Risk factors for damage to the dura mater in thoracic and lumbar spine injury

Objective. To clarify a significance of the risk factors for damage to the dura mater (DM) in fractures of the thoracic and lumbar spine.

Material and Methods. The study is based on the analysis of examination data and surgical treatment results of 350 patients with spinal cord injury (SCI). Fractures of the thoracic spine were observed in 124 patients, and those of the lumbar spine in 226. The study included 167 operated patients who underwent posterior decompression at the fracture level using laminectomy and transpedicular fixation of the injured spinal motion segment. There were two groups of patients: study group included 55 patients with DM rupture and control one – 112 patients without damage to the DM.

Results. Damage to the DM was found in 32.9 % of patients, the rupture was localized on the posterior surface of the dural sac. In patients with rupture of the dura mater, ASIA type A and B neurological disorders were significantly more common (p = 0.00065). The DM damage occurs significantly more often in patients with  type C fracture according to the AOSpine classification, with multilevel spinal injuries and combined SCI (Injury Severity Score more than 27.58 ± 9.46 points). The most significant risk factors for the development of DM ruptures are narrowing of the spinal canal at the fracture level by more than 50 %, a fracture of the vertebral arch, an increase in the relative interpedicular distance of more than 20 %, and diastasis between the fragments of the arches by more than 2.5 mm.

Conclusion. The damage to the dura mater is a common complication of vertebral fracture. The prediction of dura mater rupture will allow optimizing surgical approach and improving the treatment outcome.

1. Афаунов А.А., Кузьменко А.В., Басанкин И.В. Дифференцированный подход к лечению больных с травматическими стенозами позвоночного канала на нижнегрудном и поясничном уровне // Инновационная медицина Кубани. 2016. № 2. С. 5–16. [Afaunov AA, Kuzmenko AV, Basankin IV. Differentiated treatment in patients with traumatic vertebral canal stenosis at lower thoracic and lumbar levels. Innovatsionnaya meditsina Kubani = Innovative Medicine of Kuban 2016;(2):5–16].

2. Гринь А.А., Кордонский А.Ю., Львов И.С., Кайков А.К., Сытник А.В., Богданова О.Ю. Фактор времени в хирургии позвоночно-спинальной травмы (обзор литературы) // Нейрохирургия. 2018. Т. 20. № 3. С. 81–90. [Grin’ AA, Kordonskiy AYu, Lvov IS, Kaikov AK, Sytnik AV, Bogdanova OYu. The timing in surgery of spinal trauma (a review). Russian journal of neurosurgery. 2018;20(3):81–90]. DOI 10.17650/1683-3295-2018-20-3-81-90.

3. Крылов В.В., Гринь А.А, Тимербаев В.Х., Генов П.Г., Ефременко С.В., Григорьева Е.В., Никитин С.С., Куренков А.Л., Хить М.А. Травма позвоночника и спинного мозга. М., 2014. [Krylov VV, Grin’AA, Timerbaev VKh, Genov PG, Efremenko SV, Grigor’eva EV, Nikitin SS, Kurenkov AL, Khit’ MA. Trauma of the Spine and Spinal Cord. Moscow, 2014].

4. Aydinli U, Karaeminogullari O, Tiskaya K, Ozturk C. Dural tears in lumbar burst fractures with greenstick lamina fractures. Spine. 2001;26:E410–E415. DOI 10.1097/00007632-200109150-00012.

5. Cammisa FP Jr, Eismont FJ, Green BA. Dural laceration occurring with burst fractures and associated laminar fractures. J Bone Joint Surg Am. 1989;7:1044–1052. DOI: 10.2106/00004623-198971070-00011.

6. Xu JX, Zhou CW, Wang CG, Tang Q, Li JW, Zhang LL, Xu HZ, Tian NF. Risk factors for dural tears in thoracic and lumbar burst fractures associated with vertical laminar fractures. Spine. 2018;43:774–779. DOI: 10.1097/BRS.0000000000002425.

7. Ozturk C, Ersozlu S, Aydinli U. Importance of greenstick lamina fractures in low lumbar burst fractures. Int Orthop. 2006;30:295–298. DOI: 10.1007/s00264 005 0052 0.

8. Park JK, Park JW, Cho DC, Sung JK. Predictable factors for dural tears in lumbar burst fractures with vertical laminar fractures. J Korean Neurosurg Soc. 2011;50:11–16. DOI: 10.3340/jkns.2011.50.1.11.

9. Skiak E, Karakasli A, Harb A, Satoglu IS, Basci O, Havitcioglu H. The effect of laminae lesion on thoracolumbar fracture reduction. Orthop Traumatol Surg Res. 2015;101:489–494. DOI: 10.1016/j.otsr.2015.02.011.

