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The effect of incidental dural lesions on outcome after decompression surgery for lumbar spinal stenosis: results of a multi-center study with 800 patients

European Spine Journal volume 26, pages 2504–2511 (2017)Cite this article

Abstract

Purpose

Incidental durotomy is one of the most common complications in lumbar spine surgery. There are conflicting reports whether a dural lesion is associated with an inferior outcome after lumbar decompression. This study analyzed the effect of incidental durotomy in this specific group of patients (Dura+) and compared the results with the remaining cohort without dural laceration (Dura−).

Methods

This prospective multi-center study included 800 patients with lumbar spinal stenosis who underwent exclusive decompression surgery. All procedures were performed as part of a multi-center investigation at three highly specialized spine clinics. Outcome measures (ODI, EQ5D, VASback pain and VASleg pain) were obtained preoperatively as well as 3 and 12 months after surgery. The effect of an incidental durotomy on the clinical outcomes was analyzed statistically between the two cohorts.

Results

An intraoperative dura lesion was recorded in 6.5 % (n = 52/800) of all cases. Both cohorts (Dura+ and Dura−) did not reveal any differences regarding patient demographics, risk factors, or co-morbidities at baseline. The length of the hospital stay was significantly longer for the Dura+ cohort (8.0 vs. 6.4 days; p < 0.01). After 12 months, the Dura− cohort demonstrated a significantly greater improvement in VASback pain in comparison to the Dura+ cohort (Δ21.4 vs. Δ7.2 points; p < 0.05). The differences for the remaining outcome measures were not statistically significant (p > 0.05).

Conclusions

The results of this study reveal that an incidental durotomy was associated with a significant increase in the patient’s length of stay, and risk for re-intervention for the treatment of persisting CSF leakage. In contrast to previous reports which have investigated the effects of incidental durotomies on the clinical outcome after lumbar decompression surgery, our data further suggest a possible inferior outcome in terms of low back pain improvement in the Dura+ cohort, which became clinically apparent at the 12-month follow-up period. Future studies should investigate whether a more pronounced decompression required for adequate exposure and repair of a dural laceration may, ultimately, result in increased segmental instability and in clinically undesirable low back pain.

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References

  1. Weinstein BK, Tosteson TD, Lurie JD et al (2008) Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 358:794–810

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  2. Athiviram A, Yen D (2007) Is spinal stenosis better treated surgically or nonsurgically? Clin Orthop Relat Res 458:90–93

    Google Scholar 

  3. Malmivaara A, Slatis P, Heliovaara M et al (2007) Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine 32:1–8

    Article  PubMed  Google Scholar 

  4. Papavero L, Thiel M, Fritzsche E, Kunze C, Westphal M, Kothe R (2009) Lumbar spinal stenosis: prognostic factors for bilateral microsurgical decompression using a unilateral approach. Neurosurgery 65:182–187

    PubMed  Google Scholar 

  5. Podichetty VK, Spears J, Isaacs RE, Booher J, Biscup RS (2006) Complications associated with minimally invasive decompression for lumbar spinal stenosis. J Spinal Disord Tech 19:161–166

    Article  PubMed  Google Scholar 

  6. Adogwa O, Huang MI, Thompson PM et al (2014) No difference in postoperative complications, pain, and functional outcomes up to 2 years after incidental durotomy in lumbar spinal fusion: a prospective, multi-institutional, propensity-matched analysis of 1741 patients. Spine J 14:1828–1834

    Article  PubMed  Google Scholar 

  7. Desai A, Ball PA, Bekelis K et al (2012) Surgery for lumbar degenerative spondylolisthesis in Spine Patient Outcomes Research Trial. Does incidental durotomy affect outcome? Spine 37:406–413

    Article  PubMed  PubMed Central  Google Scholar 

  8. Sin AH, Caldito G, Smith D et al (2006) Predictive factors for dural tear and cerebrospinal fluid leakage in patients undergoing lumbar surgery. J Neurosurg Spine 5:224–227

    Article  PubMed  Google Scholar 

  9. Strömqvist F, Jönsson B, Strömqvist B, Swedish Society of Spinal Surgeons (2012) Dural lesions in decompression for lumbar spinal stenosis: incidence, risk factors and effect on outcome. Eur Spine J 21:825–828

    Article  PubMed  Google Scholar 

  10. Baker GA, Cizik AM, Bransford RJ et al (2012) Risk factors for unintended durotomy during spine surgery: a multivariate analysis. Spine J 12:121–126

    Article  PubMed  PubMed Central  Google Scholar 

  11. Du JY, Aichmair A, Kueper J et al (2014) Incidental durotomy during spinal surgery. Spine 39:E1339–E1345

    Article  PubMed  Google Scholar 

  12. Yoshihara H, Yoneoka D (2014) Incidental dural tear in spine surgery: analysis of a nationwide database. Eur Spine J 23:389–394

    Article  PubMed  Google Scholar 

  13. Grannum S, Patel MS, Attar F, Newey M (2014) Dural tears in primary decompressive lumbar surgery. Is primary repair necessary for a good outcome? Eur Spine J 23:904–908

    Article  PubMed  PubMed Central  Google Scholar 

  14. Mayer HM, Korge A (2009) Microsurgical decompression of degenerative lumbar spinal stenosis. Eur Spine J 18:1989–1990

    Article  PubMed  Google Scholar 

  15. Gallagher EJ, Liebman M, Bijur PE (2001) Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emerg Med 38:633–638

    CAS  Article  PubMed  Google Scholar 

  16. Fairbank JC, Pynsent PB (2000) The Oswestry Disability Index. Spine 25:2940–2952 (discussion 2952)

    CAS  Article  PubMed  Google Scholar 

  17. EuroQol Group (1990) EuroQol—a new facility for the measurement of health-related quality of life. Health Policy 16:199–208

