Incidental durotomy is a relatively common occurrence during spinal surgery. There remains significant concern about this complication despite reports of good associated clinical outcomes. There have been few large clinical series on the subject.

Durotomy can cause postural headaches, nausea, vomiting, dizziness, photophobia, tinnitus, and vertigo and even severe meningitis and death.

Traditional management includes bed rest for up to 7 days to eliminate traction and reduce hydrostatic pressure during the healing process.

Methods: All patients who had spine surgery in our institute by the same surgeon during the last three years, enrolled into the study. Patients who did not have canal exploration as part of their procedure, were excluded.

Once durotomy had been recognized, immediate repair of the dura was done. An intra-operative Val-Salva maneuver was preformed and once no CSF leak was observed, the wound was tightly closed and no drains were left. In cases where no access to the leaking durotomy was possible, or the Val-Salva maneuver ended with CSF leak, a combination of fibrin glue and hemostatic materials were used to cover the dura.

On the first postoperative day the dressing was carefully inspected for any secretions. Patients who had their dressing dry and clean were allowed to get out of the bed with regular, unlimited, postoperative course. Patients who had a wet dressing due to CSF leak were instructed to stay in bed and a CD catheter was considered.

Results: There were 381 patients in the study group, 281 had instrumented procedures combined with canal decompression and 110 had decompression only. Incidental durotomy occured in 13 patients (3.4%); complete closure of the dura was possible in 10 while the rest had the fibrin glue sealing procedure. From the 3 patients, only one had a CD insertion due to continuous CSF leak, developed gram-negative meningitis and died. All accept the one patient had regular postoperative mobilization without any late CSF discharge or other related complications.

Conclusions: Although rare, incidental durotomy is one of the upsetting complications in spine surgery. No fixed, well-established protocol exists and the post-operative recommendation varies among surgeons.

Our experience shows that, based upon the described algorithm, one can safely mange patients who had incidental durotomy with a regular post-operative course.

With advances in surgical technique and instrumentation, the anterior approach to the thoracolumbar spine becomes more popular. Anterior approach is considered particularly when ventral decompression of neural structures is needed, providing optional stability by fusing the involved segment with instruments specially designated for that purpose. The usual approach is done through a 10th or 11th rib thoracotomy, opening of the pleural cavity and a semilunar cut at the periphery of the diaphragm, in order to expose the anterolateral aspect of the vertebral column. This technique involves the risk of phrenic nerve injury and diaphragmatic paralysis combined with morbidity of the chest tube. A variant of that technique is the retrodiaphragmatic approach, which provides the surgeon with the advantages of ventral exposure, potentially avoiding the morbidity of the standard transpleural thoracotomy.

Methods: During a three-year period, all patients with major anterior pathology at the T11, T12 or Ll level, were operated using the retrodiaphragmatic anterior approach. This involved an 10th or 11th rib thoracotomy with the patient in a lateral decubitus position. Following rib resection, blunt dissection of the diaphragm from the chest wall was performed without its surgical incision. The parietal pleural was mobilized medially and left intact and the thoracolumbar spine was exposed for the procedure. In case of a major pleural defect, a chest drain was inserted.

Results: Fifteen patients (10 males and 5 females, mean age: 32.6y) made up by study group. This included six patients who had a thoracolumbar fracture, five patients who were diagnosed as having idiopathic scoliosis and four patients who presented with metastatic disease in the thoracolumbar region. Adequate decompression was achieved in all patients as well as stable fixation of the involved segment. Mean operating time was 4.5 hours, average hospitalization length was six days. Three patients (20%) required a chest drain following the procedure. The drain was removed within three postoperative days of the operation. In five cases (40%) blood transfusion was required. Mainly for the underlying disease. The average decrease in the hemoglobin values, in the patient subgroup not requiring blood transfusion, was 3mg% at discharge comparing to the preoperative level. No intra-operative complications related to the surgical technique or instrumentation, were noted, nor any case of mortality. Complications such as respiratory distress, neurological damage, infection, hardware loosening or failure, pseudoarthrosis or hernia in scar were not observed during the post operative follow-up.

Conclusion: The retrodiaphragmatic approach to the thoracolumbar spine is safe and technically easy to apply in cases where ventral exposure of the spine is needed. This technique spares the need for diaphragmatic incision and in most cases, leaves the pleural cavity intact.

