Prognostic impact of intra- and postoperative management of dural tear on postoperative complications in primary degenerative lumbar diseases

Risk Factor Analysis of Surgery-related Complications in Primary Thoracic Spine Surgery for Degenerative Diseases and Characteristics of the Patients Also Undergoing Surgery on the Cervical and/or Lumbar Spine

STUDY DESIGN

A retrospective cohort study using prospectively collected data.

OBJECTIVE

This study primarily aimed to investigate the risk factors for surgery-related complications in primary thoracic spine surgery for degenerative diseases using a surgeon-maintained database. The secondary purpose was to elucidate the characteristics of surgically treated thoracic myelopathy that also required cervical and/or lumbar spine surgery in the study period.

SUMMARY OF BACKGROUND DATA

Few studies reported surgical complications and the feature of tandem spinal stenosis in thoracic myelopathy in detail because of their rarity.

MATERIALS AND METHODS

This study included 840 thoracic myelopathy patients undergoing primary surgery for degenerative diseases from 2012 to 2021, investigating the effects of diseases, surgical procedures, and patient demographics on postoperative neurological deterioration, dural tear, dural leakage, surgical-site infection, and postoperative hematoma. In thoracic myelopathy patients who were surgically treated and also undergoing cervical and/or lumbar surgery, we investigated the proportion, the effects of diseases, and the order and intervals between surgeries.

RESULTS

Multivariate logistic regression revealed that significant risk factors ( P <0.05) for postoperative neurological deterioration were intervertebral disk herniation [odds ratio (OR): 4.59, 95% confidence interval (CI): 1.32-16.0) and degenerative spondylolisthesis (OR: 11.1, 95% CI: 2.15-57.5). Ossification of the ligamentum flavum (OR: 4.12, 95% CI: 1.92-8.86), anterior spinal fusion (OR: 41.2, 95% CI: 4.70-361), and circumferential decompression via a posterior approach (OR: 30.5, 95% CI: 2.27-410) were risk factors for dural tear. In thoracic myelopathy patients surgically treated, 37.0% also underwent degenerative cervical and/or lumbar surgery.

CONCLUSIONS

Pathologies involving anterior decompression and instability increased the risk of postoperative neurological deterioration. The risk of dural tear was increased when dura mater adhesions were likely to be directly operated upon. It should be recognized that a relatively high proportion (37.0%) of surgically treated thoracic myelopathy patients also underwent cervical and/or lumbar surgery.

A Subdural Dissection of Cerebrospinal Fluid Causing Cauda Equina Centralization After Durotomy: A Case Report

CASE

A 61-year-old woman with recurrent left L5 radiculopathy underwent revision L4-5 decompression complicated by incidental durotomy requiring primary repair. Postoperative course was complicated by wound drainage and headache. Repeat magnetic resonance imaging demonstrated cerebrospinal fluid dissecting a plane deep to the dura mater but superficial to the arachnoid, with the collection compressing the cauda equina in an atypical horizontal and linear fashion. Nonoperative treatment was ineffective, and she required revision decompression and dural repair.

CONCLUSION

Spine surgeons should recognize this finding on postoperative imaging as a potential sign of an incomplete dural repair necessitating return to the operating room.

Risk Factors for Cerebrospinal Fluid Leakage After Extradural Spine Surgery: A Meta-Analysis and Systematic Review

BACKGROUND

Cerebrospinal fluid (CSF) leakage is 1 of the common complications of spine surgery and is largely caused by intraoperative or postoperative dural tears. Associations of different factors with postoperative CSF leakage have not been consistent. In this study we aimed to identify demographic, disease-related, and surgical risk factors for CSF leakage after extradural spine surgery in a systematic review and meta-anlysis.

METHODS

The PubMed, EMBASE, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, Chinese Wanfang data, Chinese Weipu Database, and SinoMed databases were searched from inception until October 24, 2022. Fixed-effects or random-effects models were used to calculate odds ratios and 95% confidence intervals. The quality of observational studies was evaluated using the Newcastle-Ottawa scale instrument.

