Risk factors for management failure following incidental durotomy: insights from 24,438 consecutive spinal surgeries.

BACKGROUND CONTEXT: Incidental durotomy (IDT) is a frequent intraoperative complication in spine surgery. While most cases are managed successfully with primary repair, management failure leads to persistent symptoms and necessitates secondary intervention, resulting in significantly poorer clinical outcomes.

PURPOSE: To identify independent risk factors for management failure following IDT through a comprehensive analysis of patient demographics, pathological conditions, and surgical approaches.

STUDY DESIGN/

SETTING

A retrospective cohort study at a single tertiary institution.

PATIENT SAMPLE: A total of 1,180 patients with confirmed IDT, identified from a continuous series of 24,438 spinal procedures performed between 2011 and 2024.

OUTCOME MEASURES: The incidence of IDT and the rate of management failure, defined as the requirement for secondary surgical intervention.

METHODS

To evaluate factors contributing to IDT management failure, the cohort was categorized into three distinct surgical subgroups based on the surgical approach used: anterior cervical, posterior thoracic OPLL (ossification of the posterior longitudinal ligament)/OLF (ossification of the ligamentum flavum), and general posterior approaches. A comparative evaluation of clinical, anatomical, and operative variables was performed between the success and failure groups to derive independent predictors of surgical failure.

RESULTS

The overall incidence of IDT was 4.8% (1,180/24,438), with a management failure rate of 3.22% (38/1,180). Failure rates varied by procedure, peaking in anterior cervical corpectomy and fusion (13.3%) and posterior thoracic OPLL/OLF surgery (9.5%). In the thoracic OPLL/OLF subgroup, revision surgery (42.9% vs 5.4%, p=.015) and a higher OPLL occupying ratio (55.9% vs 16.3%, p<.001) were significantly associated with management failure. In minimally invasive procedures, 74.7% of IDTs were successfully managed without primary sutures. In the general posterior approach subgroup, multivariate analysis identified radiotherapy history (OR 14.82, 95% CI 3.12-70.45, p<.001), dural patch use (OR 5.32, 95% CI 2.05-13.84, p<.001), long-segment surgery (≥ 4 levels) (OR 3.12, 95% CI 1.28-7.62, p=.012), and higher body weight (OR 1.04, p=.019) as independent predictors of failure.

CONCLUSIONS

Management failure after IDT is driven by patient-specific and anatomical factors. High-risk scenarios-specifically previous radiotherapy, revision thoracic procedures, and severe OPLL-starkly increase this risk, necessitating proactive surgical strategies. To prevent secondary interventions, surgeons must move beyond primary repair alone, optimizing the local environment by obliterating anatomical dead space and ensuring adequate extrinsic tamponade.