Antibiotic polymethylmethacrylate (PMMA) beads are known as an effective drug delivery system for local antibiotic therapy in bone and soft tissue infections. Over the years it has become an efficient method to treat osteomyelitis and other infections in orthopaedic surgery. Whilst this method has gained popularity primarily in infected arthroplasty, trauma and chronic osteomyelitis, its application in spine surgery is less known.

Methods: From 1997 to 2000 we have followed prospectively all patients who developed severe purulent wound infection following various types of instrumented spine fusion. Any patient, who had the typical presentation of surgical wound infection was enrolled into the study. Revision consisted of radical debridement of all necrotic tissue from the surgical wound, jet irrigation with saline and application of antibiotic contained PMMA beads. Primary closure over a suction drain was done in all cases and the patient was treated with parenteral antibiotic therapy. Following first revision, patients were treated with broad-spectrum parenteral antibiotic therapy, which was converted to culture-sensitive antibiotic. Suction drains were removed when the output was less than 50cc/24hr. Patients were returned for a second revision when local and systemic parameters showed no evidence of active infection.

This revision consisted of PMMA bead removal, debridement as necessary and irrigation. Primary closure over a suction drain was performed in all cases. No hardware removal was done in any of the cases. Follow up studies included radiographs and gallium bone scan.

Results: There were five patients in the study group. Of these, two had posterior spinal fusion for trauma; the remaining three had fusion for a various etiologies (tumor, corrective osteotomy in ankylosing spondylitis and lumbar instability). Causative organism was staphylococcus aureous (2 patients) and MRSA (3 patients). Mean interval from primary surgery to the first revision was 12 days and 19 days until the second revision. None of the patients had a third revision. There was no evidence for exacerbation of the infectious disease during follow up nor any pain or other signs which could mark the beginning of chronic osteomyelitis. No systemic or local complications related to the surgical technique or the PMMA beads were noted during the period between revisions. Galium scan was performed in only three of the five patients for a different reason. Scan results were negative in all three.

Conclusion: Two-stage revision surgery with PMMA antibiotic beads in a purulent surgical wound infection following spinal fusion, is a highly efficient method. This approach can assure proper healing of the surgical wound with no need for instrumentation removal or prolonged secondary healing of the surgical

Correction of spinal deformities such as those seen in idiopathic scoliosis, are one of the challenging aspects of the spine surgeon’s routine. A significant progress has been made in sense of the surgical approaches, implants design and methods of correction during the last two decades. Since the pioneer conception of Paul Harrington that a scoliotic curve can be corrected by distraction, other methods such as derotation and translation came out as an alternative ways to get a straight and balanced spine. Recently, a new concept of correction for spinal deformities named in-situ contouring, has brought to our attention. This method is based on a 6mm Titanium rod (SCS Eurosurgical Inc.) connected to the spine with a multiple hooks and screws system. The rod is bend according to the curve in the coronal plane and loosely secure with setscrews. Following primary application of the rod, the surgeon begins to bend it manually in situ, in a contrary direction to the curve’s shape. By applying a combination of a sagittal and coronal plane forces, the surgeon is able to achieve a final result of a straight and nicely balanced spine.

Methods: The medical records of patients with idiopathic scoliosis, who had surgery during the last three years, were reviewed. Patients, whose operation evolves using of the SCS system, enrolled into the study group. Clinical as well as radiographical data were retrieved from the hospital charts. Curves were classified according to King et al., measurements were taken using the Cobb’s method.

Results: There were 10 patients in the study group (7 females, 3 males, mean age: 16.6 years). All curves were primary thoracic from which 9 were type II and only one was type III. Mean pre-operative angle of the primary curve was 56°, mean post-operative angle was 22° with a 61% correction rate. Patients were followed for an average period of 12 months. No complications related to surgery, correction techniques, or neurological status was noted.

Conclusions: The in-situ contouring system has no drawbacks compare to other known methods. Our feeling is that this new technique gives the surgeon an ability to achieve the final position of the corrected spine, by a slow and gradual manipulation. This is taking a crucial advantage of the elastic property of the spine in order to get good correction and to avoid neurological complications or hooks pull out.