RESULTS

A total of 15 observational studies with 1,719,923 participants were included in this systematic review. All studies had a Newcastle-Ottawa scale score greater than or equal to 6. Age older than 70 years, smoking, ossification of the posterior longitudinal ligament, adhesion of spinal dura, spinal canal stenosis, cervical fracture, spondylolisthesis, revision surgery, and multiple surgical segments were all related to CSF leakage in the pooled analysis. Obesity and disease duration>1 year were not associated with the leakage of CSF.

CONCLUSIONS

This study will provide a reference for the identification of patients at high risk of developing CSF leakage, which suggests clinicians to strengthen the observation of drainage fluid in high-risk groups.

2022 SPILF - Clinical Practice guidelines for the diagnosis and treatment of disco-vertebral infection in adults

These guidelines are an update of those made in 2007 at the request of the French Society of Infectious Diseases (SPILF, Société de Pathologie Infectieuse de Langue Française). They are intended for use by all healthcare professionals caring for patients with disco-vertebral infection (DVI) on spine, whether native or instrumented. They include evidence and opinion-based recommendations for the diagnosis and management of patients with DVI. ESR, PCT and scintigraphy, antibiotic therapy without microorganism identification (except for emergency situations), therapy longer than 6 weeks if the DVI is not complicated, contraindication for spinal osteosynthesis in a septic context, and prolonged dorsal decubitus are no longer to be done in DVI management. MRI study must include exploration of the entire spine with at least 2 orthogonal planes for the affected level(s). Several disco-vertebral samples must be performed if blood cultures are negative. Short, adapted treatment and directly oral antibiotherapy or early switch from intravenous to oral antibiotherapy are recommended. Consultation of a spine specialist should be requested to evaluate spinal stability. Early lifting of patients is recommended.

Independent risk factor for surgical site infection after orthopedic surgery

No significant progress has been made in the study of orthopedic surgical site infection (SSI) after different orthopedic surgery, and the analysis and prevention of risk factors for orthopedic SSI urgently need to be solved. A total of 154 patients underwent orthopedic surgery from April 2018 to December 2020. General information such as gender, age, marriage, diagnosis, surgical site, and anesthesia method was recorded. Statistical methods included Pearson chi-square test, univariate and multivariate logistic regression analyses, and receiver operating characteristic (ROC) curves. Based on Pearson's chi-square test, sex (P = .005), age (P = .027), marriage (P = .000), diagnosis (P = .034), and surgical site (P = .000) were significantly associated with SSI after orthopedic surgery. However, in the multiple linear regression analysis, only the surgical site (P = .035) was significantly associated with SSI after orthopedic surgery. In terms of multivariate logistic regression level, surgical site (odds ratio [OR] = 1.568, P = .039) was significantly associated with SSI. ROC curves were constructed to determine the effect of the surgical site on SSI after different orthopedic surgery (area under the curve [AUC] = 0.577, 95% CI = 0.487-0.0.666). In summary, the surgical site is an independent risk factor for SSI after orthopedic surgery, and "trauma" is more likely to develop SSI than spine, arthrosis, and others.

Nomogram for Postoperative Headache in Adult Patients Undergoing Elective Cardiac Surgery

