Conservative Management for Late Presenting Dural Tears After Spine Surgery: An Institutional Experience and Literature Review.

Background: Symptoms and evidence of cerebrospinal fluid (CSF) leak after an uneventful intraoperative and immediate postoperative course are a rare entity in spine surgery. The literature is sparse on the description of such late presenting dural tears (LPDTs). They may need further admissions, wound management, and additional surgical procedures that add to the morbidity of the patient.

Methods: A retrospective review of spine surgeries done at our institute for degenerative spinal conditions between January 2017 and January 2018 was conducted. A mini meta-analysis was performed on studies comparing conservative and surgical management of LPDTs.

Results: Among 1929 patients, 6 cases (5 lumbar and 1 cervical) had an LPDT. Five of them had a CSF fistula and 1 patient had a pseudomeningocele. Two patients with CSF fistula were complicated by superficial surgical site infection (SSI). There was additional evidence of pneumocephalus and pneumorachis in 1 case. The SSI was managed by bedside debridement, regular dressing, and culture-sensitive antibiotics. CSF fistulas were managed by deep suturing, and pseudomeningocele was managed by excision of the sac and plication of the neck. All the patients had a good to an excellent outcome at the end of a 1-year follow-up.

Conclusions: One should be aware of the possibility of LPDTs. A combination of history, clinical examination, and imaging may aid in the diagnosis. It can be associated with complications like CSF fistula, pseudomeningocele, SSI, pneumocephalus, or pneumorachis. Conservative trial can have good to excellent outcomes in the management of such cases though there is insufficient evidence to establish it.