Original Article Incidental Durotomy during Lumbar Spine Surgery: Management and Complications. A Retrospective Review

Transcription

1 Egyptian Journal of Neurosurgery Volume 3 / No. 2 / April June Original Article Incidental Durotomy during Lumbar Spine Surgery: Management and Complications. A Retrospective Review Shafik El Molla* and Emad H. Abouelmaaty Department of Neurosurgery, Ain Shams University Received: 24 April 206 Accepted: 20 August 206 Key words: Incidental durotomy, Lumbar spine surgery, Subfascial drain 206 Egyptian Journal of Neurosurgery. All rights reserved ABSTRACT Background: An incidental dural tear is a frequent intraoperative complication of spine surgery. Various studies have reported incidences ranging from % to 7%. Cerebrospinal fluid (CSF) leakage is a potential complication resulting from a dural violation during spinal surgery. Objectives: The aim of this study is to evaluate different modalities of management of uintended durotomy during lumbar spine surgery. Patients and Methods: Thirty patients (twenty two males and eight females) who were subjected to uintended durotomy in lumbar spine surgery in Ain Shams University hospitals were included in the study. They were evaluated for different modalities of management of unintented durotomy. Results: 46.66% (fourteen cases) of our patients had a de novo lumbar pathology and 53.33% were recurrent cases. As regard the operated spinal level L4-5 was the most involved level in twenty cases (67.67%) and L-2 the least in one case (3.33%). Intra operative site of dural tear was dorsal in 9 cases (65.5%), ventral in two cases (6%) and lateral in 8 cases (27.5%). In twenty four patients a subfascial drain was kept, while six patients had no subfascial drain. Post operative insertion of subarachnoid lumbar drain was done in seven patients with failure in two patients. The infection rate with the use of lumbar subarachnoid drain was (4.2%). Conclusion: Although the reported results constitute a preliminary data of along term follow up of patients with incidental durotomy and post operative CSF leakage. These results point to: no difference in success rate between patients with sutured fat graft, sutured muscle graft and Duragen. Better results in patients managed without subfascial drain. INTRODUCTION An incidental dural tear is a frequent intraoperative complication of spine surgery,2 epidural injections and myelography. 3 Various studies have reported incidences ranging from % to 7%. 3,4 Spine surgeons tend to underestimate the frequency of incidental durotomy. 2 Several consequences of inadequately treated dural tears have been reported. If the dural tear is not properly closed or unrecognised patients can present with postural headaches, vertigo, posterior neck pain, neck and/or stiffness, nausea, diplopia, photophobia, tinnitus, and blurred vision. These symptoms are caused by a persistent cerebrospinal fluid leak from the subarachnoid space. The decrease in cerebrospinal fluid pressure leads to a loss of buoyancy and caudal displacement of the intracranial content. Cain et al. 5 have studied the biology of dural tear repair in a canine model. They found that fibroblastic bridging of the dural defect starts on the 6 th day and by the 0th day the defect is healed. 6 Cerebrospinal fluid (CSF) leakage is a potential complication resulting from a dural violation during *Corresponding Author: Shafik El Molla MD Lecturer of Neurosurgery Ain Shams university drshafiktahseen@hotmail.com; Tel.: spinal surgery. Incidental durotomy and the resultant complications are increasingly important issues in spinal surgery because the number of indications for spine surgery is growing and the complexity of operations undertaken is increasing 7. Ultimately, appropriate treatment of an incidental durotomy or CSF leak, depends on the time of diagnosis, size and location of the defect, and the patient's symptoms. Intraoperative identification of an incidental durotomy demands immediate and meticulous surgical repair. The modality of repair, whether primary suture repair, use of a graft, or both, depends on the size of the defect, accessibility, and the integrity of the dura. Dural defects that are diagnosed after surgery, if small and well-contained, may spontaneously resolve with conservative management. CSF fistulas with minimal CSF drainage may be amenable to treatment with a percutaneous epidural patch, temporary closed subarachnoid drainage, or both. Profuse CSF drainage, large symptomatic pseudomeningoceles, or a persistent CSF fistula despite prior treatment measures, however, warrants re-exploration with definitive surgical repair. 8 PATIENTS AND METHODS This study design is a retrospective descriptive cohort on thirty patients operated electively for any Egyptian Journal of Neurosurgery 9

