硬脊膜损伤及脑脊液漏的防治

目的探讨硬脊膜损伤的分型处理及脑脊液漏的防治措施。方法对2002年3月至2008年4月44例硬脊膜损伤及9例术后脑脊液漏的临床资料进行分析总结。结果44例硬脊膜损伤均经修补手术,9例发生脑脊液漏。其中2例经二次手术修补硬脊膜均治愈出院,未发生感染及脑脊液囊肿。结论对于发生的硬脊膜损伤进行修补。术后正规治疗,大多数脑脊液漏患者可以保守治愈,少数无效者需再次手术重新修补硬脊膜。     

显微内镜腰椎间盘髓核摘除术并发脑脊液漏的防治

目的探讨MED术并发脑脊液漏的原因及防治措施。方法对我院行MED术并发脑脊液漏11例进行回顾性分析。结果术中发现脑脊液漏10例,术后全部出现脑脊液漏;1例术中未发现硬脊膜损伤术后发生脑脊液漏。11例脑脊液漏经正规保守治疗3~14天后痊愈,无1例发生脑脊髓膜炎,无继发深部感染。结论MED因其自身的特点,易发生硬脊膜损伤并脑脊液漏;术前仔细分析病例,具备一定的手术技巧,可以减少硬脊膜损伤的发生;术中对较小的硬脊膜损伤行体位处理,术后采取正规保守治疗措施,脑脊液漏可治愈。     

脊柱手术中硬脊膜损伤及术后脑脊液漏的处理

目的 探讨脊柱外科手术的常见并发症——术中硬脊膜损伤及术后脑脊液漏的外科处理措施，并观察其疗效。方法 回顾性分析2002年6月-2006年3月接受脊柱手术的405例患者资料。其中男298例，女107例；年龄11～78岁，平均46．2岁。病程3个月～5年。术中硬脊膜损伤或切开者28例（6．91％），其中颈椎3例，胸椎和腰椎19例，骶椎6例：28例中术后有6例发生脑脊液漏。术中未发现硬脊膜损伤而术后发生脑脊液漏2例。术后脑脊液漏的总发生率为1．98％。采用修复硬脊膜裂口、严密缝合切口各层、卧床休息和伤口加压包扎等综合措施处理。观察并记录处理疗效。结果 所有患者获随访3个月～4年，平均1年5个月。术前症状获不同程度缓解。8例术后脑脊液漏患者均获临床治愈，其中6例硬脊膜囊背侧瘘主要通过卧床休息、伤口加压包扎和再次手术缝合治愈，2例硬脊膜囊腹侧和侧方瘘尚需附加持续腰椎蛛网膜下腔引流。并发中枢神经系统感染1例，经多科协作治疗而愈合。结论 及时、正确地进行术中干预和术后处理，可有效治疗脊柱手术中硬脊膜损伤并预防术后脑脊液漏形成。     

腰椎内镜髓核摘除术硬脊膜损伤或脑脊液漏的原因分析及防治

目的探讨显微内镜下髓核除手术(microendoscopic discectomy，MED)并发硬脊膜损伤或脑脊液漏的原因及防治。方法回顾分析1999年12月～2003年12月我院452例MED手术15例发生硬脊膜损伤或脑脊液漏的临床资料。结果术中发现硬脊膜损伤13例，9例术后出现脑脊液漏；2例术中未发现硬脊膜损伤术后发生脑脊液漏。11例脑脊液漏经正规保守治疗后3～7d治愈，无1例发生脑脊髓膜炎，无继发深部感染。结论MED因其自身的特点，易发生硬脊膜损伤；术前仔细分析病例，术中具备一定的手术技巧，可以减少硬脊膜损伤的发生；术中对损伤硬脊膜及时堵塞或修补，术后采取正规保守治疗措施，脑脊液漏均可治愈。     

显微内窥镜腰椎间盘切除术并发脑脊液漏的防治

目的 分析显微内窥镜腰椎间盘切除术(MED)中硬脊膜损伤的防治措施.方法 回顾性分析18例MED手术致硬脊膜损伤患者的临床资料.结果 经过术中、术后处理18例硬脊膜损伤中9例脑脊液漏经过非手术治疗后于7～28 d内治愈,无一例发生感染及脑脊液囊肿.结论 通过术中对硬脊膜的修补,严密缝合腰背肌筋膜,术后积极妥当处理,绝大多数脑脊液漏可治愈.     

