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Objective: To evaluate the current status of classification and repair methods for dural injury caused by spinal surgery or trauma, providing new strategies and ideas for the clinical repair of dural injury and the development of related materials. Methods: The literature related to dural injury both at home and abroad in recent years was thoroughly reviewed and analyzed in order to draw meaningful conclusions. Results: There have been numerous retrospective studies on dural injury, but there is a scarcity of prospective and multi-center studies, resulting in a low level of evidence-based research. The incidence and risk factors of dural injury have primarily been studied in relation to common degenerative spinal diseases of the cervical and lumbar spine, with insufficient research on thoracic spine-related diseases. Currently, a universally recognized method for grading and classifying dural injury has not been established, which hampers the development of clinical guidelines for their repair. Furthermore, although there are repair materials and surgical strategies available to address clinical issues such as suture leakage and surgical repair of dural injury in complex locations, there is a lack of comprehensive clinical research and evidence-based data to validate their scientificity and reliability. Conclusion: Regardless of the classification of dural injury, suture remains the most important repair method. It is important to further develop new patches or sealants that can meet clinical needs and reduce the difficulty of repair.

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BACKGROUND AND AIM: We propose a vast study to examine the effect of high-frequency bipolar coagulation used in the operating room to prevent the development of epidural fibrosis after lumbar microdiscectomy. MATERIALS AND METHODS: A total of 1004 participants were divided into two groups: no high-frequency bipolar coagulation (NC group) and high-frequency bipolar coagulation (C group). Postoperative epidural fibrosis, infection rates, reoperation status, and dural injury complications during the operation were recorded. RESULTS: Considering the epidural fibrosis rates of the two groups, epidural fibrosis was seen in 10.6% of the patients in the NC group. In contrast, it was seen in only 6.2% of the patients in the C group. CONCLUSION: The complication of epidural fibrosis that develops after lumbar microsurgery operations both impairs patient comfort and brings with it the complications of reoperation. After performing hemostasis with bipolar, coagulating the annulus may effectively reduce epidural fibrosis and prevent reoperation.

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Introduction: Remote cerebellar hemorrhage (RCH) has been reported as a serious complication of spine surgery and is considered to be caused by dural injury. However, we have experienced a case in which intracranial hemorrhage occurred immediately after lumbar spine surgery without dural tear. There were no reports of RCH in spinal surgery without dural injury as far as we could find. Case Report: We described a rare presentation of an 80-year-old male who suffered a loss of consciousness after lumbar surgery. He was diagnosed with impaired consciousness due to chronic and acute intracranial hemorrhage. He went through two hematoma removal surgeries and his consciousness improved. Conclusion: RCH can occur in spinal surgery in patients with predicted cerebrovascular fragility, even in the absence of dural injury. Pre-operative imaging evaluation could be useful in assessing cerebrovascular fragility.

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Pneumocephalus as a complication of anterior lumbar spinal surgery is extremely rare. A 53-year-old male patient presented with L4 fracture. Posterior fixation from L3 to L5 was conducted one day after the trauma. As the patient's neurological deficit persisted, additional anterior surgery by L4 vertebral body replacement was performed on the 19th day. Both surgeries were completed without obvious intraoperative complications. Two weeks after the anterior lumbar surgery, the patient complained of severe headaches, and computed tomography scan revealed pneumocephalus and massive fluid retention in the abdomen. The symptoms improved with conservative treatment, including bed rest, spinal drainage, intravenous drip infusion, and prophylactic administration of antibiotics. Due to the lack of tamponade effect in the soft tissues, a large amount of cerebrospinal fluid leakage may induce and cause progression of pneumocephalus in anterior dural injury.

