Little information is available about the incidence and outcome of incidental dural tears associated with microendoscopic lumbar decompressive surgery. We prospectively examined the incidence of dural tears and their influence on the outcome six months post-operatively in 555 consecutive patients (mean age 47.4 years (13 to 89)) who underwent this form of surgery. The incidence of dural tears was 5.05% (28/555). The risk factors were the age of the patient and the procedure of bilateral decompression via a unilateral approach. The rate of recovery of the Japanese Orthopaedic Association score in patients with dural tears was significantly lower than that in those without a tear (77.7% vs 87.6%; p < 0.02), although there were no significant differences in the improvement of the Oswestry Disability Index between the two groups. Most dural tears were small, managed by taking adequate care of symptoms of low cerebrospinal fluid pressure, and did not require direct dural repair. Routine MRI scans were undertaken six months post-operatively; four patients with a dural tear had recurrent or residual disc herniation and two had further stenosis, possibly because the dural tear prevented adequate decompression and removal of the fragments of disc during surgery; as yet, none of these patients have undergone further surgery. . Cite this article: Bone Joint J 2014;96-B:641–5

The June 2014 Spine Roundup. 360 . looks at: spinal pedicle screws in paediatric patients; improving diagnosis in lumbar spine stenosis; back pain all in the head?; brace three patients, save one scoliosis operation; pedicle screws more often misplaced than one would think; and incidental dural tears usually no problem

To establish whether incidental durotomy complicating lumbar spine surgery adversely affects long-term outcome. Data was collected prospectively. The study population comprised 200 patients. 19 patients who sustained dural tears (Group A) were compared to a control group of 181 patients with no tear (Group B). Outcomes were measured with the SF-36, Oswestry Disability Index (ODI) and visual analogue scores for back (VB) and leg (VL) pain. Scores for the 2 groups were compared pre-operatively, at 2 and 6 months post-op for all patients and at long-term follow-up (range 2-9 years) for patients in group A. In addition for patients in group A the patients satisfaction with the procedure, ongoing symptoms, employment status and analgesic intake were documented. Pre-operative scores were similar between the 2 groups apart from significantly higher vb scores (63 –A vs 46-B). Results at 2 and 6 months showed no significant differences between the 2 groups. Outcome scores for group A at long-term follow-up do not show any significant decline. Our study demonstrates that incidental dural tears complicating lumbar spine surgery do not adversely affect outcome in the long-term

Purpose. To establish whether incidental durotomy complicating lumbar spine surgery adversely affects long-term outcome. Methods. Data was collected prospectively. The study population comprised 200 patients. 19 patients who sustained dural tears (Group A) were compared to a control group of 181 patients with no tear (Group B). Outcomes were measured with the SF-36, Oswestry Disability Index (ODI) and visual analogue scores for back (VB) and leg (VL) pain. Scores for the 2 groups were compared pre-operatively, at 2 and 6 months post-op for all patients and at long-term follow-up (range 2-9 years) for patients in group A. In addition for patients in group A the patients satisfaction with the procedure, ongoing symptoms, employment status and analgesic intake were documented. Results. Pre-operative scores were similar between the 2 groups apart from significantly higher vb scores (63 –A vs 46-B). Results at 2 and 6 months showed no significant differences between the 2 groups. Outcome scores for group A at long-term follow-up do not show any significant decline. Conclusion. Our study demonstrates that incidental dural tears complicating lumbar spine surgery do not adversely affect outcome in the long-term. Ethics - none, Interest –none

Introduction: Pseudoarthrosis in Ankylosing spondylitis is often misdiagnosed as infection. It is a slow progressing lesion resulting in a kyphosis and slow onset weakness of the lower limbs. We are presenting our strategy and experience in treating 9 patients with such a lesion. Method: 9 patients age range from 40–55 years who presented with pseudoarthrosis of the ankylosed spine underwent back-front surgery during 2001–204. 6 patients had dorsal spine lesion, 2 had dorso-lumbar junctional lesion and 1 had cervico-dorsal junctional lesion. 8/9 patients had insidious onset with progressive weakness of both lower limb. 1 patient had an acute onset with deformity. 7/9 patients had neurodeficit (Frankel C) 1/9 had complete paraplegia. All patients underwent posterior kyphosis correction and decompression of the spinal cord. During posterior decompression 8/9 patients had an incidental dural tear due to adherence fractured lamina. The dura was repaired primarily or patch graft. 5/9 patients had single stage back and front surgery. The rest of the patients had staged surgery. The front surgery was excision of the tough fibrotic psuedoarthosis and reconstruction using strut graft/cage. Results: Average duration of surgery was 4 ½ hours (3 ½ to 6 hours). Blood loss was 800 ml (600–1300 ml). All patients required blood transfusion. Primary dural repair was done in 7/8 cases, patch graft in 3/8 cases, ceiling with fusion glue and fat graft in 1 patient. 5 patients who had less that 1000 ml blood loss during posterior surgery had same stage anterior reconstruction. Rest of the patient had 2 staged surgery. 4/9 patients had previous THR B/L. All patients showed rapid improvement in the neurological status and at 3 months follow up all were Frankel E. Conclusion: The surgical outcome of the ankylosing spondylitis patients with Andersson lesion with neurological deficit is encouraging. Excision of the pseudoarthroses anteriorly and posterior spinal stabilization resulted in full recovery of the deficit. However there were difficulties encountered during the posterior decompression due to adhesions of the posterior elements to the dura

