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

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Ali Majed, Pia Kmeid, Georges Koberianos, Abduljalil Hajaig, Hamza Kahwaji, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5449800/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract 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. Figures Figure 1 Figure 2 Figure 3 Introduction Incidental durotomies (IDTs) are a well-known complication in spine surgery, with reported incidence rates ranging from 1.6–17.4%, marking them as a frequent challenge in the field ( 1 – 3 ). These tears can lead to a range of postoperative complications, including arachnoiditis, pseudomeningocele, and durocutaneous fistulas, complicating recovery ( 4 ). Studies suggest that early mobilization—within 24 hours post-surgery—reduces wound issues, medical complications, and hospital length of stay (LOS) in patients with IDTs ( 5 ). However, major complications and reoperation rates appear unaffected by early versus delayed mobilization ( 6 ). While minimally invasive spine surgery (MISS) has advanced as a means to reduce collateral tissue damage and enhance recovery relative to open spine surgery (OSS), the risk of IDTs remains comparable across techniques ( 7 ). Nonetheless, MISS has demonstrated improved postoperative outcomes in lumbar spine procedures, including shorter LOS, reduced blood loss, decreased postoperative pain, and less soft tissue trauma ( 7 , 8 ). Understanding the differential outcomes of IDTs in MISS versus OSS is therefore critical for optimizing patient care. Current literature highlights the general benefits of MISS over OSS, yet specific data on IDT management outcomes—including LOS, complication rates, reoperation rates, and follow-up—are limited ( 9 ). This gap poses challenges in establishing best practices for IDT management in different surgical settings. This systematic review aims to assess differential IDT outcomes in MISS versus OSS, focusing on LOS, complication rates, reoperation frequency, and follow-up periods in patients mobilized within 24 hours postoperatively. By examining these factors, we aim to provide clearer guidance for managing IDTs in both MISS and OSS settings to improve patient outcomes and reduce healthcare burdens. Methods Search Strategy This systematic review, following PRISMA guidelines, aims to evaluate differential IDT outcomes in MISS and OSS ( 10 ). We searched PubMed, Embase, and Cochrane databases through October 2024, with no initial restrictions on language, publication date, or publication type. Inclusion criteria: Patients experiencing IDTs during lumbar or thoracic spine surgery Open or minimally invasive surgical approaches Documentation of mobilization timing within 24 hours post-IDT Clinical outcomes reported for LOS, major and minor complications, reoperation rates, and follow-up durations relative to mobilization timing Exclusion criteria: Cervical spine IDTs Undefined timing of ambulation Comparisons of endoscopic techniques Patients with intentional durotomies The search strategy (Tables 1 and 2 ) used terms such as: Table 1 Table demonstrating the PICO strategy. Population Intervention Comparison Outcome Patients with incidental dural tears during lumbar or thoracic spinal surgery who were mobilized within 24 hours post-operatively MIS techniques Open techniques 1. Minor complications 2. Major complications 3. Length of hospital stay Table 2 Search strategy for open surgery versus MISS after incidental durotomy Foundational word Text word Mesh word Dural tear - Durotomy - Dural tear - Dural Leak - Cerebrospinal fluid leak - CSF leak "Cerebrospinal Fluid Leak"[Mesh] MIS - Minimally invasive procedure - Minimally invasive surgery - Minimally invasive technique "Minimally Invasive Surgical Procedures"[Mesh] Open spinal surgery Open surgery Early Mobilization - Ambulation - Mobilization - Mobilization - Accelerated Ambulation - "Early Ambulation"[Mesh] Bed rest - Bed Rest - "Bed Rest"[Mesh] ((Durotomy) OR (Dural tear) OR (Dural Leak) OR (CSF Leak) OR (Cerebrospinal Fluid Leak)) AND ((Minimally Invasive Surgery) OR (Open Surgery)) AND ((Early Ambulation) OR (Bed Rest)) Following removal of duplicates, studies were screened by title and abstract, then by full text based on inclusion and exclusion criteria. This process was conducted independently by two researchers, with a third resolving any disagreements. Figure 1 depicts the PRISMA chart which outlines the process, and Tables 1 and 2 detail the PICO framework and search terms. Study quality was assessed using the Oxford Centre for Evidence-Based Medicine criteria ( 11 ). Data Extraction Two researchers independently extracted data on study details (author, year, evidence level), patient demographics, surgical specifics, and clinical outcomes. Extracted outcomes included major/minor complications, reoperation rates, pseudomeningocele incidence, drains, and nature of surgery. Risk of Bias Assessment Risk of bias was evaluated across randomization, intervention adherence, missing data handling, outcome measurement, and result selection. Independent assessments were conducted, with a third researcher facilitating consensus where needed. Level I studies were not included in the risk assessment. Visual bias plots were generated using Robvis (Figs. 2 and 3 ) ( 12 ). Statistical Analysis Data analysis compared MISS and OSS outcomes post-IDT. Continuous variables (e.g., age, LOS, reoperation rates) were summarized with means and standard deviations, while categorical outcomes (e.g., complication rates) were presented as percentages. Unpaired t-tests assessed continuous variables, while chi-squared tests evaluated categorical outcomes, with a significance level set at p < 0.05. For instance, MISS patients showed a trend toward shorter LOS (2.0 ± 1.8 days) versus OSS (5.7 ± 2.9 days; p = 0.0617), and minor complications were significantly lower in MISS (2.2% vs. 6.0%, p = 0.0454). All calculations were conducted using IPSS software, providing consistent confidence intervals for a precise comparison of MISS and OSS outcomes following IDTs. Results The literature search yielded 95 studies, with 12 meeting the inclusion criteria: 7 focused on OSS and 5 on MISS ( 5 , 13 – 23 ). These studies included one Level I, three Level II, and eight Level IV studies, with data encompassing 832 patients (653 OSS and 179 MISS) who experienced incidental dural tears (IDTs) and were mobilized within 24 hours (Table 3 ). Table 3 Table depicting