Management of Dural Tears in Spine Surgery: A Worldwide Survey of Current Practices and Complications

Abstract

Study Design

Cross-sectional survey.

Objectives

To determine the prevalence and predictors of incidental durotomy (ID) among AO Spine surgeons globally, and assess current management strategies and associated complications.

Methods

An electronic questionnaire was distributed to 937 AO Spine surgeon members in October-November 2024, to collect data on surgeon demographics, work characteristics, experience with ID, and preferred management techniques. Logistic regression identified predictors of frequent IDs (>5% of surgeries). Significance was set at P ≤ 0.05.

Results

Surgeons reported ID frequencies ranging from 1% to >20%. Overall, 12% reported frequent IDs. Longer surgical experience (OR = 0.406, P = 0.031) was protective, while working in a public/ governmental hospital (OR = 1.775, P = 0.023) was a risk factor. Medium-sized IDs (1-10 mm) were most common in lumbar surgery (52.2%). Sutures and sealants were commonly used for medium and large tears. Prolene sutures (76.5%) and autologous grafts (53.8%) were preferred. Subfascial drains without suction were frequently used. Management of large and medium tears commonly included 48 and 24 hours of bed rest, respectively. Immediate ambulation was most frequent for small tears. Most surgeons (79.2%) reported occasional or rare complications from dural tears, with a significant association with dural graft repair (OR = 1.946,P < 0.001). Disclosure of IDs to patients was nearly universal (97.3%).

Conclusion

The study highlights the frequency with which incidental durotomy occurs globally during spinal surgery. Longer surgical experience was a protective factor of frequent ID, while working in a public/ governmental hospital was a risk factor. Standardized protocols for small tears or guidelines for deciding between repair and non-repair are recommended.

Introduction

One of the most frequent side effects of spine surgery is incidental durotomy (ID). Depending on the kind of surgery and its complexity, the incidence reported in the literature ranges from 1 to 17%.^1,2 The frequency of dural damage associated with spinal surgery was 5.8%, according to a meta-analysis of 23 studies. ³ Two commonly known risk factors associated with increased dural rips are revision procedures and dural calcifications/adhesions. Devastating side effects, such as delayed wound healing, surgical site infection, pseudo-meningocele formation, arachnoiditis, and generally poor surgical results, can arise from prolonged cerebrospinal fluid (CSF) leakage caused by dural injuries.^4-6 Dural rips can occasionally result in significant medico-legal issues as well as long-term clinical aftereffects.^7,8 Only a few studies, if any, have found that patients with appropriately identified and repaired rips do not experience an increase in perioperative morbidity or complications.

A systematic review and meta-analysis of 49 papers on managing unintentional dural rips during spine surgery found that the overall failure rate for spinal dural repair, irrespective of treatment modality, was 6.1%. ⁹ Therefore, in practical practice, dural repair materials should be replaced regularly. ¹⁰ A questionnaire was administered to members of the Canadian Neurological Surgical Society to explore methods of closure of iatrogenic durotomy, showed areas of uncertainty about iatrogenic dural tear management, and disagreement regarding management of anterior and nerve root tears, pinhole-sized tears in any location of the spine, and whether patients should be admitted to hospital or should be on bed rest following a pinhole-sized dural tear. This study recommended a robust comparative research study of dural repair strategies. ¹¹ Thus, several unanswered questions remain concerning proper intra- and postoperative care and consequences after dural damage. Therefore, the purpose of this study was to determine the prevalence of frequent dural tears as reported by AO spine surgeons around the world, as well as to identify the predictors of frequent dural tears, describe current surgical practices and management strategies for spinal dural tears, and list the complications that arise after an incidental dural injury.

Methods

AO Spine represents a premier global academic community dedicated to advancing education and research in spine care. A cross-sectional electronic questionnaire survey was conducted among spine surgeon members of AO Spine across various AO regions over two months in October and November 2024. All active on-duty surgeons at the time of the survey were eligible for inclusion. A total of 937 surgeons submitted valid, completed questionnaires. Questionnaires with incomplete responses or missing data were excluded.

