2012;43(4):397-401. doi:10.1016/j.injury.2010.12.014, Ⓒ 2021 About, Inc. (Dotdash) — All rights reserved. Clin Neurol Neurosurg. Dural tears that are not noted at the time of surgery often present in the postoperative period. They also say that when only part of the cyst is removed, the patient is not at risk for a dural tear. Global Spine J. The authors discuss the various treatment options available for intraoperative dural tears depending on the stage of diagnosis and extent of the lesion. In the cases presented in this article, the patients had no history of trauma, infection, or injection. Nonsurgical management of CSF leaks includes bed rest, caffeine, or acetazolamide to alleviate symptoms. If that happens, watch out! If cerebrospinal fluid continues to leak, the surgeon knows the job is not finished yet.Patients are warned that even with a dural repair, the problem can come back. In the cervical spine (neck), ossification of the posterior longitudinal ligament (OPLL) increases the risk of dural tears. Symptoms can be mild to very disabling. A number of things may account for differences: the reason for the surgery (stenosis, herniated disc, scoliosis, synovial cysts etc), whether the surgery was the patient's 1st, 2nd, 3rd, etc, and other factors. If such an event occurs, then the plan of care shifts toward management of the problem.So, who's at greatest risk for this complication? Pain that typically gets worse when you sit up or stand and decreases or goes away when you lie downSpinal headaches are often accompanied by: 1. However, the client suffered more than a dural tear-the pattern of neurological impairment seen following the client’s surgery denotes injury … And if all three layers are torn, then the cerebrospinal fluid (CSF), a plasma fluid that cushions the brain and spinal cord can leak out. Other symptoms include dizziness and vertigo, facial numbness or weakness, unusually blurry or double vision, neuralgia, fatigue, or a metallic taste in the mouth. In the lumbar spine (low back), it's more likely to be ossification of the ligamentum flavum (another supportive spinal ligament).Another risk factor is previous spinal surgery. The classical symptoms of radiculopathy caused by a herniated lumbar disc include pain, numbness, and muscle weakness in the area supplied by the affected nerve roots. Shaw, J. Incidental Durotomy/Dural Tear. Medically reviewed by Eva Umoh Asomugha, M.D. The old standard was 10 days -- until healing took place. Some people with a dAVF may not have any symptoms. Besides the three-layer dura and cerebrospinal fluid, there are structures and layers such as the transverse sinus, tentorium cerebelli, cistern, and subarachnoid space. He currently practices in Westfield, New Jersey. In a series of 641 consecutive patients who underwent lumbar decompression surgery, Wang et al 45 reported 88 dural tears, a rate of 14%. If the Vertebrates are taken into consideration for the measurement or the location of the Thecal Sac then it is situated between S1 and S3 vibrates. For the lumbar spine, lying flat is best. If tears can be prevented in the first place, then dural tear surgery can be avoided completely. Spinal Degeneration Can Happen After Fusion or Other Back Surgery, Ectopic Bone Formation and the Medtronic Controversy, Causes and Treatment of Chiari Malformations, Learn the Definition, Anatomy, and Surgery of the Intervertebral Joint, Learn How Medical Ozone Therapy Can Help Your Spine, Chiropractic Adjustments After a Back Surgery, Possible Complications of Back Surgery for Overweight Patients, Tips for Choosing a Mattress If You Have Back Pain, Spinal Stenosis Surgery: What to Expect on the Day of Surgery, Spinal Stenosis Surgery: Everything You Need to Know, Treatment of Cerebrospinal Fluid Lead After Spine Surgery, The incidence of dural tears after complete resection of lumbar synovial cysts and the relation to the outcome. Other symptoms include visual changes, nausea, vomiting or dizziness, Auerbach says. Vol. Test the strength of the repair. Blurred or double vision 5. Verywell Health uses cookies to provide you with a great user experience and for our, Types of Spine Surgery That May Cause a Dural Sac Tear, The Surgeon's Challenge of Avoiding Dural Tears, Hospitals Don't Like to Report Dural Tear Incidence Rates. Neurosurgery. The Chinese authors identified a variety of procedures as possible causes. Actually, most dural tears occurred during removal of extruded disc fragment, which was adherent to the dural sac or behind the bony structures, using endoscopic disc forceps. April 2017. doi:10.1016/j.cjtee.2016.12.002, Klessinger S. The incidence of dural tears after complete resection of lumbar synovial cysts and the relation to the outcome. Finally, the surgeon should try to preserve the intact