first time, the myelographic findings of a dural rupture in a cat and also describes a bilateral Horner's syndrome in a cat.

MR cisternography/myelography of post-traumatic spinal CSF fistulae and meningeal lesions in small animals

BACKGROUND

The diagnosis of post-traumatic spinal cerebrospinal fluid (CSF) fistulae due to dural tears or lesions remains a challenge. Thus far, CT myelography is the standard test used to diagnose these complications.

PURPOSE

To evaluate the diagnostic ability of gadolinium-enhanced MR cisternography/myelography (intrathecal gadopentate dimeglumine or Gd-DTPA) in small animals that had experienced accidental spinal trauma.

MATERIAL AND METHODS

Four dogs and one cat suffered traumatic accidents resulting in neurological deficits underwent spinal MRI with intrathecal Gd-DTPA after routine plain films and MR images.

RESULTS

T2-weighted SE images showed high water content in the epidural space or in the surroundings of the vertebrae in four animals. MR myelography revealed CSF leakage in all of them. In two animals CSF leaks were observed exuding from the spinal canal and tracking towards adjacent loose fat and interfascial planes. In two other animals Gd-DTPA extravasation was diffusely collected in paraspinal tissues around the vertebral arch. In the fifth animal a focal pseudomeningocele was observed adjacent to the traumatized region.

CONCLUSION

Intrathecal administration of Gd-DTPA is an effective method to reveal and confirm post-traumatic spinal CSF fistulae or other dural lesions in animals with potential application in humans.

[Analysis of intraoperative complications of microendoscopic disectomy and corresponding preventive measures]

OBJECTIVE

To analyze the reasons of intraoperative complications of microendoscopic disectomy (MED) and corresponding preventive measures.

METHODS

From October 2001 to January 2012, the data of 851 patients with lumbar disc herniation underwent MED were retrospectively analyzed. There were 469 males and 382 females with an average age of 42.5 years ranging 16 to 75. Course of disease was from 1 to 18 months with an average of 3 months. The segments of herniated disc including L3,4 of 24 cases, L4,5 of 418 cases and L5S1 of 409 cases . Main symptoms included low back pain with lower extremity radial pain and numbness. Of them,unilateral lower extremity symptom was in 729 cases and bilateral symptom was in 122 cases. There were at least 2 abnormal signs in the four signs which including feeling anormaly, muscle strength anormaly,dysreflexia and muscle atrophy. Distraction test of nerve was positive. CT or MRI findings must coincide with the clinical symptoms and signs. No lumbar instability,spinal stenosis,the upper lumbar disc herniation or combined with cauda equina nerve syndrome were found in 851 patients. The intraoperative complications were recorded and analyzed for the reasons of the intraoperative complication and related prevention measures.

RESULTS

According to the Macnab standard,424 cases obstained excellent results, 321 good,106 fair,with excellent and good rate of 87.5%. The result was similar to the traditional open operation. One cases transferred to open operation due to equipment breakdown, case died for myocardial infarction at 11 days after the operation, 2 cases occurred acute epidural hematoma in 1 hour after operation. Injury of dura mate of spinal cord occurred in 28 cases and incidence rate was 3.29%(28/851); traction injury of nerve root occurred in 38 cases and incidence rate was 4.46% (38/851). One case occurred in retroperitoneal hematoma, 2 cases in incomplete cauda equina injury and 2 cases in incomplete nerve root breakage.

CONCLUSION

Skilled endoscopic hemostasis techniques,careful and meticulous operation is very important for the prevention of intraoperative complications. Moreover,timely finding and treating the complications was effective measures to prevent the coniplications.

Delayed presentation of incidental durotomy

Two case reports illustrate a delayed clinical presentation of incidental durotomy following surgical posterior decompression of the lumbar spine. The clinical presentation as well as radiographic imaging studies used in diagnosing this relatively rare surgical complication are discussed. Both nonoperative as well as surgical treatment alternatives are outlined.

[Incidence of accidental dura mater punctures in a university hospital: a prospective observational study]

OBJECTIVE

Accidental dura mater puncture is a potential complication during epidural block, and may be associated with multiple factors. Our objective was to determine the prevalence and risk factors of accidental dural puncture in a university hospital, evaluating the differences in the number of complications during different working hours.

MATERIAL AND METHODS

A prospective observational study was conducted on all women who requested regional anaesthesia in the Epidural Analgesia Unit between 1 January 2009 and 1 January 2011, and who fulfilled the inclusion criteria. The technique employed to control labour pains was epidural analgesia.

RESULTS

A total of 12,480 pregnant women were included. The prevalence of accidental dura mater puncture was 0.4% (50 patients). Of these, 28% were due to medical residents. More accidental dura mater punctures were observed during September and in the afternoon shift.

CONCLUSIONS

The prevalence of accidental dura mater puncture is similar to other patient series. In ours, tiredness or lack of sleep did not influence the incidence of complications in analgesia for labour pains in a 24 hour care unit. This may be due to the distribution of on-call shifts not exceeding more than 6 hours.

[The finding of glucose in the fluid obtained by epidural catheter after its insertion during combined intradural-epidural anaesthesia with hyperbaric bupivacaine is a usual occurrence]

OBJECTIVES

To determine whether the appearance of glucose in the fluid spontaneously obtained by the epidural catheter after its insertion during combined intradural-epidural anaesthesia with hyperbaric bupivacaine is a usual occurrence.

PATIENTS AND METHODS

A prospective, observational study was conducted on 34 patients with combined intradural-epidural anaesthesia in whom an epidural catheter was introduced, after locating the epidural space with a saline solution, inserting a spinal needle and injecting hyperbaric bupivacaine. After observing whether any fluid was spontaneously dripping from it, it was determined if this contained glucose. Withdrawal of the needle and washing its lumen with saline solution, it was checked whether there was glucose in washout. The samples were analysed using a glucose meter. When the motor block disappeared a dose of local anaesthetic was administered through the epidural catheter. The relationship of the demographic parameters with the spontaneous dripping of the epidural catheter was evaluated.

RESULTS

Spontaneous dripping by the epidural catheter after its insertion was observed in 22 patients. All the samples obtained contained glucose. There was glucose in 9 out of 34 epidural needle wash samples. None of the patients suffered from excessive motor-sensory block. There was a statistically significant relationship between patient age (P<.05) and spontaneous dripping by the catheter (the higher the age, more dripping).

CONCLUSION

The finding of glucose in the fluid obtained by the epidural catheter is a frequent occurrence and is of no clinical significance. We propose that it could be due to a leak of cerebrospinal fluid by the dural puncture needle during or after the administering of the hyperbaric bupivacaine and the spillage of this into the epidural space.

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

STUDY DESIGN

Retrospective review of a series of patients who underwent spinal surgery at a single spine unit during a 1 year period.

OBJECTIVES

To assess the incidence, treatment, clinical consequence, complications of incidental durotomy during spine surgery and results of 37 months clinical follow-up.

SUMMARY OF BACKGROUND DATA

Incidental durotomy is an underestimated and relatively adverse event during spinal surgery. Several consequences of inadequately treated dural tears have been reported.

METHODS

A 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.

RESULTS

Fifty-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.

CONCLUSIONS

Incidental 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.