Data Collection

An online survey generator created a web-based, cross-sectional survey informed by a comprehensive literature review and expert insights.^12,13 A panel of experts performed a preliminary screening through consensus, followed by testing an initial version of the questionnaire on a pilot sample of 5 Orthopedic surgeons and 5 Neurosurgeons with diverse years of experience to address ambiguity, confirm comprehension, and assess completion time. In response to their feedback, certain questions were rephrased to enhance clarity. In developing the final questionnaire, we assessed the logical arrangement of items and the anticipated relationships between responses to ensure overall coherence. The tool demonstrated strong internal consistency, evidenced by an overall Cronbach’s alpha of 0.83. This survey was reviewed and approved by the AO Spine Degenerative Knowledge Forum. The e-questionnaire comprised three sections designed to gather data on demographics, experiences with spinal dural tears, and preferred management techniques,^11,13-15 as outlined below:

Section (1) encompasses work-related characteristics that examine the nature of participants’ responsibilities. Enquiries concerning the work environment, spine practice community, workload volume (including estimated population served, specialty—orthopedics or neurosurgery, years of experience, surgical caseload, workdays per week and hours per operational day), and overall workload level were incorporated.

Section (2) provides information regarding incidental durotomy. Enquiries regarding the incidence of durotomy includes categories of infrequent (<1% of surgeries), moderate (1–5%), and frequent (>5% of surgeries). Additionally, considerations involve the complication rate, types of complications, and the extent of disclosure to patients, categorized as always, sometimes, or never. Dural tears were categorized as small (<1 mm), medium (1 to 10 mm), and large tears (>10 mm) based on surgeons’ subjective estimates.

Section (3) Management of dural tear. The enquiries focused on management types (sutures, sealant, artificial dural patch, tissue graft, drain), materials utilised (Silk, Prolen, Gortex, others), sealant classifications (fibrin glue, synthetic, others), patch categories (autologous graft, absorbable collagen, dura substitute, others), drain types (subfascial under negative pressure, subfascial without suction, subcutaneous drain), and postoperative protocols (immediate ambulation or the following day, bed rest for 24 hours, 48 hours, or longer).

This study was conducted electronically from October to November 2024, involving three contacts (including two reminders), which yielded an 82% response rate (Of 1143 surgeons contacted, 937 surgeons responded).

Data Analysis

Data analysis was conducted using SPSS software version 28 for data entry and analysis. Descriptive statistics were employed, including mean score, standard deviation, frequency, and percentages of all independent variables. Analytic statistics were utilized to examine the associations between the frequency of dural tears and work-related characteristics. The Pearson chi-square and Chi-square tests for linear trend were employed for qualitative data analysis. Univariate analyses investigated the associations between frequent dural tears (occurring in more than 5% of the surgeries performed by the surgeon) and potential risk factors. Logistic regression analysis was conducted to identify the key predictors of frequent dural tears, incorporating only those independent variables that demonstrated significance in the univariate analyses (Years of experience, training background, and practice setting). Another logistic regression analysis was conducted to identify the association between different ID repair techniques and post-ID complications, adjusting for all independent variables that showed significant associations with complications in univariate analyses (region, practice setting, specialty, and years of experience). Odds ratios and their corresponding 95% confidence intervals were calculated to evaluate the strength of association of potential risk factors with frequent dural tear and its complications. Significance was defined as P-values of ≤.05.

Results

Table 1 presents the demographic and work-related characteristics of the surgeons involved in the study. Orthopaedic surgeons represented 62.9% of the total surgeon population, with degenerative conditions (93.1%) and trauma/spinal cord injury (68.3%) being the predominant subspecialties. Surgeons’ annual surgical case volume varied, with 30.4% performing fewer than 100 cases per year and 3.5% exceeding 500 cases yearly. Their years of experience ranged from less than 5 years (28.2%) to more than 20 years (21.4%). Most surgeons (84.7%) were board-certified, while the remaining 15.3% completed residencies in various specialties. Approximately 63.9% of surgeons obtained fellowships in the field, with post-fellowship experience varying from less than 5 years (36.7%) to more than 20 years (16%).

