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。     

脊柱外科中脑脊液漏的预防和治疗

目的 探讨脊柱外科中脑脊液漏的防治措施.方法 回顾性分析2004年1月至2010年7月发生的30例脊柱手术后脑脊液漏患者的临床资料.颈椎手术6例,胸椎手术4例,腰椎手术16例,骶椎手术4例.术中均发现硬脊膜破裂,行修补或填塞硬脊膜漏口,逐层严密缝合伤口,置管引流,伤口加压包扎,术后卧床休息等综合措施处理.结果 经过术中、术后仔细的处理,30例脑脊液漏患者全部经保守治疗后于6～26d内治愈.结论 通过术中对硬脊膜损伤及时修补或堵塞,术后采取正规的保守治疗措施,绝大多数脑脊液漏均可治愈.     

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。     

胸椎黄韧带骨化症手术并发硬脊膜损伤或脑脊液漏的原因分析及防治

目的：分析胸椎黄韧带骨化症(ossification of ligamentum flavum,OLF)手术并发硬脊膜损伤或脑脊液漏的原因，并探讨其防治方法。方法：对103例手术治疗的胸椎OLF患者中并发硬脊膜损伤或脑脊液漏病例的临床资料进行回顾性分析。结果：30例发生硬脊膜损伤，发生率为29．13％；22例术后发生脑脊液漏，发生率为21．36％，其中21例患者经以俯卧位为主的综合治疗后痊愈，1例发生伤口全层裂开，二次手术后痊愈。结论：硬脊膜损伤或脑脊液漏是胸椎OLF手术易发生的并发症；俯卧位为主的综合治疗是治疗术后脑脊液漏的有效方案，但患者较痛苦，有待改进。     

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。     

颈椎手术脑脊液漏的处理方法分析

[摘要]目的：脑脊液漏是在脊柱手术的最常见的并发症。颈椎脑脊液漏的发生率是0．5～3％。探讨4种治疗颈椎脑脊液漏的方法。方法：177例患者,其中77例颈椎脑脊液漏的方法是硬脑膜间断缝合或者连续缝合修补。硬脑膜修补片修复27例。17例行腰椎脑脊液分流术。56例联合应用纤维蛋白胶闭合。     

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。     

超声骨刀在胸椎管狭窄症手术中应用的有效性与安全性

目的 :探讨超声骨刀在胸椎管狭窄症手术中应用的有效性与安全性。方法 :2014年12月~2015年5月确诊为胸椎管狭窄症并应用超声骨刀进行后路胸脊髓减压术的患者28例,其中单纯行胸椎管后壁切除术者16例,共计切除胸椎管后壁55个节段;在胸椎管后壁切除基础上再行单节段环形减压术者12例,共计切除胸椎管后壁44个节段。术中实时记录胸椎管后壁切除时间、术中出血量、术中有无神经根损伤和脊髓损伤、有无硬膜损伤和脑脊液漏;术后第5天评估患者症状改善情况。结果:28例患者单个节段胸椎管后壁切除的时间为3.0±1.4min(2.0~5.7min)。单纯行胸椎管后壁切除术的16例患者单个节段胸椎管后壁切除的术中出血量为108.3±47.3ml(50.0~200.0ml);行环形减压术的12例患者术中出血量为513.8±217.0ml(255.0~800.0ml)。未出现因为超声骨刀切割导致的硬膜损伤、脑脊液漏;在进行"揭盖式"胸椎管后壁切除术中,2例患者分别发生左侧T2、T4神经根切割,均发生在黄韧带骨化导致椎管严重狭窄的节段,其中1例患者术后出现左侧胸壁放射痛,保守治疗4周后好转;另1例术后无明显不适。术后第5天28例患者的症状均有不同程度的改善,无脊髓损害症状加重的患者。结论:应用超声骨刀可以相对安全、有效地完成胸椎管狭窄症的减压手术;在黄韧带骨化导致胸椎管严重狭窄的节段,应用超声骨刀进行"揭盖式"胸椎管后壁切除时有损伤相应节段神经根的风险,应严格控制切割深度。     

