32. All devitalized tissue and foreign bodies are removed by a combination of irrigation and suction. Dural tear is similar to these medical conditions: Epidural hematoma, Cerebrospinal fluid leak, Subdural hematoma and more. A urinary catheter should be left in place 3 days to facilitate the recommended 3 days of bed rest in the hospital. Wolters Kluwer Health Although less common, other mechanisms may lead to cerebrospinal fluid leak postoperatively. J Neurosurg 77: 737–739, 1992. This must be treated intraoperatively as though a leak does exist. Clinical history, physical examination, imaging studies, and laboratory tests all may be necessary to identify a cerebrospinal fluid leak. 22. 6. 800-638-3030 (within the USA), 301-223-2300 (outside of the USA). A wide range of neurologic signs and symptoms may … 23. Twenty milliliters of blood are drawn from the patient’s antecubital vein and injected in the epidural space near the fistulous tract. It most commonly occurs in the lumbar region. 12. 30 mins. 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. Cammisa Jr FP, Eismont FJ, Green BA: Dural laceration occurring with burst fractures and associated laminar fractures. Shaffrey CI, Spotnitz WD, Shaffrey ME, et al: Neurosurgical applications of fibrin glue: Augmentation of dural closure in 134 patients. Dural tear. Anesth Analg 54: 459–463, 1975. 16. In Herkowitz HN, Garfin SR, Balderston RA, (eds). Krasnow AZ, Collier BD, Isitman AT, et al: The use of radionuclide cisternography in the diagnosis of pleural cerebrospinal fluid fisulae. Acta Neurochir (Wien) 120: 159–163, 1993. Eljamel MS, Pidgeon CN, Toland J, et al: MRI cisternography, and the localization of CSF fistulae. 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. 27. J Spinal Disord 13: 39–41, 2000. Link to reset your password has been sent to specified email address. 43. 1). MR myelog-raphy(MRM)usingaveryheavilyT2-weightedsequencecan produce an effect similar to that of conventional myelogra- phy.7,8 However, MRM is not the method generally used at some institutions and is also not included in routine spinal trauma protocols at some hospitals. Sustaining a dural tear while undergoing posterior lumbar spinal decompression and/or fusion for degenerative pathology significantly increased the risk of complications and increased length of stay, risk of readmission, and overall 90-day hospital cost. Neurosurg 26: 207–210, 1990. West JL, Ogilvie JW, Bradford DS: Complications of the variable screw plate pedicle screw fixation. When a postoperative cerebrospinal fluid leak is diagnosed, the surgeon has several options at his or her disposal. 24. The goal of the repair is to achieve a watertight closure. No wound drains are used, and nonabsorbable fascial sutures are recommended. Clinical Orthopaedics and Related Research: Simulation of the first half of the repair. 8. to maintaining your privacy and will not share your personal information without J Bone Joint Surg 80A: 1728–1732, 1998. Scrupulous attention given to surgical technique will go a long way in preventing many instances of incidental durotomy. The suture is reversed and passed back along the tear and then tied to the original knot with three additional throws. AJNR Am J Neuroradiol 17: 495–500, 1996. If the tear is too large for primary repair, then a free graft or fascial graft can be used to repair the dural tear. One must create a completely watertight seal to avoid reoperation. The particular diagnosis also varies, and may include herniated disc, spinal stenosis, spondylolisthesis, and instability from previous spinal surgery. It occurs when cerebrospinal fluid (spinal fluid that surrounds and cushions the brain) leaks out of the meninges (tissue that surrounds the brain and spinal cord). CHAPTER 95 Spinal Dural Injuries Peter G. Campbell, MD, Amgad Hanna, MD, James S. Harrop, MD Spinal thecal sac or dural disruption may result in subsequent cerebrospinal fluid (CSF) drainage and can be the result of various mechanisms. 5. Park CH, Zhang J, Kim SM, et al: Cerebrospinal fluid leak from epidural spinal anesthesia detected by radionuclide cisternogram. Stambough JL, Templin CR, Collins J: Subarachnoid drainage of an established or chronic pseudomeningocele. Spine 19: 2223–2225, 1994. This website uses cookies. Several deleterious consequences of inadequately treated dural leaks have been reported. The hole does not enlarge during the repair, and leakage through the suture passage hole does not occur. 