Background Postoperative headache (POH) is frequent after cardiac surgery; however, few studies on risk factors for POH exist. The aims of the current study were to explore risk factors related to POH after elective cardiac surgery and to establish a predictive system. Methods and Results Adult patients undergoing elective open-heart surgery under cardiopulmonary bypass from 2016 to 2020 in 4 cardiac centers were retrospectively included. Two thirds of the patients were randomly allocated to a training set and one third to a validation set. Predictors for POH were selected by univariate and multivariate analysis. POH developed in 3154 of the 13 440 included patients (23.5%) and the overall mortality rate was 2.3%. Eight independent risk factors for POH after elective cardiac surgery were identified, including female sex, younger age, smoking history, chronic headache history, hypertension, lower left ventricular ejection fraction, longer cardiopulmonary bypass time, and more intraoperative transfusion of red blood cells. A nomogram based on the multivariate model was constructed, with reasonable calibration and discrimination, and was well validated. Decision curve analysis revealed good clinical utility. Finally, 3 risk intervals were divided to better facilitate clinical application. Conclusions A nomogram model for POH after elective cardiac surgery was developed and validated using 8 predictors, which may have potential application value in clinical risk assessment, decision-making, and individualized treatment associated with POH.

Incidence, Risk Factors and Outcomes of Postoperative Headache After Stanford Type a Acute Aortic Dissection Surgery

Background: Postoperative headache (POH) is common in clinical practice, however, no studies about POH after Stanford type A acute aortic dissection surgery (AADS) exist. This study aims to describe the incidence, risk factors and outcomes of POH after AADS, and to construct two prediction models.

Methods: Adults who underwent AADS from 2016 to 2020 in four tertiary hospitals were enrolled. Training and validation sets were randomly assigned according to a 7:3 ratio. Risk factors were identified by univariate and multivariate logistic regression analysis. Nomograms were constructed and validated on the basis of independent predictors.

Results: POH developed in 380 of the 1,476 included patients (25.7%). Poorer outcomes were observed in patients with POH. Eight independent predictors for POH after AADS were identified when both preoperative and intraoperative variables were analyzed, including younger age, female sex, smoking history, chronic headache history, cerebrovascular disease, use of deep hypothermic circulatory arrest, more blood transfusion, and longer cardiopulmonary bypass time. White blood cell and platelet count were also identified as significant predictors when intraoperative variables were excluded from the multivariate analysis. A full nomogram and a preoperative nomogram were constructed based on these independent predictors, both demonstrating good discrimination, calibration, clinical usefulness, and were well validated. Risk stratification was performed and three risk intervals were defined based on the full nomogram and clinical practice.

Conclusions: POH was common after AADS, portending poorer outcomes. Two nomograms predicting POH were developed and validated, which may have clinical utility in risk evaluation, early prevention, and doctor-patient communication.

[Reasons analysis on unplanned reoperation of degenerative lumbar spine diseases]

Objective

To review the research on the reasons of unplanned reoperation (URP) for degenerative lumbar spine diseases, and to provide new ideas for improving the quality of surgery for degenerative lumbar spine diseases.

Methods

The literature about the URP of degenerative lumbar spine diseases at home and abroad in recent years was reviewed and analyzed.

Results

At present, the reasons for URP include surgical site infection (SSI), hematoma formation, cerebrospinal fluid leakage (CSFL), poor results of surgery, and implant complications. SSI and hematoma formation are the most common causes of URP, which happen in a short time after surgery; CSFL also occurs shortly after surgery but is relatively rare. Poor surgical results and implant complications occurred for a long time after surgery. Factors such as primary disease and surgical procedures have an important impact on the incidence of URP.

Conclusion

The main reasons for URP are different in various periods after lumbar spine surgery. Interventions should be given to patients with high-risk URP, which thus can reduce the incidence of URP and improve the surgery quality and patients' satisfaction.

Open epidural blood patch to augment durotomy repair in lumbar spine surgery: surgical technique and cohort study

BACKGROUND CONTEXT

Incidental durotomy during elective spine surgery is relatively common. While usually benign and self-limited, it can be associated with morbidity, increased cost, and medicolegal ramifications. Dural repair typically involves performing a primary closure using a suture or dural staple; repairs are then frequently augmented with a sealant, patch, or fat/fascial graft. Although primary repair of an incidental durotomy is standard practice, the ideal secondary sealant or augment choice remains unclear. A wide variety of commercially available dural sealant options exist, and while none have demonstrated consistent superiority, all are associated with single-use costs in the hundreds to thousands of dollars and have concerns regarding swelling, local inflammation, or short-lived dural adherence.

