Management of Dural Tears



Management of Dural Tears


Ehsan Saadat

John M. Rhee



General Principles of Dural Repair



  • The key to managing dural tears is to prevent them: NEVER perform a move in spine surgery unless you are absolutely certain it is safe.


  • When a durotomy occurs, care should be taken to avoid injury to the underlying rootlets, which can herniate out of the tear.



    • Identify an edge of the tear, lift it up with a nerve hook, and then reduce any herniated rootlets with a small spatula.


    • If the hole is too small to reduce extruded rootlets, it may be necessary to incise the dura and make the hole bigger first.


  • Once the neural elements are covered with a cottonoid, focus should be directed to preventing an increase in the size of the tear, while removing enough bone to allow for unobstructed primary dural repair.



    • The key step is to gain enough exposure to allow for repair. This will generally involve enlarging the laminectomy before attempting to place sutures.


    • Use a cottonoid patty placed over the tear to protect and cover the rootlets while creating further bony exposure, so that rootlets do not get inadvertently cut.


    • Avoid the use of high-speed burr in the vicinity of exposed roots, which can create a “vortex” that can suck up the rootlets into the burr. If a burr is necessary, make sure that any exposed rootlets are protected by a cottonoid.


    • Use microsuction tips to prevent suction of rootlets and suction on a cottonoid when possible.


  • In general, we prefer to repair the tear as soon as possible after it occurs in order to limit the egress of spinal fluid, which can then lead to decreased dural turgor and greater epidural bleeding.


  • If a watertight repair cannot be obtained at the time of surgery, it is very likely that cerebrospinal fluid (CSF) will continue to leak postoperatively.



    • Spend the extra time it takes to make sure the repair is as tight as possible.


    • Where not possible, consider placement of a lumbar drain to divert CSF away from the site of repair.


  • Flat bed rest postoperatively



    • Customary for 24 to 72 hours post-op, depending on the quality of the repair.


    • After the appropriate period of bed rest, the height of bed is gradually elevated in 20° to 30° increments over 4 to 5 hours until the patient is upright.



      • During this time, the patient is monitored for positional headaches.


      • If a positional headache occurs, the patient is put back on flat bed rest.


  • Use of subfascial drains

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Oct 13, 2019 | Posted by in ORTHOPEDIC | Comments Off on Management of Dural Tears

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