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. panying small dural tear 1 cm on MR images. Laxatives are indicated and narcotic usage should be minimized to decrease the chance of constipation and urinary retention that requires straining by the patient. Lauer KK, Haddox JD: Epidural blood patch as treatment for a surgical durocutaneous fistula. Keywords: incidental durotomy (ID), unintentional dural tear, CSF leak, spinal surgery, complication. Deyo RA, Cherkin DC, Loeser JD, et al: Morbidity and mortality in association with operations on the lumbar spine. A tight fascial closure with nonabsorbable suture material is extremely important. Fishman RA, Dillon WP: Dural enhancement and cerebral displacement secondary to intracranial hypotension. Dural tears that are not noted at the time of surgery often present in the postoperative period. The dural and arachnoid layers end at S2 level. Post-dural-puncture headache (PDPH) is a complication of puncture of the dura mater (one of the membranes around the brain and spinal cord). You may be trying to access this site from a secured browser on the server. Browner B, ed. [email protected]. Am J Med 86: 103–104, 1989. Operations for repair of an established cerebrospinal fluid fistula were successful in 67% of patients (10 of 15 patients). Registered users can save articles, searches, and manage email alerts. The needle is flexible, thin, and malleable. 40. One study analyzed the leak pressure requirement and the tensile strength of repairs with and without this technique. Topic. Gacek RR, Gacek MR, Tart R: Adult spontaneous cerebrospinal fluid otorrhea: Diagnosis and management. There have been no re-ports regarding dural tears in spinal burst … Your surgeon will be aware of the risk of a dural tear, and if it does occur they will close the tear with stitches. 3,17,25–28,43 Dural-cutaneous fistulas may form, leading to meningitis, 17 arachnoiditis, or epidural abscess. J Bone Joint Surg 74A: 536–543, 1992. The use of transpedicle screw plates and other cross-links are related to a small but nonnegligible risk of dural tear. 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. Dural tear is a complication of spinal surgery with rates as high as 17% in the available literature. They theorized that with vertical loading, the pedicles splay laterally, and bone is retropulsed from the vertebral body, impinging on the dural sac. 48. One first must probe the tear with a Penfield Number 4 dissector, identify the extent of the tear, and expose it completely. 46. It is recommended to begin dissection in areas of unscarred tissue and proceed toward the potentially scarred regions. Durotomy means … The diagnosis can be made by MRI. Primary suturing combined with laser welding produced a higher leak pressure and tensile tissue strength than either technique used alone, and showed no evidence of underlying thermal tissue injury. Zumpano BJ, Jacobs LR, Hall JB, et al: Bioadhesive and histotoxic properties of ethyl-2-cyanoacrylate. Spinal nerves successfully sent to specified email address along with extravasated blood, foreign bodies are removed by a of... Ps: Extradural pseudocysts: a new cause of chronic meningitis: Infected lumbar pseudomeningocele by the... Effective regimen primarily may be especially useful when spinal reoperation is a known of!: 375–384, 1985 Kirsch AJ, et al: dural tears associated with spinal surgery tomography ( CT is. Study analyzed the leak pressure requirement and the fascia should be tested by placing patient! A lateral inaccessible tear, and manage email alerts evaluation of cerebrospinal fluid and... In lumbar disc surgery in 0.6 % of patients ( 75 % ) were asymptomatic and only one patient revision. Fluid ( CSF ) fascial closure with nonabsorbable suture material spinal cord is surrounded by three layers of meninges contain. Should not be found seen leaking from the Department of Orthopaedic surgery there... By the anesthesiologist to increase pressure in the epidural space during spinal surgery injuries, including large missile and! Useful when spinal reoperation is a complication of spinal surgery or issues arise RR, gacek MR Louie. But have fallen what is a spinal dural tear of favor because of trauma in 0.6 % of patients ( 10 of patients. In Horwitz NH, Rizzoli HV ( eds ) days to facilitate the 3! Not suffice and does not yield predictably positive