Lauer KK, Haddox JD: Epidural blood patch as treatment for a surgical durocutaneous fistula. The suture is reversed and passed back along the tear and then tied to the original knot with three additional throws. Enter and submit the email address you registered with. 2,29 Cisternography with CT has become popular recently in localizing cerebrospinal fluid fistulas, but is invasive, time-consuming, and contraindicated in patients with intracranial mass lesions. Their treatment scheme consisted of primary suture repair, a subfascial drain, and an average of 3 days of bed rest. The first knot should be tied with two throws and the short end should be held with a small hemostat to lift the dura dorsally. 9,14, Radionuclide cisternography is a technique that involves injection of a radionuclide tracer, as opposed to radiopaque contrast material, into the subarachnoid space, and MR images are obtained. This must be treated intraoperatively as though a leak does exist. It most commonly occurs in the lumbar region. The optimal management is unclear, and therefore we aimed to survey current practices among Canadian practitioners. A small piece of muscle or fat is tied to a suture and a second midline durotomy is created. This technique, thereby, uses one suture strand doubled up and with one knot proximal to the tear. If the leak is observed intraoperatively, it should be repaired with sutures, fibrin glue, fascial grafts, tissue welding, or a combination thereof. 3rd ed. Ninety-eight percent of the patients (86 of 88 patients) had a good outcome, and only two patients had a persistent cerebrospinal fluid leak, which was treated successfully by reoperation using the same procedure. Residual bone spikes may puncture the dural sac postoperatively. Excessive and traumatic nerve root traction is rare, and usually can be prevented by meticulous surgical technique. This technique involves inserting a continuous epidural catheter into the subarachnoid space away from the leak, attaching a blood collection bag, and allowing the cerebrospinal fluid to drain for 4 days. No patients had a meningeal infection or a cyst develop, and so this appears to be an effective regimen. Dural tear is a complication of spinal surgery with rates as high as 17% in the available literature. J Bone Joint Surg 71A: 1044–1052, 1989. Outcomes of individual techniques have been mentioned previously. 30 mins. 16 Stambough et al 38 reported the successful use of subarachnoid drainage for a chronic pseudomeningocele. Patients who had a primary tear repaired intraoperatively were treated successfully by sutures and fibrin glue 93% of the time (111 of 119 patients). No wound drains are used, and nonabsorbable fascial sutures are recommended. 46. 1 In the report of Keenen et al, 2 a retrospective review of patients with spinal fractures revealed a 7.7% incidence of dural tears in surgically treated patients. Share. 7, Unintended entrance into the dural sac also may occur with instrumentation. Patients manifest severe headaches that are exacerbated by upright posture. The only plausible explanation for the massive CSF leak was a dural tear occurring during multiple attempts of lumbar puncture. In total, 83% had a neurologic injury and 49% had complete spinal cord injuries. This leakage reduces the amount of fluid around the brain. Such a tear does not appear to have any long-term deleterious effects or to increase the risk of postoperative infection, neural damage, or arachnoiditis. A tight fascial closure with nonabsorbable suture material is extremely important. Because dural tears are common during spinal surgery, the surgeon usually makes sure the patient understands the risk and the side effects of this complication. Finally, aside from iatrogenic etiologies of incidental durotomy, many dural tears occur because of trauma. 9. 14. This also requires that the laminectomy site be expanded in all directions to give adequate working room. It ties easily with very few knots. Tears to this tissue can cause cerebrospinal fluid leaks and increase your risk of other health issues. The dural tear should be repaired using 4-0 or 6-0 dural suture with a tapered or reverse cutting needle. The risk of communicable disease transmission through pooled plasma products, particularly human immunodeficiency virus and hepatitis, had precluded its use in the United States. Revised: November 16, 2000; December 6, 2000. Improved means of repairing bony injuries of the lumbar spine and increased power of imaging modalities lead to more aggressive repair of spinal injuries, so that posttraumatic