The Open Orthopaedics Journal




ISSN: 1874-3250 ― Volume 13, 2019
RESEARCH ARTICLE

Incidence and Management of Incidental Spinal Durotomies Noticed During Spinal Surgery



Ishvinder Singh Grewal1, Urpinder Singh Grewal2, *, Tom Eadsforth3, Christopher Barrett3, Robin Pillay3
1 Royal London Hospital, Barts Health NHS Trust Whitechapel Road, London,U.K.
2 Medway Maritime Hospital, Medway Foundation Trust Windmill Road, Gillingham, Kent, ME7 5NY,U.K.
3 The Walton Centre NHS Foundation Trust Lower Lane, Fazakerley, Liverpool, Merseyside L9 7LJ,U.K.

Abstract

Purpose:

The aim of this study was to assess the incidence of dural tears and compare the outcomes depending on management.

Methods:

A retrospective analysis of all spinal surgery over a four year period at one institution. A review of operation, and case notes to assess the intra- and post-operative management of patients suffering a dural tear and their outcomes.

Results:

3361 patients underwent invasive spinal intervention over four years. The age range was 17 to 94. The dural tear rate was higher in lumbar surgery (7.8%) compared with cervical (1.4%) and thoracic (3.8%); (p=0.000) and also in revision surgery (13.5%) compared with primary (4.8%) (p=0.000). When looking at all dural tears there was no significant difference in outcome between varying methods of dural repair and no repair at all (p=0.790). The persistent leak rate was higher in those kept in bed (17.2%) compared to those mobilised immediately (10.5%), this wasn’t statistically significant (p=0.320).

Tears occurred in 42 lumbar microdiscectomies; 93% were mobilised immediately and 79% had no dural repair, one patient developed a persistent leak. There was no difference between different repairs (p=0.964) and mobilization regimes (p=0.929). In patients undergoing bony lumbar decompression there was a difference between suture repair of the dura (9.5%) and non-suture (18%), this was not significant (p=0.304).

Conclusion:

We advocate that patients who suffer an intra-operative dural tear should be mobilised immediately. In minimally invasive surgery such as microdiscectomy a watertight layered closure is sufficient, however, tears occurring during more invasive decompression procedures should all undergo a primary suture repair.

Keywords: Incidental spinal durotomy, Spinal surgery, Complication rates, Lumbar, Suture repair.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 47
Last Page: 52
Publisher Id: TOORTHJ-13-47
DOI: 10.2174/1874325001913010047

Article History:

Received Date: 23/10/2018
Revision Received Date: 2/1/2019
Acceptance Date: 21/1/2019
Electronic publication date: 20/02/2019
Collection year: 2019

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© 2019 Grewal et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this auther at the Medway Maritime Hospital, Medway Foundation Trust Windmill Road, Gillingham, Kent, ME7 5NY; Tel: +447988507440; E-mail: urpinder.grewal@nhs.net




