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Are Dural Tears and Cerebrospinal Fluid Leaks Something To Worry About?

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Updated May 29, 2013

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Question: Are Dural Tears and Cerebrospinal Fluid Leaks Something To Worry About?

A dural tear, also known as a durotomy, is a complication of spine surgery in which the thin covering over the spinal cord (called dura mater) is nicked by the surgeon’s instrument.

Answer:

As of March 2012, many studies show that if a dural tear is properly treated, it’s likely you won’t experience long-term problems. The jury is still out on this, however, and it remains to be seen if treatment initially received for a dural tear results in permanent resolution of the problem.

Dural tears tend to occur most frequently in revision spine surgery, as compared to other types of surgery. Multi-level spine surgery is next on that list, followed by fusion, then multi-level decompression (for spinal stenosis). Disc surgery and single level decompression surgeries tend to result in the smallest number of dural tears, relatively speaking.

Dural tears are associated with what happens during surgery. But even for a surgeon with magic hands, it’s hard not to nick the sac that contains the spinal cord. The membrane that covers the spinal cord is not like bone, skin or muscle, Dr. Joshua D. Auerbach, Chief of Spine Surgery at Bronx-Lebanon Hospital Center in New York City, tells me. “It’s delicate and easily torn.”

While your doctor’s technique with the scalpel (or other instrument) may be what ultimately creates the tear, pre-existing conditions and/or deformities can increase your risk. For example, using steroids, having diabetes, and/or being a smoker all increase your risk for a dural tear. The same is true if you have certain spine problems, namely: spondylolithesis, stenosis, scoliosis, or kyphosis.

Hospitals Resistant To Reporting Their Dural Tear Incidence Rates

Dural tear is one of the most common complications of a back surgery. However, many hospitals appear to be slow to report tears that occur in their institutions. For this and possibly other reasons, the incidence of dural tears may be underestimated.

As it is, incidence rates reported in research studies vary widely. A number of things may account for differences: the reason for the surgery (stenosis, herniated disc, scoliosis, etc), whether the surgery was the patient's first one or a reoperation, and other factors.

On the low side, a January 2011 study published in Neurosurgery examining over 108,000 spine surgery patients found 1.6% experienced a dural tear. On the high side, Medscape reports that a 1989 study published in Spine calculated a 17.4% incidence rate of dural tears in a study population consisting of 481 people who underwent back surgery.

The ICD-CM Coordination and Maintenance Committee (a committee that plays an important role in cataloging diagnoses) found that 57% of hospitals they scrutinized underreported the incidence of dural tears. The committee asserts that 46% of the 2,446 hospitals reported no dural tears at all! It also asserts that the hospitals report treating dural tears, but they don't report the dural tears ever happening. Go figure.

Yet when the doctors doing spine surgery in many of these hospitals participated in clinical research studies (which are separate from the administrative reporting on the part of hospitals), the incidence of dural tears was, in some cases, as high as 10%.

The ICD-CM Committee estimates that these hospitals report only about half the dural tears that actually occur.

Dural Tear and Cerebrospinal Fluid Leaks - Symptoms and Treatment

Symptoms of a dural tear include cerebrospinal fluid leakage (called CSF leak). Dr. Auerbach informs me that if you have a CSF leak, you may notice a clear fluid discharging from your surgical wound. You may also experience position-related headaches that get worse when you stand up and that are relieved when you lie down. Other symptoms of a CSF leak include visual changes, nausea, vomiting or dizziness, Auerbach says.

A cerebrospinal fluid leak requires prompt medical attention and can have negative consequences on your health if it is not treated properly. Should you experience any of the symptoms listed above, speak with your doctor as soon as you can.

Generally, though, a dural tear is caught by your doctor while you’re in surgery and is treated right then and there.

Just the same, late symptoms are possible, and in this case it will be up to you to notice them and take action. If you experience any or all symptoms listed above, be sure to discuss them with your doctor as soon as you can.

Treatments for dural tears include bed rest, draining, and if the leaking continues, surgery. The surgery for a dural tear is much like plugging a hole in a tire. As of March 2012, most dural tear surgeries involve sutures (stitches), but suture-less techniques are now being developed as well.

Sources:

Auerbach, J., MD. Chief of Spine Surgery, Bronx-Lebanon Hospital Center, Assistant Professor of Surgery, Albert Einstein College of Medicine. Phone Interview. March 2012.

Espiritu MT, Rhyne A, Darden BV 2nd. Dural tears in spine surgery. J Am Acad Orthop Surg. 2010 Sep;18(9):537-45. http://www.ncbi.nlm.nih.gov/pubmed/20810935

Guerin P, El Fegoun AB, Obeid I, Gille O, Lelong L, Luc S, Bourghli A, Cursolle JC, Pointillart V, Vital JM. Incidental durotomy during spine surgery: Incidence, management and complications. A retrospective review. Injury. 2011 Jan 18. [Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/21251652

Medscape News. Protocol for Incidental Dural Tears in Degenerative Lumbar Spine Surgery: Discussion. Medscape website. Accessed March 2012.

Shaw, J. Incidental Durotomy/Dural Tear. ICD-9-CM Coordination and Maintenance Committee. March 19-20, 2008. Powerpoint Presentation.

Stolke D, Sollmann W, Seifert V. Intra- and postoperative complications in lumbar disc surgery. Spine 1989;14:56-9.

Williams, BJ, et. al. Incidence of unintended durotomy in spine surgery based on 108,478 cases. Neurosurgery. 2011 Jan;68(1):117-23; discussion 123-4. http://www.ncbi.nlm.nih.gov/pubmed/21150757"

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