颈椎手术后并发脑脊液漏的原因和处理

目的：分析颈椎手术后并发脑脊液漏（CSFL）的原因，探讨其处理方法及疗效。方法：1999年12月～2004年12月共行颈椎减压手术562例，术后发生CSFL5例，其中4例为前路减压时切除后纵韧带骨化块或椎体后方骨赘时直接损伤硬膜所致，1例为后路颈椎管双开门扩大成形后发生CSFL。但术中未见明确硬膜撕裂：4例在术后1～3d发现，1例于术后第9d发现。发现CSFL后均拔除伤口引流、缝合封闭皮肤裂口、常规应用抗生素，并采取头高脚低位和经腰椎蛛网膜下腔持续引流治疗。结果：5例漏口均在1～3d内停止渗出．4～8d内伤口愈合。引流时间11～16d，引流量每天150～410ml，平均320ml。引流过程中4例出现头痛、恶心、呕吐：1例有嗜睡、神志淡漠，检查发现有低钠血症，予补液、对症处理后症状缓解。术后随访10～38个月（平均20个月），无切口感染及脑脊液囊肿形成。结论：密闭伤口、头高脚低位并经腰椎蛛网膜下腔持续引流治疗颈椎术后CSFL，有利于漏口闭合，操作简单易行，是值得应用的非手术治疗措施。     

颈椎手术并发脑脊液漏的治疗

目的探讨颈椎手术并发脑脊液漏(CSFL)的治疗方法。方法对颈椎手术215例中并发CSFL12例,术中采用硬膜破损缝合、筋膜片修补、明胶海绵压迫,配合术后引流管口缝合,保持切口干燥及腰椎蛛网膜下腔持续引流等方法治疗。结果8例术后未见明显脑脊液被引流出,切口一期愈合。4例于术后5、6d拔除引流管后仍持续有较多脑脊液渗出,其中2例采用腰椎蛛网膜下腔持续引流,于7d和14d后切口愈合;1例采用缝合法治愈;1例缝合后切口处出现大小2cm×2cm波动性包块,3周后消失。结论颈椎手术并发CSFL根据硬脊膜损伤不同给予相应的修复是首选方法,术后控制引流量、并发症能有效防治术后脑脊液漏的发生。     

颈前路手术并发脑脊液漏的原因及处理

目的探讨颈前路手术并发脑脊液漏(CSFL)的原因及处理方法。方法2006年4月~2009年4月我治疗组共行颈前路手术728例,术后发生CSFL6例,其中3例为颈椎后纵韧带骨化症患者,1例为多节段颈椎病患者,1例为外伤后颈椎脱位患者,1例为颈椎后纵韧带骨化合并硬膜囊骨化患者。6例患者均于术中发现脑脊液漏。除1例后纵韧带骨化合并硬膜囊骨化患者在切除后纵韧带骨化块后发现硬膜有一处约3×2mm左右缺损外,余患者均未发现明显硬脊膜缺损。1例正中部位硬膜囊破损患者术中行硬膜囊修补术,其余5例无法修补硬脊膜患者采用自体筋膜和明胶海绵、生物蛋白胶填塞处理。全部病例术后采用头高脚低卧位,常规使用抗生素、补足液体及应用白蛋白并加强伤口换药,保持伤口清洁干燥。结果经上述处置后,全部6例患者在术后5~17d脑脊液漏完全治愈,未并发椎管内及颅内感染、脊髓及神经根症状、脑脊液囊肿形成。术后患者神经功能恢复良好。JOA评分提高4~6分(平均4.8分)。结论对颈前路手术发生CSFL的患者术中尽量修补破损的硬脊膜,并采用自体筋膜填塞,术后采用头高脚低位并重视补液及加强换药,可以有效治疗脑脊液漏。该方法操作简单易行,无严重并发症发生,是值得应用的治疗措施。     

颈椎前路手术并发脑脊液漏的防治

[目的]探讨颈椎前路手术减压并发脑脊液漏的原因及防治措施。[方法]回顾分析本院2000年5月～2007年8月行颈椎前路手术624例，发生脑脊液漏19例。采用术中明胶海绵、筋膜片封堵，配合术后头低脚高位，细盐袋适度加压，保持切口干燥及腰椎蛛网膜下腔持续引流等方法治疗。[结果]12例经采用术中填塞封堵明胶海绵的方法，切口Ⅰ期愈合。5例术中填塞封堵明胶海绵，术后抬高床尾，颈部适度加压，对症处理，7～10d切口愈合。2例采用腰椎蛛网膜下腔持续引流，术后2周切口愈合。[结论]颈椎前路手术并发脑脊液漏，采用明胶海绵、筋膜片填塞封堵，紧密缝合切口，抬高床尾，颈前适度均匀加压，腰椎蛛网膜下腔持续引流等方法，是行之有效的非手术治疗措施。     

