Traumatic dural tears: what do we know and are they a problem?

doi:10.1016/j.spinee.2013.03.049

The Spine Journal

Volume 14, Issue 1, 1 January 2014, Pages 49-56

https://doi.org/10.1016/j.spinee.2013.03.049 Get rights and content

Abstract

Background context

Iatrogenic dural tears are common complications encountered in spine surgery with known ramifications. There is little information, however, with respect to the implications and complications of traumatic dural tears.

Purpose

To describe the demographics and characteristics of traumatically acquired dural tears and evaluate the complication rate associated with traumatic dural tears in patients who have undergone surgical treatment for spine injuries.

Study design

Retrospective review of a single Level I trauma center to identify patients with traumatic dural tears between January 1, 2003 and December 31, 2009.

Patient sample

The sample comprises 187 patients with traumatic dural tears identified from 1,615 patients who underwent operative management of their traumatic injury.

Outcome measures

The outcome measures consisted of a description of the location and nature of dural tears and associated fracture patterns and neurologic status as well as an assessment of complications attributable to the traumatic dural tear.

Methods

No funding was received or used in this study. In total, 1,615 operatively managed spine injuries over a 7-year period were reviewed to identify 187 patients with traumatic dural tears. Operative reports were reviewed to assess location and description of injury as well as type of repair, if done. Associated spinal cord injuries as well as fracture level, patterns, and complications were recorded. Postoperative records were assessed focusing on complications related to the traumatic dural tears.

Results

Traumatic dural tears were identified in 9.1% (67/739) of cervical, 9.9% (45/452) of thoracic, and 17.6% (75/424) of lumbosacral spine fractures. Among the patients, 82.3% (154/187) had a formal dural repair. Fracture patterns included burst (AO Type A3) 26.2% (49/187), flexion distraction (AO Type B) 16% (30/187), and fracture dislocations (AO Type C) 36.4% (68/187). A complete neurologic injury was noted in 48.7% (91/187) of the patient population, whereas no neurologic injury was noted in 17.1% (32/187). Two patients (1%) developed a persistent cerebral spinal fluid leak that necessitated an irrigation and debridement with exploration and closure of the cerebral spinal fluid tear. Two patients (1%) developed a pseudomeningocele; one required a return to the operating room for irrigation and debridement, and the other suspected of having developed meningitis was treated with intravenous antibiotics. Among the patients, 2.1% (4/187) were noted to have a complication directly related to a traumatic dural tear.

Conclusions

Traumatic dural tears occurred in 11.6% of patients with operatively managed traumatic spine injuries at a regional Level 1 trauma center. In total, 83% had a neurologic injury and 49% had complete spinal cord injuries. Patients with traumatically induced dural tears have a low likelihood of developing a complication attributable to the dural tear.

Introduction

Evidence & Methods

Dural tears occurring as a result of traumatic spinal injuries have not been well-characterized. The authors present their experience with this injury.

The authors found dural tears in about 12% of operative cases. They occurred more commonly in cases of severe spinal trauma (eg, spinal cord injury, fracture dislocation). However, complications as a direct result of the tear were very uncommon.

This information is valuable both for surgical planning (in other words, when to be prepared for a tear) and for insight into prognosis.

Traumatic lacerations of the dura are commonly associated with spine injuries with reports ranging from 18% to 36% [1], [2], [3], [4], [5]. Usually, traumatic dural tears are not identified with advanced imaging tools such as magnetic resonance imaging but are identified at the time of operative management either at decompression or by cerebral spinal fluid (CSF) leaking around the injured segments [6], [7]. The classic fracture patterns most associated with traumatic tears are lumbar burst fractures with associated vertical lamina fractures in which the dura may become trapped; however, traumatic tears are also seen with other injuries as well, particularly highly unstable injuries [1], [2], [3], [4], [8].

