Postoperative Management Protocol
for Incidental Dural Tears during
Degenerative Lumbar Spine Surgery
Despite dural tears (DTs) being a recognized potential intraoperative complication of spine surgery, there is a limited understanding of the actual frequency of this commonly observed event.
Literature has reported a range of incidences, from 1.8% to as high as 17.4%, of dural tears during spine surgery, and this variability may be attributed to differences in patient characteristics and surgical techniques. If a dural tear goes unnoticed or unaddressed, it may lead to an ongoing leakage of cerebrospinal fluid (CSF) during the postoperative phase.
Symptoms and indications of a dural tear arise due to an ongoing leakage of cerebrospinal fluid (CSF) from the subarachnoid space. The presence of clear drainage or photophobia, among other symptoms, should also prompt the physician to consider the possibility of this complication. If postural headaches persist and there is continued clear drainage despite non-surgical interventions, this may indicate the necessity for further surgical management.
Pseudomeningocele, CSF fistula, and even meningitis are potential complications that may arise from a dural tear. Literature has reported that patients who experience a dural tear during surgery have higher rates of back pain and headaches in comparison to a control group of matched subjects. In spine surgery, this complication is the second most frequently cited cause of malpractice lawsuits.
The non-surgical management of an unaddressed dural tear is typically ineffective. Various surgical approaches are available for treating dural tears, including primary repair, the use of tissue sealants or blood patches, and tissue grafting.
Studies in the literature have indicated a success rate of 95% for a suture less repair method that involves a synthetic collagen matrix graft. The defect begins to undergo fibroblastic bridging on the sixth day, with complete healing typically taking place around the tenth day. Although spontaneous healing of a recognized intraoperative dural tear may occur, the surgeon should not depend solely on this outcome, and the repair of the tear is necessary.
In most cases, the dural defect was repaired using 4-0 nylon and subfascial drains were inserted. It is common practice to perform a few Valsalva maneuvers after the repair to ensure that the defect has been adequately sealed.
The placement of subfascial drains does not necessarily lead to the development of a CSF fistula in patients. Typically, the subfascial drain is switched from suction to a gravity-based system on the morning after surgery, allowing for the drainage of around 80 to 100 mL of CSF per shift.
The practice of switching the drain to gravity, rather than suction, is based on the idea that it enables the subfascial CSF pressure to determine the amount of drainage without drawing any additional CSF from the subdural space. Subfascial drains are beneficial in decompressing the subfascial area, which helps prevent the accumulation of CSF. The buildup of CSF can be harmful to tissue and increase the risk of developing a fistula.
The subfascial drain is typically removed on the third day, regardless of whether or not CSF is still visible in the drain. If there is continued CSF drainage beyond 72 hours, it is likely that the patient will not be able to undergo early mobilization and may require a repeat exploration of the dura.
Therefore, the subfascial drain is typically removed after 72 hours to assess the need for further intervention. Patients with persistent headaches or wound drainage beyond 72 hours underwent surgical repair. In cases where persistent CSF leaks were detected even after the second exploration and repair, intrathecal drains are used.
An effective strategy involved a brief period of bed rest followed by early mobilization, according to the literature. A small proportion of cases may exhibit persistent symptoms lasting more than 72 hours after the initial surgery, which may necessitate reoperation. One theory suggests that bed rest helps to alleviate hydrostatic pressure on the mended dura.
Performing a Valsalva maneuver may aid in the identification of a suspected DT. Successful outcomes are achieved in the majority of cases when the dural defect is promptly identified and carefully closed during surgery. According to the literature, subfascial drains have been found to be useful in the treatment of DT after repair. A repeat surgical re-exploration is required in only a minority of cases.
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I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
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