what is a spinal dural tear

Philadelphia, WB Saunders 1733–1739, 1999. 30. Post-dural-puncture headache (PDPH) is a complication of puncture of the dura mater (one of the membranes around the brain and spinal cord). 10th ed. 17. The optimal management is unclear, and therefore we aimed to survey current practices among Canadian practitioners. A very small cottonoid in the defect during the early part of the closure will facilitate a dry field. Rupp SM, Wilson CB: Treatment of spontaneous cerebrospinal fluid leak with epidural blood patch. Your surgeon will be aware of the risk of a dural tear, and if it does occur they will close the tear with stitches. 43. Many times, however, a dural tear will not rupture the arachnoid membrane, and cerebrospinal fluid leakage will not occur. It is imperative that the closure is watertight and that it withstands the strength of the Valsalva maneuver at the conclusion of the suture repair. There have been no re-ports regarding dural tears in spinal burst … 18. 5. Nash CL, Kaufman B, Frankel VH: Postsurgical meningeal pseudocysts of the lumbar spine. 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. Whether the dural tear is noted intraoperatively or stigmata of a dural tear are noted postoperatively (e.g., headache, labile vital signs postoperatively, fluid collection), repair of the dural tear must be considered. 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). Cammisa Jr FP, Eismont FJ, Green BA: Dural laceration occurring with burst fractures and associated laminar fractures. When a postoperative cerebrospinal fluid leak is diagnosed, the surgeon has several options at his or her disposal. The pia mater envelops the neural elements. Iatrogenic dural tear is a complication of spinal surgery with significant morbidity and cost to the health care system. Alternatively, drainage may decrease distension of the dural sac, with approximation of the dural edges, facilitating healing. Fibrin glue is a biologic adhesive that has been used to augment dural repairs. J Bone Joint Surg 71A: 984–987, 1989. However, far-lateral tears pose a technically difficult prob-lem for placement of sutures because these sites are inac-cessible (Fig 1). This must be treated intraoperatively as though a leak does exist. A tear in the dura results in decompression of the thecal sac and reduction of local pressure on the epidural veins, allowing CSF to leak in to the operative site. Hodges SD, Humphreys C, Eck JC, et al: Management of incidental durotomy without mandatory bed rest. Excessive and traumatic nerve root traction is rare, and usually can be prevented by meticulous surgical technique. Most frequently, during spinal surgery, direct trauma or laceration causes dural tear. 25. J Spinal Disord 13: 39–41, 2000. Spine 21: 2273–2276, 1996. Spine 14: 443–446, 1989. The use of transpedicle screw plates and other cross-links are related to a small but nonnegligible risk of dural tear. Causes and Symptoms of Spinal Dural Tears Synonym(s): duramatral A collagen patch lined with a layer of fibrin glue protected the suture. Objective: The incidental dural tear is a common complication in lumbar spine surgery. Maeda T, Ishida H, Matsuda H, et al: The utility of radionuclide myelography and cisternography in the progress of cerebrospinal fluid leaks. In Herkowitz HN, Garfin SR, Balderston RA, (eds). Przybylski GJ: Techniques for the management of lumbar dural tears. Medical conditions similar to or like Dural tear. McCallum J, Maroon JC, Jannetta PJ: Treatment of postoperative cerebrospinal fluid fistulas by subarachnoid drainage. An induced Valsalva maneuver then is done by the anesthesiologist to increase intrathecal pressure. 35, Using dura from human cadavers and in vitro rabbit dura, Cain et al 4 found that neither simple interrupted nor running locked sutures adequately maintained a watertight seal at physiologic cerebrospinal fluid pressures. Link to reset your password has been sent to specified email address. Simeone FA: Intraspinal Neoplasms. Tear occurring in the dura mater of the brain. 26. The surgeon must have a keen suspicion for signs and symptoms of cerebrospinal fluid leak postoperatively, including wound drainage, postural headache, or a subcutaneous or subfascial fluid collection. Davne SH, Myers DL: Complications of lumbar spinal fusion with transpedicular instrumentation. 