Reported complications of dural lacerations include CSF leak leading to pseudomeningocele [9], [10], [11], dura-cutaneous fistula [12], meningitis [13], arachnoiditis, epidural abscess [14], intracranial subdural hematoma [15], nerve root entrapment [11], wound healing complications, persistent headache, and return to the operating room for closure of the leak. The majority of these complications have been described in the setting of elective spine surgery in which the durotomy was created iatrogenically. The incidence of iatrogenic durotomy during elective spine surgery has been reported to occur at a rate of 1% to 16% and appears to be higher in cases of revision surgery or previously irradiated spines [16], [17], [18], [19], [20], [21]. The most common complication of incidental durotomies in elective spine surgery is persistent CSF leak leading to pseudomeningocele and/or chronic wound drainage occurring at a rate of 2% to 3% [16], [21].

Little information exists in the literature describing the overall nature of traumatic dural tears as a result of spine injuries. The primary purposes of this study were twofold: to describe the demographics and nature of traumatic dural tears and evaluate the complication rate associated with traumatic dural tears in patients who have undergone surgical treatment for spine injuries.

Section snippets

Materials and methods

After obtaining institutional review board approval, the prospectively collected trauma registry at a Level I trauma center was assessed to identify all traumatic spine fractures managed operatively between January 1, 2003 and Dec 31, 2009.

A total of 1,615 operatively managed, traumatic spine cases were reviewed. Operative reports for each case were scrutinized for any evidence of a traumatic dural tear mentioned in the body of the report. Known iatrogenic tears in the setting of these patients

Results

Of the 1,615 operatively managed spine injuries treated operatively at our facility, 739 involved injuries to the cervical spine, 452 to the thoracic spine, and 424 to the lumbar spine. Traumatic dural tears occurred in 67/739 cervical spine injuries (9.1%), 45/452 (9.9%) thoracic spine injuries, and 75/424 (17.6%) lumbosacral spine injuries, for a total of 187/1,615 (11.6%) patients with traumatic dural tears (Fig. 1). No patient in this group was identified as also having an associated

Discussion

This series of 187 patients with traumatic dural tears in a population of 1,615 consecutive patients with traumatic spine injuries managed operatively represents the 7-year experience at a regional Level I trauma center that covers a five state region. The incidence of dural tears was 9.1% in the cervical spine, 9.9% in the thoracic spine, and 17.6% in the lumbosacral spine for an overall incidence of 11.6%. This is lower than previously reported statistics, which range from 18% to 36%, but

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Cited by (35)