Introduction: This study is a retrospective review of patients who underwent corticosteroid spinal injections and/or surgery for lumbar juxtafacet cysts to determine the effectiveness of corticosteroid injection and/or surgery for the treatment of lumbar juxtafacet cysts. Methods: The charts of 40 patients who underwent corticosteroid injection and/or surgery for the treatment of symptomatic juxtafacet cysts were reviewed and an outcome questionnaire was sent to each patient. All patients responded to the questionnaire (100%). Results: Forty-four juxtafacet cysts were treated in 40 patients. 28 cysts were initially treated with corticosteroid injection. 18 facet joints adjacent to the cysts were injected (4 were injected on two or more occasions), 13 underwent epidural injection and 5 underwent nerve sheath exit foraminal blocks. 18 obtained no Benefit from the use of corticosteroid injections and proceeded to surgical treatment. Of the 10 patients that did not undergo surgery, at follow-up 2 reported no clinical change and were considering surgical treatment. This represents a 71% failure rate for non-operative treatment with corticosteroid injections. 34 cysts were resected from 31 patients. Two (6%) were ligamental and 32 were facetal. 31 cysts were resected by laminectomy alone and 3 patients underwent laminectomy and bone only fusion. One cyst (3%) recurred and was managed by repeat laminectomy. One patient required instrumented lumbosacral fusion for increasing anterolisthesis. Incidental dural tear was the most common surgical complication occurring in two cases (6%). One patient demonstrated significant weakness of ankle and foot dorsiflexion which recovered incompletely. Average follow-up for the surgical group was 18 months (5–72 months). 27 scored an excellent or good outcome (79%), 3 scored a fair outcome, 3 were considered poor and one patient was worse. 30 (88%) patients were satisfied having complete improvement or improved with residual back or leg symptoms. Three responded as no change and one was worse. Discussion: Juxtafacet cysts are an uncommon cause of radiculopathy. Corticosteroid injection into the adjacent facet joints, epidural space or exit foraminae of the spine produces disappointing results. Surgical resection is the treatment of choice with low rates of complications, recurrences and residual complaints

Introduction and Aims: Incidental dural tears and cerebrospinal fluid (CSF) leaks are common complications of spinal surgery. Collagen matrix (DuraGen, Integra LifeSciences) derived from bovine flexor tendons allows CSF absorption up to 100 times its weight without a volume change. Aim of this study was categorising the dural tears and monitoring post-operative complications. Method: In this three-year prospective study, 35 patients (22 males, 13 females; mean age 53.8 years (range 16–82)) were selected by the following criteria: (1) any spine operation resulting in intra-operative CSF leak due to dural tear; or (2) persistent post-operative CSF leak. Collagen matrix was cut according to the extent of the dural defect (pinhole, < 1cm, 1–2 cm, and > 2cm). Dural matrix was moistened and applied as a graft and overlying tissues were meticulously reconstituted. Collagen sponge was not sutured on the dura. Subfascial drain was used at the discretion of surgeon to avoid hematoma and blood loss. Results: The 39 procedures were as follows: 23 laminectomies, six diskectomies, four hematoma repairs, three structural repairs, two fracture stabilisations and one cystectomy. The locations of the 39 procedures were: 27 lumbar, seven thoracic, and five cervical. In 33 of 39 procedures, hemovac subfascial drain was used to avoid hematoma and excessive blood loss. Fibrin glue was used in two cases only. In 13 cases the dural defect was > 2cm, five cases 1–2cm, five cases < 2cm, and nine were pinhole defects. Of importance was the successful repair of 13 large dural tears (> 2cm) using the collagen sponge. Our study showed a 97.4% success rate for repairing dural tears using the collagen sponge surpassing the established techniques success rates by up to 10%. There were no wound infections post-operatively, versus the 6% rate of deep wound infection using the standard suture and fibrin glue. The mean follow-up time was 3.1 months. In two out of 39 procedures collagen sponge was used to repair persistent post-operative CSF leaks (no dural sponge used in the original operation). Conclusion: Considering the technical challenge of dural tears, especially ventral or lateral tears, the use of collagen sponge offers an excellent alternative mini-mising a prolonged procedure, wound infection, use of tissue grafts, as well as excessive blood loss. This study showed collagen sponge to be effective as a permanent dural substitute

The August 2014 Spine Roundup³⁶⁰ looks at: rhBMP complicates cervical spine surgery; posterior longitudinal ligament revisited; thoracolumbar posterior instrumentation without fusion in burst fractures; risk modelling for VTE events in spinal surgery; the consequences of dural tears in microdiscectomy; trends in revision spinal surgery; radiofrequency denervation likely effective in facet joint pain and hooks optimally biomechanically transition posterior instrumentation.