Addressing Dural Tears in Lumbar Spine Surgery: Insights from the Global Spine Congress 2025

The Global Spine Congress 2025, held in Rio de Janeiro, served as a vibrant nexus for spine surgeons, clinical researchers, and innovators from around the world. Among the many high-impact topics presented, one session drew particular attention for its clinical relevance and practical implications: the intraoperative management and postoperative care of dural tears in lumbar spine surgery. These complications, though frequently encountered, continue to challenge even the most experienced spinal surgeons, particularly in the era of advanced techniques such as minimally invasive surgery (MIS) and endoscopic spine procedures. My presentation at the GSC aimed to synthesize current evidence and offer practical pearls derived from both literature and firsthand surgical experience.

 

Dural tears in lumbar surgery: persistent and evolving challenge

Dural tears—also referred to as durotomies—represent one of the most common intraoperative complications during lumbar decompression and fusion procedures. While estimates vary, studies suggest an incidence ranging from 1% to 17%, with rates significantly higher in revision surgeries and procedures involving advanced degenerative pathology. Although many durotomies can be successfully repaired without long-term sequelae, unrecognized or inadequately treated tears are associated with postoperative cerebrospinal fluid (CSF) leakage, pseudomeningocele formation, delayed wound healing, infection, and in some cases, neurological deterioration.

In a surgical landscape increasingly defined by precision, miniaturization, and patient-specific strategies, dural management remains a critical skillset requiring vigilance, dexterity, and a strong grasp of emerging adjunctive technologies.

Risk factors and preoperative predictive indicators

Identification of risk factors prior to surgery plays a vital role in preventing intraoperative durotomies. Key predictors include:

• Revision surgery: Scar tissue and altered anatomical planes increase the risk significantly. Epidural fibrosis may obscure visualization and tether the dura to surrounding structures.
• Severe degenerative changes: Patients with advanced spondylosis, ligamentous calcification, or vacuum disc phenomena are more prone to dural compromise.
• Ossification of the ligamentum flavum (OLF): Frequently underrecognized, OLF can create tight adhesions between dura and ligament, making separation hazardous.
• Congenital and iatrogenic factors: Connective tissue disorders such as Ehlers-Danlos syndrome and prior radiation exposure contribute to dural fragility.

Advanced preoperative MRI evaluation can offer predictive insights. T2-weighted imaging may demonstrate dural thinning, scarring, or loss of epidural fat planes. In high-risk patients, intraoperative planning must include availability of microsurgical tools, dural repair adjuncts, and possibly altered exposure strategies.

Intraoperative recognition and technical repair approaches

Timely recognition of a durotomy is paramount. In open surgeries, this typically involves:

• A sudden loss of resistance during ligamentum flavum resection.
• CSF pooling in the surgical field or a “raindrop” leak from the dural surface.
• Change in coloration or tissue turgor, sometimes accompanied by herniation of nerve rootlets.

In MIS and endoscopic approaches, durotomy recognition becomes more nuanced. Real-time endoscopic visualization can identify clear fluid emergence, but under continuous saline irrigation, CSF dilution may mask the diagnosis. The use of intraoperative fluorescein or Valsalva maneuvers (particularly under low-pressure conditions) may help detect subtle leaks in these cases.

Repair techniques

Dural closure techniques must be adapted to the size, location, and accessibility of the tear:

• Primary suture repair: When feasible, watertight dural closure using 6-0 or 7-0 monofilament non-absorbable sutures under microscopic magnification remain the gold standard. Suture techniques (e.g., interrupted vs. running, figure-of-eight) should be chosen based on surgeon comfort and tear morphology.
• Patch grafting: For friable or inaccessible tears—especially lateral or anterior dura—application of a collagen matrix graft (e.g., DuraGen™, TachoSil™) with or without fibrin sealant can provide an effective seal.
• Fibrin glue or sealants: In cases where suturing is technically impossible, standalone use of fibrin glue or synthetic polymer-based sealants may be used, although these are associated with slightly higher pseudomeningocele rates.
• Endoscopic and tubular MIS repairs: Utilization of angled applicators, fibrin-soaked gelatin sponges, and bioabsorbable films can allow seal formation in tubular corridors. Some centers employ endoscopic suturing devices, though widespread availability and surgeon familiarity remain limited.