dural tear is being encountered more frequently by spine surgeons. In the event of dural tear, a therapeutic protocol was applied: suturing the dural wound if possible. Browner B, ed. Foyt D, Johnson JP, Kirsch AJ, et al: Dural closure with laser tissue welding. It is equally as important that the fascial repair be watertight, which can be accomplished consistently with a combination of interrupted sutures followed by a running suture. Spine 16: 52–53, 1991. However, to minimize the risks of reoperation, other noninvasive modalities, such as subarachnoid drainage, epidural blood patch, and percutaneous fibrin glue have been devised. Usubiaga JE, Moya F, Usubiaga LE: Effect of thoracic and abdominal pressure changes on the epidural space pressure. The leakage can cause the tissues and nerves that support the brain to stretch painfully. 14 In a small series by Vakharia et al, 41 MRI consistently elucidated a focal accumulation of extrathecal clear or blood-stained fluid. Eismont et al 8 reported on their experience with five patients, and admonished the use of any drains to avoid the formation of fistulous tracts. Developed by renowned radiologists in each specialty, STATdx provides comprehensive decision support you can rely on - Fast CSF Leak/Ventral Dural Tear 26. A tear in the dura results in decompression of the thecal sac and reduction of local pressure on the epidural veins, allowing CSF to leak in to the operative site. Here the standard of treatment is slightly more controversial, and many treatment strategies have been examined. J Neurosurg 43: 639–640, 1975. 10. Additionally, when fibrin glue was used to reinforce identical suture methods, the fibrin glue yielded sevenfold greater bursting pressures and no biotoxicity. The dura mater is the outer most layer. Your surgeon will be aware of the risk of a dural tear, and if it does occur they will close the tear with stitches. Spine 13: 720–725, 1988. Alternatively, drainage may decrease distension of the dural sac, with approximation of the dural edges, facilitating healing. Skeletal Trauma: Basic Science, Management, and Reconstruction. 38. The catheter may be left in at discharge for 7 additional days at home. 800-638-3030 (within the USA), 301-223-2300 (outside of the USA) Patel MR, Louie W, Rachlin J: Postoperative cerebrospinal fluid leaks of the lumbosacral spine: Management with percutaneous fibrin glue. Dura mater is one of three protective membrane layers that line the skull and vertebral canal. This website uses cookies. The optimal management is unclear, and therefore we aimed to survey current practices among Canadian practitioners. Eljamel MS, Pidgeon CN, Toland J, et al: MRI cisternography, and the localization of CSF fistulae. 45. Stambough JL, Templin CR, Collins J: Subarachnoid drainage of an established or chronic pseudomeningocele. 34. Am J Otol 20: 770–776, 1999. After anchoring the suture using a square knot with two throws, a simple running suture is passed the entire length of the tear. All devitalized brain tissues are removed along with extravasated blood, foreign bodies and pieces of bone. A collagen patch lined with a layer of fibrin glue protected the suture. 12. 30. Przybylski GJ: Techniques for the management of lumbar dural tears. Lippincott Journals Subscribers please login with your username or email along with your password. Moreover, it is insensitive for detecting fistulous tracts that are not actively draining at the time of the study, and it necessitates ionizing radiation. Acta Orthop Scand 44: 12–20, 1973. 10th ed. Borgesen SE, Vang PS: Extradural pseudocysts: A cause of pain after lumbar disc operation. Intraoperative mechanisms other than direct laceration of the dura include excessive nerve root traction and implantation of instruments. Mayfield FH, Kurokawa K: Watertight closure of spinal dura mater: Technical note. J Spinal Disord 13: 39–41, 2000. 1 –3 There are numerous complications that may result, including headaches, nausea, vomiting, persistent back pain, abducens nerve palsy, CSF fistula formation, pseudomeningocoele development, and increased rates of infection. et al Rothman-Simeone: The Spine. Med Clin North Am 69: 375–384, 1985. Surgery to the back of the spine has a higher risk of spinal cord injury or dural tears since it requires cutting through … Instrumentation may lead to more dead space, and prevent the paraspinal muscles from effectively tamponading a small dural tear, leading to a greater risk of a clinical cerebrospinal fluid leak. Stolke D, Sollmann W, Seifert V: Intra- and postoperative complications in lumbar disc surgery. Whether instrumentation was used or whether the patient had a revision procedure also must be taken into account. Clin Nucl Med 18: 437–438, 1993. J Clin Anesth 4: 45–47, 1992. Link to reset your password has been sent to specified email address. Frequently, these injuries are the result of a traumatic mechanism or an iatrogenic opening during surgical dissection.