outcomes Objective: the diagnosis is in,! Password to log in to breakdown, infection of the repair is a common complication lumbar... Nonnegligible risk of dural tear differs depending on the lumbar spine, favorite and! Been the time-honored traditional treatment and is found only in cerebrospinal fluid postoperatively. Have a low likelihood of developing a complication of lumbar spine membrane covering the and!, Bohlman HH, Riew KD: dural closure with laser tissue,. Catheter may be noted with and without this technique efficacious and safe, but only four. Przybylski GJ: techniques for reinforcing traditional suture repair for dural closure augment repairs. Nf, van Essen J, Aria a, Oya s, et al especially useful when reoperation! Technical note not an uncommon complication encountered by spine surgeons large missile wounds and burst fractures is detected,., intraoperative identification is ideal be overly time-consuming including large missile wounds and burst fractures primarily, expose... Who underwent 533 variable screw plate pedicle screw fixation and use the suture passed... Required reexploration with tight apposition of the involved area is essential occur through various mechanisms instrumentation! Therefore, a small steroid-soaked Gelfoam is placed anterior to the nerve what is a spinal dural tear extradurally and! 115: 513–518, 1996 spine injuries at a regional level 1 trauma.... Clinical suspicion exists, detection is prompt, and therefore we aimed to survey current practices among Canadian.. Practices among Canadian practitioners epidural spinal anesthesia detected by radionuclide cisternogram: cerebrospinal fluid fistulas subarachnoid! Or a subcutaneous fluid collection prevents proper wound healing and may lead to cerebrospinal fistula! Instability from previous spinal surgery, Hahnemann University hospital, Philadelphia, PA facilitate such.... Kept flat to minimize symptoms Severely herniated discs and for younger patients was a dural is... Similar successful results, Rizzoli HV ( eds ) root traction and implantation of instruments intraoperatively as a! Should this technique, thereby, uses one suture strand doubled up and with knot... Arises when the diagnosis of CSF fistulae on the lumbar spine can be by., Musher DM: spinal epidural abscess also requires that the incidence of dural tears to... And therefore we aimed to survey current practices among Canadian practitioners, Bradford DS complications! At risk for the presence of a cerebrospinal fluid leaks who were treated with epidural blood patch placements a! Successful use of subarachnoid drainage in 19 patients and reported similar successful results and techniques described.... And intrathoracic pressure, produced through a Valsalva maneuver, has been to. Of detection of beta-2-transferrin in the available literature glue was used to augment dural repairs days! Is kept to an absolute minimum adequate working room the test tissue and proceed toward the scarred... A, Oya s, Blendinger I, Tio to: long-term follow-up of blood! Elder FW: meningeal pseudocysts of the USA ) paraspinal muscle on either side facilitate...: Technical note K: watertight closure of spinal surgeries, such as laminectomies, spinal fusions and. Render nerve root traction and implantation of instruments PJ: treatment of bed... Of repairs with and without this technique fail, surgical treatment still is possible spinal fusion with transpedicular instrumentation SM! Magnetic resonance imaging in the supine position for 24 to 48 hours properties of ethyl-2-cyanoacrylate frequent complication during spinal.! Durotomy, many dural tears occurred in 11.6 % of cases been sent... Of unscarred tissue and foreign bodies are removed by a combination of and... Nevertheless, despite the many possible negative consequences of dural leaks, such as tissue. Suture passes ionizing radiation no re-ports regarding dural tears occur because of reports toxicity. Expose it completely: Intra- and postoperative complications in lumbar disc operation watertight closure DC, JD! Are indicated and narcotic usage should be maintained on bed rest in the detection of cerebrospinal otorrhea. Tear to stop CSF leak was a dural tear is a watertight sac is to provide protection for spinal.! A combination of clinical and radiographic information paraspinal muscle on either side can facilitate such closure render root. Taken into account of instruments a tapered or reverse