26. The leakage can cause the tissues and nerves that support the brain to stretch painfully. For immediate assistance, contact Customer Service: Generally, 200 to 300 mL are collected per 24-hour period, and this can be adjusted by changing the height of the collection bag. Introduction The spinal cord is surrounded by three layers of meninges which contain the cerebrospinal fluid (CSF). 47. The authors simply will plug the dural rent with a small piece of muscle and use the suture method described above. Ali SA, Cesani F, Zuckermann JA, et al: Spinal-cerebrospinal fluid leak demonstrated by radiopharmaceutical cisternography. J Bone Joint Surg 63A: 1132–1136, 1981. The use of transpedicle screw plates and other cross-links are related to a small but nonnegligible risk of dural tear. 46. Epidural blood patch has gained popularity recently as another nonoperative alternative to treat a cerebrospinal fluid fistula. 40. Eljamel MS, Pidgeon CN, Toland J, et al: MRI cisternography, and the localization of CSF fistulae. 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. J Nuc Med 30: 120–123, 1989. Register with us for free 1). 35, Using dura from human cadavers and in vitro rabbit dura, Cain et al 4 found that neither simple interrupted nor running locked sutures adequately maintained a watertight seal at physiologic cerebrospinal fluid pressures. Other factors to consider are any patient actions that act to increase cerebrospinal fluid pressure through a Valsalvalike effect, such as coughing, violent awakening from anesthesia, or postoperative seizures. Objective: The incidental dural tear is a common complication in lumbar spine surgery. 1,5,7 –10 These in turn have significant associated … The graft then is inserted into the thecal sac and pulled through the lateral defect from the inside out, effectively plugging the tear. Davne and Myers 6 studied 486 patients who underwent 533 variable screw placements during a 5-year period. Vol 2. J Neurosurg 43: 639–640, 1975. Laxatives are indicated and narcotic usage should be minimized to decrease the chance of constipation and urinary retention that requires straining by the patient. Many opportunities for effective treatment of incidental durotomy exist, but prompt diagnosis and repair is critical. Continuous cerebrospinal fluid leak also predisposes the wound to pseudomeningocele formation, with possible trapping of nerve roots and neurologic symptoms such as sciatica and cranial nerve palsies, particularly of cranial nerve VI, which manifests as strabismus. In a series of 641 consecutive patients who underwent lumbar decompression surgery, Wang et al 45 reported 88 dural tears, a rate of 14%. Otherwise, the patient is at risk for the development of pseudomeningocele and meningitis. A collagen patch lined with a layer of fibrin glue protected the suture. Registered users can save articles, searches, and manage email alerts. This is done in part by using a double passage and one knot above the cephalad end of the tear. Maycock NF, van Essen J, Pfitzner J: Post-laminectomy cerebrospinal fluid fistula treated with epidural blood patch. J Bone Joint Surg 71A: 1044–1052, 1989. Skedros DG, Cass SP, Hirsch BE, et al: Beta-2-transferrin assay in clinical management of cerebral spinal fluid and perilymphatic fluid leaks. When detected intraoperatively, primary repair is the ideal course of action, but other effective methods of treatment are available should simple suturing not be feasible. Clinical Orthopaedics and Related Research®389:238-247, August 2001. Preparation of the glue consists of mixing two solutions: one containing fibrinogen and other clotting factors, and the second containing calcium and thrombin. 4. 33. The dura mater is the outer most layer. Spine 14: 443–446, 1989. Kitchel et al 16 used subarachnoid drainage in 19 patients and reported similar successful results. These authors describe several theories as to why this technique leads to healing of a cerebrospinal fluid fistula. 2,9,18,20,29, The most important aspect of treatment of a cerebrospinal fluid leak is prevention. Waisman M, Schweppe Y: Postoperative cerebrospinal fluid leakage after lumbar spine operations: Conservative treatment. The optimal management is unclear, and therefore we aimed to survey current practices among Canadian practitioners. Spine 21: 2273–2276, 1996. Vaquero J, Aria A, Oya S, et al: Effect of fibrin glue on postlaminectomy scar formation. All registration fields are required. 3rd ed. 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. Patients who had a primary tear repaired intraoperatively were treated successfully by sutures and fibrin glue 93% of the time (111 of 119 patients). 42. When a durotomy occurs, care should be taken to avoid injury to the underlying rootlets, which… Reprint requests to Stephen J. Bosacco, MD, Department of Orthopaedic Surgery, Hahnemann University Hospital, Broad and Vine Streets, Mail Stop 420, Philadelphia, PA 19102. If dural tear is associated with a brain injury, wide exposure of the wound is done to examine the extent of brain damage. If it is removed, the patient is allowed out of the bed during the first 10 postoperative days only for bathroom privileges and meals. AJNR Am J Neuroradiol 17: 495–500, 1996. The authors’ choice of repair is a simple running suture with tight apposition of the dural edges creating a watertight seal. Otolaryngol Head Neck Surg 115: 513–518, 1996. Sorry, the specified email address could not be found. Many studies focused on suture repair for dural tear to stop CSF leak. When the diagnosis is in question, immunofixation electrophoresis for β-2-transferrin can be done. The particular diagnosis also varies, and may include herniated disc, spinal stenosis, spondylolisthesis, and instability from previous spinal surgery. 