Incidental Durotomy Significantly Increases the Risk of Postoperative Infection Following Lumbar Spine Surgery for Degenerative Conditions: A Systematic Review and Meta-analysis

  • International Journal of Spine Surgery
  • September 2025,
  • 8790;
  • DOI: https://doi.org/10.14444/8790

Abstract

Background Accidental dural tear (ADT), an unintended intraoperative breach of the dura mater, is a recognized complication in lumbar spine surgery for degenerative conditions. Postoperative surgical site infections are serious adverse outcomes in this context. However, the role of ADT in increasing postoperative infection risk remains insufficiently defined. This systematic review and meta-analysis aimed to comprehensively assess the association between ADT and the occurrence of postoperative infection.

Methods A systematic literature search was performed in PubMed, ScienceDirect, and CENTRAL from inception to 6 August 2024. Studies involving degenerative lumbar surgery and reporting data on both incidental durotomy and postoperative infections were included. Study quality, including risk of bias analysis, was appraised by 2 independent observers. Subsequently, 2 meta-analyses were conducted, estimating the pooled incidence of infection among patients with ADT and another calculating pooled odds ratios to evaluate infection risk.

Results Fourteen studies comprising 376,164 patients met the inclusion criteria. The incidence of ADT ranged from 1.9% to 11.8%, with higher rates observed in revision surgeries. Key risk factors included obesity, diabetes, revision surgery, advanced age, and extended operative time. The meta-analysis comprised 7 studies, including 7500 patients with dural tears and 189,058 patients without dural tears. The pooled incidence of postoperative infection among patients with ADT was 13.1% (95% CI: 6.8%–23.8%), which was significantly higher compared with 5.4% (95% CI: 3.1%–7.5%) among patients without ADT (P = 0.00078). Substantial heterogeneity was observed across studies (I 2 = 76.5% for ADT patients and 96.0% for non-ADT patients; Tau2 = 0.63). A separate meta-analysis of 5 studies reported a pooled odds ratio of 3.86 (95% CI: 2.48–6.3, P < 0.00001), indicating a significantly increased infection risk associated with ADT.

Conclusion ADTs during lumbar spine surgery for degenerative conditions are associated with a significantly increased risk of postoperative infections. Although this relationship is multifactorial, affected by surgical complexity and patient comorbidities, these findings underscore the importance of heightened vigilance in infection prevention and control following ADT to reduce infection-related morbidity.

Clinical Relevance Incidental dural tear during lumbar spine surgery for degenerative conditions significantly increases the risk for postoperative infection and should be a focus of preventive strategies.

Level of Evidence 1.

Introduction

Accidental dural tear (ADT), resulting from incidental puncture of the spinal dural sheath, is a recognized complication during lumbar spine surgery, particularly prevalent in revision procedures. The reported incidence of ADT ranges from 3% to 5% in primary lumbar surgeries, increasing to 7% to 17% in revision cases due to a variety of previously described risk factors, including scarring, adhesions, and disrupted anatomical landmarks.1–8 A common consequence of ADT is cerebrospinal fluid leakage (CSFL), reported in up to 17.4% of cases.9,10 Although timely and effective intraoperative repair often results in favorable outcomes,3,11,12 ADT can occasionally lead to significant complications, including persistent CSFL, delayed wound healing, low-pressure headaches, meningitis, and intracranial hemorrhage.13–16

Several factors predispose patients to ADT. Advanced age, elevated body mass index, prior spinal surgery, and anatomically complex procedures are among the most established risks.17 Aging contributes to reduced dural elasticity and redundancy, while degenerative changes, such as severe stenosis and thickened ligamentum flavum, can tether and thin the dura, increasing its vulnerability to injury.7,18–20

Beyond its direct intraoperative implications, ADT has been associated with longer hospital stays, higher reoperation rates, reduced quality of life, and increased healthcare costs.21 These consequences may be compounded by postoperative surgical site infections (SSIs), a serious and potentially preventable complication in spinal surgery. SSI incidence following lumbar procedures varies widely, from 1% to 20%, influenced by procedural complexity, patient comorbidities, and instrumentation use.21–23 While several studies suggest that ADTs may increase the risk of SSI, especially in cases involving CSFL, comprehensive data quantifying this relationship remain lacking.24,25 To address this gap, we conducted a systematic review and meta-analysis to evaluate the association between ADTs and postoperative infection following lumbar spine surgery for degenerative conditions.

