Incarceration of Spinal Nerve Root through Incidental Durotomy as a Cause of Sciatica

Incidental durotomies are a frequent complication during spinal surgery. Cerebrospinal fluid (CSF) leakage from a dural tear may be visually apparent intraoperatively, but occasionally, a tear may not be recognized during the procedure. We report our experience in 2 cases of postoperative incarceration of nerve root as a cause of sciatica, without CSF leakage intraoperatively. When durotomy attributable to surgical manipulation does occur, intraoperative identification is mandated. If a patient develops unexplainable postoperative pain and neurological deficits after lumbar discectomy, incarceration of nerve root should be considered in the differential diagnosis.

Incidental Dural Tears During Lumbar Spine Surgery: A Retrospective Case Study of 84 Degenerative Lumbar Spine Patients

STUDY DESIGN: A retrospective case study. PURPOSE: To retrospectively review all incidental dural tears (DTs) that occurred at a single institution, classify them anatomically and evaluate the clinical significance of each subgroup. OVERVIEW OF LITERATURE: Dural tears are considered the most commonly encountered complication during lumbar spine surgery. In contrast to the high frequency of DTs, reports on the characteristic location and mechanism are sparse. METHODS: We retrospectively retrieved all cases of degenerative lumbar spine surgery performed over a 9-year period and classified all identified DTs according to two independent planes. The coronal plane was divided into lower, middle and upper surgical fields, and the sagittal plane into posterior, lateral and ventral occurring tears. Demographic and clinical variables were retrieved and analyzed to search for significant associations. RESULTS: From 2003 to 2011, 1,235 cases of degenerative lumbar spine conditions were treated surgically at our institution. In 84 operations (6.8%), an incidental DT was either identified intraoperatively or suspected retrospectively. The most commonly involved location was the lower surgical field (n=39, 46.4%; p=0.002), followed equally by the middle and upper fields (n=16, 19%). In the sagittal plane, the most commonly involved locations were those in close proximity to the nerve root (n=35, 41.6%), followed by the dorsal aspect of the dural sac (n=24, 28.6%). None of the variables recorded was found to be associated with a particular location. CONCLUSIONS: In our series, incidental DTs were found to occur most commonly in the lower surgical field. We hypothesize that local anatomic feature, such as the lordotic and broadening lumbar dura, may play a role in the observed DT tendency to occur in the lower surgical field. In light of the high frequency and potentially substantial resulting morbidity of incidental DTs, a better characterization of its location and mechanism may optimize both prevention and management.

Incidental Dural Tear during Posterior Surgery of Degenerative Lumbar Disease / 대한척추외과학회지

STUDY DESIGN: A retrospective study. OBJECTIVE: To analyze the clinical features and prognosis of intraoperative incidental durotomy during posterior surgery for degenerative lumbar disease. In addition, we tried to evaluate clinical outcome and safety of skillful neglect of pin point dural tear. SUMMARY OF LITERATURE REVIEW : Incidental durotomy is one of the most common complications during the operation of degenerative lumbar disease. It may cause signs and symptoms of cerebrospinal fluid leakage and complications such as meningitis, wound infection, pseudomeningocele and fistula. From the literature review, primary repair is mandatory even in the case of pin point dural tear. MATERIALS AND METHODS: Seven hundred fifty-five patients with degenerative lumbar disease, who were operated posteriorly from Jan. 1990 to Feb. 2002, were reviewed retrospectively. Primary operations were 378 cases of laminectomy without instrumentation and 377 cases of decompression and instrumented fusion. Of these patients, 44 (6 percent) sustained an incidental dural tear. We analyzed the mechanisms of dural tear, intraoperative treatment, postoperative management and clinical outcome. RESULTS: Eight cases (2.1%) of dural tears occurred during discectomy, 36 (9.5%) during instrumentation and fusion, and 12 (20%) during revision surgery. Dural tears were treated intraoperatively by primary repair in 20 cases, by fascial graft in 2 and without repair (skillful neglect) in 22. There were no cases of persistent cerebrospinal fluid leakage or fistula formation, and the symptoms of cerebrospinal fluid leakage were transient. Of 36 patients followed for more than one year, 82% had good or excellent result. CONCLUSION: Incidental durotomy occurred in 5.8 percent of lower back surgery patients, and more frequently in revision surgery. Very small dural tears did not have significant influence on the clinical outcome, whether they were repaired or not. Skillful neglect of pin point dural tear may be a reasonable treatment option.