====== Unintended durotomy ======

Unintentional opening of the [[dura]] during [[spinal surgery]] has an incidence of 0.3–13% (risk increases to ≈ 18% in redo operations)
((Goodkin R, Laska LL. Unintended 'Incidental' Durotomy During Surgery of the Lumbar Spine: Medicolegal Implications. Surg Neurol. 1995; 43:4-14)).

Terminology: The terms “unintended durotomy,” “[[incidental durotomy]],” or even just “[[dural opening]],” have been recommended in preference to “[[dural tear]]” which may imply carelessness.
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[[Cerebrospinal fluid fistula]] is a common [[complication]] of surgery involving the lumbar spine. 

Cerebrospinal fluid fistula can be troublesome, leading to [[pseudomeningocele,]] cutaneous [[cerebrospinal fluid fistula]], and [[meningitis]]. [[Revision surgery]] is unavoidable in some cases. 

===== Etiology =====
Potential causes are many, and include:
((Goodkin R, Laska LL. Unintended 'Incidental' Durotomy During Surgery of the Lumbar Spine: Medicolegal Implications. Surg Neurol. 1995; 43:4-14))

unanticipated anatomic variations, adhesion of the [[dura]] to removed bone, [[slippage]] of an [[instrument]], an obscured fold of dura caught in a rongeur or curette, thinning of the dura in cases of longstanding [[stenosis]], and the possibility of a delayed [[CSF leak]] caused by perforation of the dura when it expands onto a surgically created spicule of bone
((Horwitz NH, Rizzoli HV, Horwitz NH, et al. Herniated Intervertebral Discs and Spinal Stenosis. In: Postoperative Complications of Extracranial Neurological Surgery. Baltimore: Williams and Wilkins; 1987:1–72)).
The risk may be increased with anterior decompression for OPLL, with revision surgery, and with the use of high-speed drills
((Hodges SD, Humphreys C, Eck JC, et al. Management of Incidental Durotomy Without Mandatory Bed Rest. Spine. 1999; 24:2062–2064)).
====Risk factors====
523 patients who underwent lumbar and thoracolumbar spine surgery, were compared in whom a dural tear occurred with data from patients who did not experience durotomy. The data included basic demographic information, intraoperative data, and clinical information from a medical record review. 

131 patients underwent discectomy and 392 patients underwent laminectomy. Among the 131 patients who underwent discectomy 6 patients had a dural tear. Among the 392 patients who underwent laminectomy 49 patients had dural tear. Patients with incidental durotomy were older (mean 65 ± 13 vs 60 ± 14 years of age; p = 0.044, t-test), and had longer surgery (146 ± 59 vs 110 ± 54 minutes; p = 0.025, t-test), compared with the patients without dural tear. The incidence of dural tear was more common in patients with a history of previous spine surgery (p < 0.001).

In patients who underwent lumbar and thoracolumbar spine surgery for degenerative problems, previous surgery and older age were found to be predisposing factors for dural tear
((Smorgick Y, Baker KC, Herkowitz H, Montgomery D, Badve SA, Bachison C,
Ericksen S, Fischgrund JS. Predisposing factors for dural tear in patients
undergoing lumbar spine surgery. J Neurosurg Spine. 2015 Feb 20:1-4. [Epub ahead 
of print] PubMed PMID: 25700240.
)).

====Open Versus Tubular Revision Microdiscectomy====
The incidence of durotomy and postoperative CSF fistula in lumbar revision microdiscectomy does not significantly differ between minimal access and standard open procedures. 
====Prevention====
Usage of a polyethylene glycol (PEG) sealant in combination with standard closure techniques has been shown to be effective in preventing Cerebrospinal fluid fistulas in animal models and adult patients, but the results of its use have not been reported in the pediatric population. 

Results of a study indicated no benefit of prolonged flat [[bed rest]] (BR), after an adequately repaired [[incidental durotomy]] in [[lumbar spine surgery]]
((Farshad M, Aichmair A, Wanivenhaus F, Betz M, Spirig J, Bauer DE. No benefit
of early versus late ambulation after incidental durotomy in lumbar spine
surgery: a randomized controlled trial. Eur Spine J. 2019 Sep 24. doi:
10.1007/s00586-019-06144-5. [Epub ahead of print] PubMed PMID: 31552537.
)).

===== Treatment =====

[[Unintended durotomy treatment]].

===== Outcome =====
It can lead to significant patient [[morbidity]] and [[mortality]], including [[meningitis]] and even [[death]].

The impact of durotomy on long-term outcomes remains a matter of debate. 
In the [[Spine Patient Outcomes Research Trial]] (SPORT), during first-time [[lumbar laminectomy]] for [[lumbar spinal stenosis]] did not impact long-term outcomes in affected patients
((Desai A, Ball PA, Bekelis K, Lurie J, Mirza SK, Tosteson TD, Weinstein JN.
SPORT: Does Incidental Durotomy Affect Longterm Outcomes in Cases of Spinal
Stenosis? Neurosurgery. 2015 Mar;76 Suppl 1:S57-63. doi:
10.1227/01.neu.0000462078.58454.f4. PubMed PMID: 25692369.
)).

===== Case series =====

[[Unintended durotomy case series]].

===== References =====