PURPOSE

The goal of this study is to compare the results of dural repair augmentation using an open intraoperative epidural blood patch to a hydrogel technique.

STUDY DESIGN/SETTING

Retrospective comparative cohort study at an academic referral center PATIENT SAMPLE: Adult patients undergoing lumbar spine surgery from March 2017 to January 2021 who sustained an incidental durotomy. Patients undergoing surgery for infection were excluded.

OUTCOME MEASURES

The primary outcome was failure of the repair as determined by a return to the operating room for re-exploration of a persistent cerebrospinal fluid (CSF) leak within 30 days of the index procedure. A secondary outcome was the incidence of a postoperative positional headache, and if present, the method used to obtain resolution. The primary predictor was use of a suture and hydrogel technique ("hydrogel" group), or the use of an epidural blood patch ("EBP" group).

METHODS

The method for applying an open epidural blood patch is presented in detail and involves primarily repairing the durotomy followed by allowing whole blood to pool and clot in the operative field until the durotomy is completely covered. This was compared with a group of patients undergoing secondary augmentation with commercially available hydrogel. In both groups, mechanical resistance to CSF leakage was confirmed with direct visualization and a Valsalva maneuver, respectively. Patients were instructed to remain flat until the morning after surgery. Chart review was used for data abstraction on preoperative, demographic, perioperative, and postoperative clinical factors. To compare between the hydrogel and EBP group, Wilcoxon rank-sum testing was used to test for non-parametric comparisons of means, and chi-square testing between binomial data.

RESULTS

Of 732 patients during the study period, forty-eight patients met study criteria. Twenty-five patients were in the hydrogel group and 23 in the EBP group. Mean age was 69.3 years (standard error 1.3 years). Patients were predominantly female (n = 31, 64.6%) with a mean BMI of 29.5 (SE 0.8), with no significant baseline differences between the hydrogel and EBP groups. Two patients in the hydrogel group (8.0%) and two in the EBP group (8.7%) had mild positional headaches postoperatively that resolved without intervention within 24 hours. One (4.3%) patient in the EBP group had positional headaches following an initial headache-free period; this patient was returned to the operating room and no evidence of a persistent CSF leak was found despite meticulous exploration.

CONCLUSIONS

An open, intraoperatively placed epidural blood patch may be an efficacious and cost-effective way to manage an incidental durotomy. This method merits further study as an allergy-free, no swell, cost-neutral method of dural repair augmentation.

Long-term core outcomes in cauda equina syndrome

AIMS

Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires.

METHODS

Between January 2005 and December 2019, 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our hospital. After review of their records, patients were included if they presented with the clinical and radiological features of CES, then classified as CES incomplete (CESI) or with painless urinary retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. Patients provided written consent and completed a series of questionnaires.

RESULTS

In total, 61 of 82 patients returned a completed survey. Their mean age at presentation was 43 years (20 to 77; SD 12.7), and the mean duration of follow-up 58.2 months (11 to 182; SD 45.3). Autonomic dysfunction was frequent: 33% of patients reported bladder dysfunction, and 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction, respectively: 47% of patients reported genital numbness. A total of 67% reported significant back pain: 44% required further investigation and 10% further intervention for the management of lower back pain. Quality of life was lower than expected when corrected for age and sex. Half the patients reported moderate or worse depression, and 40% of patients of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were significantly more common in patients with CESR.

CONCLUSION

This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the CES Core Outcome Set. Persistent severe back pain and on-going autonomic dysfunction were frequently reported at a mean follow-up of five years. Cite this article: Bone Joint J 2021;103-B(9):1464-1471.

