Dural tear

Dural tear is a known complication of spinal surgeries, such as laminectomies, spinal fusions, and disc excisions. It most commonly occurs in the lumbar region.

In general, the tear is noted at the time of operation when leakage of cerebrospinal fluid (CSF) is noted by the surgeon. 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.

Dural tears that are not noted at the time of surgery often present in the postoperative period. Patients manifest severe headaches that are exacerbated by upright posture.

In addition, CSF can be seen leaking from the wound, or a subcutaneous collection may be noted. Confirmation that the fluid is CSF can be gained by testing the fluid for beta-2 transferrin.

What to Do

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.

Otherwise, the patient is at risk for the development of pseudomeningocele and meningitis. Once the condition is identified, the patient should be kept flat to minimize symptoms. The goal of the repair is to achieve a watertight closure.

The dural tear should be repaired using 4-0 or 6-0 dural suture with a tapered or reverse cutting needle. The closure can be accomplished with simple interrupted or running locking suture technique.

If the tear is too large for primary repair, then a free graft or fascial graft can be used to repair the dural tear. The repair should be tested by placing the patient in reverse Trendelenburg position or via a Valsalva maneuver.

If the leakage of CSF persists, then the repair can be augmented with fibrin glue, additional suture, gelatin sponge, or autologous fat. Once complete, the paraspinous muscles and the fascia should be closed in two layers. The fascial layer is responsible for preventing durocutaneous fistulae.

A drain should not be left behind, as the negative pressure created may encourage a persistent leak. After repair of a dural tear, all patients should remain on bed rest in the supine position for 24 to 48 hours.

Suggested Readings

Browner B, ed. Skeletal Trauma: Basic Science, Management, and Reconstruction. 3rd ed. Philadelphia: WB Saunders; 2003:937.

Canale ST, ed. Campbell’s Operative Orthopaedics. 10th ed. Philadelphia: Mosby; 2003.

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