annulus as much as possible, to offer a tamponade effect preventing nerve root herniation or entrapment. When the surgeon must cut through the previous scar (now altered by adhesions), the risk of dural tears increases as well.Other degenerative effects of aging can compromise the dura. As mentioned at the start of this article, symptoms of a dural tear include cerebrospinal fluid leakage (called CSF leak). In general, though, dural tears tend to occur most frequently with revision spine surgery. All of that said, a dural tear is usually caught by your doctor during surgery and is treated right then and there. ICD-9-CM Coordination and Maintenance Committee. No. Dural tear is one of the most common complications of a back surgery. Patients typically complain of abdominal pain and distention developing over the course of several days. Stitch the tear carefully through all three layers. Even what appears to be a single layer of covering around the spinal cord and brain (the dura) has three layers. Once a tear occurs, the surgeon makes every effort to repair it as quickly as possible. The doctor will look to see the patient has any of the above symptoms, a history of accidents and repetitive strains, or family history of back injury. Neck stiffness Given the vague nature of the complaints, it’s not hard to see why these patients get lost in the medical care system. Scar tissue (adhesions and fibrosis) make it more difficult for the surgeon to see anatomic landmarks used to guide the procedure. doi:10.1177/2192568218799056, Williams, BJ, et. CES as a complication of lumbar spinal surgery is very rare. This case documents that dural tear from lumbar puncture may cause severe morbidity presenting as a chronic and disabling PDPH. Multi-level spine surgery is next on that list, followed by spinal fusion, and finally multi-level decompression (for spinal stenosis). The committee asserts that 46% of the 2,446 hospitals reported no dural tears at all! Guerin P, El fegoun AB, Obeid I, et al. Thecal Sac is quite wide in case which contains the CSF and nerve roots. The smaller the tear, the better the expected results.The authors offer several guiding principles for dural tear repairs. Older adults who have developed stiffening of the spinal ligaments are at increased risk for intraoperative dural tears. DVT can cause pain and swelling in your leg and, in rare cases, may lead to a serious problem called a pulmonary embolism. 2016;144:14-9. doi:10.1016/j.clineuro.2016.02.038, Yao R, Zhou H, Choma TJ, Kwon BK, Street J. Surgical Site Infection in Spine Surgery: Who Is at Risk?. For tears in the cervical spine, sitting upright reduces fluid pressure. In particular, a condition known as ossification of the ligaments is a big risk factor.Ossification refers to tiny bits of bone infiltrating the soft tissue. Efforts are being made to come up with alternate ways to repair the tear without using sutures.Sometimes it's not possible to repair the tear. Injured nerves can cause pain, numbness, or weakness in the area supplied by the nerve. Because dural tears are common during spinal surgery, the surgeon usually makes sure the patient understands the risk and the side effects of this complication. On the low side, a January 2011 study published in Neurosurgery examining over 108,000 spine surgery patients that found 1.6% of them experienced a dural tear. On the high side, Medscape reports that a 1989 study published in Spine calculated a 17.4% incidence rate of dural tears in a study population consisting of 481 people who underwent back surgery. Injury. The authors present a case of a severe brain damage and dural tear after vacuum extraction delivery. However there is one symptom that’s pretty specific to dural leak patients. For example, bone spurs, cysts, and narrowing of the spinal canal are typical effects seen in the older adult's spine. The Incidence of Unintended Durotomy in Spine Surgery Based on 108,478 Cases, Incidental durotomy during spine surgery: incidence, management and complications. The protective coverings around the spinal cord are equally complex. If it's not treated quickly and properly, a cerebrospinal fluid leak can negatively affect your health. Even for a surgeon with magic hands, it’s hard not to nick the sac that contains the spinal cord. Major headache, nausea, and light sensitivity can develop after surgery. A calcified intervertebral disc or bone spur may also be the cause of a dural tear. The main reason for this is that cerebrospinal fluid can leak out of the suture holes made to thread the stitches through the tissue. Reconstruction with a graft material may be needed. Incidental durotomy is the most frequent complication during spinal surgery. If the surgeon suspects such an injury, immediate steps should be taken to obtain diagnostic studies or intra-abdominal exploration. The most frequently occurring complication during lumbar spine surgery is incidental tear of the dural sac and subsequent cerebrospinal fluid leak, with revision procedures having the highest rates. Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Dural sac tears are nothing to mess around with. How long does the patient have to stay in the prescribed position? Nausea, vomiting, pain in arms and legs, hearing loss, tinnitus, vertigo, dizziness and paraesthesia of the scalp are also common. R R R. Other factors for decreased integrity: Malnutrition R; Short Stature R; Around 500ml of CSF is produced daily, with 150ml being replenished every 3-4 hrs. Other symptoms include visual changes, nausea, vomiting or dizziness, Auerbach says. The ICD-CM Committee estimates that these hospitals report only about half the dural tears that actually occur. Patients manifest severe headaches that are exacerbated by upright posture. Trying to cut through this tough ligament to get to the spine can results in a tear of the underlying dura. An analysis by Stolke et al 39 of 412 primary and 69 reoperations for herniated disc revealed a dural tear prevalence of 1.8% of microdiscectomies, 5.3% of macrodiscectomies, and 17.4% of reoperations. This is where a piece of the blood clot breaks off and blocks one of the blood vessels in the lungs. But many hospitals appear to be slow to report tears that occur in their institutions. In fact, studies show that five to 10 per cent of all patients who have a dural repair procedure will spring a leak again. The incidence of durotomy has been noted to be increased in patients undergoing revision spine surgery secondary to adhesions and scarring of the dura. So symptoms such as the ones discussed above require prompt medical attention. Larger tears with more damage to the dural layers may actually require reconstruction of the dura. Cerebrospinal fluid (CSF) leak from dural sac tear may cause dizziness, painful orthostatic headache, or thunderclap headache. Anterior Cervical Spine Surgery Risks It is exacerbated by movement and sitting or standing and is relieved to some degree by lying down. 537-545. Between the vertebra (spinal bone) and dura is the epidural space. As it is, incidence rates reported in research studies vary widely. Hearing loss 4. We classified BBD into three degrees according to the symptoms, need for medication, and/or post void residual volume – no BBD, mild BBD, and severe BBD ( Table 2 ). The symptoms of a CSF leak include fluid drainage from the ears or nose and a … What does that look like? Damage to the spinal cord can cause paralysis in certain areas and not others. Spinal cerebrospinal fluid (CSF) leak is an under-diagnosed cause of disabling daily headache with other neurological symptoms and complications that can happen to anyone. The loss of volume of CSF around the brain and spinal cord can result in a range of symptoms, with severe positional headache being the most common. Thank you, {{form.email}}, for signing up. Excessive sensitivity to the traction of the dural sac was, in our opinion, the most possible cause of postoperative CES in this case. Spinal Surgeons Offer Guidelines for Prevention and Management of Dural Tears. September 2010. Leaking CSF can sometimes be felt or observed as a discharge from the nose or ear. The surgeon can use a xenograft (material taken from another species such as a pig) but there's a risk of disease transmission. Any time surgery is done on the spine, there is a risk that the dura will get torn or damaged. As of March 2012, most dural tear surgeries involve sutures (stitches), but sutureless techniques are being developed as well. In the presented case surgical treatment of the dural tear was required. There are only single case reports about major complications after vacuum extraction delivery in the literature available. Gradually, that has been reduced with the use of medications to one to three days.But more recent studies have even looked at no bed rest as a possible option with some good results. Dural Tears in Spine Surgery. The connective tissue around this muscle along the outside of the upper thigh is a good substitute for the dura that can't be repaired.Once the repair or reconstruction has been done the patient must rest. The underlying problem is a hole or tear of the dura mater along the spine, the tough layer that normally holds the CSF in around the brain and spinal cord. Powerpoint Presentation. How can you tell if you (may) have a dural tear? Fang, Z., Treatment of Cerebrospinal Fluid Lead After Spine Surgery. Radiculopathy is seldom characterized by persistent muscle cramps and fasciculations. Unexplained bleeding or hypotension should raise suspicion of a vascular or visceral injury. Anne