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. Campbell’s Operative Orthopaedics. After closure, a small steroid-soaked Gelfoam is placed anterior to the nerve root extradurally, and may inhibit perineural scar postoperatively. J Clin Anesth 4: 45–47, 1992. Fortunately, in most cases, fluid extravasation can be visualized directly. Developed by renowned radiologists in each specialty, STATdx provides comprehensive decision support you can rely on - Fast CSF Leak/Ventral Dural Tear Cammisa Jr FP, Eismont FJ, Green BA: Dural laceration occurring with burst fractures and associated laminar fractures. Dural tear. Synthetic oxygen carriers or Artificial blood. 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. Patients manifest severe headaches that are exacerbated by upright posture. 5 Cammisa et al 5 evaluated the incidence of dural tears with burst fractures, or axial loading vertebral fractures, and found that a burst fracture with an associated laminar fracture was 100% sensitive and 74% specific for the presence of a dural tear. Rupp SM, Wilson CB: Treatment of spontaneous cerebrospinal fluid leak with epidural blood patch. 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. Try again. The pia mater envelops the neural elements. The only plausible explanation for the massive CSF leak was a dural tear occurring during multiple attempts of lumbar puncture. Br J Anaesth 39: 612–618, 1967. Simeone FA: Intraspinal Neoplasms. 25. The dural tear should be repaired using 4-0 or 6-0 dural suture with a tapered or reverse cutting needle. Multivariable logistic regression analysis interrogated for independent risk factors of dural tears. 27. They reported only occasional dural tears, all of which were repaired primarily, and none of which required reexploration. Dural tear is similar to these medical conditions: Epidural hematoma, Cerebrospinal fluid leak, Subdural hematoma and more. 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. Immediate reoperation has been the time-honored traditional treatment and is the gold standard. Simulation of the second half of the repair. 26 Severely herniated discs may render nerve root dissection and dural retraction difficult. Removing the spinous processes and mobilizing the paraspinal muscle on either side can facilitate such closure. Spine 17 (Suppl 6): S184–S189, 1992. Additionally, when fibrin glue was used to reinforce identical suture methods, the fibrin glue yielded sevenfold greater bursting pressures and no biotoxicity. A spinal headache is a very intense headache. How to cite this article: Kalevski S K, Peev N A, Haritonov D G. Incidental dural tears in lumbar decompressive surgery: Incidence, causes, treatment, results. Maeda T, Ishida H, Matsuda H, et al: The utility of radionuclide myelography and cisternography in the progress of cerebrospinal fluid leaks. A probe is inserted between the first and second suture passes. 2. The closure can be accomplished with simple interrupted or running locking suture technique. A wide range of neurologic signs and symptoms may … After anchoring the suture using a square knot with two throws, a simple running suture is passed the entire length of the tear. Please try after some time. Clin Nucl Med 23: 152–155, 1998. 19,21,24 This may be a valuable tool in small persistent cerebrospinal fluid leaks. Dural tear is a complication of spinal surgery with rates as high as 17% in the available literature. One may need to bend the curve of the needle a bit more tightly. 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. Borgesen SE, Vang PS: Extradural pseudocysts: A cause of pain after lumbar disc operation. Once the condition is identified, the patient should be kept flat to minimize symptoms. The next layer is the transparent arachnoid membrane, which contains CSF in the subarachnoid space. 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. Neurology 43: 609–611, 1993. 3,25,27,28 Finally, a debilitating headache that arises when the patient sits upright and resolves on recumbency may occur. After repair, the patient should be maintained on bed rest, with or without a subfascial drain to prevent hematoma or seroma formation. During the passage one should maintain light tension on the suture material. With recent attempts to minimize invasiveness and to avoid the inherent morbidity associated with surgical procedures, particularly revision procedures, other methods have surfaced and have proven extremely effective. A dural tear resulting in a cerebrospinal fluid (CSF) leak is a well-known risk of lumbar spinal procedures. The authors prefer to use 5-O Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ) suture on a TT9 needle (W. L. Gore & Associates), but other dural sutures also are available. Please try again soon. 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. 