Dural lesions in lumbar disc herniation surgery: incidence, risk factors, and outcome

In lumbar disc herniation surgery, dural lesions seem to be the most common complication today. Studies on incidence of and outcome after a dural lesion are mainly based on retrospective studies. In a prospective study within the framework of the Swedish Spine Register, 4,173 patients operated on for lumbar disc herniation were evaluated using pre- and 1-year postoperative protocols and complication registration. Mean patient age was 41 (18–81) years and 53% of the patients were male. 93% of the operations were performed on the two lowermost lumbar levels. The incidence of dural lesions in the material was 2.7%. In patients with previous disc surgery, the incidence was doubled, 5%, a significant increase (P = 0.02). Patients with dural lesions preoperatively had more back pain and inferior scores in general health and role emotional domains of the SF-36. These factors, however, were because they had been operated on previously, not related to the dural lesion as such. The relative improvement after surgery was similar whether a dural lesion had occurred or not. It is concluded that a dural lesion is a technical complication which must be solved at the time of surgery but which does not bear any negative implications on the long-term outcome for the patient

Higher preoperative Oswestry Disability Index is associated with better surgical outcome in upper lumbar disc herniations

To evaluate the surgical outcome in terms of functional and subjective recovery, patients who needed discectomies at L1–L2, L2–L3 and L3–L4 levels were compared with an age and sex-matched group of patients who required L4–L5 and L5–S1 discectomies. We prospectively enrolled 50 consecutive patients, referred to our center, who had L1–L2, L2–L3 and L3–L4 herniations and required surgical intervention. Likewise, a comparative group of 50 consecutive patients with herniations at L4–L5 and L5–S1 were selected. All 100 patients were treated and followed for a 1 year period. Physical examination findings as well as Oswestry Disability Questionnaire before surgery were recorded. After 1 year, patients were requested to fill the same questionnaire. Significant decline in the Oswestry Disability Index (ODI) scores was considered to be a measure of functional improvement and recovery. The mean age of patients with upper lumbar disc herniation (L1–L2, L2–L3, L3–L4) was 45.7 years and patients with lower lumbar disc herniation (L4–L5, L5–S1) had a mean age of 41.2 years. There was no statistically significant difference in age between the two groups. The preoperative Oswestry Disability (ODI) Index score had a statistically significant impact on ODI score improvement after surgery in both lower and upper lumbar disc groups. All 100 patients with either lower or upper lumbar disc herniation had statistically significant ODI change after surgical intervention (P < 0.0001 for both groups). However, patients with upper disc herniations and moderate preoperative disability (ODI of 21–40%) did not show significant improvement, while patients with ODI greater than 40% had significant reduction (P = 0.018). Surprisingly, as many as 25% of the former had even an increase in ODI scores after surgery. Gender was also a conspicuous factor in determining the surgical outcome of patients with upper lumbar disc herniation, and male patients had more reduction in ODI score than female patients (P = 0.007). Since the functional recovery in patients with herniated lumbar disc, especially upper lumbar herniation, is influenced by preoperative ODI scores, the use of ODI or any other standard pain assessment tool is a sensible consideration as an inherent investigative method to preclude unfavorable surgical outcome

Conduta na lesão dural intraoperatória em artrodese da coluna lombar Conducta en lesión de duramadre intraoperatoria en artrodesis de la columna lumbar Management of intraoperatory dural tear in lumbar spine arthrodesis

OBJETIVO: estudo retrospectivo de pacientes com lesão dural intraoperatória de cirurgia da coluna vertebral lombar, conduzido por meio de um protocolo independente da extensão da lesão, complicações associadas e resultados após seguimento mínimo de um ano. MÉTODOS: um total de 10 pacientes com durotomia acidental em cirurgias de descompressão e artrodese da coluna vertebral lombar, no período de Janeiro de 2007 a Janeiro de 2009, para tratamento de doença degenerativa, tiveram seus prontuários revisados, após terem sido tratados por meio de um protocolo embasado em reparo primário da lesão, drenagem subaracnoidea fechada, subfascial e subcutânea aspirativa realizados por cirurgião experiente, associado a repouso relativo com mobilidade precoce e terapia medicamentosa. Suas anotações e exames radiológicos foram verificados com seguimento pós-operatório e direcionados para identificação de sintomas sugestivos de complicações. RESULTADOS: todos os pacientes apresentaram boa evolução, sem ocorrência de fístula liquórica ou infecção pós-operatória; três deles apresentaram cefaleia pós-operatória de leve intensidade. Não houve necessidade de reoperação em nenhum desses pacientes. CONCLUSÃO: concluiu-se que a conduta adotada é segura e de bom resultado para os pacientes quando ocorre esse tipo de lesão, independentemente da extensão da mesma.<br>OBJETIVO: un estudio retrospectivo de pacientes con lesión de la duramadre intraoperatoria de cirugía en la columna lumbar, llevada a cabo por medio de un protocolo independiente de la extensión de la lesión, complicaciones asociadas y los resultados de seguimiento después de un mínimo de un año. MÉTODOS: 10 pacientes con durotomía accidental en la descompresión quirúrgica y artrodesis de la columna vertebral lumbar, en el período de enero de 2007 a enero de 2009, para el tratamiento de enfermedades degenerativas, tuvieron sus registros revisados después de tendieren sido tratados por un protocolo basado en la reparación primaria de la lesión, subaracnoidea drenaje cerrado, aspiración subfascial y subcutánea realizada por cirujanos con experiencia, combinada con el reposo relativo, con la movilización precoz y el tratamiento farmacológico. Sus notas y las imágenes fueron verificadas con el seguimiento postoperatorio y direccionadas para la identificación de síntomas sugestivos de complicaciones. RESULTADOS: todos los pacientes tuvieron buena evolución, sin registro de pérdidas de líquido cefalorraquídeo o infección postoperatoria, tres tuvieron cefalea en el postoperatorio de intensidad leve. No hubo necesidad de reintervención en esos pacientes. CONCLUSIÓN: la conducta adoptada es segura y con buen resultado para pacientes en los que este tipo de lesión se produce, independiente de la extensión de la misma.<br>OBJECTIVE: a retrospective study of patients with spinal dural intraoperative lumbar spine surgery, conducted by means of a protocol regardless of the extent of the injury, associated complications and follow-up results after a minimum of one year. METHODS: a total of 10 patients with accidental durotomy in surgical decompression and arthrodesis of the lumbar spine during the period from January 2007 to January 2009 for treatment of degenerative disease had their records reviewed after being treated by a protocol based in primary repair of the lesion, closed subarachnoid drainage, subfascial and subcutaneous aspiration drainage performed by experienced surgeons, combined with relative rest with early mobilization and drug therapy. Their notes and imaging were verified with follow-up aimed to identify symptoms that could suggest complications. RESULTS: all patients had a good outcome, without occurrence of cerebrospinal fluid leaks or postoperative infection; three had postoperative headache of mild intensity. There was no need for reoperation in these patients. CONCLUSION: we concluded that the conduct adopted is safe and has a good outcome for patients when this type of injury occurs, regardless of its extent