Autonomic Dysreflexia with Hypertension Following Durotomy-Related Intradural Spread of Irrigation Fluid and Air During Spinal Endoscopy

Trivialization of durotomy can cause complications for endoscopic spine surgeons when a patient's neurological or cardiovascular status unexpectedly deteriorates during or after surgery. The literature on fluid management strategies, irrigation-related risk factors, and clinical consequences of incidental durotomy during spinal endoscopy is limited. However, it suggests that most patients can be managed with supportive care without formal dural repair. There is currently no validated irrigation protocol for endoscopic spine surgery. In this chapter, the authors report severe complications in several patients, including the spread of irrigation fluid, blood, and air into the intradural and intracranial spaces. They concluded that patients should be informed about the risks associated with irrigated spinal endoscopy before surgery. Infrequent yet not insignificant, adversities encompassing intracranial hemorrhage, hydrocephalus, cephalalgia, cervical discomfort, convulsive events, and the perilous autonomic dysreflexia manifesting as hypertensive episodes can transpire should the irrigation fluid inadvertently enter the spinal cord or dural sac. Adept endoscopic spinal surgeons postulate an association between durotomy events and equilibration pressures associated with irrigation, a conjunction that, when amalgamated with copious irrigation volumes, may prove disconcerting. Further research is needed to determine whether specific thresholds for pressure, flow, and total volume of irrigation fluid should be established and to identify any additional risk factors beyond incidental durotomy or prolonged surgery time.