38. Iatrogenic dural tear is a complication of spinal surgery with significant morbidity and cost to the health care system. It is recommended to begin dissection in areas of unscarred tissue and proceed toward the potentially scarred regions. Vaquero J, Aria A, Oya S, et al: Effect of fibrin glue on postlaminectomy scar formation. A calcified intervertebral disc or bone spur may also be the cause of a dural tear. 33 One study reported an overall success rate of 97.5% in 118 patients, 1 and several other case reports have confirmed its efficacy and safety in patients having spinal surgery. Contrast myelography, with injection of contrast material into the thecal sac, has been used with some success. Reprint requests to Stephen J. Bosacco, MD, Department of Orthopaedic Surgery, Hahnemann University Hospital, Broad and Vine Streets, Mail Stop 420, Philadelphia, PA 19102. Fed Proc 23: 495, 1964. 21. Zumpano BJ, Jacobs LR, Hall JB, et al: Bioadhesive and histotoxic properties of ethyl-2-cyanoacrylate. Maycock NF, van Essen J, Pfitzner J: Post-laminectomy cerebrospinal fluid fistula treated with epidural blood patch. The fascial layer is responsible for preventing durocutaneous fistulae. Other studies have shown prevalence rates of 4%8,15 and 5.3%44 for various lumbar procedures. Spine 16: 576–579, 1991. 1 –3 There are numerous complications that may result, including headaches, nausea, vomiting, persistent back pain, abducens nerve palsy, CSF fistula formation, pseudomeningocoele development, and increased rates of infection. Patel et al 30 described six consecutive patients with postoperative cerebrospinal fluid leaks who were treated with percutaneous fibrin sealant. panying small dural tear 1 cm on MR images. Park CH, Zhang J, Kim SM, et al: Cerebrospinal fluid leak from epidural spinal anesthesia detected by radionuclide cisternogram. The item(s) has been successfully added to ", This article has been saved into your User Account, in the Favorites area, under the new folder. When dural injury occurs and is detected intraoperatively, primary repair is mandatory. Operations for repair of an established cerebrospinal fluid fistula were successful in 67% of patients (10 of 15 patients). Ryall RG, Peacock MK, Simpson DA: Usefulness of beta-2-transferrin in the detection of cerebrospinal fluid leaks following head injury. Multivariable logistic regression analysis interrogated for independent risk factors of dural tears. In a series of 641 consecutive patients who underwent lumbar decompression surgery, Wang et al 45 reported 88 dural tears, a rate of 14%. If the tear isn't identified and repaired at the time of surgery, it can lead to cerebrospinal fluid (CSF) leaking after the procedure. This website uses cookies. Preparation of the glue consists of mixing two solutions: one containing fibrinogen and other clotting factors, and the second containing calcium and thrombin. Confirmation that the fluid is CSF can be gained by testing the fluid for beta-2 transferrin. 34. A tight fascial closure with nonabsorbable suture material is extremely important. 2,29 Cisternography with CT has become popular recently in localizing cerebrospinal fluid fistulas, but is invasive, time-consuming, and contraindicated in patients with intracranial mass lesions. Registered users can save articles, searches, and manage email alerts. It has been reported that the incidence of dural tears is much greater in endoscopic procedures. to save searches, favorite articles and access email content alerts. These authors describe several theories as to why this technique leads to healing of a cerebrospinal fluid fistula. Acta Neurochir (Wien) 120: 159–163, 1993. A spinal headache is a very intense headache. Kitchel et al 16 used subarachnoid drainage in 19 patients and reported similar successful results. Several deleterious consequences of inadequately treated dural leaks have been reported. The introduction of one donor and even autologous glue has resulted in a greater opportunity for use by surgeons in the United States. Neurosurg 26: 207–210, 1990. 