2 degenerative lumbar spine pathology with accompanying unintended durotomy in the Department of Neurosurgery of Ain Shams University. Patients with a degenerative spine disease who underwent surgery for this purpose were enrolled in the study when they met one of the following inclusion criteria:. Intra-operative observation of durotomy productive of CSF either an irreparable or tenuously repaired, 2. Documented clearing drain output of greater than 50 ml daily on 3 rd day. 3. Clinical evidence of postoperative CSF leak either before or after subfascial drain removal. Excluded from the study were patients with: Delayed CSF leakage after discharge, Cases with CSF leakage not registered in our record. Analysis was done for patient demographic data (sex and age, smoking), medical history of the patient that may affect the healing process, previous surgical history (recurrent versus denovo), surgical indication (preoperative diagnosis), duration of postoperative hospital stay, and drainage output over the recorded interval. Final notice was taken of whether or not patients required subsequent intervention for CSF leakage treatment and any other complications associated with CSF leak treatment. A durotomy was defined as any incidental perforation of the dura that occurred during surgery. CSF leakage was considered positive if drain output greater than 50 ml on 3 rd day post operatively. Data collection and stastic analysis: Data was collected from original records and computerized data base of neurosurgery department {Oricle 0 G.} Data entry and analyses were performed using SPSS statistical package version 0 (SPSS, Inc., Chicago, IL, USA). The quantitative data were presented as a mean and standard deviation. The qualitative data were presented as number and percentage. RESULTS The study was conducted on thirty patients, twenty nine of intra operative detection of dural tear and one of post operative CSF leakage. Thirty patients were enrolled in our study. The mean age ± standard deviation was 48.7±0. years (minimum= 32 years and maximum= 68 years). (Table ) Table : Distribution of Age in Sex groups. Variable N Proportion (%) Total Mean Age (Years) Mean±SD (Years) Sex ± 0. Male 22(73.3) 47.9±0.2 Female 8(26.7) 48.9±0.2 Table 2: Co-morbidities in the patients Co-Morbidity Diabetes Mellitus Diabetes Mellitus +Hypertension Hypertension HCV None N Percentage The main clinical presentation of the patients was sciatica and occurred in twenty three patients (76.33%) followed by neurogenic claudication in four patients (3.33%). One patient presented with foot drop. (Table 3) Table 3: Clinical presentation of the patient Presentation. Sciatica Claudication No Percentage (%) Femoralgia 3.33 Sciatica with urinary retention 3.33 Foot drop 3.33 Presentation of pathology: 46.66% (fourteen cases) of our patients had a de novo lumbar pathology and 53.33% were recurrent cases. As regard the operated spinal level L4-5 was the most involved level in twenty cases (67.67%) and L-2 the least in one case (3.33%). Intra operative site of dural tear was dorsal in nineteen cases (65.5%), ventral in two cases (6%) and lateral in eight cases (27.5%). (Tables 4 & 5) 20 Egyptian Journal of Neurosurgery

3 Table (4): Presenting pathology and its level. Presenting pathology N Percentage (%) Lumbar Disc Herniation Lumbar Canal Stenosis Spondylolisthesis 3.3 Removal of broken Screws 3.3 Level of Pathology N Percentage (%) L L L L4-5+L5-S L5-S Presentation of pathology De novo Recurrence Site of dural tears N (%) Table 5: Site of dural tear Dorsal Ventral 9 (63.3) 2(6.67) Lateral 8(26.67) Intraoperative water-tight dural suturing was attempted in seventeen patients. Closure was performed with vicryl 4-0 dural suture, a fat or muscle graft in was used in ten cases over the primary dural repair.(direct suture without graft in seven patients 4%,suture with fat graft in five patients 29.5%,suture with muscle graft in five patients 29.5%).Twelve patients (40%) had no intra operative dural suture with application of muscle graft in two cases and fat graft in one case of them and duragen in five of them. (Table 6) Fat graft was used in six cases (20.6%), muscle graft in seven cases (24.%) and in five cases (7.2%) duragen was used. (Table 7) Suture Non suture Table 6: Intra operative management With graft Fat (n = 0) Muscle Without graft Synthetic graft Muscle graft Fat graft 5 patients 5 patients 7 patients 5 patients 2 patients patient Table 7: Intra operative use of graft Type of Graft Fat graft Muscle graft Duragen N % 20.6% 24.% 7.2% In twenty four patients a subfascial drain was kept, while six patients had no subfascial drain. Postoperatively, all thirty patients were managed with the same protocol, which consisted of a short period of bed rest (average,3-5days),lower extremity manual massage and elastic stocking with or without addition of S.C fractionated heparin as a prophylaxis for deep venous thrombosis. The patients were followed-up during the hospital stay with a mean duration of hospital stay (8.66) day range (3 to 28 days). Post operative leakage was noticed in nine cases. (Table 8) Table 8: Post operative CSF leakage, subfascial drain Subfascial drain No subfascial drain Post operative CSF leakage 9 patients 0 patient Percentage 37.5% 0% Egyptian Journal of Neurosurgery 2

