![]() Add a graft if necessary or use a fat plug to make a water tight seal around the hole and/or around the sutures.Īs you might expect, smaller tears (pinhole size) are easier to manage. Stitch the tear carefully through all three layers. The surgeon is advised to keep the area well-lit (e.g., use a head lamp and an operating microscope) and dry (e.g., stop any bleeding or leakage of cerebrospinal fluid). The authors offer several guiding principles for dural tear repairs. The smaller the tear, the better the expected results. Once a tear occurs, the surgeon makes every effort to repair it as quickly as possible. And the ossification mentioned can be sharp enough to erode through the dura over time.ĭuring the dural repair procedure, the surgeon will do everything possible to avoid puncturing this delicate structure. For example, bone spurs, cysts, and narrowing of the spinal canal are typical effects seen in the older adult's spine. Other degenerative effects of aging can compromise the dura. When the surgeon must cut through the previous scar (now altered by adhesions), the risk of dural tears increases as well. Scar tissue (adhesions and fibrosis) make it more difficult for the surgeon to see anatomic landmarks used to guide the procedure. In the lumbar spine (low back), it's more likely to be ossification of the ligamentum flavum (another supportive spinal ligament).Īnother risk factor is previous spinal surgery. In the cervical spine (neck), ossification of the posterior longitudinal ligament (OPLL) increases the risk of dural tears. Trying to cut through this tough ligament to get to the spine can results in a tear of the underlying dura. Ossification refers to tiny bits of bone infiltrating the soft tissue. In particular, a condition known as ossification of the ligaments is a big risk factor. Older adults who have developed stiffening of the spinal ligaments are at increased risk for intraoperative dural tears. So, who's at greatest risk for this complication? Naturally, anyone who is having spine surgery. If such an event occurs, then the plan of care shifts toward management of the problem. The plan of care must include prevention of dural tears. The surgeon must also know what puts patients at an increased risk of dural tears. But the surgeon does in order to make a successful repair. The average patient doesn't really need to know the ins and outs of spinal anatomy. Outside the dura are the arachnoid, denticulate ligament, subarachnoid space, and pia mater. Between the vertebra (spinal bone) and dura is the epidural space. ![]() The protective coverings around the spinal cord are equally complex. ![]() Besides the three-layer dura and cerebrospinal fluid, there are structures and layers such as the transverse sinus, tentorium cerebelli, cistern, and subarachnoid space. ![]() Three intricate drawings are provided to show the various layers of tissue and fluid that surround the brain and the spinal cord. In this article, spinal surgeons review the complex anatomy of the dura mater and cerebrospinal fluid, point out risk factors (who is most likely to have a tear of this type), and guide surgeons through the intricate process of performing a dural repair. Patients are fully informed up front (before surgery) about the risk of a dural tear and the fact that if a dural tear occurs, a second surgery to repair the tear may be needed. If that happens, watch out! Major headache, nausea, and light sensitivity can develop after surgery.īecause dural tears are common during spinal surgery, the surgeon usually makes sure the patient understands the risk and the side effects of this complication. And if all three layers are torn, then the cerebrospinal fluid (CSF), a plasma fluid that cushions the brain and spinal cord can leak out. Any time surgery is done on the spine, there is a risk that the dura will get torn or damaged. Spinal surgeons and patients having spinal surgery are affected most by this discovery. Thanks to the invention of the electron microscope, it is possible to magnify tissues enough to see the finest detail. Even what appears to be a single layer of covering around the spinal cord and brain (the dura) has three layers. There's nothing simple about any part of the human body. Spinal Surgeons Offer Guidelines for Prevention and Management of Dural Tears ![]()
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