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

Safety and benefit of ambulation within 24 hours in elderly patients undergoing lumbar fusion: propensity score matching study of 882 patients

BACKGROUND CONTEXT

Elderly patients are less likely to recover from lumbar spine fusion (LSF) as rapidly compared with younger patients. However, there is still a lack of research on the effect of early ambulation on elderly patients undergoing LSF surgery for lumbar degenerative disorders.

PURPOSE

To evaluate the safety and benefit of ambulation within 24 hours in elderly patients who underwent LSF.

STUDY DESIGN

A retrospective study.

PATIENT SAMPLE

Consecutive patients (aged 65 and older) who underwent elective transforaminal lumbar interbody fusion surgery for degenerative disorders from January 2019 to October 2022.

OUTCOME MEASURES

Outcome measures included postoperative complications, postoperative drainage (mL), laboratory test data, length of hospital stay (LOS), readmission and reoperation within 3 months.

METHODS

Early ambulation patients (ambulation within 24 hours after surgery) were propensity-score matched 1:1 to a delayed ambulation patients (ambulation at a minimum of 48 hours postoperatively) based on age, intraoperative blood loss, and number of fused segments. The incidence of postoperative adverse events (AEs, including rates of complications, readmission, and prolonged LOS) and the average LOS were used to assess the safety and benefit of early ambulation, respectively. Multivariable regression analysis was performed to assess the association between early ambulation and postoperative AEs. The risk factors for delayed ambulation were also determined using multivariable logistic analyses.

RESULTS

A total of 998 patients with LSF surgery were reviewed in this study. After excluding 116 patients for various reasons, 882 patients (<24 hours: N=350, 24-48 hours: N=230, and >48 hours: N= 302) were included in the final analysis. After matching, sex, BMI, preoperative comorbidities, laboratory test data and surgery-related variables were comparable between the groups. The incidence of postoperative AEs was significantly lower in the EA group (44.3% vs 64.0%, p<.001). The average postoperative LOS of the EA group was 2 days shorter than the DA group (6.5 days vs 8.5 days, p<.001). Patients in the EA group had a significantly lower rate of prolonged LOS compared with the DA group (35.1% vs 55.3%, p<.001). There was no significant difference in postoperative drainage volumes between the two groups. Multivariable analysis identified older age (odds ratio [OR] 1.07, p<.001), increased intraoperative EBL (OR 1.002, p=.001), and higher international normalization ratio (OR 10.57, p=.032) as significant independent risk factors for delayed ambulation.

CONCLUSIONS

Ambulation within 24 hours after LSF surgery is independently associated fewer AEs and shorter hospital stays in elderly patients. Implementing the goal of ambulation within 24 hours after LSF surgery into enhanced recovery after surgery protocols for elderly patients seems appropriate. Older age, increased intraoperative blood loss and worse coagulation function are associated with delayed ambulation.

Early ambulation versus prolonged bed rest for incidental durotomies in spine procedures: a systematic review and meta-analysis

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.

Complications after early versus late mobilization after an incidental durotomy: a systematic review and meta-analysis

BACKGROUND

An incidental durotomy (IDT) is a frequent complication of spinal surgery. The conventional management involving a period of flat bed rest is highly debatable. Indeed, there are scanty data and no consensus regarding the need or ideal duration of post-operative bed rest following IDT.

OBJECTIVE

To systematically evaluate the literature regarding the outcomes of mobilization within 24 h and after 24 h following IDT in open lumbar or thoracic surgery with respect to the length of hospital stay, minor and major complications.

METHODS

A systematic review of the literature using PubMed, Embase and Cochrane and dating up until September 2022 was undertaken following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Quality of evidence was assessed using a modified version of Sackett's Criteria of Evidence Support.

RESULTS

Out of 532 articles, 6 studies met the inclusion criteria (1 Level-I, 4 level-III and 1 Level-IV evidence) and were analyzed. Overall, 398 patients of mean age 59.9 years were mobilized within 24 h. The average length of stay (LOS) for this group was 5.7 days. Thirty-four patients (8.5%) required reoperation while the rate of minor complications was 25.4%. Additionally, 265 patients of mean age 63 years with IDT were mobilized after 24 h. The average LOS was 7.8 days. Twenty patients (7.54%) required reoperation while the rate of minor complications was 55%. Meta-analysis comparing early to late mobilization, showed a significant reduction in the risk of minor complications and shorter overall LOS due to early mobilization, but no significant difference in major complications and reoperation rates.