腰椎后路减压融合术并发脑脊液漏的多因素分析

【摘要】 目的：探讨腰椎后路减压融合术并发脑脊液漏的危险因素,为临床预防脑脊液漏的发生提供依据。方法：回顾2001年1月～2011年12月收治的758例因腰椎管狭窄症行腰椎后路减压融合术患者的病史及随访资料,以是否并发脑脊液漏将患者分为两组,记录患者的年龄、性别、吸烟饮酒史、有无合并糖尿病、体重指数（body mass index,BMI)、既往手术史、病程、手术方式、手术节段数、最低手术节段及术中有无调整螺钉位置。将上述可能与并发脑脊液漏相关的因素先行单因素分析,筛选出有统计学差异的因素再行多因素Logistic回归,分析其与腰椎后路减压融合术并发脑脊液漏的关系。结果：758例患者中99例并发脑脊液漏,脑脊液漏的发生率为13.1%（99/758）,首次手术脑脊液漏的发生率为10.3%（66/638）,翻修手术为27.5%（33/120）。99例并发脑脊液漏患者中,45例术中即发现硬膜损伤或脑脊液漏,54例（54.5%）为迟发性脑脊液漏,术中未发现硬膜损伤或脑脊液漏,迟发性脑脊液漏出现时间为术后1～9d。单因素分析结果显示两组病例在年龄、吸烟、病程、翻修手术、手术节段数、最低手术节段方面差异有统计学意义（P＜0.05）;多因素Logistic回归分析显示,年龄（OR=2.153, 95% CI=1.045-4.433）、吸烟（OR=1.615,95% CI=1.015-2.572）、翻修手术（OR=3.386,95% CI=2.047-5.603）、手术的节段数（OR=2.503,95% CI=1.580-3.966）及最低手术节段（OR=2.391,95% CI=1.085-5.269）是并发脑脊液漏的危险因素（P＜0.05）。结论：年龄、吸烟、翻修手术、手术的节段数及最低手术节段对腰椎后路减压融合术并发脑脊液漏有重要影响。     

退变性腰椎疾患后路减压术后脑脊液漏的相关因素分析及处理

目的:分析退变性腰椎疾患后路减压术后脑脊液漏的相关因素,探讨其处理方法.方法:收集2011年1月～2012年12月在北京大学第三医院骨科腰椎组手术治疗患者的病历资料,纳入因腰椎间盘突出症(LDH)、腰椎管狭窄症(LSS)、腰椎滑脱(LS)、腰椎退变性侧(后)凸(LDS)行腰椎后路减压术的患者,记录患者的性别、年龄、体重指数、诊断、是否翻修手术、手术方法、减压节段数、融合方式、术后引流量、引流管留置时间、脑脊液漏的诊断、术中及术后处理方法.按1:3配比选择对照组,观察脑脊液漏组术后引流特点和引流管留置时间.结果:共纳入因退变性腰椎疾患行后路减压手术治疗的患者1425例,其中男675例,女750例,年龄16～80岁,平均54.6±13.1岁.LDH 378例,LSS 647例,LS 304例,LDS 96例;初次手术1351例,翻修手术74例;1节段减压635例,2节段减压491例,3节段减压204例,4节段及以上减压95例.术后57例发生脑脊液漏,发生率为4.0％,其中LDH 7例,发生率为1.9％;LSS 30例,发生率为4.6％;LS 13例,发生率为4.3％;LDS 7例,发生率为7.3％.4种疾病脑脊液漏的发生率无显著性差异(P＞0.05).翻修手术发生脑脊液漏9例,发生率为12.2％;初次手术发生脑脊漏48例,发生率为3.6％,差异有显著性(P＜0.05).减压节段数4节段及以上者脑脊液漏的发生率为13.7％,高于1节段(1.9％)、2节段(3.7％)和3节段(6.9％)者.多因素Logistic回归分析结果显示翻修手术和减压节段数≥4是术后并发脑脊液漏的危险因素.脑脊液漏患者采用预防感染、体位调节、引流管留置平均5.6d,卧床休息6～7d,无一例出现伤口不愈合或感染,无一例形成脑脊液囊肿或瘘管,但引流量较对照组大.结论:翻修手术与减压节段数≥4是退变性腰椎疾患后路减压术后脑脊液漏发生的危险因素;发生脑脊液漏患者术后引流管留置5～6d是安全的.     

