Perioperative Impact of Incidental Durotomy in Elderly Patients Undergoing Elective Spine Surgery: A Multicenter European Cohort Study

AIM: Incidental durotomy is among the most frequent intraoperative complications in spine surgery, yet elderly patients may be especially vulnerable to its downstream consequences because of frailty, multimorbidity, delayed mobilization, and postoperative neurocognitive complications. The literature suggests that durotomy is associated with increased perioperative resource utilization, whereas long-term functional outcomes are not well reported. METHODS: We performed a retrospective multicenter cohort study across five European academic neurosurgical centers. Consecutive patients aged 65 years or older who underwent elective spine surgery between 2019 and 2024 were reviewed. Patients with incidental durotomy during the index procedure were compared with those without durotomy. Outcomes of interest included length of stay, thromboembolic events, postoperative infection, delirium, readmission, revision surgery, postoperative intensive care use, and discharge disposition. RESULTS: Among 723 included patients, 107 (14.8%) sustained an incidental durotomy. Operative time was longer in the durotomy cohort (median 178 vs 138 minutes; p < 0.001), as were length of stay (8 vs 5 days; p < 0.001), thromboembolic events (6.5% vs 1.8%; p = 0.010), and postoperative delirium (14.0% vs 5.2%; p = 0.001). In descriptive analyses of patients older than 75 years, median length of stay was 10 vs 6 days, delirium occurred in 17.7% vs 7.4%, and thromboembolic events occurred in 8.1% vs 2.2%. Postoperative infection, 30-day readmission, revision surgery, intensive care use, and discharge disposition were not significantly different between groups. CONCLUSIONS: In elderly patients undergoing elective spine surgery, incidental durotomy was associated mainly with increased perioperative morbidity rather than clearly worse short-term post-discharge outcomes. The signals for prolonged stay, delirium, and thromboembolic complications—especially in patients older than 75 years—support age-sensitive perioperative pathways emphasizing meticulous repair, early mobilization when clinically appropriate, delirium prevention, and close medical surveillance.