Dural Tears During Lumbar Spinal Endoscopy: Surgeon Skill, Training, Incidence, Risk Factors, and Management

Abstract

Background: Incidental dural tears during lumbar endoscopy can be challenging to manage. There is limited literature on their appropriate management, risk factors, and the clinical consequences of this typically uncommon complication.Materials and Methods: To improve the statistical power of studying durotomy with lumbar endoscopy, we performed a retrospective survey study among endoscopic spine surgeons by email and chat groups on social media networks, including WhatsApp and WeChat. Descriptive and correlative statistics were done on the surgeons' recorded responses to multiple-choice questions. Surgeons were asked about their clinical experience with spinal endoscopy, training background, the types of lumbar endoscopic decompression they perform by approach, the decompression instruments they use, and incidental durotomy incidence with routine lumbar endoscopy.Results: There were 689 dural tears in 64 470 lumbar endoscopies, resulting in an incidental durotomy incidence of 1.07%. Seventy percent of the durotomies were reported by 20.4% of the surgeons. Eliminating these 19 outlier surgeons yielded an adjusted durotomy rate of 0.32. Endoscopic stenosis decompression (54.8%; P , .0001), rather than endoscopic discectomy (44.1%; 41/93), was significantly more associated with durotomy. Medium-sized dural tears (1-10 mm) were the most common (52.2%; 48/93). Small pinhole durotomies (less than 1 mm) were the second most common type (46.7%; 43/93). Rootlet herniations were seen by 46.2% (43/93) of responding surgeons. The posterior dural sac injury during the interlaminar approach (57%; 53/93) occurred more frequently than traversing nerve-root injuries (31.2%) or anterior dural sac (23.7%; 22/93). Exiting nerve-root injuries (10.8%;10/93) were less common. Over half of surgeons did not attempt any repair or closure (52.2%; 47/90). Forty percent (36/90) used sealants. Only 7.8% (7/ 90) of surgeons attempted an endoscopic repair or sutures (11.1%; 10/90). DuralSeal was the most commonly used brand of commercially available sealant used (42.7%; 35/82). However, other sealants such as Tisseal (15.9%; 13/82), Evicel (2.4%2/82), and additional no-brand sealants (38; 32/82) were also used. Nearly half of the patients (48.3%; 43/ 89) were treated with 24-48 hours of bed rest. The majority of participating surgeons (64%; 57/89) reported that the long-term outcome was unaffected. Only 18% of surgeons reported having seen the development of a postoperative cerebrospinal fluid (CSF)-fistula (18%;16/89). However, the absolute incidence of CSF fistula was only 0.025% (16/ 64 470). Severe radiculopathy with dysesthesia; sensory loss; and motor weakness in association with an incidental durotomy were reported by 12.4% (11/89), 3.4% (3/89), and 2.2% (2/89) of surgeons, respectively.Conclusions: The incidence of dural tears with lumbar endoscopy is about 1%. The incidence of durotomy is higher with the use of power drills and the interlaminar approach. Stenosis decompression that typically requires the more aggressive use of these po...

Transforaminal Versus Interlaminar Endoscopic Lumbar Discectomy for Lumbar Disc Herniation: A Systematic Review and Meta-Analysis

“…Moreover, rates of recurrent disc herniation and dural tear did not significantly differ between both groups. The rates of dural tear following both techniques were relatively low (less than 3%), in accordance with a survey study by Lewandrowski et al, 34 but they reported a higher risk of dural tear in IELD than TELD due to the use of power tools or sharp instruments during ligamentum flavum resection and the fragile posterior dural sac exposure. However, we believe that surgeons’ learning curve significantly affected the complication rates.…”

Postoperative Intracranial Hemorrhage after an Endoscopic L5-S1 Laminectomy and Discectomy: A Case Report and Literature Review

“…Secondly, once durotomy occurs, alternative measures should be taken. Meaningful work has already been conducted to codify the workflow for dealing with durotomy [ 32 , 36 , 37 ]. Its management, mainly regarding whether the small size of the durotomy should be repaired or not, seems controversial.…”

Clinical Consequences of Incidental Durotomy during Full-Endoscopic Lumbar Decompression Surgery in Relation to Intraoperative Epidural Pressure Measurements

“…With the surgical volume rising, publications on the incidence and management of complications of endoscopic lumbar decompression procedures have appeared in print, alerting spinal surgeons interested in implementing these innovative minimally invasive surgeries into their program to their potential pitfalls [ 12 , 19 , 22 , 23 , 24 ]. While complication rates are generally lower than with traditional translaminar surgeries [ 24 ], interlaminar and transforaminal endoscopic decompression surgeries are associated with their specific sets of difficulties and postoperative sequelae that could catch the novice surgeon unfamiliar with these pitfalls off guard.…”

“…While complication rates are generally lower than with traditional translaminar surgeries [ 24 ], interlaminar and transforaminal endoscopic decompression surgeries are associated with their specific sets of difficulties and postoperative sequelae that could catch the novice surgeon unfamiliar with these pitfalls off guard. One such example relates to small dural tears that can easily be encountered in the posterior dural sac during the interlaminar approach or in the axilla formed between the exiting and traversing nerve roots during the transforaminal approach [ 22 ]. The latter is referred to as the hidden zone of Macnab because durotomies in this difficult-to-access and difficult-to-visualize area are most common and by far less common in any other portion of the epidural space.…”

“…A recent survey study among 97 spine surgeons suggested that durotomy rates are much higher among less experienced surgeons (1% to 10%) than the 0.1% rate previously reported by expert surgeons with thousands of cases of clinical experience. In that same study, some 70% of durotomies were reported by 20.4% of participating surgeons, and only 29% of surgeons had more than 10–15 years of clinical work experience [ 22 ]. In contrast, nearly half of the participating surgeons (49%) had only 1 to 5 years of experience with spinal endoscopy [ 22 ].…”