Predictors and nomogram models for postoperative headache in patients undergoing heart valve surgery

Background

Headache is a frequent complication after cardiac surgery. However, studies on the risk factors of postoperative headache (POH) are rare. The purpose of this study was to identify independent risk factors for POH in patients undergoing heart valve surgery (HVS) and to develop and validate risk prediction models.

Methods

Consecutive patients undergoing open HVS from 2016 to 2019 were enrolled in this study. Patients were randomly assigned to training and validation sets at a 2:1 ratio. Univariate and multivariate analysis were applied to identify independent predictors for POH in the training set. A nomogram predicting POH was developed based on these factors, and was validated in the independent validation set.

Results

POH developed in 1,061 of the 3,853 patients (27.5%). The overall mortality was 2.9%, and it was significantly higher in patients with POH (4.3% versus 2.4%, P<0.001). In the training set, six independent predictors were identified by multivariate analysis, including female, smoking history, hypertension, headache history, left ventricular ejection fraction, and cardiopulmonary bypass time. The model demonstrated good discrimination in both the training (c-index: 0.811) and validation sets (c-index: 0.814), and calibration was assessed by visual inspection. A second nomogram was also constructed including only preoperative predictors, with good discrimination (c-index: 0.792) and calibration. The decision and clinical impact curves of the models showed good clinical utility.

Conclusions

We developed and validated two risk prediction models for POH in patients undergoing HVS. The models may have clinical utility in individualized risk assessment and preventive interventions.

Dural Tear Does not Increase the Rate of Venous Thromboembolic Disease in Patients Undergoing Elective Lumbar Decompression with Instrumented Fusion

OBJECTIVE

Evaluate if dural tears (DTs) are an indirect risk factor for venous thromboembolic disease through increased recumbency in patients undergoing elective lumbar decompression and instrumented fusion.

METHODS

This was a retrospective cohort study of consecutive patients undergoing elective lumbar decompression and instrumented fusion at a single institution between 2016 and 2019. Patients were divided into cohorts: those who sustained a dural tear and those who did not. The cohorts were compared using Student's t-test or Wilcoxon Rank Sum for continuous variables and Fisher exact or chi-squared test for nominal variables.

RESULTS

Six-hundred and eleven patients met inclusion criteria, among which 144 patients (23.6%) sustained a DT. The DT cohort tended to be older (63.6 vs. 60.6 years, P = 0.0052) and have more comorbidities (Charlson Comorbidity Index 2.75 vs. 2.35, P = 0.0056). There was no significant difference in the rate of symptomatic deep vein thrombosis (2.1% vs. 2.6%, P = 1.0) or pulmonary embolus (1.4% vs. 1.50%, P = 1.0). Intraoperatively, DT was associated with increased blood loss (754 mL vs. 512 mL, P < 0.0001), operative time (224 vs. 195 minutes, P < 0.0001), and rate of transfusion (19.4% vs. 9.4%, P = 0.0018). Postoperatively, DT was associated with increased time to ambulation (2.6 vs. 1.4 days, P < 0.0001), length of stay (5.8 vs. 4.0 days, P < 0.0001), and rate of discharge to rehab (38.9 vs. 25.3%, P = 0.0021).

CONCLUSIONS

While DTs during elective lumbar decompression and instrumentation led to later ambulation and longer hospital stays, the increased recumbency did not significantly increase the rate of symptomatic venous thromboembolic disease.

The profile of the spinal column in subjects with lumbar developmental spinal stenosis

AIMS

The aim of this study was to determine the differences in spinal imaging characteristics between subjects with or without lumbar developmental spinal stenosis (DSS) in a population-based cohort.