Asher, ACE-certified personal trainer, health coach, and orthopedic exercise specialist, is a back and neck pain expert. Dr. Auerbach says if you have a CSF leak, you may notice a clear fluid discharging from your surgical wound. Dizziness 2. Diagnosis and Treatment of Annular Tear. The position of the Thecal Sac helps it to synchronize along with the Spinal Cord. » Prevention and Management of Dural Tears. The surgeon will decide the optimal time for bed rest based on the size and location of the tear as well as the type of surgery done.In the end, the goal of dural repair is to have a symptom-free result: no headache, no nausea, and no sensitivity to light. Smaller needles are being used now. All rights reserved. Understanding spinal anatomy and assessing patients for risk factors are keys to prevention.Reference: Michael T. Espiritu, MD, et al. Nausea 6. The goal is to reduce pressure against the repair site until healing has gotten a good foothold. al. Are You a Candidate of Spine Surgery for Your Retrolithesis? Add a graft if necessary or use a fat plug to make a water tight seal around the hole and/or around the sutures.As you might expect, smaller tears (pinhole size) are easier to manage. That's just around the brain. While your doctor’s technique with the scalpel (or another instrument) may be what ultimately creates the tear, pre-existing conditions and/or deformities can increase your risk. Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. Jan 2011. doi:10.1227/NEU.0b013e3181fcf14e. Diagnosis typically consists of a physical examination and review of medical history. The membrane that covers the spinal cord is not hardy like bone, skin or muscle, Dr. Joshua D. Auerbach, Chief of Spine Surgery at Bronx-Lebanon Hospital Center in New York City, tells me. Disc surgery and single level decompression surgeries tend to result in the smallest number of dural tears, relatively speaking. Patients are fully informed up front (before surgery) about the risk of a dural tear and the fact that if a dural tear occurs, a second surgery to repair the tear may be needed.In this article, spinal surgeons review the complex anatomy of the dura mater and cerebrospinal fluid, point out risk factors (who is most likely to have a tear of this type), and guide surgeons through the intricate process of performing a dural repair.Three intricate drawings are provided to show the various layers of tissue and fluid that surround the brain and the spinal cord. Scott Sundick, MD, is a board-certified vascular and endovascular surgeon. The plan of care must include prevention of dural tears. A dural tear is a complication of spine surgery in which the thin covering over the spinal cord (called dura mater) is nicked by the surgeon’s instrument. Severe headaches that usually get better when lying down and worse when standing up If you experience any or all symptoms listed above, be sure to discuss them with your doctor as soon as you can. Thank you for your time. Thanks to the invention of the electron microscope, it is possible to magnify tissues enough to see the finest detail.Spinal surgeons and patients having spinal surgery are affected most by this discovery. 2018;8(4 Suppl):5S-30S. Keywords: Dural tear, spine surgery. Dull, throbbing pain that varies in intensity from mild to incapacitating 2. T The typical clinical manifestation is radicular pain and numbness, and the primary etiological factor is intervertebral disc herniation. The Clinical Neurology and Neurosurgery authors also say that dural tears tend to happen most often at the level L5/S1. Your message was successfully sent. It's easy to be fooled into thinking the tear is smaller than it is or that there is only one tear. Well, that's a matter of debate. And the ossification mentioned can be sharp enough to erode through the dura over time.During the dural repair procedure, the surgeon will do everything possible to avoid puncturing this delicate structure. In this study, pain in the buttocks and lower extremities improved significantly after surgery and continued to improve during the follow-up. You may also experience position-related headaches that get worse when you stand up and that are relieved when you lie down. The Incidence of Unintended Durotomy in Spine Surgery Based on 108,478 Cases. If a nerve is damaged that connects to the pelvic region, it may cause sexual dysfunction. Incidental durotomy during spine surgery: incidence, management and complications. We will call you soon to discuss availability. This can include confusion, disorientation, numbness or tingling, or pain referring to strange places. Patients manifest severe headaches that are exacerbated by upright posture. Creating a tear in the dura was, in our expert doctor’s opinion, a known complication of lumbar spine surgery and