24例外伤性脑脊液鼻漏的经颅手术治疗疗效分析

目的 探讨外伤性脑脊液鼻漏的经颅手术治疗效果。方法 回顾性分析24例外伤性脑脊液鼻漏患者临床资料。术前均行三维CT及MRI检查,已确定漏口所在位置,并行手术治疗。明确漏口且外置靠前的20例患者应用硬膜外入路手术;4例术前漏口未能明确或靠后者,采用硬膜下入路手术。对术前未能确定漏口及确定漏口靠后者,采用硬膜下入路将硬膜打开,探查颅底骨折及漏口所在。探及漏口后仔细分离、冲洗,对有脑组织或硬脑膜、蛛网膜疝入者,予以回纳,不能回纳者切除。结果 24例患者经一次手术全部治愈,随访患者21例,平均随访2年,无一例复发,无手术后并发症。结论 在闭合性颅脑损伤患者中,脑脊液漏的发生率为2.0%～20.8%;而在开放性颅脑损伤的患者中,脑脊液漏的发生率为7%～10%,其中80%左右为脑脊液鼻漏。脑脊液鼻漏典型的临床表现为清水样鼻漏,鼻漏的量随漏口的大小及形态不等,也可随体位改变。脑脊液鼻漏诊断的难点并不在于定性,而在于定位寻找脑脊液从何处流出,如何准确地定位漏口的位置是手术成功的关键,因此确定漏口是术前准备中的一项最重要工作,是手术成功关键因素,也消除了阴性探查的机会。外伤性脑脊液鼻漏患者经颅手术修补漏口,手术安全,并发症少,疗效满意。

Transcranial surgery for traumatic cerebrospinal fluid rhinorrhea

Objective To investigate the effect of transcranial surgery in treatment of traumatic cerebrospinal fluid rhinorrhea. Methods A retrospective analysis of 24 cases of patients with cerebrospinal fluid rhinorrhea was carried out. Three dimensional CT and MRI examination were performed before surgery to determine the location of the leak,and then surgical treatment was conducted. The epidural approach was selected for 20 patients with a clear front location of the leak,and subdural approach was selected for 4 patients with undetermined location or the location near the back. The subdural approach was performed as follow： opening the dura mater,exploring skull base fractures and the locations of leaks,carefully separating and washing the leaks,retracting brain tissues for the patients with spinal cord herniation,and resection was performed for the herniation that cannot be returned. Results All 24 patients were cured by the first operation. 21 patients were followed up for 2 years in average,no relapse and complications were found after the operation. Conclusion In patients with closed craniocerebral injury,the incidence of cerebrospinal fluid leak is 2. 0% to 20. 8%; but in patients with open craniocerebral injury,the incidence of cerebrospinal fluid leak is 7% to 10%,about 80% of them for cerebrospinal fluid rhinorrhea. The clinical manifestations of cerebrospinal fluid rhinorrhea typical for watery rhinorrhea,rhinorrhea quantities with the morphology and size of the chute,can also be changed with body position. The key in the diagnosis of cerebrospinal fluid rhinorrhea is to determine the location of the leak. The transcranial surgery for traumatic cerebrospinal fluid rhinorrhea is safe,effective,and the incidence of complications is low.