Methods

Study Selection and Inclusion Criteria

We conducted a systematic review and meta-analysis to evaluate the association between ADTs and subsequent infections following lumbar spine surgery for degenerative disease. The review adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A comprehensive literature search of the following databases was performed between June and August 2024: PubMed, ScienceDirect, and Cochrane Library (Cochrane Central Register of Controlled Trials—CENTRAL). The search terms used were “durotomy” OR “dural tear” OR “CSF leak” OR “cerebrospinal fluid leak” AND infection OR spondylodiscitis OR “vertebral osteomyelitis” OR “spinal infection” AND lumbar. Only English-language studies published before 6 August 2024 were included. This review was conducted in accordance with the Declaration of Helsinki, and ethical approval was obtained from the Ethics Commission of Cologne University (registration number: 24–1298). Studies involving trauma, tumors, or spondylodiscitis as indications for surgery were excluded from consideration. Meta-analyses and systematic reviews were not included in the evaluation. Case reports were excluded due to high potential for bias. Studies that did not investigate ADTs and infection were excluded.

Screening and Data Collection Process

Two reviewers (T.B. and K.S.) independently screened each title and abstract for eligibility using Rayyan software (rayyan.qcri.org).26 Any study identified by either reviewer was included for further screening. A full-text screening of the selected records was performed by the same 2 reviewers. Disagreements were resolved by discussion and consensus. A third reviewer was available when no consensus was reached. The search strategy was completed by August 2024.

Risk of Bias Assessment

The risk of bias in the included studies was independently assessed by 2 reviewers using validated tools. Observational studies were assessed using the Newcastle-Ottawa Scale, focusing on selection (maximum 4 stars), comparability (maximum 2 stars), and outcome (maximum 3 stars).27 Studies were classified as low, unclear, or high risk of bias. Any disagreements between reviewers were resolved by consensus or with the involvement of a third reviewer.

Statistical Analysis

The primary meta-analysis estimated the pooled incidence of postoperative infections among patients with ADT. A secondary meta-analysis was conducted to calculate pooled ORs with corresponding 95% CIs. Heterogeneity across the studies was assessed using I 2 Higgins (0%–100%), χ 2, and Tau.2 Statistical significance was defined as a P ≤ 0.05. Data analysis and the forest plot were performed using Review Manager 5.3 software (Cochrane collaboration), GraphPad Prism 10 (GraphPad Software), “meta” and “metafor” packages using RStudio (version 2024.8.01), and Microsoft Excel (Microsoft Corp., Redmond, WA, USA). Whenever a meta-analysis was not feasible due to insufficient or nonextractable data, findings were synthesized descriptively.

Results

Study Characteristics and Patient Demographics

The initial search identified 483 potentially eligible studies. After title and abstract screening, 414 studies were selected for full-text evaluation. Following full-text review, 14 studies met the inclusion criteria and were included in the systematic review. The Preferred Reporting Items for Systematic Reviews and Meta-analyses flow diagram (Figure 1) provides an overview of the selection process. These 14 studies encompassed a total of 376,164 patients, with 3 prospective and 11 retrospective studies included. The mean level of evidence across all included studies was 3.5. Studies generally scored high in selection and outcome criteria on the Newcastle-Ottawa quality assessment scale (Table).

Flowchart diagram demonstrating the articles included in this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guideline.
Figure 1

Flowchart diagram demonstrating the articles included in this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guideline.

View this table:
Table

Characteristics of analyzed studies.