A hydrogel spinal dural patch with potential anti-inflammatory, pain relieving and antibacterial effects
2022, Bioactive Materials
Citation Excerpt :
Injury to the dura during spinal surgery is the direct cause of cerebrospinal fluid leakage (CSFL) [2,3]. CSFL is associated with a cascade of adverse outcomes, such as low intracranial pressure symptoms, wound infection, prolonged hospital stay, and increased medical cost [4–7]. Therefore, repair the dural defect and stop the leak of cerebrospinal fluid are difficult problems in clinical practice.
CSFL caused by spinal dural defect is a common complication of spinal surgery, which need repair such as suture or sealants. However, low intracranial pressure symptoms, wound infection and prolonged hospital associated with pin-hole leakage or loose seal effect were often occurred after surgical suture or sealants repair. Stable, pressure resistance and high viscosity spinal dural repair patch in wet environment without suture or sealants was highly needed. Herein, a bioactive patch composed of alginate and polyacrylamide hydrogel matrix cross-linked by calcium ions, and chitosan adhesive was proposed. This fabricated patch exhibits the capabilities of promoting defect closure and good tight seal ability with the bursting pressure is more than 790 mm H₂O in wet environment. In addition, the chitosan adhesive layer of the patch could inhibit the growth of bacterial in vitro, which is meaningful for the postoperative infection. Furthermore, the patch also significantly reduced the expression of GFAP, IBA-1, MBP, TNF-α, and COX-2 in early postoperative period in vivo study, exerting the effects of anti-inflammatory, analgesic and adhesion prevention. Thus, the bioactive patch expected to be applied in spinal dural repair with the good properties of withstanding high pressure, promoting defect closure and inhibiting postoperative infection.
A multilevel noncontiguous spinal fracture with cervical and thoracic spinal cord injury
2021, International Journal of Surgery Case Reports
Citation Excerpt :
The most common fracture pattern related to dura tears is fracture-dislocation associated with complete spinal cord injuries [5]. The current standard treatment of MNSF with traumatic dura tears includes early detection, ridged internal fixation plus decompression and dura repair, with results showing improvements in outcomes and reduction of deformity [4,5]. In a recent study investigating MNSF patterns based on whole spine MRI, Kanna RM et al. described five patterns of non-contiguous spinal injuries: Pattern 1: cervical and thoracic fracture, Pattern 2: thoracolumbar and lumbosacral fracture, Pattern 3: thoracic and thoracolumbar fracture, Pattern 4: cervical and thoracolumbar fracture and Pattern 5: lumbosacral facture and associated injuries [6].
A multi-level non-contiguous spinal fracture (MNSF) caused by a high-energy impact is a type of complex traumatic injury that is been frequently initially missed, and resulting in delayed diagnosis which adversely affects can result in spinal deformity and neurological deficit. This report describes the operative management of a patient with MNSF with spinal cord injury involving the cervical and thoracic vertebrae by cervical orthosis and posterior thoracic decompression and fusion.
An 18-year-old male presented with extensive neck pain and paraplegia (ASIA A), following a motor vehicle accident. Radiographic imaging revealed MNSF: a non-displaced spinous process fracture of C5 (AO Spine subaxial cervical injury classification A0) with spinal cord injury combined with fracture-dislocation of T5 to T9 (AO Spine thoracolumbar injury classification C3). Posterior thoracic decompression and fusion was performed at T3 to T8. After the patient underwent the thoracic spine and cervical orthosis treatment, He received rehabilitation program and training transfer with wheelchair without caregiver. His sitting and balance were significantly improved at the 6 months follow-up. Although the lower extremity functions (ASIA A) may not improve due to the severe spinal cord injury.
MNSF with spinal cord injury following a high-velocity accident is an unstable and complex injury. Important of the clinical assessment and according to the injuries the treatment may vary.
Cervical orthosis was alternative treatment to preserve cervical motion treatment and posterior thoracic decompression with fixation is an effective option for patients in this MNSF with spinal cord injury.
Surgical management of cervical spinal cord injury in extremely elderly patients, aged 80 or older
2021, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
Spinal cord injury in elderly populations has increased in recent years. This study aimed to investigate the pathology, severity, efficacy of the surgery, and complications of cervical spinal cord injury in extremely elderly patients aged >80 years.
Sixty-three patients who underwent surgical treatment for cervical spinal cord injury were enrolled in this retrospective multicenter study. Forty patients were aged <80 years (Group 1), and 23 patients were aged ≥80 years (Group 2). The etiology of the injury, American Spinal Injury Association impairment scale (AIS) grade, surgical procedure, neurological improvement, and surgical complications were evaluated.
Most causes of injury in extremely elderly patients were of low-energy impact. The prevalence of vertebral fracture/dislocation was low and neurological impairment was milder in these patients, than in younger patients. Although overall neural recovery was similar in both groups, patients with complete motor paralysis did not show any improvement in AIS grade in the older group. The mortality rate was the same between the groups. Complication rates in surgical treatment were similar in both groups, with a high incidence of respiratory disorder (average 19%). Respiratory complications were noted during the perioperative period.
Surgical treatment of cervical spinal cord injury in extremely elderly patients can be performed safely, with a similar neurological recovery and low rate of surgical complications as those in younger patients. Respiratory complications should be attended to in the perioperative period. Early ambulation after admission coupled with strict respiratory management is probably essential to prevent complications and mortality.
What's around the spinal cord? Imaging features of extramedullary diseases
2020, Clinical Imaging
