Abstract
Study Design
Retrospective cohort study.
Objectives
To evaluate the national incidence and hospitalization impact of incidental durotomy following elective posterior cervical decompression and fusion (PCDF), with respect to complications, length of stay (LOS), costs, and discharge disposition.
Methods
Adults undergoing elective PCDF were identified in the 2016–2022 National Inpatient Sample. Propensity score matching paired durotomy cases with controls at a 1:5 ratio using demographic, comorbidity, hospital, and procedural characteristics. Survey-weighted comparisons and multivariable regression evaluated complications, length of stay (LOS), hospitalization costs, and discharge disposition. Statistical significance was set at P < 0.05.
Results
The weighted cohort comprised 167,995 encounters, including 2,525 (1.5%) with incidental durotomy. After matching, weighted counts were 12,625 controls and 2,525 durotomy encounters. The durotomy cohort had more complications (41.2% vs 26.5%), longer LOS (7.82 vs 4.34 days), higher hospitalization costs ($65,292 vs $41,196), and more non-routine discharge (59.0% vs 47.7%). Adjusted analyses demonstrated higher odds of complications (OR, 2.03) and non-routine discharge (OR, 1.66), as well as longer LOS (adjusted mean ratio, 1.80) and higher costs (adjusted mean ratio, 1.59; all P<0.001).
Conclusions
Incidental durotomy was coded in 1.5% of elective PCDF admissions and was associated with greater inpatient morbidity and resource utilization after matching and adjustment. These findings may inform patient counseling, perioperative planning, and anticipation of discharge support needs. Potential coding inaccuracies and residual confounding inherent to administrative data limit causal interpretation.
Keywords: Incidental durotomy, dural tear, complication, costs, National Inpatient Sample
Introduction
Over the past several decades, the number of cervical spinal fusions has dramatically increased. While posterior cervical decompression and fusion (PCDF) ultimately represents a minority of those procedures, it remains a widely utilized approach.1,2 This growth reflects an aging population and expanding surgical indications for cervical spondylotic pathology, deformity, and myelopathy, with a concurrent emphasis on durable stabilization. One clinically important adverse event of PCDF is incidental durotomy, which may lead to serious complications, including nerve root entrapment and pseudomeningocele formation.3,4 Even when managed intraoperatively, incidental durotomy can necessitate additional postoperative monitoring and interventions that prolong hospitalization and increase resource utilization.
Prior national database and multicenter studies have laid an important foundation for understanding the frequency and clinical consequences of incidental durotomy in cervical spine surgery.5-7 A large database study by Yoshihara et al linked cervical dural tears to greater inpatient morbidity and worse discharge disposition, establishing their relevance to perioperative care. 8 Other studies have demonstrated longer length of stay (LOS) and higher hospitalization costs, highlighting the importance of evaluating resource utilization alongside clinical outcomes.9,10 Differences in operative exposure and tissue planes, as well as higher-risk scenarios such as revision surgery or more adherent pathology, may further contribute to this heterogeneity and to variation in postoperative management after cerebrospinal fluid (CSF) leak.11,12 Although one prior study focused specifically on PCDF, its small sample limited the precision and generalizability of its estimates. 4 Consequently, procedure-specific estimates of the incidence, clinical sequelae, and healthcare resource utilization associated with incidental durotomy after PCDF remain limited, making it difficult to counsel patients accurately and anticipate postoperative resource needs.
Given the limited literature focused specifically on incidental durotomy in PCDF, the present study used a nationwide database to further characterize its frequency and inpatient consequences. This study aimed to: 1) characterize the national frequency of coded incidental durotomy among PCDF admissions; 2) evaluate its associations with inpatient complications and LOS; and 3) assess its associations with hospitalization costs and discharge disposition. We hypothesized that, after matching for measured patient, hospital, and procedural characteristics, incidental durotomy would remain associated with greater inpatient morbidity, longer hospitalization, higher costs, and more frequent non-routine discharge.
Methods
Data Source
This study utilized the 2016 to 2022 National Inpatient Sample (NIS), which is the largest publicly available all-payer database of inpatient encounters in the United States and is maintained by the Healthcare Cost and Utilization Project (HCUP).
Cohort Identification and Exclusions
Adult patients (≥18 years) who underwent PCDF during the index admission were extracted from the database. PCDF was identified by an exact match to ICD-10-PCS codes 0RG1071, 0RG10J1, 0RG10K1, 0RG2071, 0RG20J1, or 0RG20K1 in any procedure field (Appendix 1). Encounters were excluded if they were nonelective in nature, contained missing or implausible age, cost, or negative costs/LOS. No diagnosis-specific exclusions were applied for trauma, tumor, infection, or deformity, and revision procedures were not explicitly excluded. In accordance with HCUP privacy guidelines, cell counts with 10 or fewer encounters have been suppressed and are reported as N ≤ 10.