a summary of the data extracted from the 12 studies included in this review. Variable OPEN MIS Comparison Method P-value Age Mean 60.7 61.6 Unpaired t-test 0.6621 Std. Deviation 3.5 1.5 Sex (M/F) 316/309 (51.1%/48.9%) 69/82 (45.7%/54.3%) Chi-squared 0.2833 Length of Stay (LOS) Mean 5.7 2.0 Unpaired t-test 0.0617 Std. Deviation 2.9 1.8 Major Complication 614/39 (94.0%/6.0%) 172/7 (96.1%/3.9%) Chi-squared 0.2849 Minor Complication 614/39 (94.0%/6.0%) 175/4 (97.8%/2.2%) Chi-squared 0.0454 Primary Repair Mean: 4.2 repairs, SD: 1.3 Mean: 3.5 repairs, SD: 1.1 Unpaired t-test 0.0283 Reoperation Rate Mean: 8.5%, SD: 2.1% Mean: 5.6%, SD: 1.9% Unpaired t-test 6.11e-07 Follow-Up Period Mean: 10.5 months, SD: 2.6 months Mean: 9.1 months, SD: 1.7 months Unpaired t-test 0.0170 Minimally Invasive Spine Surgery (MISS) Patient Characteristics The 179 patients in the MISS group underwent lumbar procedures with a mean age of 61.6 ± 1.5 years (69 males, 82 females). A summary of the investigated outcomes for patients undergoing MISS can be seen in Table 4 . Table 4 Table depicting the outcomes for patients undergoing MISS MISS Number of patients Mean age (years) Male:Female ratio Dural repair (%) Follow up (months) Hospital stay (days) Major complications Minor complications Than et al., 2008 5 60.2 3:2 100 8.9 0.75 0 0 Francavilla et al., 2019 30 - - 93 - 0.054 2 1 Klingler et al., 2015 21 63.5 13:8 98 - - 0 3 Ruban, 2011 51 60.7 23:30 100 10.3 3.3 1 0 Senker et al., 2013 72 61.8 30:42 100 - 3.75 4 0 Dural Repair Rate Dural repairs were achieved in 98% of cases, with three patients requiring patch repairs, reflecting strong efficacy in primary repairs for MISS. Length of Stay and Follow-Up Four studies reporting on 158 MISS patients indicated a mean LOS of 2.0 ± 1.8 days. Follow-up data for 56 patients showed a mean period of 9.1 ± 1.7 months. Reoperation and Complications Reoperation Rate : Reoperation occurred in 5.6% of patients. Major Complications : Major complications, occurring in 3.9% of cases, included conditions such as wound infection and back pain, which required further intervention. Minor Complications : Minor complications, noted in 2.2% of patients, were transient and resolved without additional surgery. Open Spine Surgery (OSS) Patient Characteristics The OSS group included 653 patients with a mean age of 60.7 ± 3.5 years (316 males, 309 females). A summary of the investigated outcomes for patients undergoing MISS can be seen in Table 5 . Table 5 Table depicting the outcomes for patients undergoing open surgery. Open Number of patients Mean age (years) Male:Female ratio Dural repair (%) Follow up (months) Hospital stay (days) Major complications Minor complications Robson et al., 2018 28 > 18 - 100 3 3.5 2 2 Radcliff et al., 2016 18 55 10:8 100 - - 2 8 Farshad et al., 2020 30 63 18:12 100 - 6.56 ± 2.64 2 2 Kogl et al., 2020 48 63.3 24:24 90 12 10.3 ± 8.0 8 0 Patel et al., 2020 255 63.8 124:131 80 36.2 ± 8.8 3.5 ± 1.67 4 0 Hodges et al., 1999 20 58.1 10:10 95 > 10 - 1 5 Verma et al., 2022 254 61 130:124 100 - 4.47 ± 3.64 20 85 Dural Repair Rate Primary repairs were completed in 95% of cases, with a subset requiring patch repairs. Length of Stay and Follow-Up Five studies of 615 OSS patients indicated a mean LOS of 5.7 ± 2.9 days. Follow-up for 351 patients showed a mean period of 10.5 ± 2.6 months. Reoperation and Complications Reoperation Rate : Reoperation was required in 8.5% of cases. Major Complications : The incidence of major complications was 6.0%, including CSF leaks and pseudomeningocele, often necessitating additional surgery. Minor Complications : Minor complications affected 6.0% of patients, covering wound issues, urinary complications, and DVT, managed without further surgical intervention. Comparative Analysis Key Findings Length of Stay (LOS) : MISS showed a shorter LOS (2.0 ± 1.8 days) versus OSS (5.7 ± 2.9 days), though not statistically significant (p = 0.0617). Minor Complications : MISS had significantly fewer minor complications (2.2%) than OSS (6.0%) (p = 0.0454). Primary Repairs and Reoperation Rates : MISS required fewer primary repairs (3.5 ± 1.1) compared to OSS (4.2 ± 1.3) (p = 0.0283), and the reoperation rate was significantly lower in MISS (5.6%) versus OSS (8.5%) (p < 0.001). Follow-Up Period : MISS patients had a shorter follow-up period (9.1 ± 1.7 months) than OSS patients (10.5 ± 2.6 months) (p = 0.0170). Discussion To our knowledge, this is the first systematic review comparing outcomes of IDTs in MISS versus OSS. Among 12 qualifying studies, MISS demonstrated significantly fewer minor complications, lower reoperation rates, and reduced need for primary repairs compared to OSS. While MISS patients had a shorter hospital stay on average than OSS patients, this difference was not statistically significant. Patel et al. (2020) contributed the largest sample (255 patients), and Farshad et al. (2020) was the sole randomized control trial, providing Level I evidence comparing early mobilization to prolonged bed rest for lumbar IDTs ( 13 , 17 ). Dural Repair In this review, 832 patients (653 OSS, 179 MISS) primarily presented with lumbar IDTs. Patel et al. (2020) uniquely reported cervical and thoracic tears alongside lumbar ( 17 ). Dural repair techniques varied across studies, with primary repairs applied in 95% of OSS cases and 98% of MISS cases. Techniques included suture repair, patching, and fibrin glue. Hodges et al. (1999) reported a 5% complication rate due to stitch loosening, necessitating reoperation ( 23 ). Francavilla et al. (2019) suggested that suture repair may be superior to patching, as it better contains nerve rootlets and reduces herniation risks ( 14 ). The role of subfascial drains remains debated; while Klingler et al. (2015) questioned their efficacy, Senker et al. (2013) advocated for their use to prevent hematomas ( 15 , 21 ). Major Complications and Reoperation Rates Major complications, requiring reoperation, were related to CSF leaks, pseudomeningoceles, and wound issues. Although no significant difference was observed in major complications between OSS and MISS, reoperation rates were significantly lower for MISS (2.2%) compared to OSS (6%). Pseudomeningocele, primarily observed in OSS cases, was notably absent in MISS patients. Robson et al. (2018) and Radcliff et al. (2016) documented pseudomeningocele cases in OSS, highlighting this complication's severity and potential for cauda equina compression if untreated ( 18 , 19 ). Minor Complications Minor complications (e.g., headaches, nausea, UTIs) were observed in both surgical groups but occurred significantly less frequently in MISS (2.2%) compared to OSS (6.0%, p = 0.0454). The reduced invasiveness of MISS likely contributes to this difference. These complications were generally resolved through bed rest and supportive care without the need for surgical intervention ( 19 , 23 ). Length of Stay A nationwide study by Yoshihara et al. (2013) found that dural tears extend LOS by approximately 1.4 days ( 24 ). In our review, LOS was shorter for MISS patients (mean 1.96 days) compared to OSS patients (5.67 days), though not reaching statistical significance (p = 0.062). Future studies could provide more definitive insights into LOS differences. Limitations This review has several limitations. First, the non-comparative nature of the included studies means we lack direct head-to-head comparisons between MISS and OSS for IDTs. Consequently, observed trends should be interpreted with caution, and conclusions regarding the superiority of one approach over another remain speculative. Additional limitations include: The retrospective nature and varied methods of dural repair among included studies. Modest risk of selection and reporting bias. Despite these limitations, our findings suggest that MISS may offer advantages over OSS following IDTs, particularly in reducing minor complications and reoperation rates. This review highlights the need for multicenter, randomized controlled trials to directly compare MISS and OSS, which could establish more definitive clinical guidelines for IDT management in spinal surgery and potentially improve patient outcomes. Conclusion This systematic review suggests that minimally invasive spine surgery (MISS) offers advantages over open spine surgery (OSS) following incidental durotomies (IDTs), with notably fewer minor complications, lower reoperation rates, and reduced primary repair needs. Although MISS demonstrated a trend toward shorter hospital stays, this finding did not reach statistical significance. The evidence indicates MISS may enhance postoperative outcomes for IDT patients, potentially minimizing the risks associated with OSS. Future multicenter, randomized studies are essential to further clarify these findings and establish optimal management protocols for IDTs in spinal surgery, aiming to improve patient safety and streamline recovery processes. Declarations Author Contribution AM – Prepared the main draft, conducted methods and statistical analysisNB – Contributed to methods and statistical analysis.PK, GK, HK, AH, YM, WN, EM-EN – Contributed to writing and editing.All authors were involved in writing and editing the paper. Data Availability Data is provided within the manuscript or supplementary information files. References Khan MH, Rihn J, Steele G, Davis R, Donaldson WF 3rd, Kang JD et al (2006) Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery: a review of 3,183 consecutive degenerative lumbar cases. Spine (Phila Pa 1976) 31(22):2609–2613 Wang JC, Bohlman HH, Riew KD (1998) Dural tears secondary to operations on the lumbar spine. Management and results after a two-year-minimum follow-up of eighty-eight patients. 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Neurosurg Focus 31(4):E15 Senker W, Meznik C, Avian A, Berghold A (2013) The frequency of accidental dural tears in minimally invasive spinal fusion techniques. J Neurol Surg Cent Eur Neurosurg 74(6):373–377 Than KD, Wang AC, Etame AB, La Marca F, Park P (2008) Postoperative management of incidental durotomy in minimally invasive lumbar spinal surgery. Minim Invasive Neurosurg 51(5):263–266 Hodges SD, Humphreys SC, Eck JC, Covington LA (1999) Management of incidental durotomy without mandatory bed rest. A retrospective review of 20 cases. Spine (Phila Pa 1976) 24(19):2062–2064 Yoshihara H, Yoneoka D (2013) Incidental dural tear in lumbar spinal decompression and discectomy: analysis of a nationwide database. Arch Orthop Trauma Surg 133(11):1501–1508 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5449800","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":425678650,"identity":"9dd93d82-956d-4035-a6e1-990a78a0830f","order_by":0,"name":"Ali 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Cambridge","correspondingAuthor":false,"prefix":"","firstName":"Neel","middleName":"","lastName":"Badhe","suffix":""},{"id":425678658,"identity":"c2396506-399d-4fd6-b809-24cd68b0e36c","order_by":8,"name":"Eduardo Muscogliati","email":"","orcid":"","institution":"Hull York Medical School","correspondingAuthor":false,"prefix":"","firstName":"Eduardo","middleName":"","lastName":"Muscogliati","suffix":""},{"id":425678659,"identity":"bf1fd54f-e942-4b3b-9be3-90747942a31b","order_by":9,"name":"Elie Najjar","email":"","orcid":"","institution":"Centre for Spinal Studies and Surgery, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham","correspondingAuthor":false,"prefix":"","firstName":"Elie","middleName":"","lastName":"Najjar","suffix":""}],"badges":[],"createdAt":"2024-11-13 23:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5449800/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5449800/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78422576,"identity":"6c6835e3-d389-4bd5-89ea-7217661346b0","added_by":"auto","created_at":"2025-03-13 05:59:39","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":555513,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA chart for systematic review of database\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5449800/v1/4f60d90d8e62f93628840e16.jpeg"},{"id":78422586,"identity":"52951373-11aa-4db8-bde8-f8aa06678051","added_by":"auto","created_at":"2025-03-13 05:59:39","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":483870,"visible":true,"origin":"","legend":"\u003cp\u003eRisk of bias for each of the included studies\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5449800/v1/cb0d2618651059c457a7df8f.jpeg"},{"id":78424630,"identity":"6b65b906-8f7c-4c84-8669-e38cd4c4edb9","added_by":"auto","created_at":"2025-03-13 06:15:39","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":249824,"visible":true,"origin":"","legend":"\u003cp\u003eOverall risk of bias\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5449800/v1/fe583c0c345d14ef42eb88c2.jpeg"},{"id":78426056,"identity":"96f1b7af-50e0-412e-9354-b62d5ffdc28b","added_by":"auto","created_at":"2025-03-13 06:23:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2208058,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5449800/v1/008538ba-346a-4d1b-81ea-8706fb570e91.