Table 1.

Demographic and Work-Related Characteristics of the Study’s Spine Surgeons

Characteristics	No.	%
Region
North America	113	12.3
Latin America	155	16.9
Europe & Southern Africa	278	30.3
Middle East & Northern Africa	119	13.0
Asia Pacific	252	27.5
Practice Setting
Academic/university hospital/affiliate	390	42.1
Private hospital	306	33.1
Public hospital or Government/Military hospital	214	23.1
Others	16	1.7
Specialty
Orthopedics	582	62.9
Neurosurgery	329	35.6
Others	14	1.5
Subspecialty @
Degenerative	860	93.1
Deformities	420	45.5
Trauma/Spinal cord injury	631	68.3
Tumor	464	50.2
Others	43	4.7
Surgical case volume/year
<100	281	30.4
100 - 200	350	37.8
201 - 300	183	19.8
301 - 400	54	5.8
401 - 500	26	2.8
>500	32	3.5
Years of experience
<5	260	28.2
5 - 10	197	21.3
11 - 15	162	17.6
16 - 20	106	11.5
>20	198	21.4
Training background
BC in neurosurgery	270	29.2
BC in orthopedic surgery	494	53.4
BC in trauma surgery	21	2.3
Residency in neurosurgery	51	5.5
Residency in orthopedic surgery	49	5.3
Residency in trauma surgery	5	0.5
Others	36	3.8
Fellowships
Yes	592	63.9
No	334	36.1
Years post-fellowships b
<5	214	36.7
5 - 10	127	21.8
11 - 15	93	16.0
16 - 20	56	9.5
>20	93	16.0

Abbreviations: BC, Board-certified.

^@ categories are not mutually exclusive.

^b data for only those who receive fellowships.

Table 2 indicates that the frequency of incidental durotomy reported by surgeons varied from 1% (31.7%) to over 20% (0.3%) across their careers, with the most common frequency being 1%–5% (56.3%), resulting in an overall prevalence of 12% for frequent dural tears. Only 1.8% of surgeons indicated that they experienced more than 10% throughout their careers. Less than one-third of surgeons (31.3%) reported extending postoperative antibiotic coverage for a few days. Almost all surgeons indicated that they inform patients about incidental tears, with 74.7% doing so consistently and 22.6% occasionally. Figure 1 shows the rate of different complications of IDs. Pseudomeningocele was identified as the most common complication of incidental durotomy (59.9%), followed by CSF fistula (47.7%), meningitis (19.8%), arachnoiditis (13.2%), and epidural abscess (7.3%).

Table 2.

Frequency of Incidental Durotomy and Disclosure of Tear

	No	%
Frequency of incidental durotomy (%)	No	%
- Less frequent (<1%)	273	31.7
- Average frequency (1 – 5%)	485	56.3
- Frequent (>5%)	104	12.0
◦ (6 – 10%)	88	10.2
◦ (11 – 20%)	13	1.5
◦ (>20%)	3	0.3
What to do in the case of an incidental durotomy?
- Extend your postoperative antibiotic coverage for a few days	266	31.3
- Do not change the antibiotics protocol for a dural tear	571	67.1
- Others	14	1.6
Disclosure of durotomy
- Yes, all the time	633	74.7
- Yes, sometimes	191	22.6
- Never	23	2.7

Figure 1.

The Rate of Different Complications of Incidental Durotomy

Table 3 indicates that medium-sized durotomies (1-10 mm) were the predominant type observed during lumbar spine surgery, accounting for 52.2%, while small-sized durotomies ranked second at 46.7%. Sutures and sealants were utilized in the majority of medium-sized (85.9% and 63.9%) and large-sized (87.8% and 64.1%) tears, as well as in nearly half of small-sized (46.5% and 53.1%) tears. No interventions were performed for 17.6%, 2%, and 1.2% of small, medium, and large-sized tears, respectively.

