标准大骨瓣术后带蒂颞肌筋膜瓣修补硬脑膜缺损

目的总结带蒂颞肌筋膜瓣修补硬脑膜缺损在标准大骨瓣开颅术治疗颅脑损伤病人中的应用经验。方法总对实施该项手术的63例患者进行回顾性总结。结果术后恢复良好46例,中残9例,重残1例,植物状态2例,死亡6例。没有出现脑嵌顿、皮下积液、脑脊液切口漏、感染和颞肌下坠等并发症。结论带蒂颞肌筋膜瓣是一种理想的硬脑膜修补材料,具有裁剪方便,手术操作简单等优点。     

神经补片在颅脑损伤硬脑膜减张修补中的应用

在神经外科手术中，修补缺损的硬脑膜对于维持解剖学的完整和保护脑组织，防止脑脊液漏、颅内感染、脑膨出、癫痫等并发症是十分必要的。目前．在国内主要是应用自体膜及人工硬脑膜材料来修补缺损的硬脑膜。硬脑膜修补取材多样，各有优缺点。本院对2004年9月至2008年3月对颅脑损伤行去骨瓣减压术的208例病人，应用Neuro—Patch神经补片修复硬脑膜122例，与86例开颅自体组织修复硬脑膜分组进行比较．取得了一定的疗效。报告如下。     

生物型人工硬脑膜在重型颅脑损伤术中的应用

目的 探讨生物型人工硬脑膜在重型颅脑损伤术中的应用价值.方法回顾性分析92例重型颅脑损伤患者因外伤导致硬脑膜缺损或开颅去骨瓣减压术需硬脑膜减张缝合而采用生物型人工硬脑膜进行硬脑膜修补,对其术后相关并发症及其随访结果进行分析.结果全部病例手术切口愈合良好,无颅内感染、脑脊液漏的发生.随访无迟发性排异反应发生,4例分离颞肌与硬脑膜黏连时不慎将新生硬脑膜分破,未发现硬脑膜与皮层相黏连.结论生物型人工硬脑膜在重型颅脑损伤术中的应用是安全、有效的.     

矢状窦旁脑膜瘤切除术后早期局部积液的预防

目的探讨矢状窦旁脑膜瘤切除术后早期局部积液的预防方法及效果。方法将119例接受矢状窦旁脑膜瘤切除术的患者分为2组。对照组(67例)脑膜瘤切除术后修补硬脑膜时行水密缝合,头皮下不放引流管,以普通绷带包扎。引流组(52例)不做水密缝合,头皮下放置引流管,应用弹力绷带适当加压包扎。比较2组术后早期局部积液的发生率。结果对照组13例(19.4%)术后早期出现局部积液,引流组为3例(5.8%),2组差异有统计学意义(P0.05)。结论矢状窦旁脑膜瘤切除术后修补硬脑膜时行水密缝合,皮下放置头引流管并适当加压包扎,可减少术后早期局部积液的发生率。     

急性外伤性脑脊液鼻漏、耳漏合并颅内血肿的手术治疗

目的总结颅底骨折所致急性脑脊液鼻漏、耳漏合并颅内血肿的手术治疗效果. 方法对37例患者进行手术治疗,在清除颅内血肿的同时行硬脑膜修补,骨蜡、肌肉组织填塞颅底骨折缝隙、额窦、乳突气房,硬脑膜漏口及颅底骨折均用EC耳脑胶粘合以加固修补. 结果术后33例脑脊液漏一次性治愈;1例鼻漏患者术后15 d漏液,经再次修补治愈;1例颅内感染(脑膜炎),经腰穿鞘内注射噻吗灵治愈;2例直接死于颅脑损伤. 结论急性外伤性脑脊液鼻漏、耳漏合并颅内血肿有手术指征者,血肿清除后应在硬脑膜水平进行漏口修补,同时将颅底骨折缝隙、破裂的额窦、乳突、筛板严密封闭,可有效预防术后颅内感染.     

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。     

人工脑膜修复硬脑膜的临床应用

颅脑损伤、颅内肿瘤开颅手术,往往由于颅内压高、疾病原因切除硬脑膜等使硬脑膜难以缝合,自体组织因取材困难,手术时间延长而放弃修复硬脑膜,术后增加了切口感染、颅内感染、脑脊液漏、癫痫发作等并发症可能.本院自2000年5月起应用美国博纳公司脑膜卫士修复硬脑膜30例,与30例开颅未行硬脑膜修复进行比较,取得了明显的疗效.报告如下.     