1. INTRODUCTION

An incidental durotomy or dural tear is defined by ICD-10 as an accidental puncture or laceration of dura during a procedure [1Bosacco SJ, Gardner MJ, Guille JT. Evaluation and treatment of dural tears in lumbar spine surgery: A review. Clin Orthop Relat Res 2001; (389): 238-47.[http://dx.doi.org/10.1097/00003086-200108000-00033] [PMID: 11501817] ]. These procedures include spinal surgery [2Bosacco SJ, Gardner MJ, Guille JT. Evaluation and treatment of dural tears in lumbar spine surgery: A review. Clin Orthop Relat Res 2001; (389): 238-47.[http://dx.doi.org/10.1097/00003086-200108000-00033] [PMID: 11501817] ] and interventional procedures such as epidural injection [3Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections. Pain Physician 2012; 15(2): 131-40.[PMID: 22430650] ]. The published incidence of incidental durotomy varies in the literature and is dependent on the procedure being performed, the experience of the surgeon, and patient factors but can range from 1% to 17% [4Guerin P, El Fegoun AB, Obeid I, et al. Incidental durotomy during spine surgery: Incidence, management and complications. A retrospective review. Injury 2012; 43(4): 397-401.[http://dx.doi.org/10.1016/j.injury.2010.12.014] [PMID: 21251652] ]. The consequences of a dural tear to a patient can vary from nil to patient death; for example, if CSF infection [5Koo J, Adamson R, Wagner FC Jr, Hrdy DB. A new cause of chronic meningitis: Infected lumbar pseudomeningocele. Am J Med 1989; 86(1): 103-4.[http://dx.doi.org/10.1016/0002-9343(89)90238-6] [PMID: 2642652] ] leads to sepsis [6Jones AAM, Stambough JL, Balderston RA, Rothman RH, Booth RE Jr. Long-term results of lumbar spine surgery complicated by unintended incidental durotomy. Spine 1989; 14(4): 443-6.[http://dx.doi.org/10.1097/00007632-198904000-00021] [PMID: 2718049] ]. The most common manifestations of dural tear to the patient are headache, and symptoms of meningism, which are usually self-limiting [7Marshall LF. Cerebrospinal fluid leaks: Etiology and repair.The spine 1992; 1892-9.]. They are caused by a drop in CSF pressure leading to caudal displacement of the intracranial contents [8Vakharia SB, Thomas PS, Rosenbaum AE, Wasenko JJ, Fellows DG. Magnetic resonance imaging of cerebrospinal fluid leak and tamponade effect of blood patch in postdural puncture headache. Anesth Analg 1997; 84(3): 585-90.[http://dx.doi.org/10.1097/00000539-199703000-00022] [PMID: 9052306] ]. The dural tear itself is usually healed within 10 days [9Cain JE Jr, Lauerman WC, Rosenthal HG, Broom MJ, Jacobs RR. The histomorphologic sequence of dural repair. Observations in the canine model. Spine 1991; 16(8)(Suppl.): S319-23.[PMID: 1785079] ], unless a persistent leak develops usually indicating a CSF fluid fistula, which may result in a pseudomeningocele [10McCormack BM, Zide BM, Kalfa IH. Cerebrospinal fluid fistula and pseudomeningocele after spine surgery.Spine surgery: Techniques, complication avoidance and management 1999; 1465-74.]. It is also the second most frequently named occurrence in medical practice cases involving surgery of the lumbar spine [11Goodkin R, Laska LL. Unintended “incidental” durotomy during surgery of the lumbar spine: Medicolegal implications. Surg Neurol 1995; 43(1): 4-12.[http://dx.doi.org/10.1016/0090-3019(95)80031-B] [PMID: 7701421] ].

The purpose of our study was to evaluate the incidence of incidental durotomies in our practice over a 4 year period, and to clarify outcomes and differences in management.

The principles of dural tear treatment have changed very little over the course of the last four decades. This consists of a primary repair; testing via Trendelenburg; watertight layered closure of muscle and fascia; and keeping the patient supine on bed rest for 4-7 days [12Eismont FJ, Wiesel SW, Rothman RH. Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am 1981; 63(7): 1132-6.[http://dx.doi.org/10.2106/00004623-198163070-00010] [PMID: 7024283] ]. Recent literature advises similar practice [4Guerin P, El Fegoun AB, Obeid I, et al. Incidental durotomy during spine surgery: Incidence, management and complications. A retrospective review. Injury 2012; 43(4): 397-401.[http://dx.doi.org/10.1016/j.injury.2010.12.014] [PMID: 21251652] , 13Khan MH, Rhin J, Steele G, et al. Postoperative management protocol for incidental dural tears during surgery: A review of 3183 consecutive degenerative lumbar cases. Spine 2006; 31: 2609-13.[http://dx.doi.org/10.1097/01.brs.0000241066.55849.41] [PMID: 17047553] -16Kalevski SK, Peev NA, Haritonov DG. Incidental Dural Tears in lumbar decompressive surgery: Incidence, causes, treatment, results. Asian J Neurosurg 2010; 5(1): 54-9.[PMID: 22028744] ].