Patient, Hospital, and Procedure Characteristics
Demographics included age, sex, race, and zip-code income quartile. Elixhauser Comorbidity Index (ECI) was calculated as a count of Elixhauser comorbidity conditions present for each encounter, with missing indicator values omitted from the sum. Hospital characteristics included hospital bed size (small, medium, or large) and region (Northeast, Midwest, South, or West). Procedure extent was captured by a multilevel flag, which corresponded to ICD-10-PCS codes representing multilevel PCDF.
Cohort Construction
The incidental durotomy exposure was defined by the presence of ICD-10-CM codes G96.00, G96.02, G96.09, G96.11, or G97.41 in any detected diagnosis field (Appendix 1). These codes were ascertained by scanning all available diagnosis fields to minimize under-capture from code position. Encounters were then classified into incidental durotomy and control cohorts for subsequent propensity-matched and survey-weighted analyses.
Complication Definitions
Overall complication was defined as the occurrence of one or more postoperative complications, including blood transfusion, acute posthemorrhagic anemia, wound disruption, surgical site infection, dysphagia, mechanical complication, hematoma, nervous system complication, deep vein thrombosis, pulmonary embolism, myocardial infarction, cerebrovascular accident, venous thromboembolism, pneumonia, acute kidney injury, hypoglycemic episode, sepsis, or anesthesia-related complications. Incidental durotomy was not included in this composite outcome.
Cost Adjustment
Total hospital charges were converted to costs using HCUP hospital- and year-specific cost-to-charge ratios, then adjusted to 2022 U.S. dollars using Consumer Price Index multipliers.
Primary Endpoints
The primary objective of this study was to characterize clinical implications and resource utilization among patients experiencing incidental durotomy. Primary endpoints included overall complication rate, LOS, inflation-adjusted hospitalization costs, and non-routine discharge rate.
Statistical Analysis
Pre-match demographics, hospital characteristics, and procedure-related variables were compared between cohorts. A 1:5 propensity score matching approach was then performed using nearest-neighbor matching without replacement and without a caliper to balance age, sex, race, ECI, zip-code income quartile, hospital bed size, hospital region, and procedure extent. Covariate balance was assessed using absolute standardized mean differences (SMDs), with values <0.10 considered acceptable. All analyses incorporated NIS survey design elements (strata and clustering) and discharge weights, with matched analyses additionally applying MatchIt-derived weights to generate nationally representative, post-match estimates. Analyses were performed in R (version 4.4.0; R Foundation for Statistical Computing, Vienna, Austria). Chi-square tests and Student’s t-tests were used to compare categorical and continuous outcomes, respectively, with all comparisons performed using survey-weighted procedures to account for the NIS complex sampling design.
In addition, survey-weighted multivariable logistic regression was used to evaluate overall complications and non-routine discharge, while survey-weighted generalized linear models with a log link were used to evaluate LOS and hospitalization costs. The log link allowed proportional comparisons between groups while ensuring positive predicted means. These models assume that the included covariates adequately describe the relationship with each outcome. Survey-based standard errors account for the sampling design but do not eliminate unmeasured confounding. All models included incidental durotomy as the primary exposure and adjusted for age, sex, race, ECI, ZIP code income quartile, hospital bed size, hospital region, and procedure extent.
Results
Cohort Identification and Baseline Characteristics (Pre-Matching)
A total of 167,995 PCDF encounters were identified, including 165,470 (98.5%) controls and 2,525 (1.5%) cases with incidental durotomy. Prior to propensity score matching, the cohorts were similar with respect to age (62.84 ± 0.07 vs 62.46 ± 0.52 years; P = 0.472), race distribution (P = 0.286), sex (P = 0.671), income quartile (P = 0.422), hospital bed size (P = 0.565), hospital region (P = 0.415), and levels fused (P = 0.186). However, comorbidity burden differed between groups, with higher ECI in the incidental durotomy cohort (2.58 ± 0.07 vs 2.34 ± 0.01; P = 0.002; Table 1).
Table 1.
