Rethinking Dural Tears: Do Minimally Invasive Techniques Outperform Open Surgery?

Background: Incidental durotomies (IDTs) are recognized complications in spinal surgery, but there is no clear consensus on whether outcomes differ significantly between minimally invasive spine surgery (MISS) and open spine surgery (OSS) following IDT, particularly with early mobilization protocols. Objective: This systematic review compares IDT-related outcomes in MISS versus OSS, focusing on length of stay (LOS), complication rates, and reoperation rates. Methods: Using PRISMA guidelines, a systematic literature review was conducted across PubMed, Embase, and Cochrane databases through October 2024. The quality of evidence was assessed with a modified Sackett’s Criteria. Twelve studies met inclusion criteria, consisting of 1 Level I study, 3 Level II studies, and 8 Level IV studies. Statistical analyses included unpaired t-tests and chi-squared tests. Results: Data included 653 OSS patients (mean age 60.7 ± 3.5 years) and 179 MISS patients (mean age 61.6 ± 1.5 years), all mobilized within 24 hours postoperatively. Dural repairs were performed in 95% of OSS cases and 98% of MISS cases. MISS patients had a shorter average LOS (2.0 ± 1.8 days) compared to OSS patients (5.7 ± 2.9 days), though this difference approached but did not reach statistical significance (p=0.0617). Complication rates showed notable differences. Minor complications were significantly lower in MISS patients (2.2%) than in OSS patients (6.0%) (p=0.0454). Major complications occurred at similar rates in both groups (6.0% for OSS vs. 3.9% for MISS; p=0.2849). MISS patients required fewer primary repairs on average (3.5 ± 1.1) than OSS patients (4.2 ± 1.3, p=0.0283), and reoperation rates were significantly lower in MISS (5.6% ± 1.9%) compared to OSS (8.5% ± 2.1%, p<0.001). Follow-up duration was slightly shorter in MISS (9.1 ± 1.7 months) than in OSS (10.5 ± 2.6 months, p=0.0170). Conclusion: MISS shows distinct advantages over OSS following IDT, with significantly fewer minor complications, reduced reoperation rates, and a lower requirement for primary repairs. These findings suggest that MISS may offer a preferable approach in IDT management, with potential benefits in patient recovery and outcomes.