CONCLUSIONS

Although early mobilization after repaired incidental dural tears in open lumbar and thoracic spinal surgery has a similar major complication/ reoperation rates compared to late mobilization, it significantly decreases the risk of minor complications and length of hospitalization.

Posterior and postero-lateral incidental durotomy during lumbar spine surgery: primary repair versus augmented primary repair

Background

Incidental durotomy (ID) during lumbar spine surgery is a frequent complication of lumbar spine surgical procedures. Many surgical techniques were described in literature for repair of durotomy, however it is a matter of debate if one technique is a gold standard method of repair. Our study described two groups with posterior and postero-lateral ID that occurred during lumbar spine surgery: group A with 34 cases with a mean age of 49.85 years repaired by primary water tight closure using prolene or silk sutures, and group B with 34 cases with a mean age of 47.18 years treated with augmented primary repair (sutures augmented with a graft from lumbar fascia and tissue sealant "Fibrin glue"). Patients were evaluated for risk factors for durotomy, post-operative clinical outcome, and need for revision surgery.

Results

Eleven cases of group A and nine cases of group B had previous spine surgery. The dural tear was < 2 cm in 41.7% of group A and 83.3% of group B. Better outcome was achieved in 32 patients of group A and 30 patients of group B. Among our study cases 2 patients from group A and 4 patients from group B needed revision surgery due to CSF leak which failed to stop with conservative management and percutaneous blood patch.

Conclusions

Dural closure technique after ID does not seem to influence revision surgery rates due to cerebrospinal fluid (CSF) leakage and its complications. Durotomies that were immediately recognized and treated did not lead to any significant consequences.

Development of cerebrospinal fluid fistula after incidental durotomy in spinal decompression surgery

BACKGROUND

Incidental durotomy (ID) during spinal surgery is a risk factor for the development of cerebrospinal fluid (CSF) fistula. The rates of ID with or without consecutive CSF fistula vary according to the extent of the surgical procedure. Revision surgery has the highest rates of dural tears. However, not every case of ID leads to CSF fistula requiring revision surgery. The objective of this study was to analyze the predictors for the development of CSF fistula after ID.

METHODS

This retrospective study included 6024 consecutive patients who had been surgically treated for degenerative spinal disease at our clinic over the past 15 years. Patients who had undergone surgical revision for CSF fistula were assigned to the CSF fistula group. A matched 3:1 control group (ID group) was formed of patients with ID but without CSF fistula. Charts, surgical reports, and radiographic data were reviewed and statistically analyzed for demographics, duration of symptoms, co-morbidities, surgical strategy, and pre- and postoperative neurological performance.

RESULTS

The 15-year incidence of CSF fistula in the overall population was 0.36% (n=22). The following locations were affected: n=18 lumbar (81.8%), n=2 cervical (9.1%), and n=2 thoracic (9.1%). The extent of ID was similar in both groups. The two groups did not significantly differ with regard to the intraoperative management of dural repair with primary suturing (p=0.345), dural patches, sealant, or collagen matrix (p=0.228; p=0.081; p=0.081). In the postoperative period, bed rest in supine position for 48 hours (p=0.037) and laxative therapy (p=0.034) were the most beneficial treatment modalities for preventing CSF fistula. Patients with CSF fistula were hospitalized significantly longer (21 days vs. 10 days in the control group; p<0.001).

CONCLUSIONS

This large test group showed a low incidence of postoperative CSF fistula after intraoperative ID. Bed rest and laxative treatment were important approaches to preventing CSF fistula.