Baseline Demographic Characteristics of Patients Prior to Propensity Score-Matching
| | Control N = 165,470 (%) | Dural Tear N = 2,525 (%) | P value | SMD |
|---|---|---|---|---|
| Age (mean ± SD) | 62.84 ± 0.07 | 62.46 ± 0.52 | 0.472 | 0.0321 |
| Race | 0.286 | | ||
| White | 127,490 (77.0) | 1,895 (75.0) | | 0.0462 |
| Black | 21,485 (13.0) | 300 (11.9) | | 0.0341 |
| Hispanic | 9,050 (5.5) | 180 (7.1) | | 0.0645 |
| Asian or Pacific Islander | 2,920 (1.8) | N ≤ 10* | | 0.0155 |
| Native American | 940 (0.6) | N ≤ 10* | | 0.0426 |
| Other | 3,585 (2.2) | 75 (3.0) | | 0.0473 |
| Sex | 0.671 | 0.0189 | ||
| Male | 87,895 (53.1) | 1,365 (54.1) | | |
| Female | 77,575 (46.9) | 1,160 (45.9) | | |
| Income Quartile | 0.422 | | ||
| 0-25th percentile | 41,485 (25.1) | 685 (27.1) | | 0.0463 |
| 26th-50th percentile | 43,735 (26.4) | 590 (23.4) | | 0.0724 |
| 51st-75th percentile | 42,390 (25.6) | 655 (25.9) | | 0.0074 |
| 76th-100th percentile | 37,860 (22.9) | 595 (23.6) | | 0.0161 |
| Hospital Bedsize † | 0.565 | | ||
| Small | 29,400 (17.8) | 425 (16.8) | | 0.0250 |
| Medium | 38,125 (23.0) | 545 (21.6) | | 0.0354 |
| Large | 97,945 (59.2) | 1,555 (61.6) | | 0.0492 |
| Hospital Region | 0.415 | | ||
| Northeast | 31,990 (19.3) | 520 (20.6) | | 0.0312 |
| Midwest | 40,345 (24.4) | 560 (22.2) | | 0.0530 |
| South | 63,160 (38.2) | 930 (36.8) | | 0.0277 |
| West | 29,975 (18.1) | 515 (20.4) | | 0.0566 |
| Levels Fused | 0.186 | 0.0617 | ||
| Single-level | 27,855 (16.8) | 370 (14.7) | | |
| Multilevel | 137,615 (83.2) | 2,155 (85.3) | | |
| ECI (mean ± SD) | 2.34 ± 0.01 | 2.58 ± 0.07 | 0.002 | 0.1370 |
N = Number; % = percentage; SD = standard deviation; SMD = standardized mean difference; ECI = Elixhauser comorbidity index. Bold values are statistically significant.
*Signifies that the count number is ≤ 10 and cannot be reported.
†Hospital bed size designated by the Healthcare Cost and Utilization Project (HCUP) based on geographic location, teaching hospital status, and number of beds.
Propensity Score Matching and Post-Matching Balance
After propensity score matching, 12,625 control patients were matched to 2,525 incidental durotomy cases. Post-matching, there were no significant differences in age (62.36 ± 0.23 vs 62.46 ± 0.52 years; P = 0.864), race (P = 0.902), sex (P = 0.909), income quartile (P = 0.986), hospital bed size (P = 0.598), hospital region (P = 0.996), or ECI (2.51 ± 0.03 vs 2.58 ± 0.07; P = 0.429), indicating good covariate balance. Fusion extent was similar between groups, although single-level fusion tended to be higher in the incidental durotomy cohort (14.7% vs 11.6%; P = 0.056; Table 2). All post-matching absolute standardized mean differences were below 0.10, ranging from 0.0018 to 0.0862, indicating good balance in measured covariates (Supplementary Figure S1).
Table 2.
