Development of cerebrospinal fluid fistula after incidental durotomy in spinal decompression surgery

BACKGROUND: Incidental durotomy (ID) during spinal surgery is a risk factor for the development of cerebrospinal fluid (CSF) fistula. The rates of ID with or without consecutive CSF fistula vary according to the extent of the surgical procedure. Revision surgery has the highest rates of dural tears. However, not every case of ID leads to CSF fistula requiring revision surgery. The objective of this study was to analyze the predictors for the development of CSF fistula after ID. METHODS: This retrospective study included 6024 consecutive patients who had been surgically treated for degenerative spinal disease at our clinic over the past 15 years. Patients who had undergone surgical revision for CSF fistula were assigned to the CSF fistula group. A matched 3:1 control group (ID group) was formed of patients with ID but without CSF fistula. Charts, surgical reports, and radiographic data were reviewed and statistically analyzed for demographics, duration of symptoms, comorbidities, surgical strategy, and pre- and postoperative neurological performance. RESULTS: The 15-year incidence of CSF fistula in the overall population was 0.36% (N.=22). The following locations were affected: N.=18 lumbar (81.8%), N.=2 cervical (9.1%), and N.=2 thoracic (9.1%). The extent of ID was similar in both groups. The two groups did not significantly differ with regard to the intraoperative management of dural repair with primary suturing (P=0.345), dural patches, sealant, or collagen matrix (P=0.228; P=0.081; P=0.081). In the postoperative period, bed rest in supine position for 48 hours (P=0.037) and laxative therapy (P=0.034) were the most beneficial treatment modalities for preventing CSF fistula. Patients with CSF fistula were hospitalized significantly longer (21 days vs. 10 days in the control group; P<0.001). CONCLUSIONS: This large test group showed a low incidence of postoperative CSF fistula after intraoperative ID. Bed rest and laxative treatment were important approaches to preventing CSF fistula.