Incidence of ADT

The incidence of ADT varied across the included studies, with rates ranging from 1.9% to 11.8%.20,25,28–31 The lowest reported rate was in lumbar discectomy (1.9%),32 while the highest was found in minimally invasive fusion procedures (11.8%), as reported by Aspalter et al.32 ADT incidence increased notably in revision procedures, reaching up to 8.1%, as documented by Cammisa et al.30

Association Between ADT and Postoperative Infection

Yoshihara and Yoneoka reported a 3.4% increase in infection-related complications among 4255 patients who sustained incidental durotomies during lumbar decompression procedures. In lumbar discectomy patients, they observed a 1.4% infection rate among 2564 cases involving incidental durotomy.20 Furthermore, Cammisa et al documented a deep wound infection rate of 8.1% in 74 patients with incidental durotomy.30 Koutsoumbelis et al reported that among 84 patients undergoing posterior lumbar instrumented arthrodesis, 13.1% of those with ADT developed postoperative infections. Their analysis revealed a nearly 4-fold increased risk of SSI associated with ADT (OR 3.95; 95% CI: 1.20–13.01; P = 0.024).33 In a large cohort study of patients undergoing primary lumbar discectomy, Puvanesarajah and Hassanzadeh found that among 41,644 patients, 2052 sustained incidental durotomies, and 49 of those developed postoperative infections (2.4%). These patients were at increased risk of wound infection compared with those without ADT (OR 1.88; 95% CI: 1.31–2.70; P < 0.001).34 Takenaka et al also observed a significantly elevated risk of SSI in patients with ADT (OR 2.68; 95% CI: 1.29–5.61; P = 0.009), with infection rates of 1.8% in patients with ADT compared with 0.7% in those without (P = 0.015).25 Li et al reported an odds of 3.86 in patients with ADT developing postoperative deep infections (95% CI: 1.32–11.27; P = 0.013).23 Moreover, Xiong et al identified intraoperative dural tears as a strong predictor of postoperative SSI, with an OR of 8.44 (95% CI: 2.73–25.33; P < 0.001).35

Meta-analysis of Infection Risk After ADT

A meta-analysis of 7 studies was conducted to estimate the pooled incidence of postoperative infections following ADT during lumbar spine surgery. The analysis included 7500 patients with dural tears, among whom 258 postoperative infections were reported, and 189,058 patients without dural tears, with 2222 infections observed. The pooled infection incidence for patients with incidental dural tears was 13.1% (95% CI: 6.8%–23.8%). In comparison, the pooled incidence among patients without incidental dural tears was 5.4% (95% CI: 3.1%–7.5%). Statistical comparison of these pooled estimates revealed a P value of 0.00078, indicating a significantly higher risk of infection associated with dural tears. Substantial heterogeneity was observed across studies, with an I 2 value of 76.5% for the ADT group and 96.0% for the non-ADT group. The estimated between-study variance (Tau2) was 0.63. The χ 2 value for the incidence meta-analysis was 402.83 with 6 degrees of freedom.

In addition, a separate meta-analysis of 5 studies reporting ORs for infection risk associated with ADT was conducted. The pooled OR was 3.86, with a 95% CI of 2.48 to 6.3 (P < 0.00001). Heterogeneity analysis revealed a χ 2 value of 8.16 with 4 degrees of freedom, suggesting moderate heterogeneity. The I2 statistic was 51%, while the Tau2 value was estimated at –0.0668, suggesting minimal between-study variance. The findings from the OR analysis are visually presented in the forest plot (Figure 2).

Forest plot showing odds of infection after accidental dural tear following lumbar spinal surgery.
Figure 2

Forest plot showing odds of infection after accidental dural tear following lumbar spinal surgery.

Discussion

This systematic review and meta-analysis comprehensively describes the association between ADT and the risk of postoperative infection following lumbar spine surgery for degenerative conditions. The findings highlight the pivotal role of ADT as a significant risk factor for SSI and further emphasize the necessity of prevention and immediate treatment strategies to reduce morbidity associated with postoperative infections.

