Intradural tumor recurrence after resection of extradural metastasis: a rare but potential complication of intraoperative durotomy

Rate and fate of incidental durotomies in spine surgery

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Multidisciplinary management of spinal metastases: what the radiologist needs to know

The modern management of spinal metastases requires a multidisciplinary approach that includes radiation oncologists, surgeons, medical oncologists, and diagnostic and interventional radiologists. The diagnostic radiologist can play an important role in the multidisciplinary team and help guide assessment of disease and selection of appropriate therapy. The assessment of spine metastases is best performed on MRI, but imaging from other modalities is often needed. We provide a review of the clinical and imaging features that are needed by the multidisciplinary team caring for patients with spine metastases and stress the importance of the spine radiologist taking responsibility for synthesizing imaging features across multiple modalities to provide a report that advances patient care.

Incidence of Unrecognized Incidental Durotomy during Surgery for Malignant Spinal Tumor

Introduction

Cerebral spinal fluid leak from durotomy is a well-known risk with spinal surgeries. The aim of this study is to identify the incidence of unrecognized incidental durotomy during posterior surgery for spinal metastases and its risk factors.

Methods

Participants comprised 75 patients who underwent posterior spine surgery for spinal metastases between January 2012 and December 2016. Cases with apparent durotomy noticed intraoperatively were excluded. Unrecognized durotomy was diagnosed as the presence of wide subcutaneous fluid retention on magnetic resonance imaging at least 3 months postoperatively. For comparison, 50 patients who underwent cervical laminoplasty due to cervical spondylotic myelopathy were examined using the same method. We also examined correlations between occurrence of durotomy and patient characteristics such as age, type of tumor, location of tumor (ventral or dorsal), extent of tumor, and history of radiotherapy before surgery.

Results

Unrecognized durotomy occurred in 21 cases of spinal metastasis (26.7%) and in 1 case of cervical spondylotic myelopathy (2%), representing a significant difference between groups. Age, type of tumor, location of tumor, extent of tumor, and history of radiotherapy before surgery did not correlate significantly with occurrence of durotomy. No local trouble was observed in durotomy cases, except in one case with subcutaneous local infection.

Conclusions

The incidence of unrecognized incidental durotomy is significantly higher during surgery for spinal metastases than that during surgery for degenerative disease.

Cerebrospinal fluid leaks after spine tumor resection: avoidance, recognition and management

Post-operative CSF leaks are a known complication of spine surgery in general, and patients undergoing surgical intervention for spinal tumors may be particularly predisposed due to the presence of intradural tumor and a number of other factors. Post-operative CSF leaks increase morbidity, lengthen hospital stays, prolong immobilization and subject patients to a number of associated complications. Intraoperative identification of unintended durotomies and effective primary repair of dural defects is an important first step in the prevention of post-operative CSF leaks, but in patients who develop post-operative pseudomeningoceles, durocutaneous fistulae or other CSF-leak-related sequelae, early recognition and secondary intervention are paramount to preventing further CSF-leak-related complications and achieving the best patient outcomes possible. In this article, the incidence, risk factors and complications of CSF leaks after spine tumor surgery are reviewed, with an emphasis on avoidance of post-operative CSF leaks, early post-operative identification and effective secondary intervention.

Obstructive Hydrocephalus Due to Intraventricular Hemorrhage After Incidental Durotomy During Lumbar Spine Surgery

STUDY DESIGN

Case report and review of literature.

OBJECTIVE

To present an exceedingly rare occurrence of obstructive hydrocephalus secondary to intraventricular hemorrhage after incidental durotomy during lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Incidental durotomies are uncommon but well recognized complications associated with spine surgery. Whereas mostly considered benign with no untoward clinical sequele, it can be symptomatic and present with spinal headaches, pseudomeningoceles, wound infection, meningitis and rarely intracerebral hemorrhage.

METHODS

A 76-year-old woman underwent L3-S1 laminectomies and fusion for lumbar spondylosis and stenosis. Intraoperatively, a small incidental durotomy was encountered and primarily repaired.

RESULTS

The patient developed altered mental status on postoperative day 2. Computed tomography of the brain revealed obstructive hydrocephalus and intraventricular hemorrhage. The patient was immediately transferred to the neurosurgery intensive care unit and an external ventricular drain was placed emergently with high opening pressure. Her mental status improved immediately after cerebral spinal fluid diversion. The external ventricular drain was successfully removed after 8 days. The patient made a full recovery and was discharged in stable condition.

CONCLUSION

Obstructive hydrocephalus after intraventricular hemorrhage is an exceptionally rare but potentially life-threatening complication of incidental durotomies. Spine surgeons should be aware of this rare but serious complication.

LEVEL OF EVIDENCE

4.

Spinal metastatic lung adenocarcinoma with dural invasion and concomitant intradural and extradural components: a case report

We report the case of a metastatic lung carcinoma that had metastasized to the thoracic extradural space and penetrated the dura, resulting in a combined extra and intradural spinal tumour. To our knowledge this is the first such report of a metastatic lung adenocarcinoma demonstrating direct dural invasion.