The prolonged recumbent period itself leads to increased risk of complications such as venous thromboembolic event [17Baglin T. Inherited and acquired risk factors for venous thromboembolism. Semin Respir Crit Care Med 2012; 33(2): 127-37.[http://dx.doi.org/10.1055/s-0032-1311791] [PMID: 22648484] ] and infection, as well as increased cost either to patient or hospital dependent on how treatment is financed. This is critically important as immediate mobilization has the potential for great benefits to both patient and hospital provider.

2. METHODS

A retrospective study of all patients who underwent invasive surgical spinal intervention in a single centre recorded on MD Analyze system (Medtech Global, Australia) from January 2007 to December 2010. MD Analyze is an integrated surgical audit and outcomes database that provides prospective data tracking from diagnosis to the final outcome; and allows a retrospective audit. A keyword search was performed for operation name/description to identify all spinal cases. The operation notes were then searched for several keywords to identify cases in which durotomy occurred. These operation notes were then individually reviewed to ascertain which of these were incidental durotomies. A case note review was then performed to obtain the demographic and details of surgery. Specifically, the age and gender of the patients, whether surgery was elective or emergent; primary or revision; and what, if any repair was performed. Also assessed from the case notes, was the post-operative management; the length of hospital stay; any persistent leak or other complications; and any additional intervention required. The department was made up of twelve consultants; all of whom had been trained by the same senior consultant; and thereby all had similar surgical technique.

To ensure that ages of patients were taken at a standardized point; age recorded for purposes of the study were that at the day of surgery. Electivity of surgery was defined by planned admission via the waiting list. Method of repair was classified simply as glue; suture or both. Complications accepted were documented persistent leak; pseudomeningocele or infection. A low-pressure headache requiring no additional intervention was not counted as a complication as it was difficult to accurately quantify retrospectively and is somewhat subjective. An additional intervention was classified as any post-operative additional sutures; drains or revision surgery.

Statistical analysis of the data was then performed to assess the incidences of dural tears in various groups and compare outcomes by Fisher’s Exact Test or Pearson Chi-Square Test.

3. RESULTS

3361 patients underwent invasive spinal intervention over four years. The age of patients ranged from 17 to 94 and was normally distributed. The median patient age was 53years old. Of the 3361 interventions, 33.3% (1120 patients) were at the cervical level, 58% (1951 patients) at the lumbar level and 8.6% (290 patients) at the thoracic level (Table 1). The vast majority were primary procedures, with under 6% revision procedures (Table 2). The incidence of dural tear was noted to be 5.3% (Table 3).

The dural tear rate in revision procedures was found to be 13.5% vs 4.8% in primary procedures, this was statistically significant with a p-value of 0.005 by Fisher’s Exact Test (Table 4). The rate of dural tear varied dependent on level operated on with cervical surgery the lowest at 1.4%, followed by thoracic 3.8% and the highest rate was 7.8% in lumbar surgery. This was statistically significant by Pearson Chi-Square Test with a p-value of 0.005 (Table 5).

Table 1
Spinal operations performed at each vertebral level.


Table 2
Primary vs. Revision procedure frequency.


Table 3
Frequency of intra-operative dural tears.


Table4
Dural tear rate in procedures compared.


Having established that the incidence of dural tear was most common in revision and lumbar procedures, we then analysed the difference in outcome dependent on intra- and post-operative management. Of the 179 patients who suffered a tear intra-operatively, the complete case notes were retrieved for 134.

Table 5
Dural tear rate at different spinal levels compared.


Intra-operatively 49.3% (66 patients) of the patients had the glue of varying brands applied, and only 5.97% (8 patients) had a suture repair. No patients had patch repairs or drains inserted. 16.4% (22 patients) had a dural repair with glue and suture and 44.8% (60 patients) had no repair of the dura. Of the patients suffering dural tear intra-operatively, 11.9% went on to develop a complication of persistent CSF leak and 9.7% required further intervention to stop this. The percentage developing persistent leaks varied from 15.9% in those glued alone, 9% in those glued and sutured, 12.5% in those sutured alone, and 10% in those with no direct dural repair. All patients had watertight layered closure of the layers above the dura. There was no significant difference (p=0.790) in the occurrence of persistent CSF leak between differing methods of closure or indeed no closure at all (Table 6).