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BACKGROUND: Over the years, lumbar laminectomy has been widely employed by spinal surgeons for many purposes throughout the spinal canal. The Misonix BoneScalpel relies on ultrasonic energy and allows the surgeon to make precise osteotomies while protecting collateral or adjacent soft tissue structures. Amplification of electric impulses allows the blade in the BoneScalpel to oscillate at very high frequencies, which thus allow it to cut bone with immense amounts of heat, which are then tempered with copious irrigation to prevent overheating. The purpose of this study is to outline and detail an innovative technique while providing insight into the technique's clinical application in a variety of spine surgeries. METHODS: Data were retrospectively collected from medical charts and surgical reports from February 2018 to July 2021 for each surgery in which the ultrasonic scalpel was used to perform the H laminectomy. Baseline demographic information was recorded, including age, gender, laminectomy indication, and the number of levels of laminectomy. RESULTS: A total of 85 patients (64 women, 21 men) were included in this study. The mean age of the patients was 63.7 years. Of those patients, 42.4% underwent H laminectomy for degenerative stenosis without instrumentation, 31.8% for degenerative stenosis with instrumentation, 9.4% for traumatic injuries, and 7.1% for revision surgery with instrumentation. Approximately 55% of patients underwent laminectomy of 2 or more levels, while the rest underwent single-level laminectomy. No patients had a dural tear or cerebrospinal fluid (CSF) leak as a result of the BoneScalpel. CONCLUSIONS: The H laminectomy is another safe and effective way to perform a lumbar laminectomy. The technique has not been previously reported in the literature. No patients experienced a dural tear or CSF leak from the BoneScalpel using the H laminectomy technique. This technique affords the surgeon enhanced control of the dura-ligamentum interface. Even if the surgeon is not very experienced with the BoneScalpel, this technique provides an inherent safety mechanism with constant visualization/tactile feedback of the tip of the instrument and osteotome.

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OBJECTIVE@#To evaluate the current status of classification and repair methods for dural injury caused by spinal surgery or trauma, providing new strategies and ideas for the clinical repair of dural injury and the development of related materials.@*METHODS@#The literature related to dural injury both at home and abroad in recent years was thoroughly reviewed and analyzed in order to draw meaningful conclusions.@*RESULTS@#There have been numerous retrospective studies on dural injury, but there is a scarcity of prospective and multi-center studies, resulting in a low level of evidence-based research. The incidence and risk factors of dural injury have primarily been studied in relation to common degenerative spinal diseases of the cervical and lumbar spine, with insufficient research on thoracic spine-related diseases. Currently, a universally recognized method for grading and classifying dural injury has not been established, which hampers the development of clinical guidelines for their repair. Furthermore, although there are repair materials and surgical strategies available to address clinical issues such as suture leakage and surgical repair of dural injury in complex locations, there is a lack of comprehensive clinical research and evidence-based data to validate their scientificity and reliability.@*CONCLUSION@#Regardless of the classification of dural injury, suture remains the most important repair method. It is important to further develop new patches or sealants that can meet clinical needs and reduce the difficulty of repair.

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BACKGROUND: Postoperative intracranial complications are rare in spine surgery not including cranial procedures. We describe an uncommon case of pseudohypoxic brain swelling (PHBS) and secondary hydrocephalus after transforaminal lumbar interbody fusion (TLIF) presenting as impaired consciousness and repeated seizures. CASE PRESENTATION: A 65-year-old man underwent L4-5 TLIF for lumbar spondylolisthesis and began experiencing generalized seizures immediately postoperatively. Computed tomography (CT) revealed diffuse cerebral edema-like hypoxic ischemic encephalopathy. He was transported to our hospital, at which time epidural drainage was halted and anti-edema therapy was commenced. His impaired consciousness improved. However, he suffered secondary hydrocephalus due to continuous bleeding from a dural defect and spinal epidural fluid collection 3 months later. Following the completion of dural repair and insertion of a ventriculoperitoneal shunt, his neurologic symptoms and neuroimaging findings improved significantly. CONCLUSIONS: PHBS can be considered in patients with unexpected neurological deterioration following lumbar spine surgery even with the absence of documented durotomy. This might be due to postoperative intracranial hypotension-associated venous congestion, and to be distinguished from the more common postoperative cerebral ischemic events-caused by arterial or venous occlusions-or anesthetics complications.

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STUDY DESIGN: Retrospective study. OBJECTIVES: Unilateral biportal endoscopic surgery (UBES) is a popular surgical method used to treat degenerative spinal diseases because of its merits, such as reduced tissue damage and outstanding visual capacity. However, dural injury is the most common complication of UBES with an incidence rate of 1.9% to 5.8%. The purpose of this study was to analyze the pattern of dural injury during UBES and to report the clinical course. METHODS: We retrospectively reviewed the medical and radiographic records of surgically treated patients who underwent UBES at a single institute between January 2018 and December 2019. RESULTS: Fifty-three patients, representing 67 segments, underwent UBES. Seven dural injuries occurred, and the incidence rate was 13.2%. Among 16 far lateral approaches, 2 dural injuries of the exiting roots occurred and were treated with fibrin sealant reinforcement. Among 51 median approaches, dural injury occurred at the thecal sac (n = 3) and traversing root (n = 2). A dural injury of the shoulder of the traversing root was treated with a fibrin sealant; however, a defect in the thecal sac required a revision for reconstruction. The other 2 thecal sac injuries were directly repaired via microscopic surgery. CONCLUSIONS: Dural injury during UBES can occur because of the various anatomical features of the meningo-vertebral ligaments. Direct repair of the central dural defect should be considered under microscopic vision. A linear tear in the lateral dura or root can be controlled with a simple patchy reinforcement under endoscopic vision.