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rethinking Dural Tears: Do Minimally Invasive Techniques Outperform Open Surgery?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIncidental durotomies (IDTs) are a well-known complication in spine surgery, with reported incidence rates ranging from 1.6\u0026ndash;17.4%, marking them as a frequent challenge in the field (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These tears can lead to a range of postoperative complications, including arachnoiditis, pseudomeningocele, and durocutaneous fistulas, complicating recovery (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Studies suggest that early mobilization\u0026mdash;within 24 hours post-surgery\u0026mdash;reduces wound issues, medical complications, and hospital length of stay (LOS) in patients with IDTs (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, major complications and reoperation rates appear unaffected by early versus delayed mobilization (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile minimally invasive spine surgery (MISS) has advanced as a means to reduce collateral tissue damage and enhance recovery relative to open spine surgery (OSS), the risk of IDTs remains comparable across techniques (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Nonetheless, MISS has demonstrated improved postoperative outcomes in lumbar spine procedures, including shorter LOS, reduced blood loss, decreased postoperative pain, and less soft tissue trauma (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnderstanding the differential outcomes of IDTs in MISS versus OSS is therefore critical for optimizing patient care. Current literature highlights the general benefits of MISS over OSS, yet specific data on IDT management outcomes\u0026mdash;including LOS, complication rates, reoperation rates, and follow-up\u0026mdash;are limited (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This gap poses challenges in establishing best practices for IDT management in different surgical settings.\u003c/p\u003e \u003cp\u003eThis systematic review aims to assess differential IDT outcomes in MISS versus OSS, focusing on LOS, complication rates, reoperation frequency, and follow-up periods in patients mobilized within 24 hours postoperatively. By examining these factors, we aim to provide clearer guidance for managing IDTs in both MISS and OSS settings to improve patient outcomes and reduce healthcare burdens.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearch Strategy\u003c/h2\u003e \u003cp\u003eThis systematic review, following PRISMA guidelines, aims to evaluate differential IDT outcomes in MISS and OSS (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). We searched PubMed, Embase, and Cochrane databases through October 2024, with no initial restrictions on language, publication date, or publication type.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion criteria:\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePatients experiencing IDTs during lumbar or thoracic spine surgery\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOpen or minimally invasive surgical approaches\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDocumentation of mobilization timing within 24 hours post-IDT\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eClinical outcomes reported for LOS, major and minor complications, reoperation rates, and follow-up durations relative to mobilization timing\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eExclusion criteria:\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eCervical spine IDTs\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eUndefined timing of ambulation\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eComparisons of endoscopic techniques\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatients with intentional durotomies\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe search strategy (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) used terms such as:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTable demonstrating the PICO strategy.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients with incidental dural tears during lumbar or thoracic spinal surgery who were mobilized within 24 hours post-operatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMIS techniques\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOpen techniques\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1. Minor complications\u003c/p\u003e \u003cp\u003e2. Major complications\u003c/p\u003e \u003cp\u003e3. Length of hospital stay\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSearch strategy for open surgery versus MISS after incidental durotomy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFoundational word\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eText word\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMesh word\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDural tear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Durotomy\u003c/p\u003e \u003cp\u003e- Dural tear\u003c/p\u003e \u003cp\u003e- Dural Leak\u003c/p\u003e \u003cp\u003e- Cerebrospinal fluid leak\u003c/p\u003e \u003cp\u003e- CSF leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"Cerebrospinal Fluid Leak\"[Mesh]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Minimally invasive procedure\u003c/p\u003e \u003cp\u003e- Minimally invasive surgery\u003c/p\u003e \u003cp\u003e- Minimally invasive technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"Minimally Invasive Surgical Procedures\"[Mesh]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen spinal surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpen surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly Mobilization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Ambulation\u003c/p\u003e \u003cp\u003e- Mobilization\u003c/p\u003e \u003cp\u003e- Mobilization\u003c/p\u003e \u003cp\u003e- Accelerated Ambulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- \"Early Ambulation\"[Mesh]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBed rest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Bed Rest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- \"Bed Rest\"[Mesh]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e((Durotomy) OR (Dural tear) OR (Dural Leak) OR (CSF Leak) OR (Cerebrospinal Fluid Leak)) AND ((Minimally Invasive Surgery) OR (Open Surgery)) AND ((Early Ambulation) OR (Bed Rest))\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eFollowing removal of duplicates, studies were screened by title and abstract, then by full text based on inclusion and exclusion criteria. This process was conducted independently by two researchers, with a third resolving any disagreements. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the PRISMA chart which outlines the process, and Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e detail the PICO framework and search terms. Study quality was assessed using the Oxford Centre for Evidence-Based Medicine criteria (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eData Extraction\u003c/h3\u003e\n\u003cp\u003eTwo researchers independently extracted data on study details (author, year, evidence level), patient demographics, surgical specifics, and clinical outcomes. Extracted outcomes included major/minor complications, reoperation rates, pseudomeningocele incidence, drains, and nature of surgery.\u003c/p\u003e\n\u003ch3\u003eRisk of Bias Assessment\u003c/h3\u003e\n\u003cp\u003eRisk of bias was evaluated across randomization, intervention adherence, missing data handling, outcome measurement, and result selection. Independent assessments were conducted, with a third researcher facilitating consensus where needed. Level I studies were not included in the risk assessment. Visual bias plots were generated using Robvis (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData analysis compared MISS and OSS outcomes post-IDT. Continuous variables (e.g., age, LOS, reoperation rates) were summarized with means and standard deviations, while categorical outcomes (e.g., complication rates) were presented as percentages. Unpaired t-tests assessed continuous variables, while chi-squared tests evaluated categorical outcomes, with a significance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. For instance, MISS patients showed a trend toward shorter LOS (2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 days) versus OSS (5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 days; p\u0026thinsp;=\u0026thinsp;0.0617), and minor complications were significantly lower in MISS (2.2% vs. 6.0%, p\u0026thinsp;=\u0026thinsp;0.0454).\u003c/p\u003e \u003cp\u003eAll calculations were conducted using IPSS software, providing consistent confidence intervals for a precise comparison of MISS and OSS outcomes following IDTs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe literature search yielded 95 studies, with 12 meeting the inclusion criteria: 7 focused on OSS and 5 on MISS (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). These studies included one Level I, three Level II, and eight Level IV studies, with data encompassing 832 patients (653 OSS and 179 MISS) who experienced incidental dural tears (IDTs) and were mobilized within 24 hours (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTable depicting a summary of the data extracted from the 12 studies included in this review.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOPEN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMIS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComparison Method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnpaired t-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.6621\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStd. Deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (M/F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e316/309 (51.1%/48.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69/82 (45.7%/54.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChi-squared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2833\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of Stay (LOS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnpaired t-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0617\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStd. Deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor Complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e614/39 (94.0%/6.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e172/7 (96.1%/3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChi-squared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2849\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinor Complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e614/39 (94.0%/6.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e175/4 (97.8%/2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChi-squared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0454\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary Repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean: 4.2 repairs, SD: 1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean: 3.5 repairs, SD: 1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnpaired t-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0283\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation Rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean: 8.5%, SD: 2.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean: 5.6%, SD: 1.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnpaired t-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.11e-07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-Up Period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean: 10.5 months, SD: 2.6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean: 9.1 months, SD: 1.7 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnpaired t-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eMinimally Invasive Spine Surgery (MISS)\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePatient Characteristics\u003c/h2\u003e \u003cp\u003eThe 179 patients in the MISS group underwent lumbar procedures with a mean age of 61.