延长引流时间治疗脊柱后路手术脑脊液漏的疗效分析

目的评价延长引流时间在治疗脊柱后路手术脑脊液漏中的效果。方法回顾分析2009年1月至2012年3月我院脊柱外科后路手术2 137例,其中术中发现硬脊膜损伤脑脊液漏157例,术后出现脑脊液漏患者68例;均采用延长引流时间的方法,术后5~7 d拔除引流管。根据硬脊膜损伤(dural tear,DT)的部位和程度分为:硬脊膜暴露面的损伤(DT-1)、硬脊膜非暴露面的损伤(DT-2)、硬脊膜暴露面和非暴露面同时损伤(DT-3)、隐形硬脊膜损伤(DT-4)。分别采用直接无创缝合修复、直接缝合+耳脑胶或生物蛋白胶、明胶海绵+耳脑胶或生物蛋白胶、自体脂肪修复+明胶海绵+耳脑胶或生物蛋白胶等方法治疗。结果 157例硬脊膜损伤中DT-1患者106例,DT-2患者18例,DT-3患者26例,DT-4患者7例。68例术后脑脊液漏中男43例,女25例,年龄23~59岁,平均(37.6±9.3)岁;其中DT-1患者30例,DT-2患者12例,DT-3患者19例,DT-4患者7例。59例患者术后第5天脑脊液漏出量小于200 m L,予以拔管后直接缝合,9例脑脊液漏出量大于200 m L延长至术后第7天予以拔管后直接缝合封闭引流口,引流口和切口均无脑脊液漏的发生,切口区域无皮下囊肿(硬脊膜假性囊肿)出现。脑脊液漏患者中有短期低颅压综合征症状者18例,切口均一期愈合。结论延长引流时间是治疗术后脑脊液漏的有效方法。     

腰椎MED手术发生脑脊液漏的原因分析及对策

目的分析显微椎间盘镜下髓核除手术(Micro Endoscopic Discectomy，MED)并发硬脊膜损伤或脑脊液漏的原因特点，探讨其预防办法。方法通过回顾性的方法对1999年12月至2003年12月期间452例MED手术发生硬脊膜损伤或脑脊液漏的15例患临床资料进行分析总结。结果术中发现硬脊膜损伤的13例患，有9例术后出现脑脊液漏；2例术中未发现硬脊膜损伤的患术后也出现了脑脊液漏；11例脑脊液漏患经术后正规的保守治疗于3～7d内治愈，无1例脑脊髓膜炎，无继发的深部感染。结论MED手术因其自身的特点，易发生硬脊膜损伤；但通过术前对病例仔细分析，术中具备一定的手术技巧，可以减少硬脊膜损伤的发生；术中对损伤硬脊膜及时堵塞或修补，术后采取正规的保守治疗措施，脑脊液漏均可治愈。     

脊柱手术后并发脑脊液漏17例分析

自１９９３年５月～１９９７年１２月我院共施行脊柱手术６８１例,术后并发脑脊液漏１７例,对其发生的原因进行回顾性分析总结如下。在６８１例患者中,原发性硬脊膜损伤２８例,医源性硬脊膜损伤１６例,计４４例。术中进行硬脊膜修补３２例,术后发生脑脊液漏７例;术...     

颈前路后纵韧带骨化切除术并发脑脊液漏的处理及疗效分析

目的:探讨颈椎后纵韧带骨化症(ossification of posterior longitudinal ligament,OPLL)患者经颈椎前路手术并发脑脊液漏的处理方法及临床疗效。方法:2008年1月~2012年1月,采用颈前路后纵韧带骨化切除术治疗颈椎OPLL患者126例,男89例,女37例;年龄46～72岁,平均61岁;病程3d～7年,平均4.2年。骨化物在矢状面上范围涉及1～3个椎体。术中发现11例患者合并硬脊膜骨化,其中7例术中发生硬脊膜破损(4例为硬脊膜撕裂,3例形成硬脊膜缺损);115例未合并硬脊膜骨化患者中,4例发生硬脊膜撕裂。术中均采用明胶海绵覆盖及生物蛋白胶封堵,术后采用常压引流、卧床休息、预防感染及营养支持等方法综合处理,观察患者脑脊液漏情况及转归。结果:11例术中硬脊膜破损的患者术后均发生脑脊液漏,脑脊液漏发生率为8.7%(11/126),其中合并硬脊膜骨化患者术后脑脊液漏发生率为63.6%(7/11),未合并硬脊膜骨化患者术后脑脊液漏发生率为0.03%(4/115),两组比较差异有统计学意义(P<0.001)。经综合处理后,3例于术后3～5d内痊愈;8例患者切口愈合拔管后形成间隙性脑脊液囊肿,经反复穿刺抽吸、颈部环形加压包扎治疗,均于术后14～30d内痊愈,其中1例合并颅内感染,经腰大池置管持续引流加鞘内注射抗生素治疗痊愈。11例患者均获随访,随访时间为1～36个月,平均12.8个月,无神经症状加重及持续性头痛等后遗症发生,术后平均神经功能改善率为51.2%。结论:颈椎OPLL患者行颈前路手术术中易发生硬脊膜损伤,术中一期修复极为困难,术后脑脊液漏发生率高,应采取综合措施处理,以获痊愈。     