The variable presentations of craniocervical and cervical dural arteriovenous malformations

The authors reviewed four patients with dural arteriovenous malformations in the upper spinal axis. Two were at the foramen magnum and two were lower cervical. The patients presented with subarachnoid hemorrhage, a slowly progressive cervical myelopathy, a rapidly progressive thoracic myelopathy, and tinnitus with a sixth nerve palsy. This report emphasizes the importance of studying both the intracranial dural vessels as well as the supply to the cervical spine in searching for a spinal arteriovenous malformation. Subarachnoid hemorrhage with negative cerebral angiography requires spinal angiography if there are any signs or symptoms suggesting cord or nerve root dysfunction. Embolization by an endovascular approach resulted in an angiographic cure in two patients. A combination of embolization and surgery resulted in obliteration of the arteriovenous malformation in one patient. Embolization achieved a clinical cure in one patient, and clinical improvement in two patients.     

Spinal injuries in motorcycle crashes: patterns and outcomes

BACKGROUND: The purpose of this study was to determine patterns of spinal injury and clinical outcomes resulting from motorcycle crashes. METHODS: We analyzed data collected on 1,121 motorcyclists involved in road traffic accidents (from 1993-2000) and identified those who had sustained a spinal injury. RESULTS: Spinal injury occurred in 126 (11.2%) riders (112 male riders [88.9%] and 14 female riders [11.1%]), with a mean age of 30.2 years (range, 16-61 years) and Injury Severity Score of 18.8 (range, 4-66). Isolated injuries to the spine occurred in 30 (23.8%) riders. The thoracic spine was injured in 69 (54.8%), the lumbar spine in 37 (29.4%), and the cervical spine in 34 (27.0%) cases. Multiple vertebral levels were affected in 54 (42.9%). Neurologic injury occurred in 25 riders (19.8%), with complete distal neurologic injury in 14 (4 cervical, 9 thoracic, and 1 lumbar). Eleven (8.7%) patients required spinal surgery. There were 13 (10.3%) deaths. CONCLUSION: The thoracic spine is the most commonly injured spinal region in motorcycle crashes. Multiple level injuries are common. Protocols concentrating on the radiographic clearance of the cervical region may miss a significant number of spinal injuries. Vigilance is required in assessing these patients, who often have multiple injuries.     

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。     

On the predictive value of radiological signs for the presence of dural lacerations related to fractures of the lower thoracic or lumbar spine.

The predictive value of radiological signs for the presence of lacerations of the thoracolumbar dura in spine-injured patients could represent an important adjunct to the rationale for the optimal management, owing to the possible onset of early or delayed complications of these lesions. Occurrence of signs assumed to be related to dural tears, such as separation of the pedicles, fractures of the laminae, and encroachment of the spinal canal, was analyzed in a consecutive series of 25 patients submitted to surgical reduction and stabilization of the fractured lower thoracic or lumbar spine in a 24-month period. No statistically significant correlation was found between dural lacerations and any of the examined signs. Leaks of cerebrospinal fluid through traumatic breachs of the meninges were found in 16 of the 25 cases. The high rate of occurrence of dural lesions associated with fractures of the lower thoracic or lumbar spine adds a further argument to the aggressive approach to these injuries.     

Thoracic spine injuries in victims of motorcycle accidents

Spinal cord injury can be devastating. Cervical spine roentgenography has been recommended in all severe multisystem trauma patients but little attention has been given to the thoracic spine. In a series of 266 motorcycle accident victims, seen over a 42-month period, 13 cases of thoracic spine injury were identified. During this same time interval four cases of cervical spine injury were identified. Eleven of the 13 cases involved a catapulting ejection from the motorcycle and resultant axial loading to the thoracic spine. Thoracic spine injuries are more common in these patients and therefore the thoracic spine should be immobilized until full thoracic spine roentgenography can be carried out.     