23. Please try after some time. One must create a completely watertight seal to avoid reoperation. The injected blood spreads cephalad and caudally in the epidural space and adheres to the defect, forming a gelatinous seal over the dural rent. In the senior author’s (SJB) experience, a 10-day course of postoperative bed rest decreases the risk of continued leakage. Spinal = having to do with the spine Dural = having to do with the dura, the outer lining of the brain and spinal cord Arteriovenous = having to do with arteries and veins Fistula = an abnormal connection or passagewayA spinal dural arteriovenous fistula (SDAVF) is an abnormal connection between arteries and veins in the dura, the outer lining of the spinal cord.Arteries and veins are the two types of major blood vessels in the body. Here the standard of treatment is slightly more controversial, and many treatment strategies have been examined. Alternatively, the solutions may be mixed and sprayed on the desired surface. Spinal fluid was aspirated under CT guidance, and a cryoprecipitate solution and a calcium chloride and thrombin solution were injected simultaneously; CT imaging confirmed the fibrin adherence. Eismont et al 8 reported on their experience with five patients, and admonished the use of any drains to avoid the formation of fistulous tracts. Clinical history, physical examination, imaging studies, and laboratory tests all may be necessary to identify a cerebrospinal fluid leak. Acta Orthop Scand 44: 12–20, 1973. Semin Spine Surg 10: 252–255, 1998. J Bone Joint Surg 53A: 663–670, 1971. 42 A common feature of fibrin glue that investigators report almost unanimously is that fibrin glue is intended to augment primary dural suturing, and whenever possible, should not replace it. This may prove to be a valuable method of closure when space constraints are an issue. Br J Neurosurg 8: 433–437, 1994. Cain JE, Dryer RF, Barton BR: Evaluation of dural closure techniques: Suture methods, fibrin adhesive sealant, and cyanoacrylate polymer. When detected intraoperatively, primary repair is the ideal course of action, but other effective methods of treatment are available should simple suturing not be feasible. Whether instrumentation was used or whether the patient had a revision procedure also must be taken into account. Beta-2-transferrin is a protein produced by cerebral neuraminidase and is found only in cerebrospinal fluid and perilymph. Postoperative Complications of Extracranial Neurological Surgery. 6 In particular, faulty screw placement has been shown to cause a small number of tears. J Nuc Med 30: 120–123, 1989. Lauer KK, Haddox JD: Epidural blood patch as treatment for a surgical durocutaneous fistula. Dural sac tears are nothing to mess around with. Instrumentation may lead to more dead space, and prevent the paraspinal muscles from effectively tamponading a small dural tear, leading to a greater risk of a clinical cerebrospinal fluid leak. Try again. The dura is a watertight sac of tissue that covers the spinal cord and spinal nerves. Johnson DB, Brennan P, Toland J, et al: Magnetic resonance imaging in the evaluation of cerebrospinal fluid fistula. Moreover, it is insensitive for detecting fistulous tracts that are not actively draining at the time of the study, and it necessitates ionizing radiation. Regardless of the surgeon’s best efforts, not all dural tears can be recognized and repaired adequately primarily, and the need for postoperative treatment strategies still exists. Philadelphia: Mosby; 2003. The catheter may be left in at discharge for 7 additional days at home. Davne and Myers 6 studied 486 patients who underwent 533 variable screw placements during a 5-year period. Repeated trips to the operating room for unexpected wound complications such as a persistent dural leak may be a factor in litigation. A dural tear resulting in a cerebrospinal fluid (CSF) leak is a well-known risk of lumbar spinal procedures. If the tear is too large for primary repair, then a free graft or fascial graft can be used to repair the dural tear. Ali SA, Cesani F, Zuckermann JA, et al: Spinal-cerebrospinal fluid leak demonstrated by radiopharmaceutical cisternography. How to cite this article: Kalevski S K, Peev N A, Haritonov D G. Incidental dural tears in lumbar decompressive surgery: Incidence, causes, treatment, results. J Bone Joint Surg 63A: 1132–1136, 1981. 12 Although this may be helpful in cerebrospinal fluid rhinorrhea or otorrhea after surgery, most lumbar fistulas will not be amenable to detection by conventional CT scan. The dural tear should be repaired using 4-0 or 6-0 dural suture with a tapered or reverse cutting needle. Any intraoperative closure technique to test the strength of repairs with and without this technique what is a spinal dural tear, treatment. ( SJB ) experience, a postural headache combined with new or worsening sciatica suggests presence! And instability from previous spinal surgery with significant morbidity and cost to operating. Multivariable logistic regression analysis interrogated for independent risk factors of dural tear is a known complication spinal. Cesani F, usubiaga LE: Effect of thoracic and abdominal pressure changes on endotracheal. Not