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 years (69 males, 82 females). A summary of the investigated outcomes for patients undergoing MISS can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTable depicting the outcomes for patients undergoing MISS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMISS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean age (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale:Female ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDural repair (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFollow up (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHospital stay (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMajor complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMinor complications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThan et al., 2008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3:2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrancavilla et al., 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKlingler et al., 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13:8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRuban, 2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenker et al., 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30:42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDural Repair Rate\u003c/h2\u003e \u003cp\u003eDural repairs were achieved in 98% of cases, with three patients requiring patch repairs, reflecting strong efficacy in primary repairs for MISS.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLength of Stay and Follow-Up\u003c/h2\u003e \u003cp\u003eFour studies reporting on 158 MISS patients indicated a mean LOS of 2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 days. Follow-up data for 56 patients showed a mean period of 9.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 months.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eReoperation and Complications\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eReoperation Rate\u003c/em\u003e: Reoperation occurred in 5.6% of patients.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eMajor Complications\u003c/em\u003e: Major complications, occurring in 3.9% of cases, included conditions such as wound infection and back pain, which required further intervention.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eMinor Complications\u003c/em\u003e: Minor complications, noted in 2.2% of patients, were transient and resolved without additional surgery.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eOpen Spine Surgery (OSS)\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003ePatient Characteristics\u003c/h2\u003e \u003cp\u003eThe OSS group included 653 patients with a mean age of 60.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5 years (316 males, 309 females). A summary of the investigated outcomes for patients undergoing MISS can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTable depicting the outcomes for patients undergoing open surgery.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean age (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale:Female ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDural repair (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFollow up (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHospital stay (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMajor complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMinor complications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRobson et al., 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadcliff et al., 2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10:8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarshad et al., 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18:12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.56\u0026thinsp;\u0026plusmn;\u0026thinsp;2.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKogl et al., 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24:24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatel et al., 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e255\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e124:131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHodges et al., 1999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10:10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVerma et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130:124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.47\u0026thinsp;\u0026plusmn;\u0026thinsp;3.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDural Repair Rate\u003c/h2\u003e \u003cp\u003ePrimary repairs were completed in 95% of cases, with a subset requiring patch repairs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLength of Stay and Follow-Up\u003c/h2\u003e \u003cp\u003eFive studies of 615 OSS patients indicated a mean LOS of 5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 days. Follow-up for 351 patients showed a mean period of 10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 months.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eReoperation and Complications\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eReoperation Rate\u003c/em\u003e: Reoperation was required in 8.5% of cases.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eMajor Complications\u003c/em\u003e: The incidence of major complications was 6.0%, including CSF leaks and pseudomeningocele, often necessitating additional surgery.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eMinor Complications\u003c/em\u003e: Minor complications affected 6.0% of patients, covering wound issues, urinary complications, and DVT, managed without further surgical intervention.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eComparative Analysis\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eKey Findings\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eLength of Stay (LOS)\u003c/em\u003e: MISS showed a shorter LOS (2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 days) versus OSS (5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 days), though not statistically significant (p\u0026thinsp;=\u0026thinsp;0.0617).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eMinor Complications\u003c/em\u003e: MISS had significantly fewer minor complications (2.2%) than OSS (6.0%) (p\u0026thinsp;=\u0026thinsp;0.0454).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003ePrimary Repairs and Reoperation Rates\u003c/em\u003e: MISS required fewer primary repairs (3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1) compared to OSS (4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3) (p\u0026thinsp;=\u0026thinsp;0.0283), and the reoperation rate was significantly lower in MISS (5.6%) versus OSS (8.5%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eFollow-Up Period\u003c/em\u003e: MISS patients had a shorter follow-up period (9.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 months) than OSS patients (10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 months) (p\u0026thinsp;=\u0026thinsp;0.0170).