Matched Demographic Characteristics of Patients After Propensity Score-Matching
| | Control N = 12,625 (%) | Dural Tear N = 2,525 (%) | P value | SMD | |
|---|---|---|---|---|---|
| Age (mean ± SD) | 62.36 ± 0.23 | 62.46 ± 0.52 | 0.864 | 0.0083 | |
| Race | 0.902 | | |||
| White | 9,750 (77.2) | 1,895 (75.0) | | 0.0503 | |
| Black | 1,315 (10.4) | 300 (11.9) | | 0.0453 | |
| Hispanic | 865 (6.9) | 180 (7.1) | | 0.0108 | |
| Asian or Pacific Islander | 210 (1.7) | N ≤ 10* | | 0.0227 | |
| Native American | 100 (0.8) | N ≤ 10* | | 0.0200 | |
| Other | 385 (3.0) | 75 (3.0) | | 0.0047 | |
| Sex | 0.909 | 0.0056 | |||
| Male | 6,790 (53.8) | 1,365 (54.1) | | | |
| Female | 5,835 (46.2) | 1,160 (45.9) | | | |
| Income Quartile | 0.986 | | |||
| 0-25th percentile | 3,335 (26.4) | 685 (27.1) | | 0.0160 | |
| 26th-50th percentile | 2,985 (23.6) | 590 (23.4) | | 0.0065 | |
| 51st-75th percentile | 3,265 (25.9) | 655 (25.9) | | 0.0018 | |
| 76th-100th percentile | 3,040 (24.1) | 595 (23.6) | | 0.0121 | |
| Hospital Bedsize † | 0.598 | | |||
| Small | 2,190 (17.3) | 425 (16.8) | | 0.0138 | |
| Medium | 2,470 (19.6) | 545 (21.6) | | 0.0491 | |
| Large | 7,965 (63.1) | 1,555 (61.6) | | 0.0309 | |
| Hospital Region | 0.996 | | |||
| Northeast | 2,580 (20.4) | 520 (20.6) | | 0.0039 | |
| Midwest | 2,750 (21.8) | 560 (22.2) | | 0.0095 | |
| South | 4,710 (37.3) | 930 (36.8) | | 0.0099 | |
| West | 2,585 (20.5) | 515 (20.4) | | 0.0020 | |
| Levels Fused | 0.056 | 0.0862 | |||
| Single-level | 1,465 (11.6) | 370 (14.7) | | | |
| Multilevel | 11,160 (88.4) | 2,155 (85.3) | | | |
| ECI (mean ± SD) | 2.51 ± 0.03 | 2.58 ± 0.07 | 0.429 | 0.0386 | |
N = Number; % = percentage; SD = standard deviation; SMD = standardized mean difference; ECI = Elixhauser comorbidity index. Bold values are statistically significant.
*Signifies that the count number is ≤ 10 and cannot be reported.
†Hospital bed size designated by the Healthcare Cost and Utilization Project (HCUP) based on geographic location, teaching hospital status, and number of beds.
Post-Matching Clinical Outcomes and Resource Utilization
Following matching, incidental durotomy was associated with significantly worse in-hospital outcomes. The incidental durotomy cohort had a higher rate of any complication compared with controls (41.2% vs 26.5%; P < 0.001), as well as a longer LOS (7.82 ± 0.37 vs 4.34 ± 0.09 days; P < 0.001) and higher hospitalization costs ($65,291.64 ± 2,655.48 vs $41,195.72 ± 610.39; P < 0.001). In addition, discharge disposition differed significantly between cohorts after matching (P < 0.001). Routine discharge was less common among patients with incidental durotomy (41.0% vs 52.3%), while non-routine discharge was more frequent (59.0% vs 47.7%; Table 3).
Table 3.
Comparison of Complications and Hospital Course Between Cohorts After Propensity Score-Matching
| | Control N = 12,625 (%) | Dural Tear N = 2,525 (%) | P value |
|---|---|---|---|
| Any Complication | 3,345 (26.5) | 1,040 (41.2) | <0.001 |
| LOS | 4.34 ± 0.09 | 7.82 ± 0.37 | <0.001 |
| Cost | $41,195.72 ± 610.39 | $65,291.64 ± 2,655.48 | <0.001 |
| Discharge Disposition | <0.001 | ||
| Routine | 6,605 (52.3) | 1,035 (41.0) | |
| Non-routine | 6,020 (47.7) | 1,490 (59.0) | |
N = Number; % = percentage; LOS = length of stay.
Bold values are statistically significant.
Adjusted Multivariable Analysis
In survey-weighted multivariable analyses, incidental durotomy was associated with higher odds of any complication (aOR, 2.03; 95% CI, 1.66–2.48; P < 0.001) and non-routine discharge (aOR, 1.66; 95% CI, 1.35–2.05; P < 0.001). Incidental durotomy was also associated with greater LOS (adjusted mean ratio, 1.80; 95% CI, 1.63–1.97; P < 0.001) and hospitalization cost (adjusted cost ratio, 1.59; 95% CI, 1.48–1.72; P < 0.001; Table 4; Figure 1).
Table 4.
Adjusted Associations Between Incidental Durotomy and In-Hospital Outcomes Following PCDF
| | Effect Measure | Adjusted Estimate (95% CI) | P value |
|---|---|---|---|
| Any Complication | Adjusted odds ratio | 2.03 (1.66–2.48) | <0.001 |
| LOS | Adjusted LOS ratio | 1.80 (1.63–1.97) | <0.001 |
| Cost | Adjusted cost ratio | 1.59 (1.48–1.72) | <0.001 |
| Non-Routine Discharge | Adjusted odds ratio | 1.66 (1.35–2.05) | <0.001 |
CI, confidence interval; LOS, length of stay; PCDF, posterior cervical decompression and fusion. Incidental durotomy was the primary exposure. Models adjusted for age, sex, race, ECI, ZIP code income quartile, hospital bed size, hospital region, and procedure extent. Binary outcomes were analyzed using survey-weighted logistic regression. LOS and hospitalization cost were analyzed using survey-weighted generalized linear models with a log link. Estimates greater than 1 indicate higher odds, LOS, or hospitalization costs among patients with incidental durotomy. Bold values are statistically significant.