8 For a lateral inaccessible tear, Mayfield and Kurokawa 22 described the lateral patch technique. 22. When the load dissipates, the bone retracts and the dura and nerve roots remain trapped in the bony fragments. Additionally, cerebrospinal fluid leakage may occur because of a postoperative dural tear. 35. Usubiaga JE, Moya F, Usubiaga LE: Effect of thoracic and abdominal pressure changes on the epidural space pressure. No patients had a meningeal infection or a cyst develop, and so this appears to be an effective regimen. When dural injury occurs and is detected intraoperatively, primary repair is mandatory. A tear in the dura results in decompression of the thecal sac and reduction of local pressure on the epidural veins, allowing CSF to … Lippincott Journals Subscribers, use your username or email along with your password to log in. Spine 13: 720–725, 1988. 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. J Neurosurg 77: 737–739, 1992. Surg Neurol 18: 452–457, 1982. In the event of dural tear, a therapeutic protocol was applied: suturing the dural wound if possible. Therefore, a postural headache combined with new or worsening sciatica suggests the presence of a pseudomeningocele. This technique shows cerebrospinal fluid as a high signal without the use of contrast media and can be done relatively quickly without ionizing radiation. Residual bone spikes may puncture the dural sac postoperatively. Shaffrey CI, Spotnitz WD, Shaffrey ME, et al: Neurosurgical applications of fibrin glue: Augmentation of dural closure in 134 patients. A small piece of autologous fascia from the fascia lata or the paravertebral muscles may be anchored, sutured, and trimmed over the defect, allowing a good watertight seal, but is technically difficult and time consuming. The injected blood spreads cephalad and caudally in the epidural space and adheres to the defect, forming a gelatinous seal over the dural rent. Beta-2-transferrin is a protein produced by cerebral neuraminidase and is found only in cerebrospinal fluid and perilymph. If the leak is observed intraoperatively, it should be repaired with sutures, fibrin glue, fascial grafts, tissue welding, or a combination thereof. 29. Hodges et al 13 retrospectively evaluated another course of therapy in 20 patients, consisting of primary repair using sutures and fibrin glue, without mandatory bed rest. 18. Anterior dislocation of the spinal chord due to CSF leak is not a recognised complication to lumbar puncture. It has been reported that the incidence of dural tears is much greater in endoscopic procedures. High-resolution computed tomography (CT) is most useful in detecting bony defects and may accurately delineate fluid collections adjacent to bony lesions. From the Department of Orthopaedic Surgery, Hahnemann University Hospital, Philadelphia, PA. Repeated trips to the operating room for unexpected wound complications such as a persistent dural leak may be a factor in litigation. West JL, Ogilvie JW, Bradford DS: Complications of the variable screw plate pedicle screw fixation. The optimal management is unclear, and therefore we aimed to survey current practices among Canadian practitioners. Your message has been successfully sent to your colleague. Traumatic dural tears occurred in 11.6% of patients with operatively managed traumatic spine injuries at a regional Level 1 trauma center. The fascial layer is responsible for preventing durocutaneous fistulae. J Spinal Disord 13: 39–41, 2000. 10. Enter and submit the email address you registered with. 26, Postoperatively, detection of a dural tear may be more difficult. 48. Incidental durotomy is the most frequent complication during spinal surgery. Detection of a cerebrospinal fluid leak postoperatively may not be as straightforward, and may require a combination of clinical and radiographic information. Incidental durotomy is a frequent complication of lumbar spinal surgery. 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. Spine 24: 2062–2064, 1999. Lauer KK, Haddox JD: Epidural blood patch as treatment for a surgical durocutaneous fistula. It most commonly occurs in the lumbar region. Patients with traumatically induced dural tears have a low likelihood of developing a complication attributable to the dural tear. Park CH, Zhang J, Kim SM, et al: Cerebrospinal fluid leak from epidural spinal anesthesia detected by radionuclide cisternogram. Several deleterious consequences of inadequately treated dural leaks have been reported. One must create a completely watertight seal to avoid reoperation. 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. It is recommended to begin dissection in areas of unscarred tissue and proceed toward the potentially scarred regions. Additional sutures may be added if necessary. Anesth Analg 54: 459–463, 1975. The health care system laxatives are indicated and narcotic usage should be minimized to decrease the chance of constipation urinary. Used, and none of which were repaired primarily, and an average of 3 days bed! Meningeal pseudocysts of the wound is done by the patient without a subfascial,. ’ s antecubital vein and injected in the evaluation of cerebrospinal fluid leaks cisternography, may... To facilitate the recommended 3 days of bed rest alone will not occur sac of tissue covers! 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