4 Table 9: Intra operative management technique and failure rate Intra operative management No. of cases CSF leakae. % Intra operative Fat graft % suturing Muscle graft % Direct % Non suturing Duragen % Fat graft 0 0% Muscle graft 2 0 0% No intervention 4 25% One patient of no intra operative evidence of dural tear, however there was a post operative CSF leakage. Smoking was positive in five patients (55.5%) (No. out of nine patients with post operative CSF leakage. While there is one case of D.M(%), 2cases of HTN (22%), two cases with D.M & HTN(22%)while four patients (45%) were medically free.(out of the nine patients with postoperative CSF leakage). Post operative insertion of subarachnoid lumbar drain was done in seven patients (23%) with failure in two patients with success rate 7%. One patient sixty eight years old diabetic male, the site of the leak was dorsal with intra operative suturing without graft with the use of subfascial drain that slipped by 2 nd day the dressing was soaked with CSF leakage from the suture line, sub arachnoid drain was inserted blocked by 4 th day with development of fever and slight neck rigidity that resolved with empirical antibiotic, culture from the wound revealing no growth.with repeated dressing the wound healing occurred. The patient was discharged from the hospital after twenty five days of hospital stay. The other one fourty years old patient, the site of tear was dorsal for which a dural suturing was done without graft, with subfascial drain for 5 days then removed with insertion of lumbar sub arachnoid drain the patient developed right foot drop, urinary retention, saddle area tingling and numbness within -2 hrs of insertion of the lumbar drain; the lumbar drain was removed with arrangement for imaging of the pt revealing no hematoma and starting of (iv steroid), gradually the pt improved, CSF leak managed conservatively with repeated daily dressing. The infection rate with the use of lumbar subarachnoid drain was (4.2%), although we routinely use a prophylactic antibiotics. This happened in one patient the wound discharging pus, infected CSF (no intra operative management but post operative lumbar drain was inserted for week with cessation of the leak one day after, the wound gapped with discharging pus; for which a wound debridment was done showing wound inflammation and discarging pus from the thecal sac. 22 DISCUSSION Dural lesions or unintended incidental durotomies seem to be the most common complication in spinal surgery, and figures between % and 4% have been presented in the literature. A dural lesion may be a minor problem treated by a suture or fibrin glue and may also be the entry point to the development of dural cutaneous fistulas, meningitis, arachnoiditis, and epidural abscesses. The small but serious risk for the latter complications calls for immediate attention when dural lesions are noted during surgery. A number of treatment modalities have been presented, ranging from direct closure by sutures to facial, muscular, or artificial grafts, fibrin glue, and closed subarachnoid drainage. 9 Teli et al., 0 mentioned that: the length of hospital stay for lumbar discectomy varies widely. Mean hospital stay in their series was 3.2 days overall. Hospital stays >48 hours were typical for patients with dural tears and did not reflect the type of surgery performed in the different groups. Our follow up showed that hospital stay varies widely with mean of 8.66 days ranging (4-28days). We found that there was no correlation between diabetes mellitus and the occurrence of post operative CSF leakage, this may be explained by the fair control of diabetic patient prior to surgery. Our results pointing to the occurrence of dural tear was found more with recurrent cases this may be explained by adhesions and local scar tissue this also keep in touch with Mustafa et al. 7 We found that There is no difference in success and failure rate between intra operatively managed dural tear with duragen, muscle graft with suturing, fat graft with failure rate was 40%, yet Lotfinia et al. found with their experience with a fat graft, a 6.52% CSF leakage rate was observed.they explained their results that: When grafts have been used, fibroblasts seem to make use of the holes made by the suturing needle to make a repair. An important property of any dural graft is its ability to prevent the formation of CSF fistulae or leaks. Egyptian Journal of Neurosurgery