Figure 1.
Adjusted associations between incidental durotomy and in-hospital outcomes
Discussion
Incidental durotomy remains a clinically important adverse event during PCDF, yet large-scale data describing its perioperative implications remain limited. Using a nationwide cohort, the present study characterized both the frequency and hospitalization impact of incidental durotomy in elective PCDF procedures. We found that incidental durotomy occurred in 1.5% of cases and was associated with a more complex inpatient course. After propensity matching on measured demographic, clinical, hospital, and procedural characteristics, patients experiencing incidental durotomy had higher complication rates, longer LOS, greater hospitalization costs, and higher rates of non-routine discharge. These findings highlight that incidental durotomy is associated with meaningful differences in clinical recovery and care delivery during the index admission, with implications for patient counseling and perioperative planning. Clinically, these findings suggest that a recognized durotomy should prompt reassessment of the anticipated recovery course and discharge support needs. Counseling should distinguish the increased burden during hospitalization from long-term functional outcomes.
In our national cohort, incidental durotomy occurred in 1.5% of open PCDF procedures. This is substantially lower than the >8% incidence reported by Ishikura et al in a smaller multicenter study of posterior open surgery. 4 Differences in cohort composition and surgical context may explain this gap, including variability in patient complexity, revision burden, and institutional practice patterns.3,4,7 Notably, our estimate aligns with prior cervical spine studies that place dural tear incidence around 1% to 4%.3,6,7 Overall, incidental durotomy was coded in approximately 1.5% of elective PCDF admissions. Differences in case mix and potential undercoding limit direct comparison with rates reported in other cervical fusion populations.
Incidental durotomy was associated with significantly higher complication rates and prolonged LOS, even after matching. These findings suggest that incidental durotomy identifies patients at risk for a more complex early postoperative course and may represent both a clinically consequential complication and a surrogate marker of greater operative complexity.11,13 Revision surgery or adherent pathology may increase both the likelihood of durotomy and postoperative morbidity, making it difficult to separate the consequences of the tear from those of the underlying operative complexity despite adjustment for measured characteristics. While prior cervical spine studies have sometimes reported limited long-term clinical sequelae following dural tears, our results indicate that clinically meaningful consequences are evident during the index hospitalization. 5,6,12 A plausible contributor to increased LOS is postoperative management after suspected or confirmed CSF leak risk, including closer monitoring, delayed mobilization, and additional interventions when symptoms develop. 6,12 Postoperative protocols vary widely, with many surgeons prescribing at least 24 hours of flat bed rest following durotomy repair, practices that have been associated with longer LOS without clear reduction in revision surgery when primary repair is adequate.14,15 These findings are consistent with population-level analyses demonstrating increased inpatient morbidity and prolonged hospitalization following dural injury.8,9 In the broader context of cervical spine surgery, early postoperative complications and extended LOS have been associated with worsened recovery trajectories and higher risk of downstream adverse events, supporting the importance of meticulous surgical technique, effective intraoperative repair when durotomy occurs, and structured postoperative management.3,16
Beyond clinical morbidity, incidental durotomy was associated with significantly higher hospitalization costs and increased rates of non-routine discharge. These outcomes are likely interrelated, as postoperative complications and prolonged LOS increase direct inpatient spending, while delayed functional recovery may necessitate post-acute care services. Prior database studies have similarly demonstrated that dural tears in cervical spine surgery are associated with greater inpatient health care burden, and that incidental durotomy is linked to meaningful cost increases across spine surgery populations.8-10 Economic analyses further suggest that increased LOS and complication management represent primary drivers of excess cost following dural injury.17,18 From a value-based care perspective, these findings underscore that even relatively infrequent adverse events may carry substantial economic impact when they occur in high-volume procedures such as PCDF. These findings also support considering durotomy-specific management within Enhanced Recovery After Surgery (ERAS) pathways, including individualized mobilization, monitoring for persistent CSF leakage, and early discharge planning. Such coordinated care may help reduce avoidable hospitalization and resource use, although the present study did not evaluate the effectiveness of these strategies. Furthermore, given known disparities in spine surgery outcomes across racial and sociodemographic groups, future investigations should evaluate whether the incidence and downstream consequences of incidental durotomy differ across patient populations and hospital settings. 19