颈椎前路手术中硬膜损伤的预防与治疗

目的探讨如何预防与治疗颈椎前路手术中出现的硬膜损伤。方法回顾分析2011年10月—2015年10月在本院接受治疗的72例颈椎前路手术中硬膜损伤患者的临床资料。术中行明胶海绵、生物蛋白胶封堵30例,皮下筋膜组织覆盖缺损处加明胶海绵、生物蛋白胶黏合加固42例。其中32例术后48 h切口引流200 m L/d,后续采用持续常压引流加弹力绷带适度绕颈环形加压的方法治疗;40例术后48 h切口引流200 m L/d,后续采用腰大池引流结合弹力绷带适度绕颈环形加压的方法治疗。术后常规卧床,预防感染,营养支持治疗。结果 32例持续常压引流的患者恢复至脑脊液漏停止的平均时间为6.4 d,40例腰大池引流的患者平均恢复时间为11.2 d。所有患者术后神经功能均显著改善,切口愈合良好,无感染发生。仅1例发生颈前脑脊液假性囊肿,经反复穿刺抽吸加腰大池引流无效,于术后半年行颈椎前路囊肿切除修补术后痊愈。结论充分的术前评估及熟练的手术技巧对于减少颈椎前路手术中硬膜损伤至关重要。对于已经形成的硬膜损伤,术中采取明胶海绵、生物蛋白胶封堵或皮下筋膜组织覆盖缺损处结合明胶海绵、生物蛋白胶黏合加固,再辅以术后伤口引流、腰大池引流等措施,可以取得满意疗效。     

颈椎严重后纵韧带骨化症前路手术脑脊液漏的预防和处理

 目的 探讨前路手术治疗颈椎严重后纵韧带骨化症过程中,预防和处理脑脊液漏(cerebrospinal fluid leakage,CSFL)的经验。方法 回顾性分析2008年1月至2011年5月行前路手术治疗的47例颈椎严重后纵韧带骨化症(骨化厚度 >5 mm,椎管狭窄率 >50%)患者资料,其中15例患者术中出现硬膜缺损,男11例,女4例;年龄40～68岁,平均55.6岁。术前认真分析CT影像,行针对性的减压准备;术中应用直接切除、间接漂浮等技巧减少硬膜损伤,采用缝线修补、肌肉覆盖等方法处理硬膜缺损;术后给予卧床、引流等措施治疗CSFL。结果 术后15例患者均获得随访,随访时间为12～18个月,平均14.8个月。10例患者伤口愈合,术后未发生CSFL;5例患者确诊出现CSFL,其中4例经加压包扎、引流等治疗4～6 d后脑脊液漏出停止;1例形成脑脊液囊肿,经反复穿刺后3周内囊肿消失。所有患者伤口均完全愈合,无一例发生椎管内及颅内感染、气道阻塞等并发症,且无一例行二次修补或转流手术,术后神经功能恢复良好。结论 颈前路手术治疗严重后纵韧带骨化过程中,术前分析CT片并行充分减压准备,术中避免硬膜损伤及有效修补缺损,术后给予卧床、引流等措施能有效预防和处理CSFL。     

脊柱手术并发脑脊液漏的处理体会

[目的]探讨脊柱手术并发脑脊液漏的非手术治疗。[方法]回顾分析本科脊柱手术并发脑脊液漏12例患者的临床资料。其中，男8例，女4例，平均44岁（32～61岁），并发于胸腰段脊柱前路手术7例，腰骶段后路手术5例。全部病例硬膜损伤均在术中被立即发现并给予了直接缝合或肌肉筋膜片覆盖修补。术后处理：病人取头低脚高位卧床休息以降低硬膜损伤局部脑脊液压力，口服醋氮酰胺以减少每日脑脊液分泌量，同时给予静脉滴注抗生素以预防感染发生。对脑脊液漏出量无减少趋势超过1周的2例病例，采用腰穿置管持续引流脑脊液直接降低脑脊液压力。[结果]全部病例的手术伤口均获正常愈合，无一并发手术伤口感染或椎管内感染。出院后随访1—3年，无并发脑脊液囊肿或存在腰痛、头痛症状的病例。[结论]硬膜损伤一发生即得到适当的修补处理，则脊柱手术后并发脑液漏可首选能降低局部脑脊液压力和促进硬膜损伤愈合的非手术治疗。     

