Traumatic Subarachnoid-Pleural Fistula with Pneumocephalus.

Traumatic subarachnoid-pleural fistula is an uncommon occurrence. We present a case of a patient sustaining a subarachnoid-pleural fistula after a gunshot wound to the neck, which ultimately resulted in substantial pneumocephalus. The patient underwent successful operative repair of the fistula with notable improvement and resolution of pneumocephalus.

GammaKnife radiosurgery for Fisch-classified jugulotympanic paragangliomas: Review of the measures and timing of treatment success.

Jugulotympanic paraganglioma (JTPG), a benign slow-growing neoplasm in the skull base with a tendency to be locally invasive, poses a treatment challenge because of its proximity to nearby neurovascular structures. The authors describe 11 patents with 12 Fisch-classified JTPGs treated with GammaKnife radiosurgery (GKRS) during a 12-year period. The observed rates of subjective improvement and tumor control were 80% and 83%, respectively. Among the individuals living longer than 5 years, tumor growth developed at 77 and 180 months after radiosurgery in two patients. Treatment-related toxicity or radiation oncogenesis was not observed. GKRS seems to be a valid treatment option for all Fisch designated skull base glomus tumors. Life-long follow-up of these patients is necessary.

Relapse of Psychosis Status Post Meningioma Resection.

A 53-year-old Caucasian female with a previous psychiatric history of bipolar I disorder and attention deficit hyperactivity disorder presented to the emergency department after endorsing 10-11 months of auditory and visual hallucinations, persecutory delusions, depression, anosmia, weakness of lower extremities, and headache. The patient described her auditory hallucinations as non-commanding voices talking to her about her family, her visual hallucinations as seeing "shadows and shapes," and her paranoid delusions as people coming after her. The patient had sustained a fall a week and a half earlier, requiring eight sutures to her posterior scalp. Her MRI of the brain showed a well-circumscribed 3.5 x 4.7 x 3.2 cm mass in the floor of the anterior cranial fossa. Computer tomography of the brain showed a 4.5 cm mass near the anterior interhemispheric fissure and edema in the right frontal cortex. Meningioma resection resulted in the cessation of hallucinations and delusions for one week. However, the patient was brought back to the emergency department because her auditory hallucinations and delusions returned. This case report demonstrates residual psychosis, even after frontal meningioma resection.

Investigating the efficacy of allograft cellular bone matrix for spinal fusion: a systematic review of the literature.

OBJECTIVE: The use of allograft cellular bone matrices (ACBMs) in spinal fusion has expanded rapidly over the last decade. Despite little objective data on its effectiveness, ACBM use has replaced the use of traditional autograft techniques, namely iliac crest bone graft (ICBG), in many centers. METHODS: In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review was conducted of the PubMed, Cochrane Library, Scopus, and Web of Science databases of English-language articles over the time period from January 2001 to December 2020 to objectively assess the effectiveness of ACBMs, with an emphasis on the level of industry involvement in the current body of literature. RESULTS: Limited animal studies (n = 5) demonstrate the efficacy of ACBMs in spinal fusion, with either equivalent or increased rates of fusion compared to autograft. Clinical human studies utilizing ACBMs as bone graft expanders or bone graft substitutes (n = 5 for the cervical spine and n = 8 for the lumbar spine) demonstrate the safety of ACBMs in spinal fusion, but fail to provide conclusive level I, II, or III evidence for its efficacy. Additionally, human studies are plagued with several limiting factors, such as small sample size, lack of prospective design, lack of randomization, absence of standardized assessment of fusion, and presence of industry support/relevant conflict of interest. CONCLUSIONS: There exist very few objective, unbiased human clinical studies demonstrating ACBM effectiveness or superiority in spinal fusion. Impartial, well-designed prospective studies are needed to offer evidence-based best practices to patients in this domain.

Spinal Fractures in Ankylosing Spondylitis: Patterns, Management, and Complications in the United States - Analysis of Latest Nationwide Inpatient Sample Data.