脊柱后路再手术并发硬脊膜损伤及脑脊液漏的护理

目的 总结脊柱后路再手术后硬脊膜损伤及脑脊液漏的围术期护理方法.方法 对21例脊柱后路再手术患者,术前做好心理护理、体位训练;对术中出现的硬脊膜损伤采用不同的方法进行修补,引流管放置采用三错位长距离置管法,术后密切观察病情,加强引流管的护理,出现脑脊液漏后采取特殊体位及抗感染治疗等措施.结果 发生硬脊膜损伤4例、脑脊液漏2例,切口均一期愈合,随访1～3个月无复发.结论 对脊柱后路再手术并发硬脊膜损伤及脑脊液漏患者采取针对性护理措施,可减少并发症的发生,利于患者康复.     

Anterior dural laceration caused by thoracolumbar and lumbar burst fractures

A retrospective review of the records of 60 patients with thoracolumbar and lumbar burst fractures was undertaken to document the incidence and evaluate the sequelae of dural injuries found during anterior procedures. In the entire series, six (10%) patients each had a preexisting vertically oriented dural tear. All patients with anterior dural lacerations were male and had associated neurologic deficits. In all six patients, preoperative computed tomography showed an asymmetrically retropulsed bone fragment. Dural tears were repaired primarily. A postoperative cerebrospinal fluid leak developed into the chest cavity of one patient, who was treated successfully with subarachnoid drainage. In patients with anterior dural laceration, primary repair is warranted and can be performed more easily after intraoperative correction of kyphosis. Subarachnoid drainage may be effective in cases of continued postoperative anterior cerebrospinal fluid leakage before repeated operation is considered.     

颈椎手术并发脑脊液漏的处理

目的 探讨颈椎手术并发脑脊液漏（CSFL）的处理方法及其疗效。方法 对11例颈椎手术并发CSFL的患者,后路手术采用自体筋膜修补2例,前路手术采用自体筋膜明胶海绵堵塞9例,手术后仍存在CSFL患者采取去枕头高足低位、延长脱水剂应用时间、行腰穿蛛网膜下腔引流。结果 2例后路手术CSFL患者修补成功。9例前路行硬膜堵塞患者4例仍有CSFL,行腰穿蛛网膜下腔引流,切口引流或漏出0—3d停止．切口在引流后7d拆线均愈合。结论 CSFL术中采用修补或堵塞硬膜破口术后采用头高足低位、延长脱水剂应用时间可减少手术后CSFL的发生;术后持续腰穿蛛网膜下腔引流,能有效终止切口内CSFL,有利于切口愈合,避免感染发生。     

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。     

Evaluation and treatment of dural tears in lumbar spine surgery: a review

Incidental durotomy is a frequent complication of lumbar spinal surgery. The number and complexity of spinal procedures is increasing, leading to a greater prevalence of dural tears; therefore, it is imperative that spine surgeons be familiar with safe and effective closure techniques. Occasionally, a tear may not be recognized during the procedure, so that one must recognize the signs and symptoms of a cerebrospinal fluid leak postoperatively. Several newer treatment concepts show promise. The current study represents an extensive review of the recent literature on the prevalence, mechanism, diagnosis, treatment, and outcomes of dural tears. The authors provide an overview of the problem, an update on current treatment strategies, and describe the senior author's technique of repair, which is easy to do and is effective in stopping additional leakage of cerebrospinal fluid.     

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.     

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.     

腰椎间盘手术致脑脊液漏的防治

分析腰椎间盘手术中硬脊膜损伤的原因,探讨了后脑脊液漏的防治。方法回顾１９９０年至１９９８年间４３例腰椎间盘手术致硬脊膜损伤的临床资料。结果经切口放置引流管的１２例病人,有８例于拔术后生了切口脑脊液漏,经切口旁皮肤,椎旁肌置管的３１例病人,拔管后无一例发生切口脑脊液漏。     

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.