早期清创闭合负压引流二期修复治疗颈椎前路术后并发食道瘘的疗效观察

目的:观察早期清创闭合负压引流二期修复治疗颈椎前路手术后并发食道瘘的效果。方法:2006年2月~2012年2月我院收治颈椎前路手术后并发食道瘘患者5例,其中我院行颈椎前路手术728例中术后并发食道瘘3例,外院转入2例。4例术后5~9d出现食道瘘,1例术后46d出现。经食道镜确诊食道瘘后,立即放置胃管,改鼻饲营养支持,静脉使用广谱抗菌素,沿原手术切口进入,拆除所有缝线,行清创术。1例迟发性食道瘘患者术中发现植骨颗粒已经部分感染、溶解,取出内固定和植骨块,术后行Halo外固定架固定;其余4例内固定均予保留。彻底清创后,将负压引流泡沫修剪成合适大小楔形放置于切口内,缝合皮肤固定泡沫,用生物贴膜覆盖泡沫贴紧于切口周围皮肤上以保持切口内密闭状态,接负压引流持续冲洗10~12d后,拆除密闭负压引流装置,常规换药2~3d后行二期食道修补术,食道瘘口均使用可吸收线缝合;迟发性食道瘘者瘘口较大术中加用生物蛋白胶覆盖已修复的瘘口,并再次行自体髂骨植入,使用Halo外固定架固定。术后常规放置切口引流管2~3d,9~12d切口拆线。结果:4例患者食道修补术后颈部切口愈合良好;随访6个月~6年,原颈部切口瘢痕愈合,无吞咽困难与颈部疼痛,无迟发性感染出现。1例迟发性食道瘘患者食道修补术拆线后切口仍有少许淡黄色透明分泌物,常规换药后1周瘢痕愈合,出院后1个月在家中死亡,死因不明,死亡时颈部切口愈合良好。结论:早期清创闭合负压引流二期修复治疗颈椎前路术后并发食道瘘有效。     

颈椎前路手术并发脑脊液漏的原因及处理方法探讨

脑脊液漏(CSFL)在颈椎手术后相对较少,但是一旦发生临床上处理起来比较棘手,尤其在经颈前路手术时,由于手术视野小、操作空间有限、切口较深,采用筋膜修补困难,如处理不当,可产生诸多并发症,严重者可引起化脓性脑膜炎,甚至危及患者生命.     

颈前路减压并发脑脊液漏的处理

目的探讨颈前路减压并发脑脊液漏(CSFL)的处理及其疗效。方法1997年10月～2002年10月共行颈椎前路减压手术1052例,颈椎病926例,颈椎后纵韧带骨化症(OPLL)126例。术中共发生CSFL11例,其中9例为颈椎后纵韧带骨化症切除骨化块后引起,2例为重度脊髓型颈椎病切除椎体后方骨赘所致。硬脊膜缺损面积为(0.6～2.0)cm×(1.0～1.5)cm。采用皮下筋膜和明胶海绵的封堵填塞法处理。术后取低枕平卧位,常规应用地塞米松、速尿及抗生素,并补充白蛋白或血浆3～5d。术后24h拔除引流条。其中3例术后仍存在CSFL(均为OPLL行颈前路切除骨化块者),采用明胶海绵填塞、缝合封闭和对症处理等方法治疗。结果经术中采用封堵填塞法和术后辅助处理后,8例治愈,切口Ⅰ期愈合;另3例术后存在CSFL者,分别在术后5、14、17d治愈。术后随访10～62个月(平均26个月)。全部病例无切口感染及脑脊液囊肿形成。术后神经功能恢复良好。结论对颈前路减压术中发生CSFL者采用封堵填塞法处理,对术后存在CSFL者行常规保守治疗、明胶海绵填塞和缝合封闭是行之有效的措施,疗效满意。     

老年腰椎椎管狭窄症患者术中硬膜囊撕裂位置及术中术后处理对策

目的探讨老年腰椎椎管狭窄症患者手术发生硬膜囊撕裂的解剖学机制,比较撕裂位置及术中、术后处理对策。方法回顾性分析2012年01月~2014年01月本院行腰椎后路手术的216例〉70岁老年患者,记录患者一般资料、病程时间、术前诊断、手术方式和节段、术中硬膜囊撕裂的位置、术后脑脊液漏情况和处理方法以及并发症等。结果共计151例患者入选,其中男89例,女62例,年龄70~93岁,平均78.12岁。术中发生硬膜囊撕裂共计34例,术后出现脑脊液漏23例,硬膜囊撕裂位置发生率硬膜囊后外侧〉根袖〉硬膜囊外侧〉硬膜囊腹侧。术中采取硬膜囊缝合修补、明胶海绵压迫、生物蛋白胶粘合等处理,术后常规给予预防感染、神经根脱水、补液等治疗,均于术后3~10 d拔管,3~4周切口愈合,全部患者未出现严重并发症。结论 〉70岁老年腰椎椎管狭窄症患者术中硬膜囊撕裂及术后脑脊液漏的发生率高于整体人群,且多位于硬膜囊后外侧及根袖,术中及时发现并仔细缝合或修补破损的硬膜、术后间断夹闭引流管、延长拔管时间能获得良好的效果。     