OBJECTIVE: Ankylosing spondylitis (AS) is a rheumatic inflammatory disease marked by chronic inflammation of the axial skeleton. This condition, particularly when severe, can lead to increased risk of vertebral fractures attributed to decreased ability of the stiffened spinal column to sustain normal loads. However, little focus has been placed on understanding the locations of spinal fractures and associated complications and assessing the correlation between these. In this review, we aim to summarize the complications and treatment patterns in the United States in AS patients with spinal fractures, using the latest Nationwide Inpatient Sample (NIS) database (2016-2018). METHODS: We analyzed the NIS data of years 2016-2018 to compare the fracture patterns and complications. RESULTS: A total of 5,385 patients were included. The mean age was 71.63 years (standard deviation [SD], 13.21), with male predominance (83.8%). The most common population is Whites (77.4%), followed by Hispanics (7.9%). The most common fracture level was thoracic level (58.3%), followed by cervical level (38%). Multiple fracture levels were found in 13.3% of the patients. Spinal cord injury (SCI) was associated with 15.8% of the patients. The cervical level had a higher proportion of SCI (26.5%), followed by thoracic level (9.2%). The mean Elixhauser comorbidity score was 4.82 (SD, 2.17). A total of 2,365 patients (43.9%) underwent surgical treatment for the fractures. The overall complication rate was 40.8%. Respiratory complications, including pneumonia and respiratory insufficiency, were the predominant complications in the overall cohort. Based on the regression analysis, there was no significant difference (p = 0.45) in the complication rates based on the levels. The presence of SCI increased the odds of having a complication by 2.164 times (95% confidence interval, 1.722-2.72; p ≤ 0.001), and an increase in Elixhauser comorbidity score predicted the complication and in-hospital mortality rate (p ≤ 0.001). CONCLUSION: AS patients with spinal fractures have higher postoperative complications than the general population. The most common fracture location was thoracic in our study, although it differs with few studies, with SCI occurring in 1/6th of the patients.

Chronic pain and substance abuse disorders: Preoperative assessment and optimization strategies.

There is an ever-increasing number of opioid users among chronic pain patients and safely managing them can be challenging for surgeons, anesthesiologists, pain experts, and addiction specialists. Healthcare providers must be familiar with phenomena typical of opioid users and abusers, including tolerance, physical dependence, hyperalgesia, and addiction. Insufficient pain management is very common in these patients. Patient-centered preoperative communication is integral to setting realistic expectations for postoperative pain, developing successful nonopioid analgesic regimens, minimizing opioid consumption during the postoperative period, and decreasing the number of opioid pills at the risk of diversion. Preoperative evaluation should identify comorbidities and identify risk factors for substance abuse and withdrawal. Intraoperative and postoperative strategies can ensure safe and effective pain management and minimize the potential for morbidity and mortality in this high-risk patient population.

Traumatic Atlantoaxial Dislocation without Neurologic Deficit.

Traumatic atlantoaxial dislocation without associated odontoid fracture or neurologic deficit is rare. We present the case of a 39-year-old male pedestrian who was struck by a vehicle and sustained a traumatic grade 4 C1-2 retrolisthesis. Closed reduction was successful, and the patient underwent posterior occipitocervical fusion. His neurologic status was good throughout the hospital stay, and he was discharged to a rehabilitation facility with full strength.

Value Proposition to a Hospital of Obtaining 36-inch Standing Scoliosis Film Technology.

Introduction Some hospitals do not have the technological capabilities of obtaining full 36-inch long-standing films to evaluate patients via proper sagittal balance spinal imaging protocol. Resistance from hospital administration for the purchase of proper hardware and software remains frustrating for spinal surgeons at both community and academic hospitals. Materials and methods Recurring transaction-based revenue streams were applied comparing cost with the different income generation at the hospital level. Cost is fixed cost, attributed to purchasing both the physical radiograph machine as well as the necessary software capabilities. Marginal cost was negligible as both materials and human capital are largely fungible and trivial at the margin. Revenue generation is largely identical to marginal revenue. Income was linked to the Hospital Outpatient Prospective Payment System for radiographic interpretation of films (Current Procedural Terminology (CPT) 72069). Income was also estimated from surgical volume calculation. Results The listed prospective outpatient radiographic reimbursement for the hospital was $24.36 per film. Medicare-defined reimbursements for a complex spinal fusion except cervical with spinal curvature, malignancy or 9+ fusions with a Major Complication or Comorbidity (MCC) was listed at $55,228, and with a Complication or Comorbidity (CC) was noted to be $40,566. Complex spinal fusion except cervical with spinal curvature, malignancy or 9+ fusions without CC/MCC was listed as $30,913. Lumbar spinal fusion except cervical with MCC was $39,164 and with CC was $23,490. University Neurosurgery at Louisiana State University (LSU) Health Sciences Center in Shreveport, LA performed 1,013 thoracolumbar procedures in fiscal year (FY) 2015 with 557 (54.9%) being instrumented procedures. At a minimum, all instrumented procedures could benefit from proper spinal axis imaging, representing $13,568.52 of transaction-based annual gross revenue from radiographs alone. Hypothetical revenue generation of $491,696.42 was calculated. Conclusion There is a significant value proposition to the hospital in obtaining the proper technology for formal standing 36-inch scoliosis imaging. Marginal cost is negligible, while there are significant opportunities for marginal revenue per image obtained through transaction-based gross revenue, as well an immense hypothetical revenue stream from surgery-related gains. More importantly, it ensures a proper and complete delivery of spinal health to the hospital's healthcare population.