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STUDY DESIGN: Case report. OBJECTIVES: To report a rare case of a spinal extradural meningioma in a patient with longstanding nonspecific thoracic nocturnal pain. SUMMARY OF LITERATURE REVIEW: Meningioma is a frequent intradural extramedullary tumor that is associated with pain, sensory/motor deficits, and sphincter weakness. Spinal meningiomas most commonly occur in the thoracic spine, although they can also be found at other locations. MATERIALS AND METHODS: A 65-year-old woman first visited the cardiac and gastrointestinal departments of our institution due to chest pain 2 years previously. No explanation for the complaint could be found in the heart or other organs. On a computed tomography scan of the thorax, a spinal mass was found a few months before the diagnosis. On magnetic resonance imaging, an extramedullary and extradural mass was observed at T7/8. RESULTS: We performed surgery and found an extradural spinal meningioma upon the histological diagnosis. Postoperatively, the patient could adequately move both legs and feet and the nocturnal chest pain disappeared after surgery without any complications. CONCLUSIONS: Awareness of the rarity and nonspecific symptoms of extradural spinal meningiomas will be beneficial for their accurate diagnosis and proper treatment.

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BACKGROUND: Occult dural injuries are rare and can occur as a result of major or minor head injury. These injuries usually manifest with cerebrospinal fluid rhinorrhea alone, or with meningitis and cerebral abscess, sometimes many years after the original injury. CASE PRESENTATION: We present a case of occult dural injury with endocranial complications which occurred in a 34 year old man, with a history of head injury forty-three years ago. The patient presented with a triad of findings; meningitis, CSF rhinorrhoea and pneumocephalus. He was managed conservatively with intravenous antibiotics and observation and made a full recovery. The presence of acute endocranial symptoms and particularly these three findings in a patient with a previous history of head injury, no matter how long it had been should raise suspicion of the presence of an occult dural injury. CONCLUSION: It need to retain a high index of suspicion for occult dural injury in patients who present with endocranial symptoms of unknown origin, especially if there is a previous history of head injury.

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BACKGROUND: Oblique lumbar interbody fusion (OLIF) through the oblique corridor between the aorta and anterior border of psoas muscle is favored among spinal surgeons who employ minimally invasive techniques. We report a case of ventral dural tear after OLIF that was associated with the inaccurate trajectory direction of endplate preparation. This is the first report to our knowledge of ventral dural tear associated with OLIF. CASE DESCRIPTION: A 72-year-old woman presented with right leg pain and numbness. X-rays showed degenerative spondylolisthesis and loss of disc height at L4-L5 and L5-S1 levels. Magnetic resonance imaging revealed right-sided paracentral disc herniation at the L3-L4 level and foraminal disc herniation at L4-L5. The initial surgical plan was OLIF of L3-L4 and L4-L5 after percutaneous screw fixation without laminectomy. With the patient in the lateral position, discectomy and endplate preparation were done successfully at the L3-L4 level, and the same procedure was done at the L4-L5 level for OLIF. A sharp Cobbs elevator for endplate preparation triggered a ventral dural defect at the L4-L5 level. We changed the patient's position to attempt dural repair. The ventral dural defect could not be repaired because it was too large. After the herniated rootlets were repositioned, TachoComb was patched over the defect site. Postoperatively, the patient has no definite neurologic deficits. CONCLUSIONS: When a surgeon performs OLIF, ventral dural injury should be avoided during the procedure of endplate preparation and contralateral annular release.