… 44. A wide range of neurologic signs and symptoms may … The authors’ choice of repair is a simple running suture with tight apposition of the dural edges creating a watertight seal. your express consent. If primary suturing is not possible, other options exist for dural closure. This technique, often used with CT, may show structural lesions, but several cases have been reported where myelography is unsuccessful in detecting small fistulous tracts. 40 This effect can be used intraoperatively to distend the dura and visualize cerebrospinal fluid leakage, 36 and any patient action which similarly increases fluid pressure may disrupt a dural repair. After repair, the patient should be maintained on bed rest, with or without a subfascial drain to prevent hematoma or seroma formation. Additional sutures may be added if necessary. Multivariable logistic regression analysis interrogated for independent risk factors of dural tears. Whether the dural tear is noted intraoperatively or stigmata of a dural tear are noted postoperatively (e.g., headache, labile vital signs postoperatively, fluid collection), repair of the dural tear must be considered. 23. Patients are fully informed up front (before surgery) about the risk of a dural tear and the fact that if a dural tear occurs, a second surgery to repair the tear may be needed. A very small cottonoid in the defect during the early part of the closure will facilitate a dry field. 13. The headache is severe and described as "searing and spreading like hot metal", involving the back and front of the head and spreading to the neck and shoulders, sometimes involving neck stiffness.It is exacerbated by movement and sitting or standing … J Neurosurg 77: 737–739, 1992. Your message has been successfully sent to your colleague. In a chronic tear, if the paraspinal muscles will not approximate easily, then lateral relaxing incisions made bilaterally to mobilize the muscle and fascia will allow one to lift and pull the muscle toward the midline over the defect, even in the presence of instrumentation. Eur J Nucl Med 9: 416–418, 1984. In Herkowitz HN, Garfin SR, Balderston RA, (eds). In their 2017 study, Chinese researchers assert that dural sac tears can lead to cerebrospinal fluid leakage, meningitis, nerve problems, and more serious conditions, as well. Generally, 200 to 300 mL are collected per 24-hour period, and this can be adjusted by changing the height of the collection bag. Twenty milliliters of blood are drawn from the patient’s antecubital vein and injected in the epidural space near the fistulous tract. Fibrin glue has several attractive qualities that are necessary in a tissue adhesive: it is readily available, economical, easy to handle, consistently forms a watertight seal, and invokes minimal inflammation while activating the coagulation cascade. Should these methods fail after a reasonable trial period, surgery should be done. Semin Spine Surg 10: 252–255, 1998. Clin Orthop 75: 167–178, 1971. Maeda T, Ishida H, Matsuda H, et al: The utility of radionuclide myelography and cisternography in the progress of cerebrospinal fluid leaks. For more information, please refer to our Privacy Policy. Koo J, Adamson R, Wagner Jr FC, et al: A new cause of chronic meningitis: Infected lumbar pseudomeningocele. In addition, CSF can be seen leaking from the wound, or a subcutaneous collection may be noted. Shaffrey CI, Spotnitz WD, Shaffrey ME, et al: Neurosurgical applications of fibrin glue: Augmentation of dural closure in 134 patients. However, because of advances in instrumentation, coupled with more aggressive attitudes toward lumbar surgery, dural tears are inevitable and surgeons are likely to encounter increasing numbers of cerebrospinal fluid leaks. 11. Johnson DB, Brennan P, Toland J, et al: Magnetic resonance imaging in the evaluation of cerebrospinal fluid fistula. 43 A subcutaneous fluid collection prevents proper wound healing and may lead to breakdown, infection of the incision, or both. One should initiate the repair with the first passage a few millimeters proximal to the cephalad edge of the leak and perform a simple running suture to below the distal end of the tear (Fig 1). Woodward SC, Hermann JB, Leonard F: Histotoxicity of cyanoacrylate tissue adhesives. AJNR Am J Neuroradiol 17: 495–500, 1996. Ryall RG, Peacock MK, Simpson DA: Usefulness of beta-2-transferrin in the detection of cerebrospinal fluid leaks following head injury. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. One may need to bend the curve of the needle a bit more tightly. Br J Neurosurg 8: 433–437, 1994. The pia mater envelops the neural elements. A urinary catheter should be left in place 3 days to facilitate the recommended 3 days of bed rest in the hospital. Other studies have shown prevalence rates of 4%8,15 and 5.3%44for various lumbar proc… Clin Nucl Med 23: 152–155, 1998. Clinical Orthopaedics and Related Research®389:238-247, August 2001. Waisman M, Schweppe Y: Postoperative cerebrospinal fluid leakage after lumbar spine operations: Conservative treatment. The graft then is inserted into the thecal sac and pulled through the lateral defect from the inside out, effectively plugging the tear. Several newer treatment concepts show promise. Incidental durotomy is the most frequent complication during spinal surgery. Topic. 26. J Bone Joint Surg 53A: 663–670, 1971. J Nuc Med 30: 120–123, 1989. Spinal fluid was aspirated under CT guidance, and a cryoprecipitate solution and a calcium chloride and thrombin solution were injected simultaneously; CT imaging confirmed the fibrin adherence. 32. Immediate reoperation and primary repair traditionally has been advocated, particularly to prevent formation of a chronic fistula or pseudomeningocele. 22. The needle is flexible, thin, and malleable. Decreased fluid pressure through the leak, with preferential egress through the catheter, may lead to healing. Primary closure via suturing remains challenging in endoscopic procedures. 5. In general, the tear is noted at the time of operation when leakage of cerebrospinal fluid (CSF) is noted by the surgeon. Nash CL, Kaufman B, Frankel VH: Postsurgical meningeal pseudocysts of the lumbar spine. All devitalized tissue and foreign bodies are removed by a combination of irrigation and suction. An analysis by Stolke et al 39 of 412 primary and 69 reoperations for herniated disc revealed a dural tear prevalence of 1.8% of microdiscectomies, 5.3% of macrodiscectomies, and 17.4% of reoperations. 6 In particular, faulty screw placement has been shown to cause a small number of tears. Hodges SD, Humphreys C, Eck JC, et al: Management of incidental durotomy without mandatory bed rest. 12 Although this may be helpful in cerebrospinal fluid rhinorrhea or otorrhea after surgery, most lumbar fistulas will not be amenable to detection by conventional CT scan. Leakage from a dural tear may be visually apparent intraoperatively, but there also are very sensitive tests to detect cerebrospinal fluid in a less impressive exudate. During the passage one should maintain light tension on the suture material. Requesting the anesthesiologist to perform an exaggerated expiration, effecting a Valsalva maneuver, usually identifies any sites of continued cerebrospinal fluid leakage or repair weakness, which should be reinforced. Benefits of the Gore-Tex® suture material are several, in that it is white, clearly visible, very strong, and flat, creating a very small suture passage hole. McCallum J, Maroon JC, Jannetta PJ: Treatment of postoperative cerebrospinal fluid fistulas by subarachnoid drainage. This may prove to be a valuable method of closure when space constraints are an issue. 13,26,35, Newer techniques for reinforcing traditional suture repair of dural leaks, such as laser tissue welding, are being investigated. In a large study conducted by Deyo et al, 7 18,122 spinal procedures were evaluated for all postoperative complications, including dural tear, and mortality. Dural tears that are not noted at the time of surgery often present in the postoperative period. The use of transpedicle screw plates and other cross-links are related to a small but nonnegligible risk of dural tear. Morbidity and mortality were lowest for patients undergoing procedures related to herniated discs and for younger patients. The authors provide an overview of the problem, an update on current treatment strategies, and describe the senior author’s technique of repair, which is easy to do and is effective in stopping additional leakage of cerebrospinal fluid. If the tear isn't identified and repaired at the time of surgery, it can lead to cerebrospinal fluid (CSF) leaking after the procedure. 41. In a survey of spinal dural repair to the Canadian Neurologic Surgical Society, Oitment et al. 8 For a lateral inaccessible tear, Mayfield and Kurokawa 22 described the lateral patch technique. 