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e To our knowledge, this is the first systematic review comparing outcomes of IDTs in MISS versus OSS. Among 12 qualifying studies, MISS demonstrated significantly fewer minor complications, lower reoperation rates, and reduced need for primary repairs compared to OSS. While MISS patients had a shorter hospital stay on average than OSS patients, this difference was not statistically significant.\u003c/p\u003e \u003cp\u003ePatel et al. (2020) contributed the largest sample (255 patients), and Farshad et al. (2020) was the sole randomized control trial, providing Level I evidence comparing early mobilization to prolonged bed rest for lumbar IDTs (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eDural Repair\u003c/h2\u003e \u003cp\u003eIn this review, 832 patients (653 OSS, 179 MISS) primarily presented with lumbar IDTs. Patel et al. (2020) uniquely reported cervical and thoracic tears alongside lumbar (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Dural repair techniques varied across studies, with primary repairs applied in 95% of OSS cases and 98% of MISS cases. Techniques included suture repair, patching, and fibrin glue. Hodges et al. (1999) reported a 5% complication rate due to stitch loosening, necessitating reoperation (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Francavilla et al. (2019) suggested that suture repair may be superior to patching, as it better contains nerve rootlets and reduces herniation risks (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The role of subfascial drains remains debated; while Klingler et al. (2015) questioned their efficacy, Senker et al. (2013) advocated for their use to prevent hematomas (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eMajor Complications and Reoperation Rates\u003c/h2\u003e \u003cp\u003eMajor complications, requiring reoperation, were related to CSF leaks, pseudomeningoceles, and wound issues. Although no significant difference was observed in major complications between OSS and MISS, reoperation rates were significantly lower for MISS (2.2%) compared to OSS (6%). Pseudomeningocele, primarily observed in OSS cases, was notably absent in MISS patients. Robson et al. (2018) and Radcliff et al. (2016) documented pseudomeningocele cases in OSS, highlighting this complication's severity and potential for cauda equina compression if untreated (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eMinor Complications\u003c/h2\u003e \u003cp\u003eMinor complications (e.g., headaches, nausea, UTIs) were observed in both surgical groups but occurred significantly less frequently in MISS (2.2%) compared to OSS (6.0%, p\u0026thinsp;=\u0026thinsp;0.0454). The reduced invasiveness of MISS likely contributes to this difference. These complications were generally resolved through bed rest and supportive care without the need for surgical intervention (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eLength of Stay\u003c/h2\u003e \u003cp\u003eA nationwide study by Yoshihara et al. (2013) found that dural tears extend LOS by approximately 1.4 days (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In our review, LOS was shorter for MISS patients (mean 1.96 days) compared to OSS patients (5.67 days), though not reaching statistical significance (p\u0026thinsp;=\u0026thinsp;0.062). Future studies could provide more definitive insights into LOS differences.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis review has several limitations. First, the non-comparative nature of the included studies means we lack direct head-to-head comparisons between MISS and OSS for IDTs. Consequently, observed trends should be interpreted with caution, and conclusions regarding the superiority of one approach over another remain speculative. Additional limitations include:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe retrospective nature and varied methods of dural repair among included studies.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eModest risk of selection and reporting bias.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eDespite these limitations, our findings suggest that MISS may offer advantages over OSS following IDTs, particularly in reducing minor complications and reoperation rates. This review highlights the need for multicenter, randomized controlled trials to directly compare MISS and OSS, which could establish more definitive clinical guidelines for IDT management in spinal surgery and potentially improve patient outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis systematic review suggests that minimally invasive spine surgery (MISS) offers advantages over open spine surgery (OSS) following incidental durotomies (IDTs), with notably fewer minor complications, lower reoperation rates, and reduced primary repair needs. Although MISS demonstrated a trend toward shorter hospital stays, this finding did not reach statistical significance. The evidence indicates MISS may enhance postoperative outcomes for IDT patients, potentially minimizing the risks associated with OSS. Future multicenter, randomized studies are essential to further clarify these findings and establish optimal management protocols for IDTs in spinal surgery, aiming to improve patient safety and streamline recovery processes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAM \u0026ndash; Prepared the main draft, conducted methods and statistical analysisNB \u0026ndash; Contributed to methods and statistical analysis.PK, GK, HK, AH, YM, WN, EM-EN \u0026ndash; Contributed to writing and editing.All authors were involved in writing and editing the paper.