Management of acute intraoperative cerebrospinal fluid leaks

Incidental durotomy in spinal surgery has been reported with incidences varying between 1 and over 16%, depending on the type of surgery and the region of the spine. When a dural tear occurs, immediate and meticulous repair is advised in order to minimize the risk of complications secondary to persistent leakage of cerebrospinal fluid (CSF). These complications include intracranial hypotension, pseudomeningocele formation and the development of a CSF fistula with secondary wound infection and meningitis. Most dural tears are caused during biting actions by Kerrison rongeurs, and dural adhesions, dural redundancy and thinned dura are known risk factors. Accurate visualization and thorough preparation of the surgical field are key steps in dural tear repair. Those tears that are amenable to it should be carefully sutured. Large defects may require a patch of dural substitute to be sewed in. Autologous fat has proven to be useful as onlay or plugin graft. The use of fibrin glue has become a widespread practice and its effectiveness as an adjunct to primary suturing and graft constructions has been well demonstrated. Hydrogel sealants and collagen matrix onlay grafts have become available to the surgeon as additional tools in dural tear repair. However, primary suturing — if possible — is still considered to be the most effective way of reducing the chance of persistent CSF leakage. Tight closure of the fascial layer is imperative. After lumbar durotomy repair, bed rest is advised. Postoperative lumbar or ventricular CSF drainage can also help as an additional protective measure. While numerous measures and tools are available, the key message is that the surgeon confronted with a dural tear should take his time and apply all intraoperative and postoperative means required to secure watertight closure.     

PTFE-fascia patch inlay method for the anterior approach for cervical intradural spinal lesion

STUDY DESIGN: A new method for prevention of cerebrospinal fluid leakage was studied. OBJECTIVE: To prevent cerebrospinal fluid leakage, we developed a polytetrafluoroethylene fascia patch inlay method. BACKGROUND: One of the major risks of the anterior approach for intra-dural spinal cord lesions is the cerebrospinal fluid leakage. METHODS: A small hemangioblastoma located on the ventral side of the cervical cord was resected with an anterior approach. The dural closure was performed using this polytetrafluoroethylene fascia patch inlay method. RESULTS: The patient had a satisfactory clinical course with no cerebrospinal fluid leakage. CONCLUSION: This polytetrafluoroethylene fascia patch inlay method is very effective. This method may provide both prevention of CSF leakage and future spinal cord adhesion to the dura.     

Cerebrospinal fluid leakage after elective disc surgery

For patients undergoing elective disc herniation surgery the risk to experience a dural tear is somewhere around 1% both for the cervical and the thoracic regions and probably slightly higher for the lumbar region. In most cases a dural tear is diagnosed and taken care of peroperatively. When a leakage of cerebrospinal fluid is suspected postoperatively a combination of the patient’s history and imaging investigations/laboratory tests usually gives the diagnosis and it is mostly treated by closure in a new surgical procedure or by a subdural lumbar drainage. There is conflicting data on the long-term effect of a dural tear in relation to disc herniation surgery. This review exemplifies, describes and discusses how to diagnose, treat a dural tear and what the results are when dealing with it during or after disc herniation surgery.     

Delayed Cerebrospinal Fluid Leak after Watertight Dural Closure with a Polyethylene Glycol Hydrogel Dural Sealant in Posterior Fossa Surgery: Case Report

A polyethylene glycol (PEG) hydrogel sealant recently has been approved as an adjunct to sutured dural closure in Japan. We treated consecutive six patients with PEG hydrogel sealant in posterior fossa operation. Three of six cases suffered delayed cerebrospinal fluid (CSF) leak after watertight dural closure with the PEG hydrogel sealant, although there was no leak case which was treated with fibrin glue, before 2 years until the adoption of the new material. These patients underwent posterior fossa craniotomy and discharged without remarkable CSF leak. The pseudomeningocele under the occipital wound caused the CSF leak occurr from 5th to 7th week postoperatively. All CSF leak cases needed surgical repair. At the repair, the PEG hydrogel was liquefied and almost absorbed. A fistula on the closure line and a dead space after the absorption of the PEG hydrogel was observed. When the absorbable PEG hydrogel sealant plugs in small gaps of sutured dura, its properties to prevent adhesion might suppress healing process of dural closure, so that CSF could leak through the gaps and collect as a pseudomeningocele in the dead space after absorption of the PEG hydrogel. In posterior fossa surgery a PEG hydrogel sealant should be applied when dural edges are closed tightly without any gaps.     