Table 6
Complication rate in different methods of dural repair.


Post-operatively out of 134 patients; 29 were kept on bedrest from periods of 24-120 hours, the other 105 were mobilized immediately, for the purposes of this study that was regarded as within 24hours from surgery. The delayed mobilization group had a higher leak rate with 17.2% developing post-operative leaks, while only 10.5% of the immediately mobilized group had a persistent leak (Table 7). This was not a statistically significant difference (p=0.320).

Table 7
Leak rate in immediately mobilized compared with delayed mobilization.


Table 8
CSF leak complications in lumbar spine surgery depending on method of dural repair.


Table 9
Leak rate in immediately mobilized compared with delayed mobilization.


We then analysed the lumbar spinal operations individually. As mentioned previously, this was by far the most common level for dural tears to occur. 152 tears were recorded intra-operatively to have occurred at this level and the complete case notes were retrieved for 113 of these. Once more, it was seen that there was no significant difference between complications and method of intra-operative repair. Those repaired with glue alone had a 15% complication rate, 5% in those repaired with glue and suture, 14% in those sutured alone and 9% in those undergoing no direct dural repair (Table 8).

Once again, post-operatively, there was no significant difference in outcome between the immediately mobilised (9%) and those kept on bed rest (15%) (Table 9).

Finally, we subdivided the lumbar surgery into those patients who had a dural tear during micro-discectomies, and those who had tear during more invasive procedures involving boney decompression.

Table 10
CSF leak complication dependent on suture repair of the dura in lumbar spine cases undergoing bony or ligamentous decompression.


Of the 42microdiscectomies who suffered a dural tear, only 1 developed a complication (persistent CSF leak). 93% of these were mobilised immediately, and 79% had no formal dural repair. There was no significant difference in outcome between the different repairs or mobilization regimes. Of the 71 patients who suffered a tear during more invasive procedures, once more there was no significant difference between the method of repair or mobilization. There was, however, a difference between those who were sutured (9.5%) and those who weren’t (18%). This did not reach statistical significance (p=0.304) but would appear to show that when a more invasive procedure is performed there is a benefit to direct primary dural repair with sutures compared with no repair of glue alone (Table 10).

4. DISCUSSION

Our dural tear incidence was comparable with that shown in a prospective UK multicenter trial which also revealed that surgeons generally underestimate the regularity with which these occur [18Tafazal SI, Sell PJ. Incidental durotomy in lumbar spine surgery: Incidence and management. Eur Spine J 2005; 14(3): 287-90.[http://dx.doi.org/10.1007/s00586-004-0821-2] [PMID: 15821921] ]. Given the aforementioned regularity of these in medicolegal cases, it is imperative that patients are accurately consented pre-operatively [11Goodkin R, Laska LL. Unintended “incidental” durotomy during surgery of the lumbar spine: Medicolegal implications. Surg Neurol 1995; 43(1): 4-12.[http://dx.doi.org/10.1016/0090-3019(95)80031-B] [PMID: 7701421] ].

We were able to confirm what has been previously shown that the frequency of dural tears is higher in revision procedures when compared with primary procedures [16Kalevski SK, Peev NA, Haritonov DG. Incidental Dural Tears in lumbar decompressive surgery: Incidence, causes, treatment, results. Asian J Neurosurg 2010; 5(1): 54-9.[PMID: 22028744] , 19McMahon P, Dididze M, Levi AD. Incidental durotomy after spinal surgery: A prospective study in an academic institution. J Neurosurg Spine 2012; 17(1): 30-6.[http://dx.doi.org/10.3171/2012.3.SPINE11939] [PMID: 22540168] -21Thomsen F, Amtoft O, Andersen M, et al. Iatrogenic dural lesions in lumbar neural decompressive surgery 2010; 172(9): 688-91.]. The rate of dural tear was seen to be higher in lumbar spine surgery and the cervical tear rate of 1.4% in our cohort is comparable with the 1% rate seen in the series reported by Hannallah et al. [22Hannallah D, Lee J, Khan M, Donaldson WF, Kang JD. Cerebrospinal fluid leaks following cervical spine surgery. J Bone Joint Surg Am 2008; 90(5): 1101-5.[http://dx.doi.org/10.2106/JBJS.F.01114] [PMID: 18451403] ].

