A systematic review and meta-analysis on the management of accidental dural tears in spinal surgery: drowning in information but thirsty for a clear message

Purpose To systematically review the published techniques for dural tear (DT) repair in spinal surgery to determine the repair method associated with the lowest failure rate. Method A systematic literature search was conducted. Studies reporting the treatment of accidental DT in elective spinal surgery were selected and reviewed with regards to the incidence of DT, repair techniques and outcome. Meta-analysis of proportions was used to compare the outcome of different repair techniques and their adjuncts. Results Forty-nine studies were included with a total of 3822 DT cases. The outcome of different dural repair techniques was available for 2329(60.9%) cases. The overall pooled risk of DT was 0.052(0.040-0.065) and the overall pooled proportion of failed DT treatment regardless of the treatment method was 0.061(0.044-0.083). The proportion of failure varied according to the repair method. The overall proportion of failure following direct repair with suture (with or without any other augment) was lower than indirect repair (with sealant and or patch): 0.037 (0.024-0.053) versus 0.047 (0.026-0.074), respectively. Bed rest and the use of sub-fascial drain were not associated with improved outcome according to our results. Conclusion Direct repair was associated with low proportion of failure. Howver, the approach to DT treatment was commonly determined on an ad hoc basis according to surgeons' preferences, and few followed defined management protocols. Future studies reporting DT treatment ought to categorise the treatment outcome according to the complexity of the DT and the specific treatment used, thus improving research quality in the field.