Dural Tears—Challenges and Costs
Dural Tears: a common adverse event
CSF Leaks = Money and Time
Dural tears in spinal surgery are relatively common.
Incidental tearing of the dura mater in spinal surgery is often
underreported by hospitals and thus may be more common than
previously thought.1 Establishing a watertight closure of the dura
mater following spinal surgery is critical, as cerebrospinal fluid
(CSF) leaks may lead to increased hospital costs.2
• In a study at the University of Pittsburgh Medical Center, the
rate of incidental dural tears during primary lumbar surgeries
was 7.6%, a rate that doubled to 15.9% for revision cases.3
• During a 5-year period at University Hospitals of Cleveland
and Case Western Reserve University School of Medicine,
88 of 641 patients (14%) sustained a dural tear.4
• In a review of 700 spinal surgeries by the University of
Toronto, more than half of the reported adverse events were
dural tears.5
Where Are the Tears?
According to the US Centers for Disease Control and
Prevention, the highest dural tear rates occur in revision and
multi-level fusion cases:
Dural Tear Rates in Spine Procedures1
A review of US spinal surgery cases during a 2-year period
(n=192,4092) found the average cost of spinal surgeries with
CSF leaks to be significantly higher than spinal surgeries
without CSF leaks.
Average Cost of Spinal Surgeries, US, 2006-20082
Without CSF Leaks
$19,333
With CSF Leaks
$25,812
Average Increased Cost Per Patient *
$6,479
*Due to increased ICU and hospital stays and pharmacy costs.
Source: Premier’s Perspective™ Database, Q4 2006-Q3 2008.
Premier, Inc., Charlotte, NC.
According to Jallo, et al., the increased costs resulting from CSF
leaks averaged $6,479 per patient and were driven primarily by
increased ICU stays (0.8 days), hospital length of stay (2.6 days)
and increased pharmacy costs.
What causes dural tears?
Dural tears can occur for many reasons. Published data points
to a variety of causes and variation in tear rates among
procedure types and institutions.
• In a prospective study of 76 patients, Sin, et al. found that
older patient age and higher level of surgical training were
factors contributing to the incidence of dural tears, but the
history of surgery was not.6
Revision Spine Surgery
Multi-level (3+) Spine Surgery
“Other” Spine Surgery
Single-level Fusion
Two-level Decompression
One-level Open Discectomy
Single-level Decompression
0
5
10
15
20
25
30
35
Percent
• Bosacco, et al. reviewed the most common mechanisms of
dural tears, listed below.7
– Revision cases: Adhesions in the epidural space and dural
scarring and fibrosis
– Primary surgery: Direct trauma or laceration; eroded or thin
dura, adhesions and fibrosis, or dural redundancy in patients
with severe spinal stenosis; severely herniated discs may
render nerve root dissection and dural retraction difficult
In addition, faulty screw placement has been shown to cause a
small number of tears. It may lead to more dead space and
prevent the paraspinal muscles from effectively tamponading a
small dural tear, leading to a greater risk of a clinical CSF leak.
1. Shaw J. Incidental durotomy/dural tear. Presentation to Centers for Disease Control and Prevention ICD-9-CM Coordination and Maintenance
Committee, March 19-20, 2008. 2. Jallo J, Ernst FR, Minshall ME. The cost of cerebral spinal fluid leaks after spinal surgery in the USA. Abstract for
presentation at Congress of Neurological Surgeons, Oct. 24-29, 2009. 3. Khan MH, et al. Postoperative management protocol for incidental dural
tears during degenerative lumbar spine surgery: a review of 3,183 consecutive degenerative lumbar cases. Spine 2006;31(22):2609-13. 4. Wang
JC, et al. 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. 5. Rampersaud YR, et al. Intraoperative adverse events and related postoperative
complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. Spine 2006;31(13):1503-10.
6. Sin AH, et al. J Neurosurg Spine 2006;5:224-227. 7. Bosacco SJ, Gardner SJ, Guille JT. Dural tears in lumbar spine surgery. Clin Orthop Relat R
2000;389:238-47.
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