10. Kahamba JF, Rath SA, Antoniadis G, Schneider O, Neff U, Richter HP. Laminar and аrch fractures with dural tear and nerve root entrapment in patients operated upon for thoracic and lumbar spine injuries. Acta Neurochir (Wien). 1998;140:114–119. DOI: 10.1007/s007010050071.

11. Keenen TL, Antony J, Benson DR. Dural tears associated with lumbar burst fractures. J Orthop Trauma 1990;4:243–245. DOI: 10.1097/00005131-199004030-00001.

12. An KC, Park DH, Kwon YW. Relationship between lamina fractures and dural tear in low lumbar burst fractures. J Korean Fract Soc. 2011;24:256–261. DOI: 10.12671/jkfs.2011.24.3.256.

13. Luszczyk MJ, Blaisdell GY, Wiater BP, Bellabarba C, Chapman JR, Agel JA, Bransford RJ. Traumatic dural tears: what do we know and are they a problem? Spine J. 2014;14:49–56. DOI: 10.1016/j.spinee.2013.03.049.

14. Pau A, Silvestro C, Carta F. Can lacerations of the thoraco-lumbar dura be predicted on the basis of radiological patterns of the spinal fractures? Acta Neurochir (Wien). 1994;129:186–187. DOI: 10.1007/BF01406502.

15. Pickett J, Blumenkopf B. Dural lacerations and thoracolumbar fractures. J Spinal Disord. 1989;2:99–103. DOI: 10.1097/00002517-198906000-00006.

16. Sharma M, Sharma AK, Gill M, Kumar G. Dural tears associated with burst fractures of lumbar vertebrae: A series of three cases. Indian J Neurosurg. 2017;6:10–14. DOI: 10.1055/s-0036-1584599.

17. Jensen MC, Kelly AP, Brant-Zawadzki MN. MRI of degenerative disease of the lumbar spine. Magn Reson Q. 1994;10:173–190.

18. Marciello MA, Flanders AE, Herbison GJ, Schaefer DM, Friedman DP, Lane JI. Magnetic resonance imaging related to neurologic outcome in cervical spinal cord injury. Arch Phys Med Rehabil. 1993;74:940–946. DOI: 10.5555/uri:pii:000399939390271B.

19. Lee IS, Kim HJ, Lee JS, Kim SJ, Jeong YJ, Kim DK, Moon TY. Dural tears in spinal burst fractures: predictable MR imaging findings. AJNR Am J Neuroradiol. 2009;30:

20. –146. DOI: 10.3174/ajnr.A1273.

21. Miller CA, Dewey RC, Hunt WE. Impaction fracture of the lumbar vertebrae with dural tear. J Neurosurg. 1980;53:765–771. DOI: 10.3171/jns.1980.53.6.0765.

22. Yoshiiwa T, Miyazaki M, Kodera R, Kawano M, Tsumura H. Predictable imaging signs of cauda equina entrapment in thoracolumbar and lumbar burst fractures with greenstick lamina fractures. Asian Spine J. 2014;8:339–345. DOI: 10.4184/asj.2014.8.3.339.

23. Denis F, Burkus JK. Diagnosis and treatment of cauda equina entrapment in the vertical lamina fracture of lumbar burst fractures. Spine. 1991;16(8 Suppl):S433–S439. DOI: 10.1097/00007632-199108001-00025.

24. Silvestro C, Francaviglia N, Bragazzi R, Piatelli S, Viale GL. On the predictive value of radiological signs for the presence of dural lacerations related to fractures of the lower thoracic or lumbar spine. J Spinal Disord. 1991;4:49–53.

25. Vaccaro AR, Oner C, Kepler CK, Dvorak M, Schnake K, Bellabarba C, Reinhold M, Aarabi B, Kandziora F, Chapman J, Shanmuganathan R, Fehlings M, Vialle L. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status and key modifiers. Spine. 2013;38:2028–2037. DOI: 10.1097 BRS.0b013e3182a8a381.

26. Maynard FM Jr, Bracken MB, Creasey G, Ditunno JF Jr, Donovan WH, Ducker TB, Garber SL, Marino RJ, Stover SL, Tator CH, Waters RL, Wilberger JE, Young W. International Standards for Neurological and Functional Classifcation of Spinal Cord Injury. American Spinal Injury Association. Spinal Cord. 1997;35:266–274. DOI: 10.1038/sj.sc.3100432.

27. Haher TR, Felmly WT, O’Brien M. Thoracic and lumbar fractures: diagnosis and management. In: Bridwell K.H., DeWald R.L., eds. The Textbook of Spinal Surgery. 2nd edition. Philadelphia, 1997:1763–1837.

28. Denis F. The three-column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817–831. DOI 10.1097/00007632-198311000-00003.