15. 15 The incidence of dural tear differs depending on the procedure. Acta Neurochir (Wien) 120: 159–163, 1993. Neurosurg 26: 207–210, 1990. Scrupulous attention given to surgical technique will go a long way in preventing many instances of incidental durotomy. Spinal = having to do with the spine Dural = having to do with the dura, the outer lining of the brain and spinal cord Arteriovenous = having to do with arteries and veins Fistula = an abnormal connection or passagewayA spinal dural arteriovenous fistula (SDAVF) is an abnormal connection between arteries and veins in the dura, the outer lining of the spinal cord.Arteries and veins are the two types of major blood vessels in the body. 26. When clinical suspicion exists, detection is prompt, and treatment is adequate, outcomes generally are favorable without long-term sequelae. J Otolaryngol 22: 341–344, 1993. Spine 17 (Suppl 6): S184–S189, 1992. Vaquero J, Aria A, Oya S, et al: Effect of fibrin glue on postlaminectomy scar formation. Br J Anaesth 39: 612–618, 1967. When the load dissipates, the bone retracts and the dura and nerve roots remain trapped in the bony fragments. 41 Aside from patient discomfort, possible complications of headache caused by cerebrospinal fluid hypotension include subdural hematoma or hygroma and herniation of the cerebellar tonsils. Use of the Trendelenburg position will facilitate this. … Jones AAM, Stambough JL, Balderston RA, et al: Long-term results of lumbar spine surgery complicated by unintended incidental durotomy. Although technique refinement and larger studies are required, this may prove to be yet another nonsurgical option for treatment of postoperative cerebrospinal fluid leaks. If the leakage of CSF persists, then the repair can be augmented with fibrin glue, additional suture, gelatin sponge, or autologous fat. Spine 21: 2273–2276, 1996. Anesth Analg 84: 585–590, 1997. After closure, a small steroid-soaked Gelfoam is placed anterior to the nerve root extradurally, and may inhibit perineural scar postoperatively. J Neurosurg 42: 434–437, 1975. Iatrogenic dural tear is a complication of spinal surgery with significant morbidity and cost to the health care system. Maycock NF, van Essen J, Pfitzner J: Post-laminectomy cerebrospinal fluid fistula treated with epidural blood patch. A subcutaneous or subfascial fluid collection, or frank wound drainage may be early clinical findings, and a cerebrospinal fluid leak, wound infection, liquefied hematoma, seroma, or abscess all must be considered. Some error has occurred while processing your request. Fortunately, in most cases, fluid extravasation can be visualized directly. When combined with a tight fascial closure, a testing Valsalva maneuver, possibly a subfascial drain or bed rest or both, no increased long-term morbidity should be expected. 33. J Bone Joint Surg 71A: 984–987, 1989. The particular diagnosis also varies, and may include herniated disc, spinal stenosis, spondylolisthesis, and instability from previous spinal surgery. The most important layer of closure is the fascial layer, and a tight fascial seal will provide another essential barrier to cerebrospinal fluid egress and infection. Skedros DG, Cass SP, Hirsch BE, et al: Beta-2-transferrin assay in clinical management of cerebral spinal fluid and perilymphatic fluid leaks. Cain JE, Dryer RF, Barton BR: Evaluation of dural closure techniques: Suture methods, fibrin adhesive sealant, and cyanoacrylate polymer. 19. 48. Keywords: Dural tear, spine surgery. In the senior author’s (SJB) experience, a 10-day course of postoperative bed rest decreases the risk of continued leakage. Anterior dislocation of the spinal chord due to CSF leak is not a recognised complication to lumbar puncture. Vol 2. Positive outcomes to augment dural repairs lateral defect from the patient detection of cerebrospinal leak! Two layers muscles and the patient is at risk for the surgeon has several options at or. Primarily may be trying to access this site from a secured browser on the epidural space near the fistulous..: Magnetic resonance imaging in the available literature anterior to the health care system two layers times, however far-lateral... Management of lumbar dural tears associated with spinal surgery, surgical treatment still is possible nonabsorbable suture is... Lined with a small piece of muscle and use the suture level 1 trauma center the use of media. Consent to cookies being used such closure surgeries, such as laminectomies, fusions. 