Incidental durotomy in lumbar spine surgery - incidence, risk factors and management

Incidental durotomy is a common complication of lumbar spine operations for degenerative disorders. Its incidence varies depending on several risk factors and regarding the intra and postoperative management, there is no consensus. Our objective was to report our experience with incidental durotomy in patients who were operated on for lumbar disc herniation, lumbar spinal stenosis and revision surgeries. Between 2009 and 2012, 1259 patients were operated on for degenerative lumbar disorders. For primary operations, the surgical approach was mino-open, interlamar, uni- or bilateral, as for recurrences, the removal of the compressive element was intended: the epidural scar and the disc fragment. 863 patients (67,7%) were operated on for lumbar disc herniation, 344 patients (27,3%) were operated on for lumbar spinal stenosis and 52 patients (5%) were operated for recurrences. The operations were performed by neurosurgeons with the same professional degree but with different operative volume. Unintentional durotomy occurred in 20 (2,3%) of the patients with herniated disc, in 14 (4,07%) of the patients with lumbar spinal stenosis and in 12 (23%) of the patients who were operated on for recurrences. The most frequent risk factors were: obesity, revised surgery and the physician’s low operative volume. Intraoperative dural fissures were repaired through suture (8 cases), by applying muscle, fat graft or by applying curaspon, tachosil. There existed 4 CSF fistulas which were repaired at reoperation. Incidental dural fissures during operations for degenerative lumbar disorders must be recognized and immediately repaired to prevent complications such as CSF fistula, osteodiscitis and increased medical costs. Preventing, identifying and treating unintentional durotomies can be best achieved by respecting a neat surgical technique and a standardized treatment protocol.

Postoperative spondylodiscitis. A review of 24 consecutive patients

BACKGROUND

Postoperative discitis is a rare complication of spine surgery that creates a significant patient suffering and requires long-term treatment. The aim of this study was to compare the empirical antibiotic treatment with the treatment according antibiotics to susceptibility of isolates germs in curing this complication.

MATERIAL AND METHOD

In the period January 2002 - December 2012, 4698 patients were operated for lumbar spine disorders:lumbar disc herniation, spinal canal stenosis. Of these patients, 47 (1%) were diagnosed with postoperative discitis. In December 2012 there were 24 cases of spondylodiscitis after lumbar disc herniation operated by inter-lamar approach and foraminotomy. The A group of 13 patients received antistaphylococcalempirical antibiotic treatment. The B group consisting of 11 patients received antibiotic therapy after germ isolation by open biopsy from discal intervertebral space (n=8)and from surgical wound secretion (n=3) and antibiotic susceptibility testing.

RESULTS

After 4 to 6 months of antibiotic treatment associated with immobilization in Boston corset the symptoms gradually improved in parallel with normalization of biological constants, ESR, CRP. Five patients of Group A did not respond to the given antibiotic treatment and required further debridement and germ isolation.

CONCLUSIONS

Spondylodiscitis is a complication of spine surgery that is treated with antibiotics given for a long time of 4-6 months. Germ isolation by needle biopsy or open biopsy allows proper antibiotic treatment and faster healing.

[Posterior fossa epidural hematoma]

Posterior fossa epidural hematomas (PFEH) are rare entities, with dark prognosis due to their specific localization. Because the simptomatology is usually nonspecific or poor, the CT should be performed as soon as posible. MRI does not offer suplimentary benefits/informations in the great majority of PFEH. Depending on the bleeding source, the rate of clinical signs appearance and the gravity of evolution varies. Early diagnosis and surgical treatment should be performed in hematomas associated with mass effect or suplimentary injuries. In all cases, in PFEH patients a careful monitoring is necessary due to unpredictable evolution and rapid clinical worsening, requiring surgical intervention.

[Primary intracerebellar hematomas: surgical indications, prognosis]

Intracerebellar primary hematoma are produced by spontaneous hemorrhages in the cerebellar parenchima and usually present an sudden onset. In the present study we analyzed a serie of 34 cases of primary intracerebellar hematoma, in patients of both genders, between 35 and 80 years old. Taking in account the incidence of symptoms, the clinical picture was dominated by the gait disturbances, headache and consciousness disorders. From the analyzed cases, 50% had had surgical indication and 50% benefits on conservative treatment. Even though the evolution was favorable in the great majority of cases,the mortality in the surgical treated group was lesser (5,88%) comparative to the conservative treated group (17,64%). The main criteria for surgical treatment were represented by GCS (Glasgow Coma Scale) score < or =13 or blood collections exceeding 3 cm in diameter.

[Cystic meningioma]

Cystic meningioma represent a rare entity, accounting 1.7 to 11.7% from the total intracranial meningiomas. We present a 41 years old patients' case who suffered of an progressive bilateral visual acuity decreasing, more pronounced on the right side. The clinical examination revealed a severe reduction of vision, represented by difficulties in light perception on the right side. The MRI and CT scan showed an expansive, multi-lobular, fronto temporal process on the right side (87/58/63 mm), presenting a liquid signal, different from intra-cerebro-spinal fluid, without contrast enhancement at the level of the septae. The patient is operated on, the total resection of an polycystic and spongious tumour being accomplished together with the aspiration of the liquid from the giant peritumoral cyst. The postoperative evolution was favourable. The anatomo-pathological result: meningothelial meningioma. Several classifications, the etiology of intra and peritumoral cysts formation are discussed together with the therapeutical possibilities.