Anterior Lumbar Dural Tear: A Transthecal Route for Primary Closure After Iatrogenic Durotomy

Jonathan Nakhla, Rani Nasser, Rafael de la Garza Ramos, Andrew Kobets, Adam Ammar, Murray Echt, Yaroslav Gelfand, Merritt D. Kinon, Reza Yassari

Research output: Contribution to journalArticle

Abstract

Background Durotomies are not infrequent in spine surgery and have increased complication rates. Primary repair is the gold standard and is feasible when access is not limited by the anatomy. A patient who presented 1 week after spinal fusion with cerebrospinal fluid (CSF) leak underwent a novel transthecal approach to repair an anterior dural tear. Objective To demonstrate the feasibility, durability, and safety of a transthecal reconstruction to repair an anterior dural tear. Methods A patient with spinal stenosis at L4–L5 and a spondylolisthesis at L5–S1 underwent an L4–S1 posterior lumbar interbody fusion. The procedure was complicated by a CSF leak during graft placement of the anterior dura. This location did not allow for a primary closure, and a fat graft was placed with fibrin glue. Nine days later, the patient developed postural headaches, and CSF was leaking from the wound. The patient underwent an exploration, and the most lateral aspect of the tear was visualized when retracting medially, although not enough for a primary repair. A posterior durotomy was made and the anterior dural tear was repaired from the inside. Results The patient symptoms resolved and had radiologic improvement of the pseudomeningocele. This represents the first reported transthecal route to repair an anterior dural tear in the lumbar spine. The procedure was technically feasible, effective, and durable, with the patient having complete resolution of his CSF leak. Conclusions Dorsal transthecal access to the ventral aspect of the lumbar thecal sac for inadvertent anterior dural tears is a safe, feasible, and durable surgical management strategy.

Original languageEnglish (US)
Pages (from-to)522-525
Number of pages4
JournalWorld Neurosurgery
Volume107
DOIs
StatePublished - Nov 1 2017

Fingerprint

Tears
Spine
Transplants
Spondylolisthesis
Spinal Stenosis
Spinal Fusion
Fibrin Tissue Adhesive
Headache
Cerebrospinal Fluid
Anatomy
Fats
Safety
Wounds and Injuries
Cerebrospinal Fluid Leak

Keywords

  • Anterior lumbar spine
  • Complication
  • CSF leak
  • Dural tear
  • Spinal fusion

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Anterior Lumbar Dural Tear : A Transthecal Route for Primary Closure After Iatrogenic Durotomy. / Nakhla, Jonathan; Nasser, Rani; de la Garza Ramos, Rafael; Kobets, Andrew; Ammar, Adam; Echt, Murray; Gelfand, Yaroslav; Kinon, Merritt D.; Yassari, Reza.

In: World Neurosurgery, Vol. 107, 01.11.2017, p. 522-525.

Research output: Contribution to journalArticle

Nakhla, J, Nasser, R, de la Garza Ramos, R, Kobets, A, Ammar, A, Echt, M, Gelfand, Y, Kinon, MD & Yassari, R 2017, 'Anterior Lumbar Dural Tear: A Transthecal Route for Primary Closure After Iatrogenic Durotomy', World Neurosurgery, vol. 107, pp. 522-525. https://doi.org/10.1016/j.wneu.2017.07.156
Nakhla J, Nasser R, de la Garza Ramos R, Kobets A, Ammar A, Echt M et al. Anterior Lumbar Dural Tear: A Transthecal Route for Primary Closure After Iatrogenic Durotomy. World Neurosurgery. 2017 Nov 1;107:522-525. https://doi.org/10.1016/j.wneu.2017.07.156
Nakhla, Jonathan ; Nasser, Rani ; de la Garza Ramos, Rafael ; Kobets, Andrew ; Ammar, Adam ; Echt, Murray ; Gelfand, Yaroslav ; Kinon, Merritt D. ; Yassari, Reza. / Anterior Lumbar Dural Tear : A Transthecal Route for Primary Closure After Iatrogenic Durotomy. In: World Neurosurgery. 2017 ; Vol. 107. pp. 522-525.
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N2 - Background Durotomies are not infrequent in spine surgery and have increased complication rates. Primary repair is the gold standard and is feasible when access is not limited by the anatomy. A patient who presented 1 week after spinal fusion with cerebrospinal fluid (CSF) leak underwent a novel transthecal approach to repair an anterior dural tear. Objective To demonstrate the feasibility, durability, and safety of a transthecal reconstruction to repair an anterior dural tear. Methods A patient with spinal stenosis at L4–L5 and a spondylolisthesis at L5–S1 underwent an L4–S1 posterior lumbar interbody fusion. The procedure was complicated by a CSF leak during graft placement of the anterior dura. This location did not allow for a primary closure, and a fat graft was placed with fibrin glue. Nine days later, the patient developed postural headaches, and CSF was leaking from the wound. The patient underwent an exploration, and the most lateral aspect of the tear was visualized when retracting medially, although not enough for a primary repair. A posterior durotomy was made and the anterior dural tear was repaired from the inside. Results The patient symptoms resolved and had radiologic improvement of the pseudomeningocele. This represents the first reported transthecal route to repair an anterior dural tear in the lumbar spine. The procedure was technically feasible, effective, and durable, with the patient having complete resolution of his CSF leak. Conclusions Dorsal transthecal access to the ventral aspect of the lumbar thecal sac for inadvertent anterior dural tears is a safe, feasible, and durable surgical management strategy.

AB - Background Durotomies are not infrequent in spine surgery and have increased complication rates. Primary repair is the gold standard and is feasible when access is not limited by the anatomy. A patient who presented 1 week after spinal fusion with cerebrospinal fluid (CSF) leak underwent a novel transthecal approach to repair an anterior dural tear. Objective To demonstrate the feasibility, durability, and safety of a transthecal reconstruction to repair an anterior dural tear. Methods A patient with spinal stenosis at L4–L5 and a spondylolisthesis at L5–S1 underwent an L4–S1 posterior lumbar interbody fusion. The procedure was complicated by a CSF leak during graft placement of the anterior dura. This location did not allow for a primary closure, and a fat graft was placed with fibrin glue. Nine days later, the patient developed postural headaches, and CSF was leaking from the wound. The patient underwent an exploration, and the most lateral aspect of the tear was visualized when retracting medially, although not enough for a primary repair. A posterior durotomy was made and the anterior dural tear was repaired from the inside. Results The patient symptoms resolved and had radiologic improvement of the pseudomeningocele. This represents the first reported transthecal route to repair an anterior dural tear in the lumbar spine. The procedure was technically feasible, effective, and durable, with the patient having complete resolution of his CSF leak. Conclusions Dorsal transthecal access to the ventral aspect of the lumbar thecal sac for inadvertent anterior dural tears is a safe, feasible, and durable surgical management strategy.

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