Diagnosis of extramedullary spinal diseases is often complex, firstly requiring a good anatomic knowledge for a precise localization of pathologies. The spinal canal, a tubular space delimited by vertebral bodies and neural arches, contains the spinal cord, nerve roots and cauda equina. Neural structures are surrounded and supported, from outer to inner, by meninges: dura, arachnoid and pia mater; meningeal layers divide extramedullary spaces in epidural, subdural and subarachnoid. Extramedullary diseases may be broadly classified in degenerative, neoplastic, traumatic, infective or miscellaneous. Imaging (MRI, CT) plays a fundamental role in the identification of pathologies, providing elements of differential diagnosis and accurate informations (location, extension, tissue characteristics) to guide further management. MRI is the best imaging modality technique to investigate extramedullary spaces and their diseases; however, CT may be useful in cases of bone involvement. The purposes of this article are to depict extramedullary anatomy, describe the most important extramedullary diseases following physiopathological and space-to-space criteria, illustrate imaging features of extramedullary pathologies, and underline imaging clues for differential diagnosis.
Common Practice in the Management of Dural Closure: An Italian Questionnaire
2019, World Neurosurgery
Citation Excerpt :
Results from the present survey are subsequently discussed with references to the pertinent literature. An effort has been made in the literature to identify risk factors that could guide the intraoperative management of dural closure.19-24 When present, these factors seem to increase the rate of CSF leak, and surgeons should prefer a meticulous dural repair.
The optimal management of dural closure is unclear; therefore, we aimed to survey current common practices among Italian practitioners.
The Delphi method was used to achieve a consensus on dura mater closing techniques in Italy. A steering committee decided 3 major topics to be investigated: pre- and postoperative conditions associated with cerebrospinal fluid (CSF) leak, indications to perform watertight dural closure, and dural closure technique. A questionnaire containing 12 statements was then submitted to Italian neurosurgeons.
The response rate was 60%. Among 60 items, 36 reached a positive consensus, 5 reached a negative consensus, and 19 did not reach consensus. Intrathecal hypertension, arachnoid opening, previous treatments, spinal incidental durotomy, wide size of osteo-dural defect, and lack of nasoseptal flap were considered major risk factors for CSF leak. Early mobilization, avoidance of stress maneuvers, and use of CSF external drainage were considered to reduce CSF leak rate. Italian neurosurgeons always attempt watertight dural closure, ideally with monofilament nonabsorbable sutures. Both autologous and heterologous dural grafts are used. Among dural sealants, fibrin glues are preferred, which are used most commonly in transsphenoidal surgery.
This study elucidates the areas of consensus and uncertainty on dural closure management among a group of Italian neurosurgeons. It provides reliable and comparable data for the investigation of the departments' daily practice in dural closure. Given the lack of solid evidence, there is a need for further comparative studies of dural repair strategies.
Influence of incidental dural tears and their primary microendoscopic repairs on surgical outcomes in patients undergoing microendoscopic lumbar surgery
2019, Spine Journal
Citation Excerpt :
A long learning curve and surgery-related complications have been posited as limitations of this technique [8]. In particular, dural tear represents a common complication of microendoscopic spine surgery [9–14]. The reported incidence of dural tears during microendoscopic lumbar surgery varies among the literature, but the rate has been reported to be between 0% to 8.7% [3,15–18], which is comparable to its reported incidence in open surgery [19].
Dural tear represents a common complication of microendoscopic spine surgery that may lead to postoperative sequelae including insufficient decompression, cerebrospinal fluid fistula, intracranial hypotension, and subdural/intraparenchymal bleeding. The gold standard to manage intraoperative dural tears is primary repair. However, the downside of conversion to open surgery can be detrimental. Therefore, understanding the most appropriate strategy for microendoscopic dural repair and its impact on postoperative outcomes is of importance.
The purpose of this study was to investigate the incidence of dural tears in patients undergoing microendoscopic lumbar surgery and to elucidate their influence on surgical outcomes whenever proper repair is accomplished microendoscopically without conversion to open surgery.
A retrospective multicenter cohort study of prospectively enrolled patients using a propensity-matched analysis.
A total of 922 consecutive patients underwent microendoscopic surgery of the lumbar spine between February and December 2012 in the three institutions belonging to our study group.
Outcome measures included the Numeric Rating Scale for back and leg pain, Oswestry Disability Index, Japanese Orthopaedic Association score, Short Form-36, and a patients’ satisfaction scale.
All incidental dural tears were repaired by microendoscopic suture of the dura mater from inside to outside using double-arm needles and/or by fibrin glue coverage without being converted to open surgery. Surgical outcomes were compared between patients with and without dural tears using a propensity-matched analysis.
Microendoscopic discectomy for lumbar disc herniation was performed on 474 patients, whereas microendoscopic laminectomy and posterior lumbar interbody fusion for lumbar canal stenosis were performed on 271 and 177 patients, respectively. Dural tears occurred in 49 (5.3%) patients. Of these, 23 (2.5%) patients required suture repair, whereas the rest received a fibrin patch for a pinhole tear, all of which were successfully performed under microendoscopy. Six hundred (65.1%) patients responded pre- and postoperatively to the questionnaire. Of them, the responses of 38 patients with dural tears were compared with those of 38 matched patients. No significant differences in any outcome measures were observed between the two groups.
In conclusion, all dural tears in our cases were managed without conversion to open surgery and did not influence surgical outcomes.

