The 4D Repair Technique for Incidental Durotomy in Spine Surgery: Surgical Technique and Clinical Outcomes in 112 Patients

Background: Incidental durotomy is a recognized complication of spinal surgery and can cause persistent cerebrospinal fluid (CSF) leakage, wound complications, and reoperation. We describe the 4D repair technique and report postoperative outcomes from a single-center clinical series. Methods: This retrospective descriptive study included 112 patients treated between 2005 and January 2025. The 4D technique combines double-layer continuous dural suturing, fibrin sealant, an autologous dermal-fat graft, and passive subfascial drainage. Clinical characteristics and postoperative outcomes were summarized descriptively without a historical comparator. Results: Mean age was 64.1 ± 9.2 years; 60 patients (53.6%) were male. Persistent CSF leakage occurred in 3 patients (2.7%), symptomatic pseudomeningocele in none, CSF fistula in 1 (0.9%), and wound dehiscence in 2 (1.8%). Nine patients (8.0%) underwent reoperation for any indication. No postoperative meningitis was recorded. Mean hospital stay was 9.1 ± 3.8 days and mean passive drainage duration was 7.5 ± 2.3 days. Conclusions: This illustrated 112-patient experience describes the application and observed postoperative course of a standardized multimodal dural repair technique. The descriptive design does not establish comparative effectiveness or the independent contribution of individual steps.