    Article  Google Scholar 

  18. Jansson KA, Nemeth G, Granath F et al (2009) Health-related quality of life (EQ-5D) before and after surgery for lumbar spinal stenosis. J Bone Joint Surg Br 91:210–216

    Article  PubMed  Google Scholar 

  19. Eismont FJ, Wiesel SW, Rothman RH (1981) Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am A63:1132–1136

    Article  Google Scholar 

  20. Jones AA, Stambough JL, Balderston RH, Rothman RH, Booth RE (1989) Long-term results of lumbar spine surgery complicated by unintended incidental durotomy. Spine 14:443–446

    CAS  Article  PubMed  Google Scholar 

  21. Burks CA, Werner BC, Yang S, Shimer AL (2015) Obesity is associated with an increased rate of incidental durotomy in lumbar spine surgery. Spine 40:500–504

    Article  PubMed  Google Scholar 

  22. Strömqvist F, Jönsson B, Strömqvist B (2010) Dural lesions in lumbar disc herniation surgery: incidence, risk factors, and outcome. Eur Spine J 19:439–442

    Article  PubMed  Google Scholar 

  23. Weinstein JN, Tosteson TD, Lurie JD et al (2006) Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcome Research Trial (SPORT): a randomized trial. JAMA 296:2441–2450

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  24. Epstein NE (2007) The frequency and etiology of intraoperative dural tears in 110 predominantly geriatric patients undergoing multilevel lamincetomy with noninstrumented fusion. J Spinal Disord Tech 20:380–386

    Article  PubMed  Google Scholar 

  25. Bosacco SJ, Gardner MJ, Guille JT (2001) Evaluation and treatment of dural tears in lumbar spine surgery: a review. Clin Orthop Relat Res 389:238–247

    Article  Google Scholar 

  26. Wang JC, Bohlmann HH, Riew DK (1998) Dural tears secondary to operations on the lumbar spine: management and results after a two-year-minimum follow-up of eighty-eight patients. J Bone Joint Surg (Am) 80:1728–1732

    CAS  Article  Google Scholar 

  27. Nandyala SV, Elboghdady IM, Marquez-Lara A et al (2014) Cost analysis of incidental durotomy in spine surgery. Spine 39:E1042–E1051

    Article  PubMed  Google Scholar 

  28. Copay A, Glassman S, Subach BR et al (2008) The minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and Pain Scales. Spine J 8:968–974

    Article  PubMed  Google Scholar 

  29. Parker SL, Adogwa O, Mendenhall SK et al (2012) Determination of minimum clinically important difference (MCID) in pain, disability, and quality of life after revision fusion for symptomatic pseudoarthrosis. Spine J 12:1122–1128

    Article  PubMed  Google Scholar 

  30. Childs JD, Piva SR, Fritz JM (2005) Responsiveness of the numeric pain rating scale in patients with low back pain. Spine 30:1331–1334

    Article  PubMed  Google Scholar 

  31. McGirt MJ, Parker SL, Asher AL, Norvell D, Sherry N, Devin CJ (2014) Role of prospective registries in defining the value and effectiveness of spine care. Spine 39:S117–S128

    Article  PubMed  Google Scholar 

  32. Strömqvist B, Fritzell P, Hägg O, Jönsson B, Swedish Society of Spinal Surgeons (2009) The Swedish spine register: development, design and utility. Eur Spine J 18:S294–S304

    Article  Google Scholar 

  33. Sigmundsson FG, Jönsson B, Strömqvist B (2015) Outcome of decompression with and without fusion in spinal stenosis with degenerative spondylolisthesis in relation to preoperative pain pattern: a register study of 1624 patients. Spine J 15:638–646

    Article  PubMed  Google Scholar 

  34. Mullholland RC (2016) The Michel Benoist and Robert Mulholland yearly European spine journal review: a survey of the “surgical and research” articles in the European spine journal, 2015. Eur Spine J 25:24–33

    Article  Google Scholar 

  35. Papavero L, Engler N, Kothe R (2015) Incidental durotomy in spinal surgery: first aid in ten steps. Eur Spine J 24:2077–2084

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Clinic for Spinal Surgery, Schön Klinik Eilbek, Dehnhaide 120, 22081, Hamburg, Germany

    Ralph Kothe & N. Engler

  2. Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    Ralph Kothe

  3. Clinic for Spine Surgery, Schön Klinik Neustadt, Neustadt in Holstein, Germany

    M. Quante

  4. Spine Center, Schön Klinik München Harlaching, Munich, Germany

    F. Heider & C. Siepe

  5. Academic Teaching Hospital and Spine Research Institute, Paracelsus Medical University, Salzburg, Austria

    F. Heider & C. Siepe

  6. Quality Management, Schön Klinik Headquarter, Prien Am Chiemsee, Germany

    J. Kneißl & S. Pirchner

Authors
  1. Ralph Kothe
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  2. M. Quante
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  3. N. Engler
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Correspondence to Ralph Kothe.

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Kothe, R., Quante, M., Engler, N. et al. The effect of incidental dural lesions on outcome after decompression surgery for lumbar spinal stenosis: results of a multi-center study with 800 patients. Eur Spine J 26, 2504–2511 (2017). https://doi.org/10.1007/s00586-016-4571-8

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  • DOI: https://doi.org/10.1007/s00586-016-4571-8

Keywords

  • Incidental durotomy
  • Complications
  • Patient-reported outcomes
  • Dural tear
  • Lumbar spinal stenosis