Table 3.

Management of Dural Tear According to Tear Size

	Small (<1 mm)		Medium (1 – 10 mm)		Large (>10 mm)
	No	%	No	%	No	%
Type of management @
Nothing	151	17.6	17	2.0	10	1.2
Sutures	400	46.5	733	85.9	750	87.8
Sealant	457	53.1	545	63.9	547	64.1
Artificial dural patch	215	25.0	313	36.7	447	52.3
Tissue (fascia/muscle/fat) graft	225	26.2	302	35.4	423	49.5
Subdural (intrathecal) drain	21	2.4	38	4.5	107	12.5
Type of drain @
Subfascial drain under negative pressure	137	16.2	109	13.0	91	10.8
Subfascial drain with no suction	325	38.4	402	47.7	430	51.2
Subcutaneous drain	58	6.9	81	9.6	90	10.7
No drain	360	42.5	280	33.3	263	31.3
Postoperative management @
Ambulate immediately or the day after	327	38.1	133	15.6	82	9.7
Keep in bed for 24 hours	303	35.3	333	39.0	253	29.9
Keep in bed for 48 hours	174	20.3	261	30.6	288	34.0
Keep in bed for >48 hours	78	9.1	151	17.7	246	29.0

^@ categories are not mutually exclusive.

The subfascial drain without suction was the predominant type of drain utilised across all sizes of dural tears, with usage rates of 38.4%, 47.7%, and 51.2% for small, medium, and large tears, respectively.

The predominant management approach for large tears involved 48 hours of bed rest (34%), whereas 24 hours was the most prevalent strategy for medium-sized tears (39%). Immediate ambulation or ambulation the following day was the most common management approach for small-sized tears (38.1%), while it was the least common for large-sized tears (9.7%).

Figure 2 shows the repair techniques according to different geographical distributions. Patch and sealant were more frequently used in ID repair in North America, while they were the least frequently used in the Middle East and North Africa (P < .001). There was no significant geographical difference in the use of sutures in repair (P = .32)

Figure 2.

Repair Techniques of Incidental Durotomy in Different Geographical Regions

Table 4 indicates that fibrin glue was the most commonly used sealant, accounting for 69%, while synthetic sealants comprised 38.3%. Most surgeons used Prolene as the suture material. Most surgeons used autologous grafts (fat/muscle/fascia) as the primary type of patch, followed by absorbable collagen and dura substitute patches.

Table 4.

Types of Suture Materials, Sealants, and Patches Used in Dural Tear

	No	%
Suture material used @
- Silk	145	15.5
- Prolen	655	69.9
- Gortex	60	6.4
- Others	77	8.2
Sealant type @
- Synthetic sealant	321	38.3
- Fibrin glue	578	69.0
- Others	58	6.9
Patch type @
- Autologous graft (fat/muscle/fascia)	457	53.8
- Absorbable collagen (Hemopatch, Tachosil, etc.)	370	43.6
- Dura substitute patches	291	34.3
- Others	22	2.6

^@ Categories are non-mutually exclusive.

Table 5 indicates that the prevalence of frequent dural tears exceeding 5% of surgeries was significantly higher among surgeons employed in public and governmental hospitals compared to those in private hospitals and academic institutions (OR = 1.95, 95% CI 1.13-3.37, P = .015), as illustrated in Figure 3. Even after adjusting for confounders, this association between employment in public and governmental hospitals and a higher rate of frequent tears remained significant (OR = 1.775, 95% CI 1.003-3.142, P = .023)*.

Table 5.

