Incidental dural tears in minimally invasive spine surgery: a narrative review of incidence, management, and outcomes

Introduction

Background

A dural tear (DT), or durotomy, refers to a defect, perforation, or laceration in the meningeal dura mater. This may occur during operative procedures involving the spinal canal or spinal cord, vertebral trauma, or invasive extradural procedures such as administration of epidural anesthetic (1). Durotomy may also be performed purposefully to access nervous tissue of the spinal cord or cauda equina (intentional durotomy). When the occurrence is inadvertent, this is known as incidental durotomy. DT is a common occurrence during extradural spine surgery, with event rates rising in tandem with increasingly complex spine procedures. In some cases, such as in patients who have had multiple spinal surgeries or have long standing severe occlusion of the spinal canal, the native dura may be deficient or eroded, resulting in a large defect (dural erosion, or dural deficiency). The clinical relevance of a DT is often contingent upon its size, location, and the surgeon’s ability to identify, manage, and/or repair the tear. In the event of a DT with persistent cerebrospinal fluid (CSF) leak, the rate, volume, and surrounding soft tissue containment drives patient symptoms and morbidity risk (2). If not identified and managed expeditiously, DTs can decrease intracranial pressure, compromise central nervous system function, increase infection risk, and cause chronic malformations such as fistulas and pseudomeningoceles.

Advancements in minimally invasive spine surgery (MISS) aim to reduce tissue damage and recovery time. However, incidental durotomy remains possible and even can go unnoticed, especially given the challenges of constrained maneuverability and visibility. Effective strategies to recognize and treat durotomy that incorporate considerations unique to MISS are crucial to minimize morbidity.

To our knowledge, no dedicated review of incidental durotomy in MISS has been performed. The objective of this narrative review is to synthesize knowledge from existing literature on incidence, intraoperative and postoperative management, and outcomes for incidental durotomy in spine surgery. Specifically, we aim to illustrate unique factors relevant to techniques and obstacles for durotomy management in MISS procedures.

Incidence and risk factors

Incidental durotomy is common in spine surgery, with reported rates ranging from 1% to 20% (3-6), though data suggest possible underestimation (6). Most MISS incidence data pertain to lumbar procedures. In a 2023 review that included over 20,000 patients undergoing endoscopic spine surgery, Compagnone et al. reported rates for uniportal full-endoscopic surgery (0.7% for transforaminal discectomy, 2.6% for interlaminar decompression) and unilateral biportal endoscopic surgery (3.4% for discectomy, 1.9% for fusion) (7). Ruban et al. noted a 9.4% incidence (53/563 patients) in MISS using tubular dilation with loupe and microscopic magnification (8).

McClain et al. found comparable durotomy rates (~3%) between open and minimally invasive lumbar microdiscectomy (9), whereas Kogias et al. reported higher rates in revision microdiscectomy (n=135) for both MISS (19.5%) and open (17%) procedures (10). Other MISS durotomy rates include 1.8-13.9% in transforaminal lumbar interbody fusion (TLIF) (11-14) and 8% in lumbar synovial cyst excision (15). Mueller et al., Ghobrial et al., and Mooney et al. have reported parity between open and endoscopic lumbar fusion durotomy rates (16-18) (Table 1).

Conversely, few studies document MISS cervical or thoracic durotomy rates. One study reported a 0% durotomy rate in posterior cervical foraminotomy and discectomy, while other MISS cervical reports omit these rates entirely (22,23,25). Robust data for thoracic MISS durotomy rates are lacking, highlighting a need for further research across vertebral levels.

Several MISS procedures carry a higher risk for incidental durotomy, including revision surgery, complex deformity corrections, discectomy, laminectomy, and cyst excision (26). Across MISS literature, the lumbar spine is consistently identified as the most frequent location for DTs (6). Ruban et al. reported significantly increased durotomy risk in patients undergoing lumbar MISS procedures with previous surgery at the same spinal level (P=0.019, no odds ratio noted), observing a durotomy rate of 9.4% using tubular dilation with microscopic magnification (8). Similarly, Klingler et al. noted a higher durotomy incidence during minimally invasive TLIF at previously operated lumbar levels (8.3%) compared to non-operated levels (5.3%), although the difference did not reach statistical significance [odds ratio (OR) 1.71, 95% confidence interval (CI): 0.81 to 3.61] (11). Additional MISS-specific contributors included ossification of the ligamentum flavum, chronic dural thinning, epidural scarring from prior surgery, and limited surgeon experience with MISS instrumentation (11,27).