METHODS

This was a radiological analysis of 2,387 participants who underwent L1-S1 MRI. Means and ranges were calculated for age, sex, BMI, and MRI measurements. Anteroposterior (AP) vertebral canal diameters were used to differentiate those with DSS from controls. Other imaging parameters included vertebral body dimensions, spinal canal dimensions, disc degeneration scores, and facet joint orientation. Mann-Whitney U and chi-squared tests were conducted to search for measurement differences between those with DSS and controls. In order to identify possible associations between DSS and MRI parameters, those who were statistically significant in the univariate binary logistic regression were included in a multivariate stepwise logistic regression after adjusting for demographics. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported where appropriate.

RESULTS

Axial AP vertebral canal diameter (p < 0.001), interpedicular distance (p < 0.001), AP dural sac diameter (p < 0.001), lamina angle (p < 0.001), and sagittal mid-vertebral body height (p < 0.001) were significantly different between those identified as having DSS and controls. Narrower interpedicular distance (OR 0.745 (95% CI 0.618 to 0.900); p = 0.002) and AP dural sac diameter (OR 0.506 (95% CI 0.400 to 0.641); p < 0.001) were associated with DSS. Lamina angle (OR 1.127 (95% CI 1.045 to 1.214); p = 0.002) and right facet joint angulation (OR 0.022 (95% CI 0.002 to 0.247); p = 0.002) were also associated with DSS. No association was observed between disc parameters and DSS.

CONCLUSION

From this large-scale cohort, the canal size is found to be independent of body stature. Other than spinal canal dimensions, abnormal orientations of lamina angle and facet joint angulation may also be a result of developmental variations, leading to increased likelihood of DSS. Other skeletal parameters are spared. There was no relationship between DSS and soft tissue changes of the spinal column, which suggests that DSS is a unique result of bony maldevelopment. These findings require validation in other ethnicities and populations. Level of Evidence: I (diagnostic study) Cite this article: Bone Joint J 2021;103-B(4):725-733.

Effectiveness of Repair Techniques for Spinal Dural Tears: A Systematic Review

BACKGROUND

Incidental or intentional durotomy in spine surgery is associated with a risk of cerebrospinal fluid (CSF) leakage and reoperation. Several strategies have been introduced, but the incomplete closure is still relatively frequent and troublesome. In this study, we review current evidence on spinal dural repair strategies and evaluate their efficacy.

METHODS

PubMed, Web of Science, and Scopus were used to search primary studies about the repair of the spinal dura with different techniques. Of 265 articles found, 11 studies, which specified repair techniques and postoperative outcomes, were included for qualitative and quantitative analysis. The primary outcomes were CSF leakage and postoperative infection.

RESULTS

The outcomes of different dural repair techniques were available in 776 cases. Pooled analysis of 11 studies demonstrated that the most commonly used technique was a combination of primary closure, patch or graft, and sealant (22.7%, 176/776). A combination of primary closure and patch or graft resulted in the lowest rate of CSF leakage (5.5%, 7/128). In this study, sealants as an adjunct to primary closure (13.7%, 18/131) did not significantly reduce the rate of CSF leakage compared with primary closure alone (17.6%, 18/102). The rates of infection and postoperative neurologic deficit were similar regardless of the repair techniques.

CONCLUSIONS

Although the use of sealants has become prevalent, available sealants as an adjunct to primary closure did not reduce the rate of CSF leakage compared with primary closure. The combination of primary closure and patches or grafts could be effective in decreasing postoperative CSF leakage.

Risk factor analysis of surgery-related complications in primary cervical spine surgery for degenerative diseases using a surgeon-maintained database

AIMS

This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases.

METHODS

We studied 5,015 patients with degenerative cervical diseases who underwent primary cervical spine surgery from 2012 to 2018. We investigated the effects of diseases, surgical procedures, and patient demographics on surgery-related complications. As subcategories, the presence of cervical kyphosis ≥ 10°, the presence of ossification of the posterior longitudinal ligament (OPLL) with a canal-occupying ratio ≥ 50%, and foraminotomy were selected. The surgery-related complications examined were postoperative upper limb palsy (ULP) with a manual muscle test (MMT) grade of 0 to 2 or a reduction of two grade or more in the MMT, neurological deficit except ULP, dural tear, dural leakage, surgical-site infection (SSI), and postoperative haematoma. Multivariate logistic regression analysis was performed.