Prevalence of Frequent Dural Tears (>5% of Surgeries) and Associated Factors

	No	Prev. (%)	X2	P-value	cOR (95%CI)	cOR (95%CI)
Region
Asia Pacific	233	29 (12.4)	5.05	0.28	1
North America	108	13 (12.0)	0.011	0.92	0.96 (0.48-1.94)
Latin America	142	10 (7.0)	2.77	0.10	0.53 (0.25-1.13)
Europe & Southern Africa	264	34 (12.9)	0.021	0.89	1.04 (0.61-1.77)
Middle East & Northern Africa	107	17 (15.9)	0.74	0.39	1.33 (0.70-2.54)
Practice Setting
Private hospital	278	26 (9.4)	(6.01)	(0.05)	1
Academic/university hospital/affiliate	367	44 (12.0)	1.14	0.29	1.28 (0.81-2.03)	1.182 (0.690-2.024)
Public hospital or Government/ Military hospital	203	34 (16.7)	5.88	0.015*	1.95 (1.13-3.37)*	1.775 (1.003-3.142)*
Specialty
Neurosurgery	307	29 (9.4)			1
Orthopedics	543	73 (13.4)	2.97	0.085	1.49 (0.95-2.35)
Subspecialty
-Degenerative vs others	807	94 (11.6)	2.07	0.15	1.56 (0.86-2.82)
-Deformities vs others	394	49 (12.4)	0.094	0.76	1.07 (0.71-1.61)
-Trauma/Spinal cord injury vs others	585	72 (12.3)	0.10	0.75	1.08 (0.69-1.67)
-Tumor vs others	434	51 (11.8)	0.081	0.78	0.94 (0.63-1.42)
Surgical case volume/year
>200	279	31 (11.1)			1
≤200	583	73 (12.5	0.34	0.55	1.13 (0.76-1.67)
Years of experience
<5	233	45 (19.3)			1
5 - 10	183	20 (10.9)			0.51 (0.29-0.90)*	0.568 (0.315-1.025)
11 - 15	289	15 (9.7)			0.45 (0.24-0.84)*	0.526 (0.2741-1.011)
≥16	236	24 (8.3)	16.41@	<0.001*	0.38 (0.22-0.64)*	0.406 (0.230-0.719)*
Training background
Board certified	252	19 (7.5)			1
Residency	468	16 (13.0)	5.01	0.025*	1.73 (1.06-2.83)*	1.082 (0.576-2.035)
Fellowships
Yes	558	65 (11.6)			1
No	304	39 (12.8)	0.26	0.61	1.10 (0.76-1.60)

Abbreviations: Prev, prevalence; X², Pearson Chi-square test; cOR, crude odds ratio; aOR, adjusted odds ratio.

@ Chi-square for linear trend test was applied.

*--statistically significant.

Figure 3.

Rate of Frequent Incidental Durotomy according to Surgical Experience, Setting, and Training Background

Surgeons with five or more years of experience in spine surgery exhibited a higher prevalence of frequent tears than their counterparts with less than five years of experience. The prevalence of frequent tears decreased significantly from 19.3% in the less experienced group to 10.9%, 9.7%, and 8.3% in the groups with 5-10 years, 11-15 years, and 16 years or more of experience, respectively (X² _LT = 16.41, P < .001), as illustrated in Figure 3. After adjusting for confounders, longer surgical experience of 16 years or more was significantly associated with a lower rate of frequent ID (OR = 0.406, 95% CI 0.230-0.719, P = .031). Regarding the surgeon’s training background, individuals with residency training reported a higher prevalence of frequent tears than those board certified (13.0% vs 7.5%, OR = 1.73, 95% CI 1.06-2.83, P = .025), as illustrated in Figure 3. However, after adjustment, this significant association disappeared.

Table 6 shows the results of the association of post-incidental durotomy complication rate with different repair techniques, adjusting for region, practice setting, specialty, and years of experience. The use of dural graft for ID repair was associated with a higher rate of complications (OR = 1.517, 95% CI 1.048-2.194, P = .027). Higher rates of ID complications were also associated with the following: surgeons working in Latin America (P < .001), and Europe & North Africa (P = .012), surgeons in the private sector (P = .002), and orthopedic surgeons (P < .001).