Occult dural injury is becoming increasingly recognized as a complication of MISS, particularly in irrigated endoscopic decompressions. The narrow, fluid-filled working corridor may obscure small rents intraoperatively, leading to delayed presentations with postural headache, recurrent radicular pain, or a CSF fistula (28). Endoscopic series and reports indicate that unrecognized tears may be missed on routine magnetic resonance imaging; when suspicion remains high, dynamic myelography may be useful to confirm the presence of a leak (28,29). In biportal and full-endoscopic approaches, “hidden” breaches frequently arise during piecemeal resection of midline ligamentum flavum near the laminar edge, where posterior meningovertebral ligaments tether dura and predispose to dorsal tears (30). Irrigation-related pressure effects may further conceal or exacerbate a durotomy, supporting a low threshold to work up delayed fistulas after endoscopic MISS procedures (31).

Patient risk factors

Several patient characteristics have also been independently associated with increased risk for intraoperative DT incidental durotomy in MISS. One study found that revision surgery (OR: 3.13) and traumatic fractures (OR: 1.83) were associated with higher odds of incidental durotomy (24). Advanced patient age, obesity [body mass index (BMI) ≥30 kg/m²], connective tissue disorders (e.g., Marfan or Ehlers-Danlos syndrome), and female sex are established risk factors (5,20,26,32-34). Additional risk factors for the cervical region include ossification of the posterior longitudinal ligament (OPLL), rheumatoid arthritis, deformity, multilevel involvement, and baseline neurological deficits (35-37). Klingler et al. noted MISS-specific associations of overweight status (BMI ≥25 kg/m²) and epidural adhesions or scarring with higher durotomy incidence, likely due to increased surgical depth and restricted tissue planes (11). Additionally, high BMI has been identified as a significant predictor for revision surgery following durotomy occurrence (OR: 1.25) (38).

High-risk areas for dural injury in MISS

Specific anatomical sites of durotomy within lumbar MISS have been described. Lewandrowski et al. identified 689 DTs (1.07%) among 64,470 lumbar endoscopic MISS procedures, with 57% occurring at the posterior thecal sac, 31.2% at the traversing nerve root, 23.7% anteriorly, and 10.8% at the exiting nerve root (39). Similarly, Park et al. found that among 29 DTs in 643 percutaneous biportal endoscopic lumbar cases (4.5%), 62% involved the thecal sac during instrument use, 31% affected the traversing nerve root, and the remainder near the exiting nerve root (40). Ruban and O’Toole corroborated these findings, reporting dural injuries most commonly at the posterior thecal sac during ligamentum flavum resection and medial facet joint decompression in tubular MISS, reflecting limited visualization and common areas for adhesions (8).

Data on cervical and thoracic MISS DTs remain sparse, reflecting procedural rarity and complexity. Boadi et al. reported durotomy rates of 0.57% (6/1,047 cases) in cervical and 2.24% (5/223 cases) in thoracic MISS procedures, confirming that DTs occur in upper spine MISS, albeit at lower frequencies compared to the lumbar region (41).

Mechanisms of injury

In MISS, incidental durotomy commonly results from direct mechanical trauma due to surgical instruments operating in narrow operative corridors with limited working angles. Unlike open surgery’s broader exposure, MISS provides enhanced but localized visualization, sacrificing depth perception and spatial orientation. Consequently, the limited visualization and reduced tactile feedback inherent to minimally invasive surgery make it possible to inadvertently injure the dura.

Several studies highlight specific instruments and technical factors linked to incidental durotomy in MISS. Klingler et al., reviewing 372 minimally invasive TLIF patients, identified Kerrison rongeurs as the most frequent cause of durotomy during ligamentum flavum and osteophyte decompression (11). Similarly, Kim et al. noted Kerrison rongeurs (56%), curettes, and high-speed burrs as predominant injury sources among 25 biportal endoscopic lumbar cases, especially hazardous due to restricted visibility and instrument mobility (42). Shetty et al. found surgeon inexperience (particularly during the initial three years) and improper bilateral decompression through a unilateral approach as significant technical contributors to durotomy in a retrospective analysis of 550 microendoscopic decompressions (43).

Anatomical alterations like dense epidural adhesions from prior surgery or chronic inflammation further predispose patients to dural injuries by tethering dura to adjacent structures. Ossification of the ligamentum flavum and osteophytic overgrowths can gradually erode the dura, heightening vulnerability to DT during routine decompressive maneuvers (43). In this setting, great care must be taken to avoid technical missteps that may trigger a durotomy. We present this article in accordance with the Narrative Review reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-48/rc).