No benefit of early versus late ambulation after incidental durotomy in lumbar spine surgery: a randomized controlled trial

PURPOSE

Incidental durotomy (ID) is a complication occurring in 4-17% of decompressive spinal surgeries. Persisting CSF leakage can occur even after ID repair and requires revision surgery. Prolonged flat bed rest (BR) to reduce the incidence of persisting CSF leakage is frequently applied but highly debated. A randomized controlled trial comparing prolonged BR versus early ambulation after ID repair is lacking. The aim of this study was to investigate the incidence of revision surgery as a result of persistent cerebro-spinal fluid (CSF) leakage and medical complications after immediate or late post-operative ambulation following ID during decompressive spinal surgery.

METHODS

Ninety-four of 1429 consecutive cases undergoing lumbar spine surgery (6.58%) were complicated by an ID. Sixty patients (mean age of 64 ± 13.28 years) were randomized to either early post-operative ambulation (EA, n = 30) or flat BR for 48 h (BR, n = 30). The incidence of CSF leakage resulting in revision surgery, medical complications and duration of hospitalization were compared between groups.

RESULTS

Two patients in the BR group and two patients in the EA group underwent revision surgery as a result of persisting CSF leakage. Four patients in the BR group experienced medical complications associated with prolonged immobilization. The duration of hospitalization was 7.25 ± 3.0 days in the BR group versus 6.56 ± 2.64 days in the EA group, p = 0.413.

CONCLUSION

The results of this study indicate no benefit of prolonged BR after an adequately repaired ID in lumbar spine surgery.

LEVEL OF EVIDENCE

Level 1b (individual randomized controlled trial). These slides can be retrieved under Electronic Supplementary Material.

Effectiveness of Method of Repair of Incidental Thoracic and Lumbar Durotomies: A Comparison of Direct Versus Indirect Repair

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.

Preferences of Spine Surgeons With Regard to Management of Intraoperative Durotomy: A Survey of Current Management

STUDY DESIGN

This was a cross-sectional study.

OBJECTIVE

The objective of this study was to determine spine surgeons' preferences for the intraoperative and postoperative management of intraoperative durotomy (IDT) in decompression and spinal fusion surgeries.

SUMMARY OF BACKGROUND DATA

Management guidelines for IDT remain elusive. Traditionally, management consists of intraoperative suturing and postoperative bed rest. However, preferences of North American spine surgeons may vary, particularly according to type of surgery.

MATERIALS AND METHODS

Spine surgeons of AO Spine North America (AOSNA) were surveyed online anonymously to determine which techniques they preferred to manage IDT in decompression and fusion. Differences in preferences according to surgery type were compared using the Fisher exact test. A series of linear regressions were conducted to identify demographic predictors of spine surgeons' preferences.

RESULTS

Of 217 respondents, most were male (95%), orthopedic surgeons (70%), practiced at an academic center (50%), were in practice 0-19 years (71%) and operated on 100-300 patients per year (70%). The majority of surgeons applied sutures (93%-96%) and sealant (82%-84%). Surgeons also used grafts (26%-27%), drains (18%), other techniques (4%-5%), blood patch (2%-3%), or no intraoperative management (1%-2%). Postoperatively, most surgeons recommended bed rest (74%-75%). Antibiotics (22%), immediate mobilization (18%-20%), reoperation (14%-16%), other techniques (6%), or no postoperative management (5%) were also preferred. Management preferences did not vary significantly between decompression and fusion surgeries (all P-values>0.05). Specialty, practice facility, years in practice, and patients per year were identified as independent predictors of IDT management preferences (P<0.05).

CONCLUSIONS

Although North American spine surgeons preferred to manage IDT with sutures augmented by sealant followed by bed rest after surgery, less common techniques were also preferred during the intraoperative and postoperative periods. Notably, intraoperative and postoperative IDT management preferences did not change in accordance to the type of surgery being conducted.

LEVEL OF EVIDENCE

Level V.

Risk Factors and Management of Incidental Durotomy in Lumbar Interbody Fusion Surgery

STUDY DESIGN

This is a retrospective study analysis.

OBJECTIVE

In this retrospective study we evaluated risk factors for incidental durotomy and its impact on the postoperative course.

SUMMARY OF BACKGROUND DATA

Lumbar interbody fusion (LIF) is increasingly applied for the treatment of degenerative instability. A known complication is incidental durotomy.