Table 6.

Association of Incidental Durotomy Repair Techniques With the Rate of Post-incidental Durotomy Complications, Adjusting for Some Potential Confounders

Predictors of complications	B	S.E.	P-value	aOR (95% CI)
Region (Asia Pacific#)			.001
North America	.358	.318	.260	1.431 (.768-2.666)
Latin America	1.281	.334	.000*	3.601 (1.873-6.924)
Europe & Southern Africa	.632	.252	.012*	1.882 (1.148-3.085)
Middle East & Northern Africa	.012	.284	.966	1.012 (.580-1.767)
Practice setting (Academic#)			.006
Private	.684	.218	.002*	1.983 (1.294-3.037)
Public/Governmental	.244	.244	.317	1.276 (.791-2.059)
Specialty (Orthopedic# vs Neurosurgery)	−1.102	.228	<0.001*	.332 (.212-.519)
Years of experience (<5 yrs#)			.561
5-10 yrs	.025	.257	.923	1.025 (.619-1.698)
10-15 yrs	.193	.287	.500	1.213 (.692-2.127)
≥16 yrs	.315	.244	.198	1.370 (.848-2.211)
Repair technique Suture	.159	.434	.713	1.173 (.501-2.744)
Sealant	.333	.210	.113	1.395 (.924-2.106)
Patch	.161	.191	.398	1.175 (.808-1.709)
Tissue graft	.417	.188	.027*	1.517 (1.048-2.194)
Drain	.194	.304	.524	1.214 (.669-2.204)
Extend postoperative antibiotics coverage	.361	.213	.089	1.435 (.946-2.178)
Constant	.413	.546	.449	1.512

Abbreviations: BC, board-certified; Res, residency; B, coefficient of determination; SE, standard error; aOR, adjusted odds ratio; CI, confidence interval.

# reference category.

* statistically significant.

Discussion

Incidental durotomy is a recognised complication of spine surgeries, occurring with greater frequency in surgical practice due to the rising incidence of both primary and revision spine procedures globally.¹⁵¹¹ The overall incidence of dural injuries in a prior study was 2.3%, with a higher incidence rate of 16.6% observed in revision surgery cases, ¹⁶ which aligns with the current literature.^17-20 In this study, surgeons reported the frequency of dural tears to range from 1% to over 20% throughout their careers, with the majority indicating a 1-5% (56.3%). This figure would align with the frequency of 5.8% reported in a meta-analysis of 23 studies. ³ Only 1.8% of surgeons indicated experiencing more than 10% durotomies over their careers, whereas a prior study found that 70% of durotomies were reported by 20.4% of surgeons. ²¹

In our study, most surgeons indicated experiencing one or more complications from dural tears. Pseudomeningocele was the most common complication of incidental durotomy, occurring in more than half of the cases, followed by CSF fistula, meningitis, arachnoiditis, and epidural abscess. In a prior study, ²¹ CSF fistulas occurred in 0.025% of all patients. Radiculopathy with dysesthesia was reported by 12.4% of surgeons, sensory loss by 3.4%, and motor weakness by 2.2%. Higher rates of ID complications were associated with orthopedic surgeons, surgeons working in Latin America, Europe & North Africa, surgeons in the private sector, and with ID repair using dural graft.

It has been reported that more than half of surgeons did not engage in any repair or closure, while 40% utilized sealants, and 7.8% attempted endoscopic sutures. ²¹ In our study, no interventions were performed for 17.6%, 2%, and 1.2% of small, medium, and large-sized tears, respectively. Sutures and sealants were utilized for most medium-sized and large-sized tears, and nearly half of the small-sized tears. A survey of Canadian spinal surgeons ¹¹ revealed a lack of consensus on closure methods for pinhole-sized tears, with a notable trend towards sealant fixation at 36.7%. In our study, medium- and large-sized tears are primarily closed using sutures and sealant. Patch and sealant were more frequently used in ID repair in North America, while they were the least frequently used in the Middle East and North Africa. There was no significant geographical difference in the use of sutures in repair.