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Objective To compare the therapeutic effect of three treatments for cerebrospinal fluid leakage induced by surgical operation of spinal fracture combined with dural injury.Methods From June 2005 to June 2010,64 patients with cerebrospinal fluid leakage after surgery to spinal fracture combined with dural injury were analyzed.Patients were treated with positioning adjustment and incision pressure dressing (Group A,n =21),with cerebrospinal fluid leakage drainage via a lumbar percutaneous subarachnoid catheter (Group B,n =21),and with continuous wound drainage followed by catheter removing and wound closure when wound is completely healed (Group C,n =22).Time to stop cerebrospinal fluid leaking from a surgical incision,wound healing time,success rate in the primary intervention and postoperative complications were reviewed among these groups.Results In Group A,the incisional cerebrospinal fluid leakage disappeared at (19.0 ±3.9)days,with healing time of (25.0 ± 4.6)days.The primary wound healing was achieved in 13 patients but failure to the primary intervention occurred in 8 patients,of whom 6 patients presented complications which were then cured.In Group B,the incisional cerebrospinal fluid leakage disappeared at (3.0 ± 1.0) days,with healing time of (16.0 ± 2.6) days.There were 15 patients with primary wound healing but 6 patients got healing after further treatment,with no complications occurred.In Group C,there was no incisonal cerebrospinal fluid leakage or complications and all patients presented primary wound healing in a period of (13.0± 1.0)days.Healing time was shorter and success rate in the primary intervention in Group C was higher than those in Groups A and B (P ＜ 0.05).Conclusions Continuous wound drainage till catheter removal and wound closure on complete wound healing is a good choice for treating cerebrospinal fluid leakage induced by surgical operation of spinal fracture combined with dural injury,for it has advantages of good incisional healing,high success rate and few complications in the primary treatment.

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Objective To report a method of handling dural injury with cerebrospinal fluid leakage during the spinal operation process and analyze its effect,to comparatively analyze with the existing methods and to find a better way processing this problem.Methods A total of 36 patients with dural injury and cerebrospinal fluid leakage during the spinal operation process were collected.Among these clinical cases,there were 15 males,21 females,age ranged from 26 to 78 years old,average 58 years old.During the spinal operation process,the injured dura was sutured or repaired.After that,the dural wound was glued with a piece of muscle or fascia by a kind of medical glue named KangPaiTe.After the operation,broad -spectrum antibiotics and timely fresh dressing changing for the wound were applied.The nature and volume of the drainage fluid was documented and analyzed.When the volume of the drainage fluid was below 50mL per day,the drainage tube was pulled away,and the incision of the drainage tube was sutured again.Results The cerebrospinal fluid leakage lasted from 0 day to 4 days,average 1.5 days;the drainage tube was placed from 1 day to 5 days,average 2 days;no wound infection and other complications occurred among all the clini-cal cases included in this study.Conclusion After the injured dura was sutured or repaired,gluing the dural wound with a slice of muscle or fascia by a kind of medical glue named Kangpaite is a better method of handling dural injury with cerebrospinal fluid leakage.

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We report a rare case of remote cerebellar hemorrhage after intradural disc surgery at the L1-2 level. Two days after the spine surgery, patient complained unexpected headache, dizziness, nausea and vomiting. From the urgently conducted brain CT, it was reported that the patient had cerebellar hemorrhage. Occipital craniotomy and hematoma evacuation was performed, and hemorrhagic lesion on the right cerebellum was effectively removed. After occipital craniotomy, the patient showed signs of improvement on headache, dizziness, nausea and vomiting. He was able to leave the hospital after two weeks of initial operation without any neurological deficit. Remote cerebellar hemorrhage following spinal surgery is extremely rare, but may occur from dural damage of spinal surgery, accompanied with cerebrospinal fluid leakage. Early diagnosis is particularly important for the optimal treatment of remote cerebellar hemorrhage.

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We report a rare case of remote cerebellar hemorrhage after intradural disc surgery at the L1-2 level. Two days after the spine surgery, patient complained unexpected headache, dizziness, nausea and vomiting. From the urgently conducted brain CT, it was reported that the patient had cerebellar hemorrhage. Occipital craniotomy and hematoma evacuation was performed, and hemorrhagic lesion on the right cerebellum was effectively removed. After occipital craniotomy, the patient showed signs of improvement on headache, dizziness, nausea and vomiting. He was able to leave the hospital after two weeks of initial operation without any neurological deficit. Remote cerebellar hemorrhage following spinal surgery is extremely rare, but may occur from dural damage of spinal surgery, accompanied with cerebrospinal fluid leakage. Early diagnosis is particularly important for the optimal treatment of remote cerebellar hemorrhage.

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