5 Our follow up showed that the use of DuraGen was associated with success rate of 60% (3 of 5 cases), on the other hand, Narotam et al. 2 mentioned that: collagen matrix (DuraGen) was successful in cerebrospinal fluid containment in >95% of patients requiring dural repair following anterior and posterior spinal surgery. In this study: the use of muscle graft /fat graft without suture was associated with 0%failure rate 3 cases this may be due to questionable violation of dura in one case, no use of sub fascial drain in the 3 cases. Current study results pointed to: the use of subfascial drain is associated with post operative CSF leakage (in nine cases out of twenty four cases), while cases with no fascial drain( six cases) associated with no CSF leakage; this may be explained that use of subfascial drain disrupt fascial layer, create a negative pressure allowing for CSF egress, disrupt blood patch. However this result should be taken cautiously as it represent a single surgeon experience, may be related to meticulous repair and homeostasis. While Couture et al. 3 placement of a drain is controversial, because it may lead to a persistent communication between the extradural and intradural space. On the other hand, Mustafa et al. 7 stated that none of their patients who had subfascial drains placed had a resultant CSF fistula. They take the subfascial drain off suction and place it to gravity on the first morning after surgery, allowing approximately 80 to 00 ml of CSF to drain per shift. Keeping the drain to gravity off suction theoretically allows the subfascial CSF pressure to dictate amount of drainage, without extracting additional CSF from the subdural space. In our follow up: the use of lumbar drain was associated with success rate of 7.42%, although this procedure was not risk free, in one patient the insertion of lumbar drain is associated with complete foot drop, urinary retention, the infection rate with the use of lumbar subarachnoid drain was (4.2%), although we routinely use a prophylactic antibiotics.this goes up with Açıkbas et al.4with reported success rate of 85%- 95%, and infection rate close to 0% in patient with subarachnoid drain, they did not use antibiotics. Post operatively all thirty patients were managed with the same protocol, which consisted of a short period of bed rest (average 3-5 days).on the other hand, Hodges et al. 5 mentioned that these patients can be safely mobilized immediately as long as precaution is taken once symptoms such as headache, nausea, or vomiting are recognized in a retrospective study conducted on 20 patients. While Tafazal et al. 2 found that mandatory bed rest was not necessary for patients who had repair of a dural tear intraoperatively. They found that 75% of those treated without bed rest were asymptomatic post-operatively. The remainder were instructed to rest if they were symptomatic. By allowing the patients to ambulate postoperatively after repair of the durotomy, the authors argued that a substantial saving in terms of hospital stay could be achieved. Yet Mustafa et al. 7 had mobilization protocol: once a patient has been identified as having a DT, they use the following postoperative management protocol: Patients are kept supine in bed rest for 24 hours. The morning after surgery, the subfascial drain is taken off suction and put to gravity. After the first 24 hours, the patients are allowed to elevate the head of bed at 30 for 8 hours. If no headache occurs, they are allowed a period of trial ambulation with assistance. If they are able to tolerate the trial ambulation, they are allowed to ambulate as tolerated. On the other hand, if the patients have a recurrent headache as a result of the bed head- elevation trial, or if they have a headache with trial ambulation with assistance, the trial protocol is restarted with bed rest for 24 hours. The subfascial drain is maintained on gravity and removed by day 3. In this study reoperation rate was 3.33% ( of 30 patients). Wang et al. 6 had a 2.3% reoperation rate (2 of 88 patients; both were revision cases). Camissa et al. 3 had a reoperation rate of 9.