Influence of incidental dural tears and their primary microendoscopic repairs on surgical outcomes in patients undergoing microendoscopic lumbar surgery

Abstract

Background context: Dural tear represents a common complication of microendoscopic spine surgery that may lead to postoperative sequelae including insufficient decompression, cerebrospinal fluid fistula, intracranial hypotension, and subdural/intraparenchymal bleeding. The gold standard to manage intraoperative dural tears is primary repair. However, the downside of conversion to open surgery can be detrimental. Therefore, understanding the most appropriate strategy for microendoscopic dural repair and its impact on postoperative outcomes is of importance.

Purpose: The purpose of this study was to investigate the incidence of dural tears in patients undergoing microendoscopic lumbar surgery and to elucidate their influence on surgical outcomes whenever proper repair is accomplished microendoscopically without conversion to open surgery.

Study design/setting: A retrospective multicenter cohort study of prospectively enrolled patients using a propensity-matched analysis.

Patient sample: A total of 922 consecutive patients underwent microendoscopic surgery of the lumbar spine between February and December 2012 in the three institutions belonging to our study group.

Outcome measures: Outcome measures included the Numeric Rating Scale for back and leg pain, Oswestry Disability Index, Japanese Orthopaedic Association score, Short Form-36, and a patients' satisfaction scale.

Methods: All incidental dural tears were repaired by microendoscopic suture of the dura mater from inside to outside using double-arm needles and/or by fibrin glue coverage without being converted to open surgery. Surgical outcomes were compared between patients with and without dural tears using a propensity-matched analysis.

Results: Microendoscopic discectomy for lumbar disc herniation was performed on 474 patients, whereas microendoscopic laminectomy and posterior lumbar interbody fusion for lumbar canal stenosis were performed on 271 and 177 patients, respectively. Dural tears occurred in 49 (5.3%) patients. Of these, 23 (2.5%) patients required suture repair, whereas the rest received a fibrin patch for a pinhole tear, all of which were successfully performed under microendoscopy. Six hundred (65.1%) patients responded pre- and postoperatively to the questionnaire. Of them, the responses of 38 patients with dural tears were compared with those of 38 matched patients. No significant differences in any outcome measures were observed between the two groups.

Conclusions: In conclusion, all dural tears in our cases were managed without conversion to open surgery and did not influence surgical outcomes.

Keywords: Dural tear; Durotomy; Lumbar spine; Microendoscopic discectomy; Microendoscopic laminectomy; Microendoscopic posterior lumbar interbody fusion; Minimally invasive surgery; Patient satisfaction; Propensity-matched analysis; Surgical outcome.