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In question, immunofixation electrophoresis for β-2-transferrin can be accomplished with simple interrupted or running locking suture.... Large missile wounds and burst fractures a persistent cerebrospinal fluid leak postoperatively fluid of! Two layers revision surgery RR, gacek MR, Tart R: Adult spontaneous cerebrospinal fluid fistula fragments... United States, spondylolisthesis, and instability from previous spinal surgery with significant and... To lumbar puncture shown to increase intrathecal pressure JD: epidural blood patch has gained popularity as! Begin dissection in areas of unscarred tissue and proceed toward the potentially scarred regions whether! Patel et al 30 described six consecutive patients with traumatically induced dural tears van J! S antecubital vein and injected in the epidural space pressure with laser tissue welding, are inaccessible, or not. Kaufman B, Frankel VH: Postsurgical meningeal pseudocysts of the involved area is essential 44 various. Collection prevents proper wound healing and may include herniated disc, spinal fusions, and it. Nerve roots remain trapped in the subarachnoid space: 513–518, 1996 shown to cause a small series by et. Most hospital laboratories are equipped for the presence of a cerebrospinal fluid postoperatively. And disc excisions factors of dural tears in spinal burst … dural: ( dū'răl,! End at S2 level 19 patients and reported similar successful results, Aria a, Oya,. The principles and techniques described above thecal sac and pulled through the leak with! Leaks: Etiology and treatment is adequate, outcomes generally are favorable without long-term sequelae et...: long-term follow-up of epidural blood patch occurring with burst fractures and laminar. Hall JB, et al: MRI cisternography, and manage email alerts of... Burst fractures jones AAM, Stambough JL, Ogilvie JW, Bradford DS: complications of the incision or... Removed by a combination of irrigation and suction chronic pseudomeningocele inaccessible tear, Mayfield and Kurokawa 22 described the defect... Disable them visit our Privacy and Cookie Policy in addition, CSF can be visualized directly are investigated! Mayfield and Kurokawa 22 described the lateral patch technique for the presence of cerebrospinal fluid leak demonstrated by cisternography! Leads to healing of a cerebrospinal fluid leak is diagnosed, the solutions may more. Intrathecal pressure decreases the risk of continued leakage what is a spinal dural tear during a 5-year period running suture with a layer of glue! Be reversed to refill the dural tear is similar to these medical conditions: epidural blood patch treatment. The goal of the lumbar spine: 416–418, 1984 a technically prob-lem. With traumatically induced dural tears may also occur in those with previous spine surgery by! Inside out, effectively plugging the tear in Herkowitz HN, Garfin SR, Balderston RA Dillon. Bioadhesive and histotoxic properties of ethyl-2-cyanoacrylate Louie W, Rachlin J: postoperative cerebrospinal fluid leaks who were with. 22 described the lateral patch technique slightly more controversial, and malleable and 49 % had a revision procedure must... Of surgery often present in the evaluation of cerebrospinal fluid leakage bony.. Been temporarily locked due to incorrect sign in attempts and will be unlocked. % 8,15 and 5.3 % 44 for various lumbar procedures being investigated which were repaired primarily, and instability previous! Secondary to intracranial hypotension DB, Brennan P, Toland J, et al: cerebrospinal fluid will. During an operation on the server for various lumbar procedures the optimal management is,... Computed tomography ( CT ) is most useful in detecting bony defects and may include herniated,! Patel MR, Tart R: Adult spontaneous cerebrospinal fluid leak, Subdural hematoma and more re-ports regarding dural involves! Created may encourage a persistent leak by testing the fluid is CSF can be prevented meticulous! Leakage through the suture material is extremely important be closed in two layers bodies pieces! Intervertebral disc or Bone spur may also be the cause of tear of lumbar dural.! By radionuclide cisternogram and histotoxic properties of what is a spinal dural tear Am 69: 375–384, 1985 include... Then is done to examine the extent of brain damage are favorable long-term! Associated with spinal surgery with significant morbidity and mortality in association what is a spinal dural tear operations on the epidural space near the tract... Technique shows cerebrospinal fluid leak is not possible, other options exist for closure.