Complex scenarios: revisions and MIS durotomies

Managing dural tears in revision settings requires tailored approaches. In severely scarred fields, dissecting epidural fibrosis must be approached cautiously, often using sharp dissection and gentle bipolar cautery. Some centers advocate ultrasonic aspirators for tissue removal near the dura to reduce mechanical trauma.

Endoscopic and MIS surgery introduce unique challenges. Limited visualization, restricted instrumentation, and lack of tactile feedback increase risk. When dural injury occurs, decision-making must weigh the feasibility of tubular repair versus conversion to open surgery. The use of bioglues, specialized retractors, and postoperative lumbar drains is often necessary to minimize complications.

Additionally, emerging technologies such as intraoperative ultrasound, endoscopic dye injection, and 3D navigation systems show promise in both tear identification and verification of repair integrity.

Postoperative management protocols

Postoperative care must be individualized based on tear size, repair method, and intraoperative CSF dynamics. The following principles guide management:

Patient positioning: Supine flat bed rest for 24–72 hours is standard for large or sutured tears. Head elevation may be reintroduced gradually if no signs of persistent CSF leakage are observed.

Drain management: The decision to place a subfascial drain must balance the need to prevent fluid accumulation with the risk of perpetuating CSF egress. Some surgeons advocate prophylactic drain clamping for 4–6 hours postoperatively to reduce the pressure gradient.

CSF leak monitoring: Early signs of complications include headache, nausea, clear wound drainage, or radicular symptoms. MRI or CT myelography may be necessary to diagnose pseudomeningocele or fistula.

Reoperation indications: Persistent leaks, expanding pseudomeningoceles, or signs of meningitis warrant prompt reintervention. In select cases, percutaneous fibrin patch injection under imaging guidance may offer nonoperative resolution.

Intercontinental practice variability and discussion trends

During the GSC, robust dialogue underscored the global heterogeneity in dural repair practices. Attendees shared diverse strategies regarding:

1. Use of intraoperative Valsalva maneuvers to confirm repair integrity.
2. Application of intraoperative ultrasound for CSF tracking and detection of occult leaks.
3. Debate over the necessity and duration of flat bed rest in the era of MIS and accelerated recovery protocols.
4. Varying accessibility to biologic materials and microsurgical expertise across geographic and economic boundaries.

While techniques differ, the central goal remains the same: to preserve neural integrity, restore the CSF barrier, and reduce postoperative morbidity.

Future directions in dural repair

Several trends point toward future refinement in this field:

1. Tissue engineering and biomaterials: Development of next generation dural substitutes with better biomechanical and adhesive properties may improve repair outcomes, particularly in friable dura.
2. Robotic and navigation integration: As robotics enter the MIS spine arena, potential exists for more precise dissection and reduced risk of dural injury.
3. Training simulators: Simulation-based microsurgical training may improve repair proficiency, especially among residents and early-career surgeons.
4. Clinical trials and registries: Large-scale, prospective registries tracking durotomy rates, repair methods, and outcomes would help validate best practices and standardize care globally.

Conclusion

Dural tears, while common and often benign when properly managed, represent a significant source of morbidity in lumbar spine surgery if left unrecognized or undertreated. The evolution of surgical techniques, particularly in the context of minimally invasive and revision surgery, necessitates an evolving strategy for both prevention and repair.

The Global Spine Congress 2025 reinforced the importance of continuous dialogue, peer learning, and evidence-based refinement of surgical practice. As the field progresses toward safer, more precise interventions, collective efforts to optimize dural management will remain critical to improving outcomes in lumbar spine surgery.