MATERIALS AND METHODS

A cohort of 541 patients who underwent primary LIF surgery between 2005 and 2015 was analyzed. Previous lumbar surgery, age, surgeon's experience, intraoperative use of a microscope, and the number of operated levels were assessed and the risk for incidental durotomy was estimated using the Log-likelihood test and Wald test, respectively. The association of incidental durotomy and outcome parameters was analyzed using the quantile regression model.

RESULTS

In 77 (14.2%) patients intraoperative cerebrospinal fluid (CSF) fistula was observed. Previous lumbar surgery (P<0.001), number of operated levels (P=0.03), and surgeon's experience (P=0.01) were significantly associated with incidental durotomy. Incidental durotomy was significantly associated with a prolonged bed rest (P<0.001), hospital stay (P=0.041), and an increased use of postoperative antibiotics (P<0.001). Eleven of 77 patients with incidental durotomy (14.3%) developed postoperative CSF fistula of whom 10 (91%) needed revision surgery for dural repair.

CONCLUSIONS

We could identify important risk factors for incidental durotomy in LIF surgery. In patients who had undergone previous lumbar surgery and those with multilevel disease particular precaution is required. Furthermore, we were able to verify the morbidity associated with CSF fistula as shown by increased immobilization and follow-up surgeries for postoperative CSF fistula which emphasizes the importance to develop strategies to minimize the risk for incidental durotomy.

A novel duraplasty technique following fenestration of a massive lumbar arachnoid cyst in a patient with scoliosis: technical case report

When a dural defect is encountered during spine surgery, the dura mater must be reconstituted to minimize the occurrence of minor or major life-threatening sequelae. The neurosurgical literature lacks strategies for managing large dural defects encountered during surgery. The authors describe a 24-year-old man who developed cauda equina syndrome secondary to altered CSF flow in a large thoracolumbar arachnoid cyst. Surgical decompression and fenestration of the arachnoid cyst were performed, and the large dural defect was treated using a multilayer closure with collagen matrix, titanium mesh, and methylmethacrylate. At his 24-month postoperative follow-up, the patient had recovered full strength in his legs, and his sensory deficits and sexual dysfunction had resolved. His incision had healed well, and there were no signs of pseudomeningocele. He had no additional positional headaches. The defect was managed effectively with this technique. Although this technique is not a first-line strategy for dural closure in the spine, it can be considered in challenging cases when large dural defects are not amenable to traditional closure techniques.

Randomized clinical trial of acetazolamide administration and/or prone positioning in mitigating wound complications following untethering surgeries

OBJECTIVE No evidence-based guideline has been approved for the postoperative management of pediatric patients with tethered cord syndrome (TCS). The purpose of this randomized clinical trial was to evaluate the effectiveness of prone positioning and acetazolamide administration on complication rates following spinal cord untethering surgeries. METHODS From October 2012 to February 2015, patients with a primary diagnosis of TCS who were admitted to the Children's Medical Center Hospital of Iran were randomly allocated to 1 of 4 intervention modality groups postoperatively: 1) Group A, acetazolamide administration for 10 days; 2) Group B, prone positioning for 10 days; 3) Group C, acetazolamide administration and prone positioning for 10 days; and 4) Group D, no intervention. CSF leakage, CSF collection, wound dehiscence, operative site infection, and secondary surgical wound repair were considered failure. RESULTS A total of 161 patients were enrolled in this study (Group A, n = 39 [24.2%]; Group B, n = 41 [25.5%]; Group C, n = 39 [24.2%]; and Group D, n = 42 [26.1%]). The overall failure rate was 12.42% (20 patients). Complication rates through pooled analyses were as follows: CSF leakage (n = 9, 5.6%), CSF collection (n = 12, 7.5%), wound dehiscence (n = 2, 1.2%), and infection of operation site (n = 3, 1.9%). Two patients (1.2%) required surgical secondary wound repair due to complications. CSF leakage and collection rates were significantly lower in patients who underwent prone positioning (p = 0.042 and 0.036, respectively). The administration of acetazolamide, either isolated or in combination with prone positioning, not only could not significantly lower the complication rates, but also added the burden of side effects. CONCLUSIONS The current study demonstrates the possible role of prone positioning in mitigating the complication rates subsequent to untethering surgeries. Clinical trial registration no.: NCT01867268 ( clinicaltrials.gov ).

