Table 5.

Showing several critical steps resulting in dural injury during spine surgery and strategies for prevention.

During exposure	Cause	Avoidance
High grade spondylolisthesis	Due to the stretched and taut ligamentum flavum	Care while using cautery tips in the inter-laminar area and use of cautery only over bony surfaces
Congenital spinal disorders	Altered bony anatomy	Proper planning with adequate pre-operative imaging
Revision surgeries	Loss of normal bony structures	Careful visualization of the bony defects in pre-operative imaging Use of operating microscope intra-operatively
During Decompression	Cause	Avoidance
Severe canal stenosis	Loss of epidural fat and thinned out dura, less space available for the passage of spinal instruments	Use of high speed burr and osteotomes, use of appropriate size rongeurs
Ossified ligamentum flavum/posterior longitudinal ligament	Adhesions to the dura, ossified dura	Avoid removing the calcified part adherent to the dura and allowing the flake to float, Pre-operative identification of signs of dural calcification like ‘double dural sign’ and extra precautions while exposure
Calcified disc (Fig. 2)	During retraction of thecal sac	Perform wide decompression of the canal before retraction of neural structures
Infective spondylodiscitis	Infected granulation tissue causing adhesions and dural thinning	Judicious use of spinal instruments
Complex spinal Deformity	Proximity of the thecal sac to the bony elements on the concave side of the deformity near the apex	Use of ultrasonic bone scalpel and forceps for bone removal
During instrumentation	Cause	Avoidance
Deformity surgeries	Smaller pedicle morphology	Selecting the appropriate pedicle for screw placement including proper screw size and including other techniques of fixation including sub-laminar wiring
Cage placement (especially in revision spine surgeries)	Retraction of thecal sac	Increase the bony window for cage placement rather than over retraction of the thecal sac