Methods

A comprehensive review of existing literature was performed to characterize incidence, intraoperative management strategies, and postoperative outcomes associated with incidental DTs during MISS. Systematic searches of three major electronic databases (PubMed, Embase, and Scopus) were conducted from database inception through April 2025. The search strategy utilized combinations of Medical Subject Headings (MeSH) and free-text keywords, including but not limited to: “minimally invasive spine surgery”, “dural tear”, “durotomy”, “incidental durotomy”, “cerebrospinal fluid leak”, “intraoperative complication”, “MIS”, “MIS-TLIF”, and “minimally invasive decompression”. Boolean operators were employed to optimize sensitivity and specificity of results across databases.

Eligible studies were limited to original clinical research articles reporting on human subjects undergoing MISS procedures, including minimally invasive decompression, discectomy, lumbar interbody fusion, and durotomy repair. Further criteria for inclusion were retrospective and prospective cohort studies, case-control studies, case series with a sample size greater than five, and randomized controlled trials. Articles were required to report at least one of the following: incidence of durotomy during MISS procedures, risk factors, details of intraoperative management techniques, postoperative care protocols, or clinical outcomes. Review articles, editorials, expert opinions, cadaveric or biomechanical studies, non-English language texts, or conference abstracts lacking full-text availability were excluded. Search strategy parameters are summarized in Table 2. To identify additional relevant studies not captured via initial search criteria, reference lists of included articles were manually screened. The final selection of studies was reviewed by all contributing authors to ensure relevance and methodological appropriateness for inclusion in this review.

Discussion/summary

Intraoperative DT identification

Incidental durotomies during MISS are typically identified intraoperatively by direct visualization, such as exposed nerve filaments, sudden CSF leakage, or dural puckering upon saline irrigation (24,44). Tears from instruments like drills or Kerrison rongeurs are commonly visible during decompression near ossified ligamentum flavum or adhesions (45). However, MISS, particularly endoscopic techniques, introduces challenges to recognition. High-pressure irrigation in endoscopic surgery often masks small “pinhole” durotomies, preventing visible CSF leakage and delaying detection until postoperative symptoms or imaging reveal intradural air or fluid collections (24). Limited tactile feedback and a constrained visual field in tubular and endoscopic MISS procedures further complicate identification. Small tears may remain hidden beneath epidural fat, ligamentum flavum remnants, or laminar margins (42). Anatomical variations, including hyperlordosis or prior surgeries, may recess the dura into difficult-to-visualize caudal regions; positional adjustments to reduce lumbar lordosis can improve visibility and aid early detection (46).

Intraoperative management of DTs in MISS

Effective intraoperative management of DTs in MISS centers on clear visualization, careful hemostasis, and prompt watertight closure. Clear exposure, often limited by narrow MISS corridors, may require surgical loupes, enhanced illumination, microscope assistance, or additional selective bony resection. Hemostasis via bipolar cautery, gelatin sponge, or cottonoid pledgets helps prevent obscuring the defect, while gentle suction reduces risk of neural injury (47). In 2015, Papavero et al. devised a 10-step repair technique for incidental durotomies, containing principles that are translatable to MISS techniques as well. The study emphasizes the importance of full exposure of the defect, inside patch for defects >5 mm, primary repair (when possible), outside patch, checking for residual leaks with Valsalva maneuver, and the crucial step of reducing dead space as much as possible during muscle and deep wound closure (48).

When feasible, primary dural repair using non-resorbable suture (e.g., Gore-Tex, polypropylene) remains ideal, providing superior mechanical strength and lower CSF leak rates (4,37,49). MISS-compatible suturing techniques have emerged, including the use of elongated micro-instruments (10), bayonet microneedle holders (11), and extracorporeal knot-tying with micropituitary rongeurs (50). In cases of limited suture feasibility (particularly in tube-based MISS), layered closure with sealants (fibrin-based or PEG-based) and dural patches (Gelfoam, TachoSil, DuraGen) provide practical alternatives (20,37,51-53). These materials are well-suited for the constrained working corridors of MISS and may aid dural healing; however, their standalone efficacy is inferior to suture-based techniques. Autologous tissue grafts (muscle, fat, fascia) enhance healing through growth factors but are less practical in MISS due to donor-site morbidity and limited access; however, combining small muscle grafts with fibrin glue has shown success in selected MISS scenarios (8,51). Synthetic graft materials remain less favored due to weaker tissue integration (54).