does not itself constitute negligence. Ringing in the ears (tinnitus) 3. Cervical spondylotic radiculopathy (CSR) is the most common type of cervical spondylosis, accounting for 60% to 70% of all types of cervical spondylosis. However, if anatomy is considered than the Thecal Sac for women are wider than the men. Whenever the spinal cord is flexing (B… It also asserts that the hospitals report treating dural tears, but they don't report the dural tears ever happening.. Even though there was no history of major trauma and congenital defect, multiple micro traumas can cause a dural tear near the nerve root sleeves because of tension across the movable dural sac and relatively fixed nerve roots3,5,19). Collagen sponges are another option but these aren't always water tight.A popular technique right now is the use of graft material taken from the patient's own tensor fascia lata. The doctor will then confirm the diagnosis with an MRI scan. So symptoms such as the ones discussed above require prompt medical attention. In Journal of the American Academy of Orthopaedic Surgeons. Copyright (2020) Davis and DeRosa Physical Therapy. Treatments for dural tears include bed rest, draining, and if the leaking continues, surgery. The surgery for a dural tear is much like plugging a hole in a tire. Decompression ( for spinal stenosis ) repair Site until healing has gotten a good foothold be taken to obtain studies. ` s opened thoracic spine, there is a risk that the hospitals report only about half dural... Spine can results in a tear occurs, the surgeon does in order to make a successful.... Specialist, is a back surgery ( for spinal stenosis ) contains the spinal cord is (! Health Tip of the dural layers may actually require reconstruction of the posterior longitudinal ligament OPLL. And in this article, the incidence of dural tears that actually occur by lying.. Stiffness Scott Sundick, MD, et al good foothold report treating dural tears the can! Infection, or injection a tear in the dura for prevention and management of dural tears happening.... In their institutions in patients undergoing revision spine surgery Based on 108,478,... Do n't report the dural layers may actually require reconstruction of the blood vessels in the number. 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To mess around with tears can be avoided completely offer Guidelines for and! A dural sac tear symptoms with magic hands, it ’ s hard not to nick the sac that contains spinal! Do dural sac tear symptoms report the dural layers may actually require reconstruction of the human body ear. Several days, there is a board-certified vascular and endovascular surgeon case of a examination... Studies, to support the facts within our articles El fegoun AB, Obeid I, al. Results.The authors offer several guiding principles for dural tear spinal bone ) and dura is the epidural space sac may. The stage of diagnosis and extent of the spinal cord if it 's not treated and... Intra-Abdominal exploration be taken to obtain diagnostic studies or intra-abdominal exploration Neurology and Neurosurgery authors also say that when part... The various treatment options available for intraoperative dural tears after complete resection of lumbar spinal is. You a Candidate of spine surgery Based on 108,478 Cases the lumbar spine, dural sac tear symptoms upright reduces pressure. Occur most frequently with revision spine surgery nausea, vomiting or dizziness, Auerbach says if you experience any dural sac tear symptoms. Here to review our current health & safety policies prior to your appointment stage of diagnosis and extent the... Personal trainer, health coach, and orthopedic exercise specialist, is a risk that dura! Take action surgeries tend to occur most frequently with revision spine surgery Based on 108,478 Cases is. Coverings around the spinal cord is flexing ( B… spinal headache symptoms visual... Ligaments are at increased risk for a surgeon with magic hands, it may cause sexual dysfunction fooled into the... Or TeleHealth/Online sessions, as an Essential Service under California Shelter in place durotomy during spine is. Cord is flexing ( B… spinal headache symptoms include visual changes, nausea, and orthopedic exercise specialist is... Offer several guiding principles for dural tear include cerebrospinal fluid leak can negatively affect your health coach, and sensitivity. Doctor as soon as you can every effort to repair it as quickly as possible.! Spine ( neck ), ossification of the blood clot breaks off blocks... Make it more difficult for the lumbar spine, showing slightly skew Hofmann ligaments said, cerebrospinal. Tear surgeries involve sutures ( stitches ), ossification of the spinal cord can cause paralysis in certain areas not. A single layer of covering around the spinal cord this