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: FDA device/drug status: Not applicable.

: Author disclosures: MJL: Nothing to disclose. GYB: Nothing to disclose. BPW: Nothing to disclose. CB: Fellowship Support: AO Spine (E, Paid directly to institution/employer), OMEGA (C, Paid directly to institution/employer), OREF (D, Paid directly to institution/employer). JRC: Board of Directors: AO Spine International (C), AO Board of Trustees (C); Endowments: Hansjoerg Wyss Endowed Chair (I, Paid directly to institution/employer); Fellowship Support: AO Spine (E, Paid directly to institution/employer), OMEGA (C, Paid directly to institution/employer), OREF (D, Paid directly to institution/employer). JAA: Nothing to disclose. RJB: Speaking/Teaching Arrangements: AO Spine NA (C); Grants: Synthes (C, Paid directly to institution/employer); Fellowship Support: AO Spine (E, Paid directly to institution/employer), OMEGA (C, Paid directly to institution/employer), OREF (D, Paid directly to institution/employer).

: The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

: Conflicts of interest and source of funding: There is no funding associated with this study. There are no conflict of interest–associated biases or applicable financial relationships related to this manuscript.

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Clinical StudyTraumatic dural tears: what do we know and are they a problem?

Abstract

Background context

Purpose

Study design

Patient sample

Outcome measures

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Am J Med

Spine J

Importance of greenstick lamina fractures in low lumbar burst fractures

Int Orthop

Impaction fracture of the lumbar vertebra with dural tear

J Neurosurg

Dural laceration occurring with burst fractures and associated laminar fractures

J Bone Joint Surg Am

Dural tears in lumbar burst fractures with greenstick lamina fractures

Spine

Dural tears associated with lumbar burst fractures

J Orthop Trauma

Can lacerations of the thoraco-lumbar dura be predicted on the basis of radiological patterns of the spinal fractures?

Acta Neurochir (Wien)

On the predictive value of radiological signs for the presence of dural lacerations related to fractures of the lower thoracic or lumbar spine

J Spinal Disord

Dural lacerations and thoracolumbar fractures

J Spinal Disord

Extradural pseudocysts. A cause of pain after lumbar-disc operation

Acta Orthop Scand

Postsurgical meningeal pseudocysts of the lumbar spine

Clin Orthop Relat Res

Pseudomeningocele nerve root entrapment after lumbar discectomy

Spine

Complications of laminectomy

Clin Neurosurg

Clinical Study
Traumatic dural tears: what do we know and are they a problem?