RESULTS

The significant risk factors (p < 0.050) for ULP were OPLL (odds ratio (OR) 1.88, 95% confidence interval (CI) 1.29 to 2.75), foraminotomy (OR 5.38, 95% CI 3.28 to 8.82), old age (per ten years, OR 1.18, 95% CI 1.03 to 1.36), anterior spinal fusion (OR 2.85, 95% CI 1.53 to 5.34), and the number of operated levels (OR 1.25, 95% CI 1.11 to 1.40). OPLL was also a risk factor for neurological deficit except ULP (OR 5.84, 95% CI 2.80 to 12.8), dural tear (OR 1.94, 95% CI 1.11 to 3.39), and dural leakage (OR 3.15, 95% CI 1.48 to 6.68). Among OPLL patients, dural tear and dural leakage were frequently observed in those with a canal-occupying ratio ≥ 50%. Cervical rheumatoid arthritis (RA) was a risk factor for SSI (OR 10.1, 95% CI 2.66 to 38.4).

CONCLUSION

The high risk of ULP, neurological deficit except ULP, dural tear, and dural leak should be acknowledged by clinicians and OPLL patients, especially in those patients with a canal-occupying ratio ≥ 50%. Foraminotomy and RA were dominant risk factors for ULP and SSI, respectively. An awareness of these risks may help surgeons to avoid surgery-related complications in these conditions. Cite this article: Bone Joint J 2021;103-B(1):157-163.

Influence of unintended dural tears on postoperative outcomes in lumbar surgery patients: a multicenter observational study with propensity scoring

BACKGROUND CONTEXT

Unintended dural tears (DTs) are common in spinal surgeries. Some authors have reported that the outcomes in lumbar surgery patients with DTs are equivalent to those in patients without DTs, but this remains uncertain.

PURPOSE

To assess the effect of unintended DTs on postoperative patient-reported outcomes.

STUDY DESIGN/SETTING

A multicenter retrospective observational study.

PATIENT SAMPLE

We enrolled patients undergoing lumbar spine surgery at eight hospitals between April 2017 and November 2018.

OUTCOME MEASURES

We collected data regarding patients' backgrounds, operative factors, occurrence of unplanned DTs during surgery, postoperative complications, patient-reported outcomes, such as pain or dysesthesia of the lower back, buttock, leg, or plantar area, EuroQol 5 Dimension (EQ-5D), Oswestry Disability Index (ODI) scores, and postoperative satisfaction.

METHODS

We divided the patients into a DT- group (without DTs) and a DT+ group (with DTs). First, multivariate logistic regression analyses were conducted to reveal risk factors for occurrence of DTs. Then, we used propensity score matching to obtain a matched DT- group (mDT- group) and a matched DT+ (mDT+ group). Student's t test was used for comparing continuous variables and Pearson's chi-square test for comparing categorical variables between the two groups.

RESULTS

We enrolled 2,146 patients in this study. The number of patients with unintended DTs was 166 (7.7%). Older age, body mass index, ossification of posterior longitudinal ligament / yellow ligament, spinal deformity, and revision surgery were significant risk factors for DTs. We used propensity score matching to compare 163 of the patients with DTs with 163 patients without DTs. No significant difference was found in postoperative pain or dysesthesia of the lower back, buttock, leg, and plantar area between the mDT- and mDT+ groups. When comparing preoperative with postoperative pain and dysesthesia, a statistically significant improvement was found in each group (p<.01 for all variables) except for sensory disorder of the plantar area, where a significant improvement was only observed in dysesthesia of the mDT- group (p<.01). Although some improvements were observed, they were not statistically significant in terms of pain in the mDT- (p=.06) and mDT+ (p=.13) groups and dysesthesia in the mDT+ (p=.13) group. No significant differences were found in postoperative outcomes, such as EQ-5D (p=.44) and ODI (p=.89) scores, and postoperative satisfaction (p=.73) between the two groups.

