Dural Tear and Cerebrospinal Fluid Leakage in Anterior Cervical Spine Surgery: Pathophysiology, Management, and Evolving Repair Techniques

Abstract

Dural tear (DT) and cerebrospinal fluid (CSF) leakage, though uncommon complications, represent a potentially serious risk of anterior cervical spine surgery, particularly in patients with ossification of the posterior longitudinal ligament (OPLL). While the incidence in routine anterior cervical discectomy and fusion (ACDF) or corpectomy (ACCF) is typically below 0.5%, it rises sharply to 4-32% in OPLL cases. Furthermore, it exceeds 60% when dural ossification (DO) is present. Adhesion and ossification obliterate the normal epidural plane, creating a fragile osteofibrotic interface that is highly susceptible to tearing during decompression. This review synthesizes current evidence on the pathophysiology of DT and CSF leakage in anterior cervical spine surgery, provides a framework for risk stratification, and outlines evolving techniques for successful repair and management. Intraoperative management has shifted from direct resection toward dura-preserving floating decompression and biologically reinforced multilayer repair using fascia, collagen matrix, fibrin adhesives, and polyethylene glycol (PEG) hydrogel sealants. Postoperative care emphasizes controlled CSF pressure regulation, sterile wound management, and early ambulation. Most DTs achieve successful closure with timely recognition and standardized treatment. However, persistent leakage may require escalation to composite reconstruction, epidural blood patch, or vascularized flap reinforcement. Emerging technologies such as bioactive hydrogels, 3D-printed dural scaffolds, and artificial intelligence-assisted imaging offer potential future improvements, although clinical adoption remains limited. This review summarizes current evidence on the mechanisms, risk factors, diagnostic predictors, repair strategies, and postoperative management of DT and CSF leakage, with specific attention to OPLL-related DO. A more apparent distinction between established clinical practice and emerging investigational technologies is provided to guide evidence-based decision-making.