A Cost-Effectiveness Analysis of the Integration of Robotic Spine Technology in Spine Surgery.

OBJECTIVE: We investigate the cost-effectiveness of adding robotic technology in spine surgery to an active neurosurgical practice. METHODS: The time of operative procedures, infection rates, revision rates, length of stay, and possible conversion of open to minimally invasive spine surgery (MIS) secondary to robotic image guidance technology were calculated using a combination of institution-specific and national data points. This cost matrix was subsequently applied to 1 year of elective clinical case volume at an academic practice with regard to payor mix, procedural mix, and procedural revenue. RESULTS: A total of 1,985 elective cases were analyzed over a 1-year period; of these, 557 thoracolumbar cases (28%) were analyzed. Fifty-eight (10.4%) were MIS fusions. Independent review determined an additional ~10% cases (50) to be candidates for MIS fusion. Furthermore, 41.4% patients had governmental insurance, while 58.6% had commercial insurance. The weighted average diagnosis-related group reimbursement for thoracolumbar procedures for the hospital system was calculated to be $25,057 for Medicare and $42,096 for commercial insurance. Time savings averaged 3.4 minutes per 1-level MIS procedure with robotic technology, resulting in annual savings of $5,713. Improved pedicle screw accuracy secondary to robotic technology would have resulted in 9.47 revisions being avoided, with cost savings of $314,661. Under appropriate payor mix components, robotic technology would have converted 31 Medicare and 18 commercial patients from open to MIS. This would have resulted in 140 fewer total hospital admission days ($251,860) and avoided 2.3 infections ($36,312). Robotic surgery resulted in immediate conservative savings estimate of $608,546 during a 1-year period at an academic center performing 557 elective thoracolumbar instrumentation cases. CONCLUSION: Application of robotic spine surgery is cost-effective, resulting in lesser revision surgery, lower infection rates, reduced length of stay, and shorter operative time. Further research is warranted, evaluating the financial impact of robotic spine surgery.

Minimally invasive spine surgery in the pediatric and adolescent population: A case series.

BACKGROUND: There is scant literature evaluating the indications, techniques, and outcomes of minimally invasive spine (MIS) surgery undertaken for pediatric and adolescent spine pathology. Our study attempts to evaluate the safe and effective use of MIS techniques in pediatric and adolescent patients and to appreciate the technical nuances of MIS surgery for this age group. METHODS: Consecutive pediatric and adolescent patients undergoing elective MIS lumbar procedures, from 2008 to 2016, were retrospectively analyzed from the practice of a single fellowship-trained academic spinal neurosurgeon. Information was retrieved regarding procedure and disease pathology. Descriptive data was obtained including age, sex, body mass index (BMI), insurance coverage, smoking status, and co-morbidities. Outcome measures were recorded including intraoperative complications, revision surgery, and return-to-function. RESULTS: Sixteen patients underwent 17 surgeries. The median BMI was 29.2 (range, 20.8-41.5). Age ranged from 12 to 19 years. Nearly 20% of the patients in our series were smokers. Most patients underwent discectomy, with L5-S1 being the most common level. One patient underwent direct pars defect repair and another underwent recurrent discectomy. More than 90% of the patients were complication-free at follow-up period of 6 months. One patient had a recurrent disc herniation and another had a superficial wound infection. Overall, 82.4% patients enjoyed full return to sports such as weight lifting, gymnastics, and contact sports. One patient required pain management to help alleviate ongoing pain. Another patient required a course of outpatient rehabilitation to help with a "foot drop." CONCLUSION: Our series illustrates the effective application of MIS techniques among carefully selected pediatric patients. Emphasis is on using a smaller (16 mm) tubular retractor and causing minimal disruption of paraspinal osseo-tendinous structures. MIS techniques can be successfully applied to the pediatric and adolescent age group.