% (6 of 66 patients). Mustafa et al. 7 had a reoperation rate of.8% (6 of the 338 patients). This is one of the early cohort study conducted in this institution with the purpose of examining the risk factors, causes and types of postoperative CSF leaks in lumbar spinal operations and evaluating the management strategies and their outcomes. It evaluated the efficacy of the current postoperative management regimen and intraoperative management of incidental durotomies, using clear predefined criteria of failure of the management, namely; Postoperative CSF leak from the wound, the need for reoperation or the development of other complications that are related to the CSF wound drainage as wound infection/breakdown, or development of epidural or spinal infection. Although failure outcomes in such case, if occurred, they can't really point out whether the cause was the defective postoperative or intraoperative management, yet the presence of an almost fixed postoperative management scheme helps narrow the possibilities towards a more thorough assessment of the intraoperative procedures as suturing techniques, use of grafts and also the use of subfascial wound drains. We are aware that this form of evaluation indeed needs large number to draw valid conclusions.the results of this study are expected to shed some light on the current status in the institution with respect to these factors and is also expected to guide future research and help in implementing unified techniques of management still bearing in mind the peculiar nature of each individual case. Yet, the small numbers of the study subjects/the limited size of the patient cohort, was the major drawback besides the retrospective nature of the study,short term follow up of the wound state (during hospital stay). Egyptian Journal of Neurosurgery 23

6 Because conclusions and strength of the recommendations is directly influenced by the magnitude of the derived percentages and results...we expect the results of the current study to be considered with caution and regarded as preliminary results of a larger cohort that's hoped to be compiled over the following years to either augment, clarify/explain or, hopefully not, contradict the current results. CONCLUSION Although the reported results constitute a preliminary data of along term follow up of patients with incidental durotomy and post operative CSF leakage. These results point to: no difference in success rate between patients with sutured fat graft, sutured muscle graft and Duragen. Better results in patients managed without subfascial drain. This needs further long term follow up prospective studies in a large scale. Declaration The author(s) declare no conflict of interest or any financial support and confirm the approval of the submitted article by the concerned ethical committee. REFERENCES. Kothe R, Quante M, Engler N, Heider F, Kneißl J, Pirchner S, Siepe C: The effect of incidental dural lesions on outcome after decompression surgery for lumbar spinal stenosis: results of a multi-center study with 800 patients, Eur Spine J. Apr 28. [Epub ahead of print], Tafazal SI, Sell PJ.: Incidental durotomy in lumbar spine surgery, incidence and management. Eur Spine J; 4:287 90, Cammisa Jr FP, Girardi FP, Sangani PK, et al. Incidental durotomy in spine surgery. Spine; 25: , Ulrich NH,Burgstaller JM,Brunner F,Porchet F,Farchad M,Pichierri G,Steuer J,Held U :The impact of incidental durotomy on the outcome of decompression surgery in degenerative lumbar spinal canal stenosis: analysis of the Lumbar Spinal Outcome Study (LSOS) data a Swiss prospective multi-center cohort study,bmc Musculskelet Disord.7: 70, Cain Jr JE, Lauerman WC, Rosenthal HG, et al. The histomorphologic sequence of dural repair: observations in the canine model. Spine; 6:S39 23, Guerin P, El Fegoun AB, Obeid I, et al.: Incidental durotomy during spine surgery: Incidence, management and complications. A retrospective review, Int J Care Injured 43: , Mustafa HK, Jeffery R, Garen S, Rick D, William FD, James DK and Joon YL: Postoperative Management Protocol For Incidental Duraltears During Degenerative Lumbar Spine Surgery. A Review of 3,83 Consecutive Degenerative Lumbar Cases. Spine 3, Hoh DJ and Lauryssen CL: Management of cerebrospinal fluid leaks in the lumbar spine. In Shen FH and Shaffrey C (Eds.): Arthritis and Arthroplasty: The Spine. 39, Stro mqvist F, Jo nsson B and Stro mqvist B: Dural lesions in lumbar disc herniation surgery: incidence, risk factors, and outcome. Eur Spine J; 9: , Teli M, Lovi A, Brayda-Bruno M, et al. : Higher risk of dural tears and recurrent herniation with lumbar microendoscopic discectomy.eur Spine J; 9: , Lotfinia I, Sima S: Incidental Durotomy During Lumbar Spine Surgery,Neurosurgery Quarterly: 22:05 2, Narotam PK, José S, Nathoo N, Taylon C and Vora Y: Collagen matrix (duragen) in dural repair: analysis of a new modified technique. Spine 29: 286-7, Couture D and Branch CL: Spinal pseudomeningoceles and cerebrospinal fluid fistulas. Neurosurg Focus 5: E6, 5, AcIkbas SC, Akyu Z M, Kazan S and Tuncer R: Complications of closed continuous lumbar drainage of cerebrospinal fluid. Acta Neurochir (Wien); 44: , Hodges SD, Humphreys C, Eck JC, et al.: Management of incidental durotomy without mandatory bed rest. Spine 24: , Wang JC, Bohlman HH and Riew KD : Dural tears secondary to operations on the lumbar spine. management and results after a two-year-minimum follow-up of eighty-eight patients. J Bone Joint Surg Am 80: , Egyptian Journal of Neurosurgery