The meta-analysis revealed a statistically significant association between ADT and an increased risk of postoperative infection, reinforcing the clinical relevance of dural tears as a surgical complication. While several individual studies have previously suggested this link, a thorough quantitative synthesis has been lacking. To the best of our knowledge, this is the first meta-analysis to specifically quantify the infection risk associated with incidental durotomy in the context of lumbar spine surgery for degenerative disease.

While some studies support the association between ADTs and an increased risk of postoperative infection,28,32 others have found no significant impact, reflecting ongoing debate in the literature. For instance, in a study on minimally invasive lumbar fusion for degenerative spine conditions, 22 patients (11.76%) experienced ADT, yet none developed postoperative infections.32 Similarly, another investigation reported no infections among 46 patients who developed iatrogenic CSFL following ADT.28 In contrast, Cammisa et al reported a postoperative infection rate of 8.1% among patients who experienced an incidental durotomy.30,36 Similarly, further studies found an increase in postoperative infections in patients with incidental durotomy undergoing lumbar spinal surgery.20,34 However, the studies substantially vary regarding the study design as well as the included patient population, limiting the generalizability of the results. Regarding the results of our study, the pooled incidence of postoperative infection among patients with dural tears was 13.1% (95% CI: 6.8%–23.8%), compared with 5.4% (95% CI: 3.1%–7.5%) in patients without dural tears. Statistical comparison revealed a P value of 0.00078, indicating a significantly higher infection risk associated with dural tears. Therefore, this meta-analysis strongly highlights that ADT is statistically significantly associated with an increase in infection risk in patients undergoing lumbar spine surgery for degenerative diseases. Substantial heterogeneity was observed across studies, both for the dural tear and nondural tear groups. The between-study variance reflected considerable variability in infection rates across different surgical settings, patient populations, and institutional practices. These findings suggest that infection risk may vary depending on surgical complexity, patient comorbidities, and postoperative management strategies. Thus, the pooled incidence should be interpreted as an average risk rather than an absolute estimate generalizable to all clinical settings. In a complementary meta-analysis assessing relative risk, the pooled OR for infection associated with ADT was 3.86 (95% CI: 2.48–6.30, P < 0.00001), demonstrating a strong and statistically significant association. This finding indicates that patients with a dural tear are nearly 4 times more likely to develop postoperative infections compared with those without a dural injury. While the CI is relatively wide, it remains well above 1, reinforcing the strength of the association despite contextual variability. Moderate heterogeneity supports the overall consistency and robustness of this finding across different studies. Collectively, these findings provide both absolute and relative perspectives on the infectious risk associated with ADTs, reinforcing their clinical relevance and highlighting the need for heightened vigilance in infection prevention and control following ADT to reduce infection-related morbidity.

Although the exact pathophysiological mechanisms linking ADT to infection are not always clearly delineated in individual studies, proposed explanations include CSFL acting as a conduit for contamination, longer operative times, and increased need for tissue manipulation or reoperation.1,37–39 This theory is substantiated by reports describing an association of CSFL and general wound healing complications. CSFL creates a favorable environment for bacterial growth, especially when dural tears are inadequately repaired, leading to a higher incidence of meningitis, wound dehiscence, and deep infections.25,40,41 Additionally, prolonged bed rest following ADT further elevates the risk of wound disruption and infection.42 Long persisting dural tear is reported to be linked to a higher risk of SSI, sepsis, pneumonia, urinary tract infection, wound dehiscence, thromboembolism, acute kidney injury, and finally to a significantly increased morbidity.24 Studies by Epstein et al and Takahashi et al confirm that delayed diagnosis and management of dural tears can lead to a cascade of severe complications, including deep wound infections and prolonged hospital stays.43,44

