Hanky-in-the-Pocket Inlay Technique for Managing Incidental Dural Tears in Lumbar Unilateral Biportal Endoscopy Using Collagen Matrix-Technical Note with Case Series.

Introduction: Unilateral biportal endoscopy (UBE) is a novel technique for spine surgeries gaining popularity in recent times. Being minimally invasive, certain complications, such as dural tears can be difficult to manage due to restricted access. Incidental dural tears are common during endoscopic spine surgery and various techniques, such as application of fibrin sealant, non-penetrating dural clips, pressure with gelfoam and conversion to minimally invasive or open surgery have been described for the management. This study aims to describe the "Hanky in the Pocket" Technique with collagen matrix inlay to manage incidental dural tears during UBE spine surgery. Case Series: We present a prospective case series of five patients with dural tears <4 mm during UBE spine surgery for the lumbar spine managed intra operatively with the aforementioned technique. All five patients achieved the Minimal Clinically Important Difference cutoff for visual analog scale (VAS) leg pain, VAS low back ache and Oswestry Disability Index Score at the end of 3 months of surgery. No complications of cerebrospinal fluid leak or neurodeficits were encountered with this technique based on a follow-up of 1 year. Conclusion: "Hanky in the Pocket" Technique with collagen matrix inlay is a safe and effective technique for the management of incidental small dural tears. Importantly, it is less time consuming, avoids conversion to open surgery and demonstrates a good functional outcome.