Adolescent idiopathic scoliosis: risk factors for complications and the effect of hospital volume on outcomes.

OBJECTIVE Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. Limited literature exists defining risk factors associated with outcomes during initial hospitalization in these patients. In this study, the authors investigated patient demographics, clinical and hospital characteristics impacting short-term outcomes, and costs in adolescent patients undergoing surgical deformity correction for idiopathic scoliosis. Additionally, the authors elucidate the impact of hospital surgical volume on outcomes for these patients. METHODS Using the National Inpatient Sample database and appropriate International Classification of Diseases, 9th Revision codes, the authors identified adolescent patients (10-19 years of age) undergoing surgical deformity correction for idiopathic scoliosis during 2001-2014. For national estimates, appropriate weights provided by the Agency of Healthcare Research and Quality were used. Multivariable regression techniques were employed to assess the association of risk factors with discharge disposition, postsurgical neurological complications, length of hospital stay, and hospitalization costs. RESULTS Overall, 75,106 adolescent patients underwent surgical deformity correction. The rates of postsurgical complications were estimated at 0.9% for neurological issues, 2.8% for respiratory complications, 0.8% for cardiac complications, 0.4% for infections, 2.7% for gastrointestinal complications, 0.1% for venous thromboembolic events, and 0.1% for acute renal failure. Overall, patients stayed at the hospital for an average of 5.72 days (median 5 days) and on average incurred hospitalization costs estimated at $54,997 (median $47,909). As compared with patients at low-volume centers (≤ 50 operations/year), those undergoing surgical deformity correction at high-volume centers (> 50/year) had a significantly lower likelihood of an unfavorable discharge (discharge to rehabilitation) (OR 1.16, 95% CI 1.03-1.30, p = 0.016) and incurred lower costs (mean $33,462 vs $56,436, p < 0.001) but had a longer duration of stay (mean 6 vs 5.65 days, p = 0.002). In terms of neurological complications, no significant differences in the odds ratios were noted between high- and low-volume centers (OR 1.23, 95% CI 0.97-1.55, p = 0.091). CONCLUSIONS This study provides insight into the clinical characteristics of AIS patients and their postoperative outcomes following deformity correction as they relate to hospital volume. It provides information regarding independent risk factors for unfavorable discharge and neurological complications following surgery for AIS. The proposed estimates could be used as an adjunct to clinical judgment in presurgical planning, risk stratification, and cost containment.

Medicare payment data for spine reimbursement; important but flawed data for evaluating utilization of resources.

BACKGROUND: Medicare data showing physician-specific reimbursement for 2012 were recently made public in the mainstream media. Given the ongoing interest in containing healthcare costs, we analyze these data in the context of the delivery of spinal surgery. METHODS: Demographics of 206 leading surgeons were extracted including state, geographic area, residency training program, fellowship training, and academic affiliation. Using current procedural terminology (CPT) codes, information was evaluated regarding the number of lumbar laminectomies, lumbar fusions, add-on laminectomy levels, and anterior cervical fusions reimbursed by Medicare in 2012. RESULTS: In 2012 Medicare reimbursed the average neurosurgeon slightly more than an orthopedic surgeon for all procedures ($142,075 vs. $110,920), but this was not found to be statistically significant (P = 0.218). Orthopedic surgeons had a statistical trend illustrating increased reimbursement for lumbar fusions specifically, $1187 versus $1073 (P = 0.07). Fellowship trained spinal surgeons also, on average, received more from Medicare ($125,407 vs. $76,551), but again this was not statistically significant (P = 0.112). A surgeon in private practice, on average, was reimbursed $137,495 while their academic counterparts were reimbursed $103,144 (P = 0.127). Surgeons performing cervical fusions in the Centers for Disease Control West Region did receive statistically significantly less reimbursement for that procedure then those surgeons in other parts of the country (P = 0.015). Surgeons in the West were reimbursed on average $849 for CPT code 22,551 while those in the Midwest received $1475 per procedure. CONCLUSION: Medicare reimbursement data are fundamentally flawed in determining healthcare expenditure as it shows a bias toward delivery of care in specific patient demographics. However, neurosurgeons, not just policy makers, must take ownership to analyze, investigate, and interpret these data as it will affect healthcare reimbursement and delivery moving forward.