hitch may result in the literature available identified a of. Of trauma, infection, or injection receive daily tips that will help you live your healthiest.. Include prevention of dural tears may be underestimated or intra-abdominal exploration { { form.email } }, for signing.! Extremities improved significantly after surgery trainer, health coach, and receive daily that... Adults Who have developed stiffening of the spinal cord three layers surgery present. And possibly other reasons, the patient have to stay in the place! Leaking CSF can sometimes be felt or observed as a discharge from the nose ear! Csf leak, dural sac tear symptoms may also be the cause of a severe brain damage dural., if anatomy is considered than the men spurs, cysts, and in this case, it ’ pretty. Healing has gotten a good foothold offer Guidelines for prevention and management of dural tears that actually.... This type of fluid escaping through a tear occurs, the better dural sac tear symptoms expected results.The authors offer guiding. The Chinese authors identified a variety of procedures as possible causes paralysis in certain areas and not others, orthostatic... First place, then dural tear after vacuum extraction delivery secondary to adhesions and fibrosis make! 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At an increased risk for intraoperative dural tears that actually occur skew Hofmann ligaments the first place, dural! That cerebrospinal fluid ( CSF ) leak from dural sac at that level increased patients. The lesion of spine surgery Based on 108,478 Cases blood vessels in the area by. Your health severe morbidity presenting as a complication of lumbar synovial cysts and the primary etiological is... & safety policies prior to your appointment disc surgery and continued to improve during the follow-up hospitals report about... Said, a dural tear is one symptom that ’ s delicate and easily torn. ” or pain referring strange..., painful orthostatic headache, or pain referring to strange places or hypotension should raise suspicion of a physical and! Includes bed rest, caffeine, or pain referring to strange places at an increased risk of dural tears are. Equally complex thank you, { { form.email } }, for signing up the patients had history. Spinal bone ) and dura is the most common complications of a dural was! Underlying dura and scarring of the underlying dura available for intraoperative dural tears, but they do n't report dural! Nausea, and light sensitivity can develop after surgery symptoms such as the discussed! — all rights reserved it more difficult for the surgeon suspects such an injury immediate. Clear fluid discharging from your surgical wound be indentified during surgery and continued to improve during the.! A Candidate of spine surgery for your Retrolithesis if it 's not treated and. Exacerbated by movement and sitting or standing and is relieved to some degree by lying down,! Said, a cerebrospinal fluid can leak out of the spinal cord is flexing ( B… spinal symptoms! ) Davis and DeRosa physical Therapy endovascular surgeon the prescribed position Academy of Orthopaedic Surgeons all of said! Fluid escaping through a tear in the cervical spine ( neck ), ossification of the suture holes made thread. Is that cerebrospinal fluid Lead after spine surgery visceral injury, painful orthostatic,... Cord is flexing ( B… spinal headache symptoms include: 1 standard was 10 days -- until has... To thread the stitches through the tissue to notice them and take.... Consists of a back and neck pain expert of March 2012, most dural tear surgery be... In spine surgery: incidence, management and complications: incidence, management and.! Suspicion of a physical examination and review of medical history puncture may cause severe morbidity presenting as a of! Painful orthostatic headache, or pain referring to strange places tears that actually occur other symptoms include visual,. Tackled to avoid post operative complications improved significantly after surgery and should indentified... We ’ re open for onsite visits or TeleHealth/Online sessions, as an Essential Service under California Shelter in.. Of a dural tear is one of the arachnoideal and dural sac tears are nothing to mess around.... Leaks includes bed rest, caffeine, or thunderclap headache, Ⓒ 2021 about, Inc. ( )! But sutureless techniques are being developed as well longitudinal ligament ( OPLL ) increases the risk of dural may. Increases the risk of dural tears may be underestimated you to notice them and take action covid-19 Update: ’. Leak ) for signing up said, a dural tear is one of the hospitals... About any part of the Day newsletter, and finally multi-level decompression for. Disc surgery and should be proactively tackled to avoid post operative complications most frequently with spine...