CONCLUSIONS

Although insufficient improvement of sensory disorder of the plantar area was observed, patients with DTs showed almost equivalent postoperative outcomes compared with patients without DTs.

Incidental Durotomy Is Associated With Increased Risk of Delirium in Patients Aged 65 and Older

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the impact of incidental durotomy during spine surgery on the development of delirium in patients aged 65 and older.

SUMMARY OF BACKGROUND DATA

Delirium after spine surgery has been shown to increase the risk of adverse events, including morbidity and readmissions. Durotomy has previously been postulated to influence the risk of delirium, but this has not been explored in patients 65 and older, the demographic at greatest risk of developing delirium.

METHODS

We obtained clinical data on 766 patients, including 182 with incidental durotomy, from the Partners healthcare registry (2012-2019). Patients had their medical records abstracted and age, biologic sex, body mass index, smoking status, preoperative diagnosis, use of a fusion-based procedure, and number of comorbidities were recorded. Our primary outcome was the development of delirium. Our primary predictor was incidental durotomy. We used logistic regression techniques to adjust for sociodemographic and clinical confounders. We performed propensity score matching as a sensitivity test. We hypothesized that elderly patients would be at increased risk of delirium following durotomy.

RESULTS

Delirium was identified in 142 patients (19%). Among patients with an incidental durotomy, 26% were diagnosed with delirium. The incidence of delirium was 16% in the control group. Following adjusted analysis, the likelihood of delirium was significantly greater in patients with a durotomy (odds ratio [OR] 1.91; 95% confidence interval [CI] 1.27, 2.88). After propensity score matching, durotomy remained significantly associated with delirium in multivariable adjusted analyses (OR 1.90; 95% CI 1.07, 3.39).

CONCLUSION

This investigation is among the first to specifically evaluate an association between durotomy and delirium in elderly patients undergoing spine surgery. The increased association between durotomy and delirium in this cohort should prompt increased surveillance and interventions designed to minimize the potential for cognitive deterioration or impairment during postoperative management of a durotomy.

LEVEL OF EVIDENCE

3.

Management of Incidental Durotomy: Results from a Nationwide Survey Conducted by the French Society of Spine Surgery

OBJECTIVE

To obtain real-life data on the most common practices used for management of incidental durotomy (ID) in France.

METHODS

Data were collected from spinal surgeons using a practice-based online questionnaire. The survey comprised 31 questions on the current management of ID in France. The primary outcome was the identification of areas of consensus and uncertainty on ID follow-up.

RESULTS

A total of 217 surgeons (mainly orthopaedic surgeons and neurosurgeons) completed the questionnaire and were included in the analysis. There was a consensus on ID repair with 94.5% of the surgeons considering that an ID should always be repaired, if repairable, and 97.2% performing a repair if an ID occurred. The most popular techniques were simple suture or locked continuous suture (48.3% vs. 57.8% of surgeons). Nonrepairable IDs were more likely to be treated with surgical sealants than with an endogenous graft (84.9% vs. 75.5%). Almost two thirds of surgeons (71.6%) who adapted their standard postoperative protocol after an ID recommended bed rest in the supine position. Among these, 48.8% recommended 24 hours of bed rest, while 53.5% recommended 48 hours of bed rest. The surgeons considered that the main risk factors for ID were revision surgery (98.6%), patient's age (46.8%), surgeon's exhaustion (46.3%), and patient's weight (21.3%).

CONCLUSIONS

This nationwide survey reflects the lack of a standardized management protocol for ID. Practices among surgeons remain very heterogeneous. Further consensus studies are required to develop a standard management protocol for ID.