Traditionally, direct repair has been considered the optimal approach for managing dural tears. Suture materials such as monofilament polypropylene and braided nylon are utilized for their hydrostatic strength.^22,23 In this study, fibrin glue emerged as the predominant sealant, accounting for more than half of the cases, while synthetic sealants comprised one-third. Synthetic grafts have emerged as an alternative to autologous fat and muscle grafts for dural repair. ¹⁶ The identified benefits encompass the capacity to establish a secure seal and the potential for use in dural defects of various irregular shapes and sizes. ¹⁶ In our study, using a dural graft for ID repair was associated with a higher rate of complications. The patch effect, dead space-filling effect, adherence, and interstice-filling effect are significant properties of these substitutes. ²⁴ Prolene was utilised as the suture material by most surgeons, accounting for two-thirds of usage. Most surgeons utilised autologous grafts (fat/muscle/fascia) as the primary type of patch, followed by absorbable collagen and dura substitute patches. In a prior investigation, ²¹ DuralSeal emerged as the predominant brand of commercially available sealant, accounting for over one-third of usage. Additional sealants utilised included Tisseal, Evicel, and generic sealants.

In a clinicopathological study of synthetic dural grafts conducted by Narotam et al, ²⁵ the collagenous matrix demonstrated advantages via its chemotactic interaction with dural fibroblasts. A retrospective review of 110 patients indicated that collagenous grafts effectively sealed the tear in over 95% of cases. ²⁶ Grannum et al ²⁷ found that non-suturing repair techniques, such as autologous and synthetic grafts, effectively address dural tears in lumbar spine surgery, with no reported adverse events or complications. In this study, the most frequently utilized patch was an autologous graft of fat/muscle or fascia, accounting for 53.8%, followed by an absorbable collagen patch at 43.6%. The study revealed no significant differences in complication rates among the different dural repair techniques. This aligns with findings from other studies.^16,28 Therefore, a patch may be utilized solely as a repair option when there are constraints regarding primary dural repair, such as the defect’s location and configuration. A prior study involving Canadian spinal surgeons indicated that Tisseal was favored by most of the respondents compared to other sealants. ¹¹

The literature lacks a clear consensus on the use of drains. A limited number of authors have advocated for the routine placement of drains in all patients with dural tears.^29-31 In contrast, several other studies^18,32 have supported the decision against the placement of drains, as the epidural hematoma typically serves as a tamponade for the dural rent. Additionally, drains may introduce a risk of contamination and the potential development of a duro-cutaneous fistula at the drain site. Our study found that one-third to one-half of surgeons reported not placing a drain for varying-sized tears. The predominant type of drain utilized for all dural tear sizes was a subfascial drain without suction. In a prior study, ¹⁶ the authors found no significant differences in immediate postoperative complications or infection rates between groups with and without drain placement. The decision to place drains should be based on individual cases, dural repair adequacy, and the surgical site’s anatomical dead space.

Traditionally, literature has advocated for prolonged bed rest to prevent persistent dural leaks and decrease hydrostatic pressure at the site of dural tear repair. ²⁴ Complications of prolonged immobilization in patients with dural tears have been documented. ³³ Previous studies indicated no significant differences in complication rates between early (<24 h) and late (>24 h) mobilization in patients with dural tears. A systematic review indicated that early mobilization significantly reduced complications such as headaches, tinnitus, nausea, and vomiting.^34,35 In our study, 48 hours of bed rest was the predominant management strategy for large tears, whereas 24 hours was the most frequently utilized approach for medium-sized tears. Immediate ambulation or ambulation the following day was the most common management approach for small-sized tears, while it was the least common for large-sized tears. One-half of surgeons advised 48 hours of bed rest, while 40.4% suggested less than 24 hours. ²¹ In a prior investigation involving Canadian spinal surgeons, it was found that, aside from pin-hole-sized tears, most respondents advised bed rest for a minimum of 24 hours in cases of medium and large dural tears. ¹⁵