Of greater importance was the finding that delayed mobilization and primary repair which was initially suggested by Eismont et al. in a series of only 5 patients is not as important as once believed [12Eismont FJ, Wiesel SW, Rothman RH. Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am 1981; 63(7): 1132-6.[http://dx.doi.org/10.2106/00004623-198163070-00010] [PMID: 7024283] ]. Most large studies since then have also advocated mandatory bed rest and primary repair with glue, suture, patch or a combination [4Guerin P, El Fegoun AB, Obeid I, et al. Incidental durotomy during spine surgery: Incidence, management and complications. A retrospective review. Injury 2012; 43(4): 397-401.[http://dx.doi.org/10.1016/j.injury.2010.12.014] [PMID: 21251652] , 14Wang JC, Bohlman HH, Riew KD. Dural tears secondary to operations on the lumbar spine. Management and results after a two-year-minimum follow-up of eighty-eight patients. J Bone Joint Surg Am 1998; 80(12): 1728-32.[http://dx.doi.org/10.2106/00004623-199812000-00002] [PMID: 9875930] -16Kalevski SK, Peev NA, Haritonov DG. Incidental Dural Tears in lumbar decompressive surgery: Incidence, causes, treatment, results. Asian J Neurosurg 2010; 5(1): 54-9.[PMID: 22028744] , 23Senker W, Meznik C, Avian A, Berghold A. The frequency of accidental dural tears in minimally invasive spinal fusion techniques. J Neurol Surg A Cent Eur Neurosurg 2013; 74(6): 373-7.[http://dx.doi.org/10.1055/s-0032-1320028] [PMID: 23250875] ]. The importance of primary repair is felt to be so great that methods have been described for performing primary suture repair during microdiscectomy as this is technically difficult to achieve [24Chou D, Wang VY, Khan AS. Primary dural repair during minimally invasive microdiscectomy using standard operating room instruments. Neurosurgery 2009; 64(5)(Suppl. 2): 356-8.[http://dx.doi.org/10.1227/01.NEU.0000338942.11337.DA] [PMID: 19404114] ]. There have been some small studies which have looked at early mobilization following dural tear and have all reported good results. These have, however, been relatively small [25Than KD, Wang AC, Etame AB, La Marca F, Park P. Postoperative management of incidental durotomy in minimally invasive lumbar spinal surgery. Minim Invasive Neurosurg 2008; 51(5): 263-6.[http://dx.doi.org/10.1055/s-0028-1082313] [PMID: 18855289] , 26Hodges SD, Humphreys SC, Eck JC, Covington LA. Management of incidental durotomy without mandatory bed rest. A retrospective review of 20 cases Spine 1 1999; 24(19): 2062-4.]. Khan et al. instigated a protocol of early mobilization and deemed this to be safe and effective in the treatment of dural tears [13Khan MH, Rhin J, Steele G, et al. Postoperative management protocol for incidental dural tears during surgery: A review of 3183 consecutive degenerative lumbar cases. Spine 2006; 31: 2609-13.[http://dx.doi.org/10.1097/01.brs.0000241066.55849.41] [PMID: 17047553] ].

Ours is the first study which has directly compared early versus delayed mobilization and differing methods of repair albeit retrospectively. The results clearly show there is no benefit of mandatory bed rest following dural tear, and despite not reaching statistical significance, it would appear to show that prolonged bed rest would actually appear to be detrimental and increase the risk of persistent CSF leak complications. Also, we can see that in cases of minimally invasive spinal surgery a good, watertight layered closure is sufficient without the need for direct dural repair.

Finally in cases which are more invasive and bony decompression has been performed, there would appear to be a benefit from direct primary suture repair of the tear. Despite not reaching statistical significance, it would also appear to show that the use of glue is not a substitute for direct suturing of the dura.