腰椎手术合并硬脊膜损伤及脑脊液漏的处理

目的 探讨腰椎手术合并脊膜损伤及脑脊液漏的处理方法。方法 对68例硬脊膜损伤者术中应用不同的方法进行修复;对于已发生脑脊液漏者,根据术中硬脊膜损伤类型进行相应处理。结果 68例硬脊膜损伤,15例发生脑脊液漏,无1例出现远期并发症。结论 术中损伤硬脊膜的修复是预防脑脊液漏的最有效方法。硬膜外引流治疗脑脊液漏有较好疗效。     

Simultaneous intra‐operative repair for inadvertent dural tear under posterior lumbar disk scope

Objective: To introduce a microsurgical suture technique for repair of dural tear under posterior lumbar disk scope. Methods: Micro endoscopic discectomy was performed on a 26‐year‐old male under local anesthesia. During the operation, an irregular tear of about 1.0 cm was inadvertently made in the dura.The cauda equina herniated through the tear with fluctuations and leakage of cerebrospinal fluid. The tear was successfully sutured with a 7/0 microsurgical thread which was held by small disk forceps in a parallel position. Results: Once the repair had been performed, minor cerebrospinal fluid leakage persisted but there was no herniation of the cauda equina. The original planned operation was completed smoothly under posterior lumbar disk scope. Conclusion: The microsurgical suture technique for dural tear under posterior lumbar disk scope described here is simple and reliable.     

Dural substitute with polyglycolic acid mesh and fibrin glue for dural repair: technical note and preliminary results

Background An ideal dural substitute that enables watertight closure, has sufficient strength, and can be absorbed without remnant materials that induce inflammation, adhesion, and infection is not available. The purpose of this study was to evaluate the efficacy of a bioabsorbable polyglycolic acid (PGA) mesh and fibrin glue as a substitute for dural repair. Methods Altogether, 10 patients with noted dural tears during extradural spinal surgery and 20 patients who underwent durotomy for intradural spinal surgery were included in this study. In a series of 20 consecutive cases, dural closure was performed by suture and fibrin glue. In the subsequent 10 consecutive patients, dural closure was performed by suture and fibrin glue with the use of absorbable PGA mesh. The medical records and magnetic resonance imaging (MRI) of the surgical site were retrospectively reviewed to evaluate the presence of a cerebrospinal fluid (CSF) fistula or leakage after the surgery. Results A CSF fistula occurred in five patients who underwent dural repair with fibrin glue alone, and postoperative MRI showed CSF leakage in two patients with incidental dural tears after laminectomy for ossification of ligamentum flavum. No CSF fistula was present in patients who underwent dural repair using PGA mesh and fibrin glue, and no adverse effects or complications were encountered postoperatively. Follow-up MRI revealed no evidence of CSF leakage around the reconstructed dura mater. Conclusions The use of PGA mesh and fibrin glue for the repair of dura mater is a useful method of preventing CSF leakage in spinal surgery.     

可吸收止血流体明胶预防术后脑脊液漏

目的:探索可吸收止血流体明胶预防术后脑脊液漏的有效性。方法:对2013年3月至9月有硬脊膜撕裂脑脊液漏的脊柱损伤17例患者进行回顾性分析,男16例,女1例;年龄16～67岁,平均(39.6±15.4)岁;颈椎1例,胸椎9例,胸腰段4例,腰椎3例;爆裂骨折4例,骨折脱位13例。神经损伤ASIA分级:A级12例,B级2例,D级2例,E级1例。车祸伤2例,高处坠落伤10例,重物砸伤4例,地震时从楼梯滚落1例。术中应用可吸收止血流体明胶封堵以预防术后脑脊液漏。记录术后每日的引流量。结果:17例患者有15例术后无脑脊液漏出现。2例术后出现脑脊液漏者引流管保留至术后第6～7天。术后未出现头痛、头晕、发热、颈项抵抗、皮疹、切口不愈合、切口感染、血肿、神经症状加重等并发症。随访9个月均未见到切口周围有异常现象。结论:术中应用可吸收止血流体明胶封堵硬脊膜撕裂预防术后脑脊液漏是有效的方法。