Before a procedure, the surgeon must communicate the advantages and possible risks associated with the surgical treatment to the patient. Surgeons must maintain transparency with patients regarding their care to prevent confusion and potential self-incrimination as complications occur. ³⁶ In our study, almost all surgeons indicated that they disclose the occurrence of incidental tears to patients at all times, or they do so sometimes. An orthopedic surgery department established a confidential, real-time reporting system for intraoperative adverse events and conducted analyses of these events during structured morbidity and mortality conferences. ³⁷ While physicians believed this process enhanced patient care, it led to a notable rise in reported error rates, which, as indicated by the authors, may have contributed to diminished quality ratings for the department. ³⁷ Our study showed that longer surgical experience was a protective factor for frequent ID. This could be attributed to technical expertise or case selection. Natural tension exists between the surgeon’s objective of elucidating the potential causes of errors and the need to empathize with the patient, their family, or other carers while mitigating legal risks. ³⁶ In our study, public/governmental hospitals increase the risk of frequent IDs, perhaps due to resource constraints or patient complexity.

Strengths and Limitations

This questionnaire differs from prior assessments by being a detailed survey encompassing work-related characteristics, enquiries regarding the frequency of durotomy, complication rates, types of complications, and disclosure of tears. It also includes questions about management strategies, materials, sealant types, patch types, drain types, and postoperative management practices. This study linked the kind of repair to the size of durotomy, an essential aspect for advancing future research. The sample size is substantial, encompassing diverse spine surgeons across various subspecialties, including neurosurgeons and orthopedic surgeons from multiple global regions. The response rate is satisfactory, allowing for a thorough examination of the uncertainties associated with managing dural tears. This would enable the generalization of our study’s conclusion.

The study presents several limitations. Methodological differences in studies across disciplines, predominantly retrospective, constrain comparisons within the general population. The anonymous nature of the survey limited the ability to compare responder and non-responder populations, thereby introducing the potential for selection bias. The reliance on self-reported data may introduce recall or social desirability bias, as surgeons might underreport complications or overreport adherence to best practices.

Future studies could mitigate this limitation by targeted follow-ups or demographic comparisons. This cross-sectional study cannot establish causality; thus, the causal relationship between the outcome (frequent dural tears) and potential risk factors such as hospital type, training background, and years of experience remains uncertain. Lastly, although the questions presented in this survey assist in pinpointing areas of uncertainty, we cannot ascertain the optimal closure methods for different types of dural tears due to the absence of individual patient data with follow-up.

Conclusion

This research employed a questionnaire to assess the prevalence of intraoperative dural tears globally among spinal surgeons and the contentious elements of their management. This study clarifies the uncertainties surrounding the management of iatrogenic dural tears. There is a lack of consensus on managing small-sized dural tears, specifically concerning the necessity of hospital admission or bed rest for patients following such an event. Standardized protocols for small tears or guidelines for deciding between repair and non-repair are recommended. However, potential barriers to their implementation, such as variations in healthcare systems and surgeon preferences, must be considered. A robust comparative research study of dural repair strategies is necessary.

The primary area of uncertainty is managing small, medium, and large dural tears. Repairs are primarily conducted using a combination of sutures and sealants. Respondents concur that a period of bed rest, along with hospital admission, is generally advisable. As tear size diminishes, consensus on optimal management decreases, with outcomes leaning towards “no repair” or sealant-only fixation for more minor tears.

Randomized controlled trials for closure techniques and longitudinal studies are recommended to assess long-term outcomes of different bed rest durations. Conducting cost-benefit analyses of different strategies would be highly beneficial, particularly considering the strain on healthcare systems, especially in pinhole-sized tears.

ORCID iDs

Sameh M. Abolfotouh https://orcid.org/0000-0001-9588-5101

Patrick C Hsieh https://orcid.org/0000-0002-7206-4842

Mostafa A. Abolfotouh https://orcid.org/0000-0003-3787-429X