Our study followed up patients for up to one year post-operatively; after this patient, no patients re-presented within the 4 year time year period with later complications. It is also unlikely that patients within the study could have presented to other hospitals; as geographically, this was the only neurosurgical centre in the entire region.

However, there remains very little data on the long term sequelae of dural tears as a result of spinal surgical procedures. Therefore, further studies are required to assess long term outcomes following dural tears. For e.g., a retrospective study of patients with incidental durotomy at 10 year follow-up found that they had worse clinical outcomes in comparison to a control group [27Saxler G, Kramer J, Barden B, Kurt A, Pfortner J, Bernsmann K. Spine (Phila Pa 1976) 15;30(20):2298-302 The long-term clinical sequelae of incidental durotomy in lumbar disc surgery 1976; 30(20): 2298-302.]. In contrast, four other comparable series to this study 189 incidental durotomies were investigated with a follow-up period from weeks to less than 5 years and no sequelae were found when the patients were treated successfully for incidental durotomies [6Jones AAM, Stambough JL, Balderston RA, Rothman RH, Booth RE Jr. Long-term results of lumbar spine surgery complicated by unintended incidental durotomy. Spine 1989; 14(4): 443-6.[http://dx.doi.org/10.1097/00007632-198904000-00021] [PMID: 2718049] , 12Eismont FJ, Wiesel SW, Rothman RH. Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am 1981; 63(7): 1132-6.[http://dx.doi.org/10.2106/00004623-198163070-00010] [PMID: 7024283] , 15Wolff S, Kheirredine W, Riouallon G. Surgical dural tears: prevalence and updated management protocol based on 1359 lumbar vertebra interventions. Orthop Traumatol Surg Res 2012; 98(8): 879-86.[http://dx.doi.org/10.1016/j.otsr.2012.06.016] [PMID: 23158786] , 28Cammisa FP Jr, Girardi FP, Sangani PK, Parvataneni HK, Cadag S, Sandhu HS. Incidental durotomy in spine surgery. Spine 2000; 25(20): 2663-7.[http://dx.doi.org/10.1097/00007632-200010150-00019] [PMID: 11034653] ]. Therefore, further studies should aim to identify prevalence of long-term sequelae and their dependence on the method of dural tear repair and mobilization status.

Currently, there is no true consensus regarding the treatment of incidental durotomies; with treatment widely varying on a surgeon by surgeon basis. Treatment modalities include primary repair with sutures, glue, muscle, fat or fascial grafts, blood or fibrin patches. Future trials should aim to randomize patients with incidental durotomies into treatment categories and then further randomize to immediate or delayed mobilization. Such trials would perhaps provide statistical clarity with regards to the gold standard treatment of incidental durotomies and mobilization status.

Limitations of this study include a limited follow-up range, absence of clinical assessment with a validated score and surgeon-to-surgeon procedural variability.

CONCLUSION

We would advocate the immediate mobilization of all patients experiencing dural tear intra-operatively and a primary suture repair of all tears occurring during invasive spinal surgery. We also believe that in minimally invasive procedures, a good layered closure is adequate and there is no benefit to technically difficult suture repair.

There are significant discrepancies between our findings and the commonly practiced approach to warrant a prospective multi-centre trial assessing early versus delayed mobilization.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No Animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION

Informed consent was obtained from all individual participants included in the study.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Bosacco SJ, Gardner MJ, Guille JT. Evaluation and treatment of dural tears in lumbar spine surgery: A review. Clin Orthop Relat Res 2001; (389): 238-47.[http://dx.doi.org/10.1097/00003086-200108000-00033] [PMID: 11501817]
[2] Bosacco SJ, Gardner MJ, Guille JT. Evaluation and treatment of dural tears in lumbar spine surgery: A review. Clin Orthop Relat Res 2001; (389): 238-47.[http://dx.doi.org/10.1097/00003086-200108000-00033] [PMID: 11501817]
[3] Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections. Pain Physician 2012; 15(2): 131-40.[PMID: 22430650]
[4] Guerin P, El Fegoun AB, Obeid I, et al. Incidental durotomy during spine surgery: Incidence, management and complications. A retrospective review. Injury 2012; 43(4): 397-401.[http://dx.doi.org/10.1016/j.injury.2010.12.014] [PMID: 21251652]
[5] Koo J, Adamson R, Wagner FC Jr, Hrdy DB. A new cause of chronic meningitis: Infected lumbar pseudomeningocele. Am J Med 1989; 86(1): 103-4.[http://dx.doi.org/10.1016/0002-9343(89)90238-6] [PMID: 2642652]
[6] Jones AAM, Stambough JL, Balderston RA, Rothman RH, Booth RE Jr. Long-term results of lumbar spine surgery complicated by unintended incidental durotomy. Spine 1989; 14(4): 443-6.[http://dx.doi.org/10.1097/00007632-198904000-00021] [PMID: 2718049]
[7] Marshall LF. Cerebrospinal fluid leaks: Etiology and repair.The spine 1992; 1892-9.
[8] Vakharia SB, Thomas PS, Rosenbaum AE, Wasenko JJ, Fellows DG. Magnetic resonance imaging of cerebrospinal fluid leak and tamponade effect of blood patch in postdural puncture headache. Anesth Analg 1997; 84(3): 585-90.[http://dx.doi.org/10.1097/00000539-199703000-00022] [PMID: 9052306]
[9] Cain JE Jr, Lauerman WC, Rosenthal HG, Broom MJ, Jacobs RR. The histomorphologic sequence of dural repair. Observations in the canine model. Spine 1991; 16(8)(Suppl.): S319-23.[PMID: 1785079]
[10] McCormack BM, Zide BM, Kalfa IH. Cerebrospinal fluid fistula and pseudomeningocele after spine surgery.Spine surgery: Techniques, complication avoidance and management 1999; 1465-74.
[11] Goodkin R, Laska LL. Unintended “incidental” durotomy during surgery of the lumbar spine: Medicolegal implications. Surg Neurol 1995; 43(1): 4-12.[http://dx.doi.org/10.1016/0090-3019(95)80031-B] [PMID: 7701421]
[12] Eismont FJ, Wiesel SW, Rothman RH. Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am 1981; 63(7): 1132-6.[http://dx.doi.org/10.2106/00004623-198163070-00010] [PMID: 7024283]
[13] Khan MH, Rhin J, Steele G, et al. Postoperative management protocol for incidental dural tears during surgery: A review of 3183 consecutive degenerative lumbar cases. Spine 2006; 31: 2609-13.[http://dx.doi.org/10.1097/01.brs.0000241066.55849.41] [PMID: 17047553]
[14] Wang JC, Bohlman HH, Riew KD. Dural tears secondary to operations on the lumbar spine. Management and results after a two-year-minimum follow-up of eighty-eight patients. J Bone Joint Surg Am 1998; 80(12): 1728-32.[http://dx.doi.org/10.2106/00004623-199812000-00002] [PMID: 9875930]
[15] Wolff S, Kheirredine W, Riouallon G. Surgical dural tears: prevalence and updated management protocol based on 1359 lumbar vertebra interventions. Orthop Traumatol Surg Res 2012; 98(8): 879-86.[http://dx.doi.org/10.1016/j.otsr.2012.06.016] [PMID: 23158786]
[16] Kalevski SK, Peev NA, Haritonov DG. Incidental Dural Tears in lumbar decompressive surgery: Incidence, causes, treatment, results. Asian J Neurosurg 2010; 5(1): 54-9.[PMID: 22028744]
[17] Baglin T. Inherited and acquired risk factors for venous thromboembolism. Semin Respir Crit Care Med 2012; 33(2): 127-37.[http://dx.doi.org/10.1055/s-0032-1311791] [PMID: 22648484]
[18] Tafazal SI, Sell PJ. Incidental durotomy in lumbar spine surgery: Incidence and management. Eur Spine J 2005; 14(3): 287-90.[http://dx.doi.org/10.1007/s00586-004-0821-2] [PMID: 15821921]
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Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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