From the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Hassanzadeh, Bell, and Bhatia), and the Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD (Puvanesarajah).
J Am Acad Orthop Surg. 2021 Mar 15;29(6):e279-e286. doi: 10.5435/JAAOS-D-20-00210.
Incidental durotomy (ID) can occur in up to 14% of all lumbar spine surgeries. The risk of this complication is markedly higher among elderly patients with advanced spinal pathology. In addition, revision cases and other more invasive procedures increase the risk of ID. When unrepaired, IDs can increase the risk of developing meningitis and can lead to the formation of cerebrospinal fluid fistulas and pseudomeningoceles. Intraoperative recognition and repair are essential to ID management, although repair techniques vary considerably. Although primary suture repair is considered the "benchmark," indirect repair alone has shown comparable outcomes. Given the concern for infection after ID, many have indicated for prolonged prophylactic antibiotic regimens. However, there is little clinical evidence that this is necessary after adequate repair. The addition of subfascial drains have been shown to promote wound healing and early ambulation, whereas no consensus on duration of indwelling drains exists and such management is largely case dependent. Early ambulation after surgery has not shown to be associated with increased risk of further ID complications and decreases rehabilitation time, length of stay, and risk of venous thromboembolism. However, there remains a role for conservation mobilization protocols in more severe cases where notable symptoms are observed.
偶然的硬脊膜切开术（ID）可发生于高达 14%的所有腰椎手术中。在患有晚期脊柱病变的老年患者中，这种并发症的风险明显更高。此外，翻修病例和其他更具侵袭性的手术会增加 ID 的风险。如果不修复，ID 会增加患脑膜炎的风险，并导致脑脊液瘘和假性脑脊膜膨出的形成。术中识别和修复对于 ID 的管理至关重要，尽管修复技术差异很大。虽然原发性缝合修复被认为是“基准”，但单独的间接修复已显示出可比的结果。由于担心 ID 后感染，许多人表示需要延长预防性抗生素方案。然而，在充分修复后，几乎没有临床证据表明这是必要的。筋膜下引流的加入已被证明可以促进伤口愈合和早期活动，尽管留置引流管的持续时间没有共识，并且这种管理在很大程度上取决于具体情况。手术后早期活动与进一步 ID 并发症的风险增加无关，反而可以缩短康复时间、住院时间和静脉血栓栓塞的风险。然而，在更严重的情况下，仍然需要采用保留活动的方案，因为这些情况下会出现明显的症状。
