Rate and fate of incidental durotomies in spine surgery

Incidental Durotomy (ID) is a well-recognized complication from spine surgery and its occurrence is often linked to negative outcomes following spine surgery. However, there is conflicting evidence in the literature regarding the risk factors, incidence and outcome following ID. This study aims to assess the rate and fate of ID in spine surgery.

A retrospective review of a prospectively maintained database all adult patients who underwent spinal surgery by a single board certified neurospine surgeon between January 2016 and October 2024 was performed to identify all patients who sustained ID. For open spinal surgeries, the intraoperative management strategy involved direct repair of durotomies using a reinforced closure technique. In minimally invasive surgery (MIS) cases, direct repair of the durotomy was not performed; however, other reinforcement steps were identical to those used in the open approach. The primary outcomes assessed included the occurrence of intraoperative durotomies and any postoperative and perioperative complications associated with durotomy. Secondary outcomes included the analysis of durotomy rates based on surgical approach, surgical instrumentation, primary versus revision surgery, and the surgeon's years of experience. The postoperative management remained unchanged between patients with and without ID.

Among 1,155 patients who underwent spinal surgeries during the study period, 56 (4.8 %) experienced ID. The overall association between age group and durotomy rate was not statistically significant (p = 0.12). Analysis showed no significant differences in the occurrence of durotomies between MIS (4.9 %) and open surgeries (4.8 %) (p = 1) and instrumented cases (5.2 %) versus non-instrumented cases (3.5 %) (p = 0.34). Durotomy rates were higher in revision surgeries (8.7 %) compared to primary surgeries (4.6 %), but this difference was not statistically significant (p = 0.21). A statistically significant difference was found between primary diagnosis and durotomy rate, with the highest chances of durotomies in patients undergoing surgery for adult spinal deformity (p < 0.0001) with a 50 % rate (8 of 16) of ID in patients who underwent three-column osteotomies. There was no significant relationship between the surgeon's years of experience as an attending and durotomy rates (p = 0.543). No patient required revision surgery for any complication related to ID.

This study provides real-world clinical data demonstrating the rate and fate of ID following spine surgery that spine surgeons can utilize during preoperative counseling and setting expectations. Surgery for adult spinal deformity, especially those involving three-column osteotomies, is associated with the highest incidence of ID. While this study suggests ID as a benign event, given possible serious postoperative sequelae, it remains essential for surgeons to employ techniques to avoid ID and, if it occurs, monitor patients closely and employ best practices to mitigate potential risks.