In a review of 628 cases, Choi et al. reported significantly lower CSF leak rates with combined suture and sealant repair (13.7%) compared to sealant or patch alone (22.1%) (51). Ruban et al. in 2011 proposed an MISS-specific approach: fibrin glue alone for partial-thickness durotomies, blood-soaked Gelfoam with fibrin glue for full-thickness tears, while combining muscle graft or collagen matrix with fibrin glue to reinforce nonwatertight primary closure of large durotomies (8). In their series of 53 patients, they were able to achieve a zero percent recurrence rate of durotomy using this algorithm. In a recent systematic review, Trathitephun et al. provide a structured framework to address durotomies specifically during endoscopic spine surgery. Importantly, they caution that for contained defects >10 mm or uncontained defects where the nerve root is unable to be repositioned into the dural sac, conversion to open repair provides the lowest likelihood of recurrent leaks. For defects between 5–10 mm, they suggest either patching technique or endoscopic repair if able (55).

In summary, effective management of incidental durotomy in MISS hinges on early identification, adequate visualization, and achieving a watertight closure. Primary suture repair remains the gold standard when feasible, though modified techniques and instrument adaptations are often necessary in tubular approaches. When suturing is not possible, layered closure using sealants and patches provides a viable alternative, with the best outcomes achieved through combined techniques. Tailored algorithms based on defect size and containment, as proposed by Ruban and Trathitephun, can guide decision-making, while structured repair protocols like Papavero’s offer reproducible strategies to avoid open conversion and reduce recurrence. A consolidated overview of primary repair strategies, including technique descriptions and their relevance to MISS, is summarized in Table 3.

Postoperative management

In MISS, incidental durotomies may go undetected intraoperatively due to masking from continuous irrigation, small defect size, or structural coverage by the ligamentum flavum or lamina (8). Prudent postoperative observation can identify clinical signifiers: orthostatic symptoms (headache, dizziness, syncope), nausea, vomiting, photophobia, wound tenderness, delayed healing, or fluid drainage from the incision (51,56). Neurologic symptoms such as diplopia (CN VI) or tinnitus (CN VIII) may also occur. Delayed presentations have been reported, with symptom onset ranging from 5 days to 3 months (56). Tear sizes vary, with larger (>1 cm) defects more likely to cause early, severe symptoms and complications such as pseudomeningocele, infection, and poor wound healing (19,21). Persistent CSF leakage may present with clear or serosanguinous fluid and can be confirmed via β2-transferrin assay (57), though mild or subclinical symptoms may evade detection (58). If durotomy is unrecognized and accordingly unmanaged, severe complications have been described including hygroma formation (59) and brain herniation secondary to intracranial hypotension (60); however, reports of these complications are not extensive. Subdural hematoma has also been described as a complication of MISS, although a strong causal link to durotomy has not been established (61-63).

The role of postoperative bedrest remains debated. Critically, outcomes hinge on the quality of dural closure. When watertight primary suture repair is achieved and commonly reinforced with patch or sealant, prolonged flat bed rest is generally unnecessary (64,65). While historically emphasized to reduce hydrostatic pressure on the dural repair, recent literature supports early mobilization, particularly in MISS. Randomized and observational data suggests that bed rest >24 hours increases medical complications and length of stay without lowering reoperation risk (66,67). A systematic review by Najjar et al. found that early ambulation (<24 hours) was associated with fewer minor complications and shorter hospital stays, with no significant difference in reoperation rates compared to late mobilization (32). Protocols tailored to MISS have emerged. Khan et al. applied a structured mobilization strategy for 338 lumbar DT cases, with supine bedrest for 24 hours, followed by gradual head-of-bed elevation and monitored ambulation (Figure 1). If symptoms developed, the protocol was reset with an additional 24-hour rest period. Using this approach, 98.2% of patients were successfully managed without reoperation (6). Hannallah et al. described a cervical spine protocol for 20 durotomy cases involving 30° head elevation, prophylactic antiemetics, and symptom-based discharge (Figure 2). At 5.4 years of follow-up, all patients had fully recovered, with only one requiring reoperation at 1 week (68). Framing bed-rest decisions within MISS goals is important: enabling early mobilization helps preserve the advantages of shorter hospital stays and lower episode costs that are central to MISS procedures (69,70) and aligns with enhanced recovery after surgery (ERAS) pathway data showing reduced length of stay when early mobilization is embedded in standardized care (71).

Figure 1 Algorithm for postoperative care following dural tear repair. This stepwise approach begins with immediate postoperative care (Step 1), including bedrest, gradual elevation, and trial ambulation. Patients without symptoms may progress to ambulation. CSF, cerebrospinal fluid.