This study has several potential limitations inherent to retrospective administrative database analyses. First, incidental durotomy and postoperative complications were identified using ICD-10 diagnosis codes; therefore, coding inaccuracies and potential underreporting inherent to administrative databases may have resulted in misclassification of some patients. Second, the NIS lacks radiographic information, including the severity of stenosis, cervical alignment, and dural ossification, as well as granular operative details such as revision status, dural tear size, repair technique, surgeon experience, and use of intraoperative adjuncts or CSF diversion strategies, limiting assessment of operative complexity and mechanistic interpretation. In addition, although propensity matching and multivariable adjustment improved comparability between cohorts, residual confounding remains possible because unmeasured factors, including operative complexity, revision status, and surgeon-specific characteristics, may influence both the likelihood of incidental durotomy and postoperative outcomes. Consequently, the observed associations should not be interpreted as causal. Formal model fit diagnostics were not performed, limiting assessment of how adequately the models represented the observed outcomes. Sensitivity analyses were not conducted, so the robustness of the findings to alternative matching and modeling approaches remains uncertain. Although age, fusion extent, and comorbidity burden were included in matching and adjustment, subgroup analyses were not performed to determine whether the associations differed across these characteristics. Additionally, the composite complication outcome does not identify which individual complications contribute most to the observed increase in inpatient morbidity. Furthermore, the database captures only index hospitalization outcomes. To this end, specific variables such as readmissions, delayed CSF leak complications, reoperations, and long-term functional outcomes could not be assessed.
Conclusion
This national database study estimated the incidence of incidental durotomy during PCDF to be 1.5%. Incidental durotomy was associated with greater in-hospital morbidity, prolonged LOS, higher hospitalization costs, and increased non-routine discharge after propensity matching and multivariable adjustment. These findings support the importance of preoperative counseling, perioperative resource planning, meticulous intraoperative management, and structured postoperative monitoring when incidental durotomy occurs. Future studies should determine whether these short-term differences translate into adverse long-term outcomes.
Supplemental Material
Supplemental material for Impact of Incidental Durotomy on Health Care Resource Utilization Following Posterior Cervical Decompression and Fusion by Mitchell K. Ng, Leonidas E. Mastrokostas, Paul G. Mastrokostas, Eli Berglas, Matthew W. Xie, Masataka Mizuno, Imran Kyeso, Avi Gupta, Jesse M. Galina, Arie Monas, Jorden Xavier, Sarah Brauer, Pemla Jagtiani, Jad Bou Monsef, Afshin E. Razi, Daniel R. Fassett, Andrew P. Alvarez, Nicholas U. Ahn, Mark F. Kurd, Ian David Kaye, Barrett Woods, Alan S. Hilibrand, Alexander R. Vaccaro, Gregory D. Schroeder, Christopher K. Kepler and Thomas D. Cha in Global Spine Journal.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Mitchell K. Ng has the following disclosures: VB Spine Inc. (paid consultant), Stryker Inc. (paid consultant), Johnson & Johnson Ethicon Inc. (paid consultant), Elevation Spine (paid consultant), CurvaFix Inc. (paid consultant), Pacira BioSciences Inc. (paid consultant), Sage Products Inc. (paid consultant), Alafair Biosciences Inc. (paid consultant), Next Science LLC (paid consultant), Bonutti Technologies Inc. (paid consultant), Hippocrates Opportunities Fund LLC (paid consultant), FISSO USA (paid consultant), MM Labs (paid consultant), Ferghana Partners Inc. (paid consultant). Afshin E. Razi has the following disclosures: 4D Motion (IP royalties), Clinical Orthopaedic Society (fiduciary officer; president; board of directors/committee