Management of intraoperative durotomies and the postoperative management of cerebrospinal fluid (CSF) leaks can pose serious problems in spinal surgery.

This chapter discusses risk factors that can predispose patients to the occurrence of an intraoperative durotomy.

We review the surgical instruments, biologic agents, and drainage catheters that are of assistance with repair of durotomies.

A discussion then occurs with respect to the particular challenges at varying locations within the spinal axis when it is approached either anteriorly or posteriorly.

Careful study of preoperative imaging studies may yield valuable information with respect to potential pitfalls during exposure of the spine.

Look out for postoperative changes from previous laminectomies or laminotomies.

Spina bifida occulta is reported in up to 10% to 15% of normal healthy adults and is a potential site for durotomy during exposure.

Incomplete ossification of the C1 laminar arch should be kept in mind during any posterior approach to the high cervical spine or craniocervical junction.

The L5-S1 interspace is a widened interspace and is a frequent area for incidental durotomy during exposure of the lumbar spine.

Ossification of the posterior longitudinal ligament, especially in the cervical and thoracic spine can often be recognized on preoperative imaging studies and carries a high risk of intraoperative CSF leak.

Often, these durotomies occur in the midline and can be repaired primarily with simple interrupted or running sutures. A 4-0 or 5-0 monofilament suture such as Prolene (Ethicon, Somerville, NJ) or nylon are appropriate.

We prefer a repair with a small tapered needle such as an RB-1 in a simple running fashion.

A good needle driver such as Castro-Viejo can be helpful to repair a tear in the lateral recess.

When an intraoperative durotomy has occurred, care should be taken to avoid any injury to the underlying neural elements.

Surgical cautery (Bovie) use should be limited when in proximity to neural elements.

Minimize the use of high-speed cutting drill bits near the spinal canal. A diamond drill bit is a much safer instrument especially in less experienced hands.

The use of appropriate-sized suction tips is recommended once a durotomy has occurred. The smallest suction tip that can be used to keep the surgical field clear should be employed.

Make sure that you have a capable and experienced assistant. Sometimes, what you really need is an extra pair of experienced hands to maximize your exposure so that you can work on primary repair of the dural defect.

Once a durotomy has taken place, protect the neural elements with a soft Cottonoid (Codman, Warsaw, IN).

Focus is then directed toward minimizing and further extension of the durotomy and attaining sufficient bone exposure to allow for primary dural repair when possible.

Whenever possible, achieve a watertight primary dural repair and reinforce with dural sealant when indicated.

Decompression of the lumbar cistern through the release of spinal fluid can also alleviate the extramural forces on the epidural venous plexus. This can result in large amounts of bleeding, which can normally be controlled with bipolar cautery or thrombin-soaked Gelfoam (Baxter Healthcare Corp., Hayward, CA).