Placement of C1 Pedicle Screws Using Minimal Exposure: Radiographic, Clinical, and Literature Validation.

BACKGROUND: Traditional C1-2 fixation involves placement of C1 lateral mass screws. Evolving techniques have led to the placement of C1 pedicle screws to avoid exposure of the C1-C2 joint capsule. Our minimal dissection technique utilizes anatomical landmarks with isolated exposure of C2 and the inferior posterior arch of C1. We evaluate this procedure clinically and radiographically through a technical report. METHODS: Consecutive cases of cranial-vertebral junction surgery were reviewed for one fellowship trained spinal surgeon from 2008-2014. Information regarding sex, age, indication for surgery, private or public hospital, intra-operative complications, post-operative neurological deterioration, death, and failure of fusion was extracted. Measurement of pre-operative axial and sagittal CT scans were performed for C1 pedicle width and C1 posterior arch height respectively. RESULTS: 64 patients underwent posterior cranio-vertebral junction fixation surgery. 40 of these patients underwent occipital-cervical fusion procedures. 7/9 (77.8%) C1 instrumentation cases were from trauma with the remaining two (22.2%) from oncologic lesions. The average blood loss among isolated C1-C2 fixation was 160cc. 1/9 patients (11.1%) suffered pedicle breech requiring sub-laminar wiring at the C1 level. On radiographic measurement, the average height of the C1 posterior arch was noted at 4.3mm (range 3.8mm to 5.7mm). The average width of the C1 pedicle measured at 5.3mm (range 2.8 to 8.7mm). The patient with C1 pedicle screw failure had a pedicle width of 2.78mm on pre-operative axial CT imaging. CONCLUSION: Our study directly adds to the literature with level four evidence supporting a minimal dissection of C1 arch in the placement of C1 pedicle screws with both radiographic and clinical validation. CLINICAL RELEVANCE: Justification of this technique avoids C2 nerve root manipulation or sacrifice, reduces bleeding associated with the venous plexus, and leaves the third segment of the vertebral artery unexplored. Pre-operative review of imaging is critical in the placement of C1-C2 instrumentation.

Occipitocervical Fusion Surgery: Review of Operative Techniques and Results.

Objective Varying types of clinicoradiologic presentations at the craniovertebral junction (CVJ) influence the decision process for occipitocervical fusion (OCF) surgery. We discuss the operative techniques and decision-making process in OCF surgery based on our clinical experience and a literature review. Material and Methods A total of 49 consecutive patients who underwent OCF participated in the study. Sagittal computed tomography images were used to illustrate and measure radiologic parameters. We measured Wackenheim clivus baseline (WCB), clivus-canal angle (CCA), atlantodental distance (ADD), and Powers ratio (PR) in all the patients. Results Clinical improvement on Nurick grading was recorded in 36 patients. Patients with better preoperative status (Nurick grades 1-3) had better functional outcomes after the surgery (p = 0.077). Restoration of WCB, CCA, ADD, and PR parameters following the surgery was noted in 39.2%, 34.6%, 77.4%, and 63.3% of the patients, respectively. Complications included deep wound infections (n = 2), pseudoarthrosis (n = 2), and deaths (n = 4). Conclusion Conventional wire-based constructs are superseded by more rigid screw-based designs. Odontoidectomy is associated with a high incidence of perioperative complications. The advent of newer implants and reduction techniques around the CVJ has obviated the need for this procedure in most patients.

Complications of Anterior Cervical Fusion using a Low-dose Recombinant Human Bone Morphogenetic Protein-2.

