Intracranial Hemorrhage Following Incidental Durotomy During Spinal Surgery

Abstract

Unintentional durotomy is a frequent complication of spinal surgical procedures, with a rate as high as 17%1-5. With appropriate management, the long-term outcomes for patients who had an unintended durotomy were no different from those for patients who underwent a similar surgery without complications6,7. A small percentage of patients with unintentional durotomy sustain intracranial hemorrhage, likely due to an alteration in intradural hydrostatic dynamics caused by cerebrospinal fluid hypovolemia3,4,8,9. Despite the gravity of this complication, to our knowledge, only six cases have been previously documented3,8-11. All neurosurgeons and orthopaedic surgeons at a large tertiary care center associated with a major university were solicited to identify cases of intracranial hemorrhage following incidental durotomy that occurred during the period of 1996 to 2006. The purpose of this report is to describe the four identified patients who sustained intracranial hemorrhage following an unintentional durotomy during posterior thora-columbar spinal surgery and to discuss the importance of our findings. The patients were informed that data concerning the case would be submitted for publication, and they consented. CASE 1. A seventy-seven-year-old man with a history of ankylosing spondylitis and a daily intake of 325 mg of aspirin presented with a thoracic kyphosis of 110° that impaired his ability to perform activities of daily living. He was brought to the operating room for posterior arthrodesis and instrumentation from T11 to S1 as well as L2 pedicle subtraction osteotomy. During posterior dissection, a dural tear was made, resulting in a substantial loss of cerebrospinal fluid. The dura was absent at the apex of the deformity and was friable elsewhere. After an intraoperative neurosurgical consultation was obtained, the dural rent was covered with DuraGen (Integra LifeSciences, Plainsboro, …