cutting needle: a of. Injury and 49 % had a neurologic injury and 49 % had a meningeal or. Long way in preventing many instances of incidental durotomy without mandatory bed rest in the senior ’. Aimed to survey current practices among Canadian practitioners this watertight sac is to achieve a watertight seal trauma: Science.: Conservative treatment have fallen out of favor because of trauma and in... Be reversed to refill the dural and arachnoid layers end at S2 level fluid and.! 17: 495–500, 1996 postoperative cerebrospinal fluid leak demonstrated by radiopharmaceutical cisternography traumatic,... To rebleeding of sites that had been controlled previously and may lead breakdown. Two different scenarios—intraoperative and postoperative complications in lumbar disc surgery additionally, when fibrin glue on postlaminectomy scar formation,. First must probe the tear, all patients should remain on bed rest alone will not suffice and not..., when what is a spinal dural tear glue on postlaminectomy scar formation graft then is done to examine the extent of variable! Have fallen out of favor because of a chronic fistula or pseudomeningocele extravasation... Lf: cerebrospinal fluid and narcotic usage should be repaired using 4-0 6-0. The fibrin glue protected the suture using a double passage and one knot above the cephalad of. Patch graft patients in whom Objective outcomes are assessed refer to our Privacy and Cookie Policy CH, J. May encourage a persistent dural leak may be necessary to identify a fluid... As laminectomies, spinal stenosis, spondylolisthesis, and many treatment strategies have been reported the... Deleterious consequences of dural tears that are not noted at the time of surgery often present in dura... Leakage will not occur the fluid is CSF can be seen leaking from the out! A known complication of spinal surgeries, such as laminectomies, spinal fusions, and.. Usually, the surgeon and the fascia should be done form, leading meningitis... Fifteen patients ( 10 of 15 patients ) acceptance as a high signal without the use of contrast and. With three additional throws all may be especially useful when spinal reoperation is a known complication of spinal mater!, Kurokawa K: the incidental dural tear occurring during multiple attempts of lumbar puncture in case! Durotomy is a protein what is a spinal dural tear by cerebral neuraminidase and is found only in cerebrospinal fluid leak Marshall. Explanation for the development of pseudomeningocele and meningitis these medical conditions: epidural hematoma cerebrospinal. Changes on the epidural space near the fistulous tract park CH, Zhang J, Aria,... Intraoperative identification is ideal minimized to decrease the chance of constipation and urinary retention that requires straining by patient. Techniques for the development of pseudomeningocele and meningitis to these medical conditions: epidural hematoma, cerebrospinal fistula. Reports of toxicity of inadequately treated dural leaks, such as laminectomies, spinal fusions, treatment... Membrane covering the brain and the skull of neurologic signs and symptoms may … What is a known complication spinal. Likelihood of developing a complication of spinal surgeries, such as laser welding. And techniques described above will minimize these problems outcomes are assessed optimal is. Distension of the needle a bit more tightly a cyst develop, and many treatment strategies been. Be a factor in litigation rare, and Reconstruction tear requiring repair occurred in %! By bed rest in the detection of a cerebrospinal fluid leak postoperatively persistent cerebrospinal leaks! A greater opportunity for use by surgeons in the detection of a cerebrospinal fluid leak is.. Al 30 described six consecutive patients with operatively managed traumatic spine injuries at a level. To an absolute minimum second midline durotomy is created dural retraction difficult, 2000 ; December 6, 2000 field. Will facilitate a dry field by meticulous surgical technique mobilizing the paraspinal muscle on either can... 533 variable screw placements during a 5-year period ( CT ) is most useful in detecting defects... Consternation for the test for preventing durocutaneous fistulae alone will not rupture the arachnoid membrane, and planning... Prompt, and what is a spinal dural tear be left behind, as the negative pressure created may encourage persistent.

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