Figure 2 Algorithm for the diagnosis and management of dural tears intraoperatively. The flowchart outlines a step-by-step approach starting with a diagnosis step 1, following a decision point regarding tear accessibility. For accessible tears, the algorithm progresses. CSF, cerebrospinal fluid.

Postoperative monitoring remains critical. Patient-reported positional headache or wound drainage during ambulation may signal a persistent leak. Relief in the Trendelenburg position or worsening symptoms with upright activity can further support CSF leakage. While 70–80% of surveyed spine surgeons admit patients post-repair for observation (21), clear postoperative surveillance protocols are lacking. Return to the operating room is indicated when symptoms persist beyond 72 hours despite conservative management, or when signs of ongoing CSF leak (e.g., positional headaches, unresolved drainage) are present (6,47). In addition, purulent discharge or other stigmata of infection (erythema, edema, wound induration, nuchal rigidity, mental status changes) (72,73) and new neurologic deficits (74) may be associated with an occult incidental durotomy and should prompt consideration of a return for operative exploration. Conversely, patients without concerning symptoms or signs of leakage may be monitored with outpatient follow-up at 2–4 weeks (68).

Drain use in MISS remains controversial. Some authors advocate for subfascial or intrathecal drainage in large tears to prevent CSF accumulation. Khan et al. used suction drains in all lumbar DT cases, transitioning to gravity and removing by POD 3; two patients required intrathecal drains after reoperation (6). Hannallah et al. placed anterior submuscular drains and posterior subfascial drains for cervical DTs, discontinued by POD 1–2 with good outcomes (68). However, MISS case series by Ruban et al., Kogias et al., Wong et al., and McClain et al. report successful durotomy management without drain use (8-10,75). Minimally invasive procedures may inherently limit fluid collection due to smaller incisions, reduced dead space, and natural paraspinal muscle recoil, reducing the need for prolonged drainage. If suction is utilized, gravity suction may be preferable as cases of severe complications related to intracranial hypotension have been reported due to rapid CSF drainage with vacuum suction (76,77). However, understanding in this realm is limited as not all studies covering MISS-related durotomies comment on drain utilization. Future prospective studies would greatly benefit conclusive examination of the role for drainage in MISS durotomy management.

Long-term prognosis and risk of recurrence

In MISS, outcomes appear equally, and in some cases superior, to those seen with open procedures. Wong et al. retrospectively reviewed 863 lumbar procedures and found a significantly lower incidence of CSF leaks in MISS cases compared to open surgery (4.7% vs. 9.0%). Among patients who sustained an incidental durotomy, those undergoing open procedures were over twice as likely to sustain a CSF leak (OR: 2.4, 95% CI: 1.2–3.7), and 25% required reoperation, compared to none in the MISS group. Additionally, patients undergoing MISS experienced 33% shorter hospital stays and 46% less postoperative bedrest, suggesting quicker postoperative recovery after durotomy repair (75). Other MISS studies echo these findings. Selznick et al. reported no reoperations or neurologic deficits across 43 MISS lumbar interbody fusions despite a durotomy rate of 14% (53). These findings suggest that, when appropriately managed, incidental durotomies in MISS may not only be safely addressed but also may confer faster recovery and lower complication rates compared to open repair.

Conclusions

Incidental durotomy is a well-recognized complication in both open and MISS. While MISS introduces specific challenges due to limited visualization and working corridors, contemporary evidence supports the safety and efficacy of DT management within these approaches. MISS techniques have demonstrated lower CSF leak rates, shorter hospital stays, and reduced reoperation risk when compared to open surgery, with careful intraoperative identification and prompt repair being critical to favorable outcomes. This review consolidates key literature on durotomy management in MISS, highlighting intraoperative mechanisms, practical repair strategies, including MISS-adapted suture techniques and sealant layering, and evidence-based postoperative care protocols. The data supports primary suture repair when feasible, with layered sealants and grafts serving as effective adjuncts or alternatives in constrained MISS settings. Early mobilization is safe in most cases and may be facilitated by the reduced dead space inherent to MISS. Drain usage should be individualized, with MISS often obviating the need for routine placement. Moving forward, prospective studies are needed to define optimal repair techniques, clarify the role of drainage, and evaluate long-term outcomes, especially in complex cases and underreported regions such as cervical and thoracic MISS. With thoughtful technique and evidence-informed management, spine surgeons can achieve excellent outcomes following durotomy in MISS.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mitchell S. Fourman) for the series “Advances in Minimally Invasive Spine Surgery” published in AME Surgical Journal. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-48/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-48/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-48/coif). The series “Advances in Minimally Invasive Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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