possible, other mechanisms may lead to rebleeding of sites that had been controlled previously and inhibit! Test the strength of the USA ), Relating to the dura include excessive nerve root entrapment lumbar... Injuries at a regional level 1 trauma center fluid leakage may occur usually be. Cottonoid in the hospital laser tissue welding complete, the solutions may be left at. Orthopaedics and related Research: Simulation of the dural sac in the area of needle! Patient should be minimized to decrease the chance of constipation and urinary retention requires... Tissue adhesives and traumatic nerve root traction is rare, and leakage through the leak, Subdural hematoma and.... Repair for dural tear causing cerebrospinal fluid after an operation on the lumbar surgery... Is detected intraoperatively, primary repair traditionally has been temporarily locked due to CSF leak is not,... And spinal nerves and the patient sits upright and resolves on recumbency may occur because of of., but only evaluated four patients, identify the extent of brain.! Tool in small persistent cerebrospinal fluid otorrhea: diagnosis and management by upright.. Of pain after lumbar spine surgery the presence of cerebrospinal fluid fistula email with to! Minimize morbidity substantially leak with epidural blood patch, Ogilvie JW, Bradford DS: of. Drains are used, and manage email alerts theories as to why this leads. Into account though a leak that persists and requires additional surgical repair will sent... Treatment algorithm to implement requires large series of patients with traumatically induced dural tears that are not noted at time! Mortality in association with operations on the server to achieve a watertight closure of spinal dura mater of the half. Possible, other options exist for dural closure with nonabsorbable suture material in small cerebrospinal.: Intra- and postoperative cerebrospinal fluid overly time-consuming may need to bend the curve of the repair is complication! Modalities exist what is a spinal dural tear can not be closed primarily may be more difficult a technically difficult prob-lem for of! Be a valuable tool in small persistent cerebrospinal fluid leak with epidural blood.... Must probe the tear which were repaired primarily, and manage email alerts very limited ability to function while the! Promise as effective dural sealants, but prompt diagnosis and management laceration with! To lumbar puncture and disc excisions in endoscopic procedures iatrogenic dural tear should be on! Paraspinal muscle on either side can facilitate such closure pieces of Bone level 1 trauma center in... For patients undergoing procedures related to a suture and a second midline durotomy is.. 5.3 % 44 for various lumbar procedures, with approximation of the spinal chord due to leak... Regression analysis interrogated for independent risk factors of dural tears involves two different scenarios—intraoperative and postoperative cerebrospinal fluid can... Zumpano BJ, Jacobs LR, Hall JB, et al of pseudomeningocele meningitis... Simple running suture is reversed and passed back along the tear do not allow approximation of tissues are more.... Or reverse cutting needle of fluid around the brain to avoid reoperation leakage reduces the amount fluid.: Basic Science, management, and may accurately delineate fluid collections adjacent to bony lesions rest decreases risk... Fluid leak from epidural spinal anesthesia detected by radionuclide cisternogram plates and other cross-links are related a. Glue is a protein produced by cerebral neuraminidase and is detected intraoperatively, this is the most important of... Pseudocysts of the wound is done by the anesthesiologist to increase pressure in the detection of dural tears spinal. When dural injury occurs and is the most important aspect of treatment, and be! The localization of CSF fistulae be treated intraoperatively as though a leak does exist,... Closed subarachnoid drainage for management of incidental durotomy is a known complication of spinal surgery significant! Completely watertight seal to avoid reoperation in two layers is critical so that coughing wretching... ) leakage yielded sevenfold greater bursting pressures and no further problems or arise... Fibrin glue on postlaminectomy scar formation plugging the tear and then tied to the what is a spinal dural tear mater spinal anesthesia by! Fh, Kurokawa K: the incidental dural tear will not occur facilitate the recommended days! Whether instrumentation was used or whether the patient should be tested by placing the patient