纳米羟基磷灰石/聚酰胺66椎体支撑体在脊柱前柱手术重建中的应用

[目的]探讨纳米羟基磷灰石/聚酰胺66(nano-hydroxyapatite polyamide66,n-HA/PA66)椎体支撑体在脊柱前柱手术重建中应用的临床治疗效果。[方法]2008年1月～2010年10月采用n-HA/PA66椎体支撑体行脊柱前柱重建手术434例,男332例,女102例,年龄18～72岁,平均43.2岁;颈椎骨折84例,胸腰椎骨折202例,脊髓型颈椎病148例。随访以脊髓神经功能Frankel分级和日本矫形外科学会(japan orthopaedic association,JOA)评分改善率评价患者神经功能恢复情况;复查X线片及三维CT了解术后脊柱序列恢复情况,评估支撑体融合以及下沉移位情况。[结果]395例患者获得随访,随访时间3～24个月,平均11.4个月。末次随访时,颈椎骨折和胸腰椎骨折患者中,分别有16例和17例完全性脊髓损伤患者术后脊髓功能无恢复,其余Frankel分级分别平均提高1.1级和1.3级;颈椎病患者术后3个月及末次随访JOA改善率76.7%、80.8%。影像学检查显示术后脊柱高度、曲度基本恢复正常;颈椎骨折与颈椎病患者术后3个月时支撑体全部融合(融合率100%...     

Surgical resection without dural reconstruction of a lumbar meningioma in an elderly woman

Meningiomas of the spine occur in the thoracic spine in approximately 80%, followed in frequency by the cervical and lumbar regions. The treatment of spinal meningiomas is complete surgical resection. As intraspinal meningiomas are almost always adherent to the dura, extensive dural resection or diathermic treatment of the dural attachment is usually performed to prevent tumor recurrence. The authors present the case of lumbar spinal meningioma in 82-year-old woman. Successful resection with preservation of the dura mater using the technique of Saito et al. (Spine 26:1805-1808, 2001) is described: After lumbar laminectomy a small incision was made in the surface of the spinal dura. The dura mater was separated into its inner and outer layers, and the tumor was resected with inner layer alone, preserving the outer layer. The outer layer is simply closed to achieve a watertight seal. The pathologic diagnosis was metaplastic (osseous) meningioma. Almost full recovery of the neurologic deficit was attained. Neither complication nor tumor recurrence has occurred in the 5 years since surgery. Dural preservation during surgical resection of spinal meningioma obviates the need for dural reconstruction and should reduce surgical morbidity. However, the patient should be followed long-term to watch for recurrence.     

颈椎小关节三维螺旋CT测量在数字骨科中的应用

[目的]观察颈椎小关节关节面的三维解剖学形态,探讨其临床意义,并为颈椎小关节界面撑开器的制作提供详细、可靠的数据。[方法]选择近1年在本院影像科螺旋CT室行颈部或甲状腺检查的人员,CT图像显示无颈椎间盘突出、颈椎管狭窄、肿瘤、感染及明显骨质增生的样本,选取120例,三维重建后在横轴面、冠状面及矢状面对小关节面进行测量。[结果]颈椎小关节面间隙、横径、上下径均依颈椎节段向下逐渐增大,C5～7节段相比颈椎其他节段在横径和上下径上均表现为男女两组无统计学差异,结合横径、上下径的变化情况可以看出颈椎越靠近胸椎变异性越小,男女差异越小。[结论]颈椎间小关节关节面的间隙宽度、各径线长度在诸节段及男、女间不尽相同。     

Cervical myelopathy from dural substitute

A case report of cervical spinal cord compression by infolding of a silicone-coated Dacron graft is presented. The possible complications of synthetic dural substitutes are discussed.