Abstract
Introduction
Dural tears during spine surgery in children may result in neurological impairment and surgical site infections.
Material and Methods
Study design: Cohort analysis. A total of 493 consecutive patients with complex spinal surgical procedures were studied. Age: 6 months to 17 years. The reasons for surgery; spinal TB and it's sequela: 203 patients, spondylodiscitis: 99, congenital abnormalities: 55, tumors of the spine: 65, spondylolisthesis: 16, degenerative disorders: 8, other diseases and deformities: 40. All had 1-day surgery including anterior column reconstruction, posterior instrumentation, and bone fusion.
Results
Incidental dural tears were observed in 34 patients (6.8%). It happened with similar frequency in patients of spondylodiskitis, congenital abnormalities, and tumors—12.3 to 12.7%; in 7.5% of spinal TB. Overall, 19/34 patients had rigid sharp-angled kyphosis, 10/34 had revision surgery. In 17 patients dural tears complicated anterior stage of spine procedure, in 8 patients the posterior, and in 9 patients the nerve root sheath was torn (5 posterior, 4 anterior). In 6 patients dura was sutured, in 10 patients the closure of the dural defect was performed using own muscular flap, in 14 patients using oxidized regenerated cellulose-based hemostat. The postoperative management included bed rest for minimum 3 days, antibiotics, drainage with minimal vacuum (less than 2 cm H2O) or puncture. In 16 patients dural tear during surgery had no manifestation subsequently. In 10 patients the duration of CSF leak postoperatively was less than 3 days, in 4 patients—4 to 9 days, in 3 patients—more than 15 days (up to 48 days). Total volume of spinal fluid loss in seven patients less than 1.0 L, in five ranged from 1.0 to 3.0 L, and in 1 patient was more than 10 L. Four out of the six cases of cerebrospinal fluid loss exceeding 1 L, dural tears occurred after upper thoracic spine reconstruction. In 11 of the 34 patients dural tears suffered postoperative neurological impairment: 9 patients by 1 point of Frankel scale, 2 more than 1. At follow-up almost all patients restored the preoperative neurological status. The outcome in one patient was subdural CSF-cyst that required secondary procedure (drainage); two patients developed asymptomatic pseudomeningocele, and one patient, a patient with the recurrence of aggressive L2–4 giant cell tumor, had the staphylococcal infection of retroperitoneal pseudomeningocele, controlled by antibiotics and drainage.
Conclusion
Risk factors for dural damage in children are sharp-angled kyphosis and revision surgery. Dural tears happen twice most often at the time of the anterior decompression of the spinal cord, during dissection of the dural sac from adherent bony structures. In cases when dural defect cannot be repaired, the use of muscle flap or oxidized regenerated cellulose-based hemostat is quite effective to terminate CSF leak. In the presence of CSF leakage the neurological deficit occurs more frequently, comparing to average numbers of complications in pediatric spine surgery. That, however, is not due to the mere fact of dura mater damage, but because of such injuries are often observed in difficult spinal cases, initially requiring more technically complex surgical manipulations.