member), and New York State Society of Orthopaedic Surgeons (fiduciary officer; secretary; board of directors/committee member). Mark F. Kurd has the following disclosures: DuraStat LLC (stock or stock options), K2M Spine (paid consultant), Medtronic (paid consultant), Spinal Elements (IP royalties), Stryker (IP royalties), and The Institute for Musculoskeletal Science & Education (IP royalties). Ian David Kaye has the following disclosures: Camber Spine (IP royalties; paid consultant; research support), Johnson & Johnson (paid consultant), North American Spine Society (board or committee member), NuVasive (paid consultant), Spinal Cord and Case Series (editorial or governing board), and Thieme (publishing royalties; financial or material support). Alan S. Hilibrand has the following disclosures: CTL Amedica (IP royalties), North American Spine Society (board or committee member), Paradigm Spine (stock or stock options), and ZimVie (IP royalties). Alexander R. Vaccaro has the following disclosures: Accelus (other financial or material support; stock or stock options), Advanced Spinal Intellectual Properties (stock or stock options), AO Spine (other financial or material support), Atlas Spine (stock or stock options), Avaz Surgical (stock or stock options), AVKN Patient Driven Care (stock or stock options), Cytonics (stock or stock options), Deep Health (stock or stock options), Dimension Orthotics LLC (stock or stock options), Electrocore (stock or stock options), Elsevier (publishing royalties, financial or material support), Flagship Surgical (stock or stock options), FlowPharma (stock or stock options), Globus Medical (stock or stock options), Harvard Medtech (stock or stock options), Innovative Surgical Design (stock or stock options), Jaypee (publishing royalties, financial or material support), Jushi (Haywood) (stock or stock options), National Spine Health Foundation (board or committee member), Nuvasive (stock or stock options), Orthobullets (stock or stock options), Parvizi Surgical Innovation (stock or stock options), Progressive Spinal Technologies (stock or stock options), Rothman Institute and Related Properties (stock or stock options), Sentryx (other financial or material support; stock or stock options), Stout Medical (stock or stock options), Taylor Francis/Hodder and Stoughton (publishing royalties, financial or material support), Thieme (publishing royalties, financial or material support), and ViewFi Health (stock or stock options). Gregory D. Schroeder has the following disclosures: Advance Medical (paid consultant), Bioventus (paid consultant), Surgalign (paid consultant), AOSpine (board or committee member; other financial or material support), Cervical Spine Research Society (board or committee member), Cerapedics (research support), DePuy, A Johnson & Johnson Company (research support), Medtronic Sofamor Danek (research support), and Wolters Kluwer Health – Lippincott Williams & Wilkins (editorial or governing board). Christopher K. Kepler has the following disclosures: Clinical Spine Surgery (editorial or governing board), Curetiva (IP royalties), and Regeneration Technologies, Inc. (IP royalties). Thomas D. Cha has the following disclosures: Globus Medical (paid consultant), K2M (research support), Kuros (stock or stock options), NuVasive (research support), and Stryker (paid consultant). All other authors have no other relevant financial disclosures. The author(s) declare that there is no conflict of interest and received no financial support for the research, authorship, and/or publication of this article. No IRB approval or informed consent was required for performance of this review.
Supplemental Material: Supplemental material for this article is available online.
ORCID iDs
Mitchell K. Ng https://orcid.org/0000-0002-5831-055X
Leonidas E. Mastrokostas https://orcid.org/0009-0006-8926-3502
Paul G. Mastrokostas https://orcid.org/0000-0002-1196-517X
Pemla Jagtiani https://orcid.org/0000-0002-6075-0255
Alan S. Hilibrand https://orcid.org/0000-0001-8811-9687
References
- 1.Ibrahim MT, Kirven JC, Kavuri V, Yu E, Singh VK. Trends in Cervical Spine Surgery in the United States: A National Database Analysis. World Neurosurg. 2025;198:123961. doi: 10.1016/j.wneu.2025.123961. [DOI] [PubMed] [Google Scholar]
- 2.Salzmann SN, Derman PB, Lampe LP, et al. Cervical Spinal Fusion: 16-Year Trends in Epidemiology, Indications, and In-Hospital Outcomes by Surgical Approach. World Neurosurg. 2018;113:e280-e295. doi: 10.1016/j.wneu.2018.02.004. [DOI] [PubMed] [Google Scholar]
