From the Research
The management of intraoperative dural tears in spine surgery should prioritize a combination of primary closure and patch or graft to minimize the risk of cerebrospinal fluid (CSF) leakage, as this approach has been shown to result in the lowest rate of CSF leakage (5.5%) 1. When a dural tear occurs, the surgeon should first identify the extent of the tear and then proceed with primary repair using 4-0 or 5-0 non-absorbable sutures in a running or interrupted fashion. For larger tears, a watertight closure is essential, which may require the use of dural substitutes such as autologous fascia, muscle grafts, or synthetic dural patches. Following repair, a Valsalva maneuver should be performed to confirm the integrity of the closure. Fibrin sealants or dural sealants can be applied to reinforce the repair, although their effectiveness in reducing CSF leakage is still a topic of debate 2. Postoperatively, patients should maintain bed rest in a flat position for 24-72 hours depending on the severity of the tear, with gradual mobilization thereafter. Prophylactic antibiotics may be continued for 24-48 hours to prevent infection. Patients should be monitored for symptoms of persistent CSF leak, including postural headaches, nausea, and clear fluid drainage from the wound. If conservative measures fail, additional interventions such as lumbar drain placement (set at 10-15 cmH2O for 3-5 days) or surgical re-exploration may be necessary 3. Proper management is crucial as untreated dural tears can lead to pseudomeningocele formation, meningitis, and delayed wound healing. Some key points to consider in the management of dural tears include:
- The incidence of dural tears with lumbar endoscopy is about 1% 4
- The use of power drills and the interlaminar approach may increase the risk of dural tears 4
- Most dural tears are small and can be successfully managed with mechanical compression with Gelfoam and sealants 4
- Patients should be educated preoperatively and reassured about the potential risks and management of dural tears 4