Comorbidities are key contributors to the risk of dural tears and subsequent infections. Advanced age, prior spinal surgery, and degenerative conditions significantly increase vulnerability for both.45 Obesity (body mass index ≥30 kg/m2), diabetes, and higher ASA scores are consistently linked to elevated SSI rates.23,33,36 Also, McMahon et al46 identified obesity, diabetes, and age as overlapping risk factors for both ADT and SSI, likely due to impaired wound healing and immune function.33,46 Revision surgery, particularly for stenosis or spondylolisthesis, is a well-established risk factor, with an increased incidence of ADTs, consistently documented in several studies due to scarring and distorted anatomy.4–7,47,48 Aging further compromises dural integrity, increasing tear susceptibility.8,18,19 Moreover, surgical factors such as prolonged operative time, greater blood loss, and the presence of multiple staff in the operating room also raise SSI risk.31,33,49 Long persisting dural tears are particularly associated with extended procedures (≥250 minutes), transfusions, and prolonged drainage, all of which correlate with postoperative infections.23,24,49 These findings underscore the importance of careful perioperative planning in high-risk patients.

Prompt surgical debridement and prolonged parenteral antibiotics are typically effective in treating SSIs, often resulting in infection eradication and preservation of instrumentation.49 Intraoperative dural tears resulting in CSFL should be addressed immediately with primary repair. In most cases, suturing is sufficient to effectively close the tear and prevent further complications.28 In cases of spinal CSFL, oversuturing the incision and applying a pressure dressing are often sufficient. If these measures are unsuccessful, bed rest in the semi-Fowler’s position is recommended to reduce CSF hydrostatic pressure in the lumbar region. Additional treatments include blood patch repair and closed lumbar subarachnoid CSF drainage. Closed subarachnoid CSF drainage is described as an effective method for treating postoperative CSF leaks and can help prevent the need for repeat surgery.28 Although lumbar drainage has an 85% to 94% success rate, complications can occur in up to 44% of cases, with headaches in 17%.28 Most CSFLs result from identifiable dural injuries, though delayed leaks from occult tears may also occur. Prevention remains paramount, requiring meticulous surgical technique and planning, as conservative management alone is rarely sufficient.29,31 As for SSI, prompt surgical debridement and prolonged parenteral antibiotics are the standard treatment, often resulting in infection eradication and preservation of instrumentation.49

This study is not without limitations. First, the relatively small number of eligible studies included in the systematic review and meta-analysis may limit the overall strength and generalizability of the findings. Furthermore, most of the studies were retrospective analyses and underlie the known limitations of retrospective work. Another limitation may be the lack of consistency of reported patient-level data across studies, as comorbidities, revision status, and surgical parameters were not always available in a standardized or extractable manner, limiting the ability to perform subgroup analyses or adjust our findings based on these risk factors. Additionally, to minimize bias and ensure methodological rigor, only studies providing raw, extractable data were included in the quantitative analyses. While this approach enhances the reliability of the statistical evaluation, it may have excluded potentially relevant studies with less detailed reporting. This constraint likely reflects the limited availability of research specifically addressing postoperative infections following ADT in lumbar spine surgery for degenerative conditions.

Conclusion

ADTs during lumbar spine surgery for degenerative conditions are associated with a significantly increased risk of postoperative infections. Although this relationship is multifactorial, affected by surgical complexity and patient comorbidities, these findings underscore the importance of heightened vigilance in infection prevention and control following ADT to reduce infection-related morbidity.

Footnotes

  • Funding The authors received no financial support for the research, authorship, and/or publication of this article.

  • Declaration of Conflicting Interests The authors report no conflicts of interest in this work.

  • Ethics Approval The study was approved by the Ethics Commission of Cologne University’s Faculty of Medicine (registration number: 24-1298). The requirement for informed consent was waived due to the retrospective nature of the study.

  • Data Availability Statement The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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In this Issue
International Journal of Spine Surgery

Vol. 19, Issue 5

1 Oct 2025

Table of Contents Index by author

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Keywords

accidental dural tear, incidental durotomy, spinal surgery, lumbar spine, infection, complication