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

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.