OBJECTIVE: There are several reports, which documented a high incidence of complications following the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in anterior cervical fusions (ACFs). The objective of this study is to share our experience with low-dose rhBMP-2 in anterior cervical spine. METHODS: We performed a retrospective analysis of 197 patients who underwent anterior cervical fusion (ACF) with the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) during 2007-2012. A low-dose rhBMP-2 (0.7mg/level) sponge was placed exclusively within the cage. In 102 patients demineralized bone matrix (DBM) was filled around the BMP sponge. Incidence and severity of dysphagia was determined by 5 points SWAL-QOL scale. RESULTS: Two patients had prolonged hospitalization due to BMP unrelated causes. Following the discharge, 13.2%(n=26) patients developed dysphagia and 8.6%(n=17) patients complained of neck swelling. More than half of the patients (52.9%, n=9) with neck swelling also had associated dysphagia; however, only 2 of these patients necessitated readmission. Both of these patients responded well to the intravenous dexamethasone. The use of DBM did not affect the incidence and severity of complications (p>0.05). Clinico-radiological evidence of fusion was not observed in 2 patients. CONCLUSION: A low-dose rhBMP-2 in ACFs is not without risk. However, the incidence and severity of complications seem to be lower with low-dose BMP placed exclusively inside the cage. Packing DBM putty around the BMP sponge does not affect the safety profile of rhBMP-2 in ACFs.

Impact of elective versus emergent admission on perioperative complications and resource utilization in lumbar fusion.

BACKGROUND: The notion of higher complication rate and mortality in emergency surgeries is well established. There is a paucity of literature demonstrating the impact of emergent versus elective admissions for spinal surgery on the perioperative outcomes. We aim to evaluate the influence of the type of admission (elective or emergent) and day of surgery (same day versus other days within the emergent group) on the incidence, pattern of perioperative complications and hospital charges in the patients undergoing lumbar fusion for degenerative spine disease. METHODS: Data was obtained from the Nationwide Inpatient Sample (NIS) database between 2002 and 2011. We performed multivariate analysis to evaluate the impact of admission type and day of surgery on perioperative outcomes. RESULTS: A total of 266439 patients were identified. The majority of the admissions were elective (92.6%). Emergent admission comprised 7.4% of the total admission. Mean Charlson comorbidity index (CCI) was significantly higher in emergent and 'other days' (<0.001) groups. Emergent admission and surgery performed on the 'other days' were the independent risk factors for the higher incidence of the venous thromboembolic events, surgical site infection and wound dehiscence. The patients in the emergent and 'other days' surgery groups had a longer stay in the hospital (P<0.001). The mean total hospital charges were higher in the emergent admission and 'other days' surgery groups (P<0.001). CONCLUSIONS: 'Emergent admission' and surgery performed on the 'other days' in lumbar fusion are independent risk factors for the higher incidence of perioperative complications. Complicated hospital course and longer stay of the patients in the emergent admission and 'other days' group seems to be associated with higher total hospital charges.

Surgical Strategies in the Management of Spinal Nerve Sheath Tumors.

OBJECTIVES: Spinal nerve sheath tumors (SNSTs) are the most common lesions in the extramedullary intradural compartment. Complex and large lesions may pose technical difficulties for the operating surgeons. We discuss the management of SNSTs and technical issues including surgical approaches, spinal fixation, and dural handling with the goal of achieving good clinical outcomes while minimizing the risk of complications. We also propose a new classification for SNSTs to guide surgical treatment of these tumors. METHODS: A retrospective analysis was performed of 61 patients who underwent surgery for SNSTs during the period 1995-2012. The posterior approach was used for removal of most tumors (n = 53). Lesions having a substantial extraforaminal component were accessed from the anterior or lateral approach or a combined approach. Concomitant spinal fixation and fusion was performed in 7 patients. RESULTS: Most of the patients (n = 53) had clinical improvement; clinical status was the same in 4 patients and worse in the remaining 4 patients. One or more complications developed in 18 patients (29.5%). Recurrence was the most common complication (n = 7). Death occurred in 2 patients with malignant peripheral nerve sheath tumors 12 and 8 months, respectively, after surgical resection. CONCLUSIONS: Lesions with large extraforaminal extension pose technical difficulty. Spinal fixation with fusion should be supplemented whenever necessary. Complications related to dura mater may be associated with significant morbidity, and all possible efforts should be made to prevent them.