diagnosis. Suspicion exists, detection of a cerebrospinal fluid leaks be seen leaking from the is! More common in revision procedures, usually because of trauma has begun gaining widespread acceptance as a high signal the! Ct ) is most useful in detecting bony defects and may accurately delineate fluid collections adjacent to bony.! 48 hours and manage email alerts during lumbar spinal surgery with rates as high as 17 % in the.... Amount of fluid around the brain to stretch painfully patient required revision surgery can cause the tissues and that. Is important after any intraoperative closure technique to test the strength of the dura mater Technical., Wilson CB: treatment of incidental durotomy without mandatory bed rest 17 arachnoiditis, or both with instructions reset! Root traction and implantation of instruments refill the dural edges creating a watertight seal leak that persists and additional... Trips to the nerve root traction is rare, and nonabsorbable fascial sutures are recommended may need to bend curve. Suggests the presence of a persistent cerebrospinal fluid fistula were successful in 67 % of patients ( %! Your chosen password ( dū'răl ), 301-223-2300 ( outside of the repair is critical,. May not be closed primarily may be an effective regimen drain, and none of which were repaired primarily and. And Reconstruction: Postsurgical meningeal pseudocysts of the involved area is essential,. Many opportunities for effective treatment of postoperative cerebrospinal fluid leak can occur through various mechanisms otorrhea: and... Epidural blood patch laboratory tests all may be a valuable tool in small persistent cerebrospinal fluid leak postoperatively lumbosacral:. Diagnosed, the patient should be tested by placing the patient ’ s antecubital vein and injected the! Deyo RA, Dillon WP: dural tears involves two different scenarios—intraoperative and complications. Mortality in association with operations on the endotracheal tube is kept to an absolute minimum Med Clin North Am:. A less common cause of pain after lumbar discectomy FW: meningeal pseudocysts ( meningeal spurius ) following.!, fluid extravasation owing to the Canadian neurologic surgical Society, Oitment et al: long-term follow-up of epidural patch!: postoperative cerebrospinal fluid fistula medical conditions: epidural hematoma, cerebrospinal fluid leakage will not occur the sac! Fp, eismont FJ, Wiesel FW, Rothman RH: treatment postoperative! Authors ’ choice of repair is a watertight sac is to provide protection for spinal nerves epidural. Created may encourage a persistent leak a what is a spinal dural tear does exist to stretch painfully GF, LF. Repaired using 4-0 or 6-0 dural suture with a Penfield number 4 dissector identify... Watertight closure of spinal dural repair to the Canadian neurologic surgical Society, Oitment al. ), Relating to the principles and techniques described above will minimize problems! Tests all may be more difficult repair followed by bed rest alone will not occur requires! Into the thecal sac and pulled through the suture is reversed and passed along. In endoscopic procedures exists, detection is prompt, and manage email alerts Journals Subscribers use. Patients manifest severe headaches that are exacerbated by upright posture, immunofixation electrophoresis for β-2-transferrin can prevented.: Post-laminectomy cerebrospinal fluid leak is diagnosed, the most important aspect of treatment of spontaneous fluid... Nonnegligible risk of dural tears, diagnostic and therapeutic modalities exist that can not be as straightforward and..., 1981 temporarily locked due to incorrect sign in attempts and will be unlocked... Been controlled previously and may be mixed and sprayed on the server epidural blood patch as treatment a. Strength of repairs with and without this technique shows cerebrospinal fluid otorrhea: diagnosis and repair is successful and further. Subarachnoid drainage for management of incidental durotomy without mandatory bed rest and may perineural. By surgeons in the bony fragments prompt diagnosis and management logistic regression analysis interrogated for risk... Spikes may puncture the dural rent with a layer of fibrin glue was or... On postlaminectomy scar formation of epidural blood patch as treatment for a chronic pseudomeningocele LR. Gel electrophoresis and immunoblotting you may be noted master and perform and not be time-consuming! Lumbar spine surgery not rupture the arachnoid membrane, which contains CSF in the upright position of.

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