الفهرس 
MECHANISM OF DURAL TEARSOnly 14 pages are availabe for public view
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Abstract
Incidental durotomy is one of the most common complications during spine surgery. Various studies have reported incidences ranging from 1% to 17% in spine surgeries. Use of high speed drills, decompression for ossification of the posterior longitudinal ligament and spine surgery revision procedures are associated with an increased risk for incidental durotomies. Minimally invasive spine surgery is at least as safe as open techniques with respect to dural tear.Unfortunately not all dural tears can be recognized and repaired adequately primarily. Even with experienced surgeons minimal dural tears may go unrecognized during surgery.
If the dural tear is not properly closed or unrecognized; patients can present with postural headaches, vertigo, posterior neck pain, and/or stiffness, nausea, diplopia, photophobia, tinnitus, and blurred vision.The subsequent clinical problems that may arise are diverse and range in severity from clinically insignificant to life-threatening conditions such as meningitis, spinal epidural abscess, and intracranial hemorrhage. However, The most common complication of incidental durotomies in elective spine surgery is persistent CSF leak leading to pseudomeningocele and/or chronic wound drainage.
Careful and complete closure of durotomies recognized at the time of surgery is recommended. It is possible to use muscles graft, fat graft, fibrin patch, fibrin glue, blood-soaked Surgicel and gelatine matrix if necessary. Many studies recommend fascial graft secured by interrupted sutures in the treatment of larger dural defects and suggested that small dural tears can be repaired with either running locked sutures or simple sutures using a fat graft.
A Valsalva maneuver is recommended to check for the completeness of repair. This maneuver increases the intrathecal pressure and will identify incompletely repaired dural tear as made evident by cerebrospinal fluid leaking through the repaired defect.
The use of drains is controversial. Some studies advised against placement of subfascial drains because it could precipitate the formation of a durocutaneous fistula but other studies reported that the use of drain is dependent on the procedure, the size of the dural tear, the tissue quality and the quality of the repair. They found that sub fascial drains did not lead to the formation of duro cutaneous fistulas in any patient. A sub fascial drain can be used in the setting of durotomies, provided that adequate repair of the tear has been achieved and the tissue quality is satisfactory.
This systematic review aims to evaluate different methods of management of iatrogenic dural tears written in literature and to compare each of them in terms of success rate.
Seven articles were selected according to the inclusion and exclusion criteria including the published results of different methods of management of dural tears. Searching in Pub Med, Cochrane library,Google scholar,Medline, Embase and other medical databases to identify relevant studies by using these key words dural tear, incidental durotomy, cerebrospinal fluid leak, glue, and fibrin sealant. The clinical results were documented, there are varieties in the 7 studies in conclusions and results which failed to recommend single accepted method for treatment of dural tears but most of them reported that prevention is the most effective way to minimize the prevalence of cerebrospinal fluid leak by preoperative planning and meticulous surgical technique. Non operative treatment of durotomies is not usually successful and better to be treated intraoperative.There is no difference in the way of management of dural tear according to level of tear (cervical,dorsal or lumbar region) or method of surgery (open or MISS) but dural tear management depends on site of tear (reachable or not),size of tear (minimal or large) and experience of surgeon (easy and applicable way of management),Therefore there is no evidence support single recommended method for dural tear management,so further studies are needed to be done.