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003e Data is provided within the manuscript or supplementary information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKhan MH, Rihn J, Steele G, Davis R, Donaldson WF 3rd, Kang JD et al (2006) Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery: a review of 3,183 consecutive degenerative lumbar cases. Spine (Phila Pa 1976) 31(22):2609\u0026ndash;2613\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang JC, Bohlman HH, Riew KD (1998) Dural tears secondary to operations on the lumbar spine. Management and results after a two-year-minimum follow-up of eighty-eight patients. J Bone Joint Surg Am 80(12):1728\u0026ndash;1732\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams BJ, Sansur CA, Smith JS, Berven SH, Broadstone PA, Choma TJ et al (2011) Incidence of unintended durotomy in spine surgery based on 108,478 cases. Neurosurgery 68(1):117\u0026ndash;123 discussion 23\u0026thinsp;\u0026ndash;\u0026thinsp;4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDu JY, Aichmair A, Kueper J, Lam C, Nguyen JT, Cammisa FP et al (2014) Incidental durotomy during spinal surgery: a multivariate analysis for risk factors. Spine (Phila Pa 1976) 39(22):E1339\u0026ndash;E1345\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerma K, Freelin AH, Atkinson KA, Graham RS, Broaddus WC (2022) Early mobilization versus bed rest for incidental durotomy: an institutional cohort study. J Neurosurg Spine 37(3):460\u0026ndash;465\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNajjar E, Hassanin MA, Komaitis S, Karouni F, Quraishi N (2023) Complications after early versus late mobilization after an incidental durotomy: a systematic review and meta-analysis. Eur Spine J 32(3):778\u0026ndash;786\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAspalter S, Senker W, Radl C, Aichholzer M, Aufschnaiter-Hiessbock K, Leitner C et al (2021) Accidental Dural Tears in Minimally Invasive Spinal Surgery for Degenerative Lumbar Spine Disease. Front Surg 8:708243\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma A, Shakya A, Singh V, Deepak P, Mangale N, Jaiswal A et al (2022) Incidence of Dural Tears in Open versus Minimally Invasive Spine Surgery: A Single-Center Prospective Study. Asian Spine J 16(4):463\u0026ndash;470\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMok JK, Gang CH, Qureshi S, McAnany SJ (2019) Using minimally invasive techniques adds to the value equation for select patients. J Spine Surg 5(Suppl 1):S101\u0026ndash;S7\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M et al (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 4(1):1\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiggins JPTTJ, Chandler J et al (2021) Cochrane handbook for systematic reviews of interventions; version 6.2. [ \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://training.cochrane.org/handbook\u003c/span\u003e\u003cspan address=\"https://training.cochrane.org/handbook\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSterne JA, Hernan MA, Reeves BC, Savovic J, Berkman ND, Viswanathan M et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarshad M, Aichmair A, Wanivenhaus F, Betz M, Spirig J, Bauer DE (2020) No benefit of early versus late ambulation after incidental durotomy in lumbar spine surgery: a randomized controlled trial. Eur Spine J 29(1):141\u0026ndash;146\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrancavilla TL, Weiss MC, Davis R (2019) Safe Discharge of Patients From an Ambulatory Care Center After Incidental Durotomy During Minimally Invasive Spine Surgery. Int J Spine Surg 13(4):386\u0026ndash;391\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlingler JH, Volz F, Kruger MT, Kogias E, Rolz R, Scholz C et al (2015) Accidental Durotomy in Minimally Invasive Transforaminal Lumbar Interbody Fusion: Frequency, Risk Factors, and Management. ScientificWorldJournal 2015:532628\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKogl N, Schenk L, Preuss-Hernandez C, Thome C, Petr O (2023) Bed rest after incidental durotomy in lumbar surgery: a redundant measure in case of watertight dural repair. J Neurosurg Sci 67(2):206\u0026ndash;212\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel J, Kundnani V, Kuriya S (2020) Dural Leak: Is It Deterrent to Outcomes in Spine Surgery? 10 Years Retrospective Analysis of Incidence, Management Protocol, and Surgical Outcomes. Spine (Phila Pa 1976) 45(23):E1615\u0026ndash;E21\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRadcliff KE, Sidhu GD, Kepler CK, Gruskay J, Anderson DG, Hilibrand A et al (2016) Complications of Flat Bed Rest After Incidental Durotomy. Clin Spine Surg 29(7):281\u0026ndash;284\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobson CH, Paranathala MP, Dobson G, Ly F, Brown DP, O'Reilly G (2018) Early mobilisation does not increase the complication rate from unintended lumbar durotomy. Br J Neurosurg 32(6):592\u0026ndash;594\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuban D, O'Toole JE (2011) Management of incidental durotomy in minimally invasive spine surgery. Neurosurg Focus 31(4):E15\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSenker W, Meznik C, Avian A, Berghold A (2013) The frequency of accidental dural tears in minimally invasive spinal fusion techniques. J Neurol Surg Cent Eur Neurosurg 74(6):373\u0026ndash;377\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThan KD, Wang AC, Etame AB, La Marca F, Park P (2008) Postoperative management of incidental durotomy in minimally invasive lumbar spinal surgery. Minim Invasive Neurosurg 51(5):263\u0026ndash;266\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHodges SD, Humphreys SC, Eck JC, Covington LA (1999) Management of incidental durotomy without mandatory bed rest. A retrospective review of 20 cases. Spine (Phila Pa 1976) 24(19):2062\u0026ndash;2064\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoshihara H, Yoneoka D (2013) Incidental dural tear in lumbar spinal decompression and discectomy: analysis of a nationwide database. Arch Orthop Trauma Surg 133(11):1501\u0026ndash;1508\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5449800/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5449800/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e This systematic review compares IDT-related outcomes in MISS versus OSS, focusing on length of stay (LOS), complication rates, and reoperation rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e 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).\u003c/p\u003e\n\u003cp\u003eComplication 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\u0026lt;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).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e 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.\u003c/p\u003e","manuscriptTitle":"Rethinking Dural Tears: Do Minimally Invasive Techniques Outperform Open Surgery?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-13 05:59:30","doi":"10.21203/rs.3.rs-5449800/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3aba9a3e-f89b-434b-80a2-949c2dfae54f","owner":[],"postedDate":"March 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-13T05:59:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-13 05:59:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5449800","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5449800","identity":"rs-5449800","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}