Management of Incidental Dural Tear During Lumbar Spine Surgery. To Suture or Not to Suture?

OBJECTIVE

Incidental durotomy (ID) during lumbar spine surgery is a frequent complication of growing clinical relevance as the number and complexity of spinal procedures increases. Yet, there is still a lack of guidelines for the treatment of ID with a large heterogeneity of established surgical techniques. The aim of this study was to investigate the efficacy of dural suturing in patients having ID during degenerative lumbar spine surgery, compared with other dural closure techniques.

METHODS

Of 1173 consecutive patients undergoing degenerative lumbar spine surgery from July 2013 to March 2015, in 64 (5.4%) patients 69 (5.8%) IDs occurred. The patients were divided into 3 groups depending on the dural closure technique used: group A, sole dural suture (n = 12, 19%); group B, patch only (TachoSil and/or muscle and/or fat) (n = 22, 32%); group C, dural suture in combination with a patch (n = 34, 49%). The primary end point was revision surgery caused by complications of cerebrospinal fluid leakage after 6 weeks. The secondary end points were operation time and hospitalization time, as well as surgical morbidity.

RESULTS

The 3 groups showed no significant difference in rates of revision surgery (group A: n = 1, 1.4%; group B: n = 4, 5.8%; group C: n = 3; 4.3%; P = 0.5). Furthermore, no significant difference for hospitalization time, operation time, and clinical outcome was found. Extent of ID, American Society of Anesthesiology score, postoperative immobilization, and insertion of a drainage tube were not associated with higher rates of revision surgery. Applying suction once a drainage tube was placed was found to be a significant risk factor for revision surgery (P = 0.003). Furthermore, patients undergoing revision surgery had a significantly higher body mass index (33 kg/m(2) vs. 26.37 kg/m(2); P = 0.006; odds ratio 1.252; P = 0.004).

CONCLUSIONS

Based on our results, the dural closure technique after ID does not seem to influence revision surgery rates due to cerebrospinal fluid leakage and its complications. Further prospective randomized studies are needed to confirm our results.

Incidence and management of cerebrospinal fluid fistulas in 336 multilevel laminectomies with noninstrumented fusions

Background:

The incidence (e.g., 3–27%) and the types of cerebrospinal fluid (CSF) fistulas occurring during multilevel lumbar laminectomy with noninstrumented spinal fusions varies.

Methods:

From 2000 to 2015, we retrospectively evaluated the incidence/etiologies of CSF fistulas occurring for 336 patients undergoing average 4.7 laminectomies with average 1.4 level noninstrumented fusions over a 15 year period. The varied etiologies of CSF leaks included; ossification of the yellow ligament (OYL) extending through the dura, postoperative surgical scar, iatrogenic traumatic leak, epidural steroid injections (ESI), resection of synovial cysts, and the removal of intradural tumors. Techniques for primary repairs included combinations of; 7-0 Gore-Tex (Newark, Delaware, USA) sutures, micro-dural staples, muscle patch/other (e.g., bovine pericardial) grafts, fibrin sealants/glues (e.g., Tisseel; Baxter International Inc., Westlake Village, CA, USA), and Duragen (Integra LifeSciences, Hawthorne, NY, USA) including both the thin and suturable types.

Results:

The etiologies of CSF fistulas in descending order included: Epidural spinal injections (ESI) (7 patients), synovial cysts (6 patients), OYL (5 patients), and equally for postoperative scar and intradural tumors (3 patients). CSF fistulas occurred in 24 (7.14%) of 336 patients; this frequency was reduced to 4.2% when ESI and intradural tumors were excluded.

Conclusion:

CSF fistulas occurred in 7.14% of 336 patients undergoing average 4.7 multilevel laminectomies with average 1.4 level noninstrumented fusions attributed to a lumbar stenosis with mild/moderate instability. The dural repair addressed seven prior ESI, six synovial cysts, five OYL, and operative scarring and intradural tumors (three apiece). Knowing the pathologies contributing to CSF fistulas should help the surgeon to better anticipate and treat these fistulas.