- 3.Badiee RK, Mayer R, Pennicooke B, Chou D, Mummaneni PV, Tan LA. Complications following posterior cervical decompression and fusion: a review of incidence, risk factors, and prevention strategies. Journal of Spine Surgery. 2020;6(1):323-333. doi: 10.21037/jss.2019.11.01. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Ishikura H, Ogihara S, Oka H, et al. Risk factors for incidental durotomy during posterior open spine surgery for degenerative diseases in adults: A multicenter observational study. PLoS One. 2017;12(11):e0188038. doi: 10.1371/journal.pone.0188038. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Milton R, Kalanjiyam GPSR, Shetty AP, Kanna RM. Dural injury following elective spine surgery – A prospective analysis of risk factors, management and complications. J Clin Orthop Trauma. 2023;41:102172. doi: 10.1016/j.jcot.2023.102172. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Oshima Y, Nakamoto H, Doi T, et al. Impact of incidental dural tears on postoperative outcomes in patients undergoing cervical spine surgery: a multicenter retrospective cohort study. The Spine Journal. 2025;25(1):91-98. doi: 10.1016/j.spinee.2024.09.020. [DOI] [PubMed] [Google Scholar]
- 7.OʼNeill KR, Neuman BJ, Peters C, Riew KD. Risk Factors for Dural Tears in the Cervical Spine. Spine (Phila Pa 1976). 2014;39(17):E1015-E1020. doi: 10.1097/BRS.0000000000000416. [DOI] [PubMed] [Google Scholar]
- 8.Yoshihara H, Yoneoka D. Incidental dural tear in cervical spine surgery: analysis of a nationwide database. J Spinal Disord Tech. 2015;28(1):19-24. doi: 10.1097/BSD.0000000000000071. [DOI] [PubMed] [Google Scholar]
- 9.Nandyala SV, Elboghdady IM, Marquez-Lara A, Noureldin MNB, Sankaranarayanan S, Singh K. Cost analysis of incidental durotomy in spine surgery. Spine (Phila Pa 1976). 2014;39(17):E1042-E1051. doi: 10.1097/BRS.0000000000000425. [DOI] [PubMed] [Google Scholar]
- 10.Schroeder GD, Kepler CK, Alijanipour P, et al. The Economic Implications of an Incidental Durotomy. Spine (Phila Pa 1976). 2016;41(19):1548-1553. doi: 10.1097/BRS.0000000000001583. [DOI] [PubMed] [Google Scholar]
- 11.Abolfotouh SM, Alnori O, Buser Z, Hsieh PC, Abolfotouh MA. Management of Dural Tears in Spine Surgery: A Worldwide Survey of Current Practices and Complications. Global Spine J. 2026;16(1):679-689. doi: 10.1177/21925682251358167. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.O’Neill KR, Fehlings MG, Mroz TE, et al. A multicenter study of the presentation, treatment, and outcomes of cervical dural tears. Global Spine J. 2017;7(1_suppl):58S-63S. doi: 10.1177/2192568216688186. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Durand WM, DePasse JM, Kuris EO, Yang JW, Daniels AH. Late-presenting dural tear: incidence, risk factors, and associated complications. The Spine Journal. 2018;18(11):2043-2050. doi: 10.1016/j.spinee.2018.04.004. [DOI] [PubMed] [Google Scholar]
- 14.Verma K, Freelin AH, Atkinson KA, Graham RS, Broaddus WC. Early mobilization versus bed rest for incidental durotomy: an institutional cohort study. J Neurosurg Spine. 2022;37(3):460-465. doi: 10.3171/2022.1.SPINE211208. [DOI] [PubMed] [Google Scholar]
- 15.Farshad M, Aichmair A, Wanivenhaus F, Betz M, Spirig J, Bauer DE. No benefit of early versus late ambulation after incidental durotomy in lumbar spine surgery: a randomized controlled trial. Eur Spine J. 2020;29(1):141-146. doi: 10.1007/s00586-019-06144-5. [DOI] [PubMed] [Google Scholar]
- 16.Nagoshi N, Yamane J, Okubo T, et al. Risk Factors and Clinical Outcomes of Perioperative Complications Following Cervical Spine Surgery. Global Spine J. 2026;16:2671-2682. doi: 10.1177/21925682251412810. Published online 24 December 2025. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Khan MH, Rihn J, Steele G, et al. Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery: a review of 3,183 consecutive degenerative lumbar cases. Spine (Phila Pa 1976). 2006;31(22):2609-2613. doi: 10.1097/01.brs.0000241066.55849.41. [DOI] [PubMed] [Google Scholar]
- 18.McMahon P, Dididze M, Levi AD. Incidental durotomy after spinal surgery: a prospective study in an academic institution. J Neurosurg Spine. 2012;17(1):30-36. doi: 10.3171/2012.3.SPINE11939. [DOI] [PubMed] [Google Scholar]
- 19.Mo K, Ikwuezunma I, Mun F, et al. Racial Disparities in Spine Surgery. Clin Spine Surg. 2023;36(6):243-252. doi: 10.1097/BSD.0000000000001383. [DOI] [PubMed] [Google Scholar]
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Supplementary Materials
Supplemental material for Impact of Incidental Durotomy on Health Care Resource Utilization Following Posterior Cervical Decompression and Fusion by Mitchell K. Ng, Leonidas E. Mastrokostas, Paul G. Mastrokostas, Eli Berglas, Matthew W. Xie, Masataka Mizuno, Imran Kyeso, Avi Gupta, Jesse M. Galina, Arie Monas, Jorden Xavier, Sarah Brauer, Pemla Jagtiani, Jad Bou Monsef, Afshin E. Razi, Daniel R. Fassett, Andrew P. Alvarez, Nicholas U. Ahn, Mark F. Kurd, Ian David Kaye, Barrett Woods, Alan S. Hilibrand, Alexander R. Vaccaro, Gregory D. Schroeder, Christopher K. Kepler and Thomas D. Cha in Global Spine Journal.