人工脑膜在颈胸椎手术硬膜损伤中的应用

[目的]探讨人工脑膜在颈胸椎手术硬膜损伤中的应用.[方法]2004年5月～2009年12月共行颈胸椎手术557例,共发生1l例手术中硬膜损伤.对硬膜裂口<1cm的7例患者采用直接缝合修补硬膜;对硬膜缺损的4例患者以及直接缝合硬膜后出现皮肤、皮下脑脊液漏的3例患者采用人工脑膜修补硬膜,术后均予头高脚低位和伤口加压包扎治疗.统计不同手术节段范围和手术入路时硬膜损伤的发生率.[结果]4例硬膜缺损患者用人工脑膜修补硬膜,手术后未发生脑脊液漏.7例直接缝合硬膜的患者中,4例治愈,3例手术后出现伤口持续性脑脊液漏,经人工脑膜修补硬膜,封闭椎管,获得痊愈.多节段颈胸椎手术中硬膜损伤的发生率高于单节段患者.[结论]人工脑膜修补硬膜,可有效预防和治疗颈、胸椎手术中硬膜破损所致术后脑脊液漏.     

硬膜-颈肌悬吊法预防枕下正中开颅减压术后皮下积液

目的研究硬膜-颈肌悬吊法在预防枕下正中开颅减压术后皮下积液的应用价值。方法研究组20例急重型小脑出血患者常规行枕下正中入路开颅减压术,清除血肿并去除骨瓣减压,将修补扩充的硬膜四点缝合悬吊于颈部肌群。对照组20例行常规分层缝合。结果研究组20例患者无1例出现症状性枕部皮下积液,对照组出现6例明显枕部皮下积液,经皮下穿刺抽液及腰穿治疗后治愈。结论硬膜-颈肌悬吊法能有效预防枕下正中开颅减压术后皮下积液的发生。     

神经内镜在经蝶入路切除垂体腺瘤术中、术后脑脊液漏中的应用

目的探讨神经内镜下修补经蝶入路切除垂体腺瘤术中、术后脑脊液漏的疗效。方法 2012年1月~2013年12月神经内镜下修补经蝶入路切除垂体腺瘤术中、术后脑脊液漏19例(20例次)。神经内镜下鞍底修补术均采用"三明治方法",即采用脂肪、人工硬膜、阔筋膜及肌肉修补缺损。结果单纯神经内镜术中脑脊液漏行神经内镜修补9例,术后再次出现脑脊液漏1例,神经内镜二次修补后未再出现脑脊液漏。显微镜术中发生脑脊液漏10例:术中行神经内镜修补1例;8例显微镜下修补术后再出现脑脊液漏,行神经内镜二次修补;1例由于漏液较少,术中未予修补,仅予腰大池持续引流,术后仍持续脑脊液漏,并在引流第5天出现颅内感染,及时进行神经内镜修补联合持续腰大池外引流后控制感染,未再发生脑脊液漏。神经内镜下一次修补成功率为94.7%(18/19)。19例术后随访1~24个月,平均7个月,无一例复发。结论神经内镜修补经蝶入路术中、术后脑脊液漏安全有效。     

Nonsuture dural repair using polyglycolic acid mesh and fibrin glue: clinical application to spinal surgery

BACKGROUND: In spinal surgery, repair of the dura is difficult when it is torn or fragile or is ossified as in cases with ossification of posterior longitudinal ligament. We report our experience with a nonsuture dural repair technique in patients undergoing spinal surgery; it uses a dura substitute composed of polyglycolic acid (PGA) mesh and fibrin glue. Here, we report the efficacy and safety of nonsuture duroplasty using PGA mesh and fibrin glue (PGA-fibrin sheet). METHODS: The artificial dura mater is composed of a PGA-fibrin sheet. The dural defect is covered with a patch sprayed with fibrin glue without suturing to the dura mater. We first evaluated this technique in an experimental study by performing water leakage tests. Between May 2001 and January 2005, we used it in 160 spinal surgeries that required intraoperative dura repair. RESULTS: Our preliminary tests showed that the threshold for water pressure without leakage was 161 +/- 42 and 96.5 +/- 32 mm Hg when the unsprayed margin around the perimeter of the patch was 5 and 2 mm, respectively. Of the 160 operated patients, 10 (6.3%) experienced subcutaneous cerebrospinal fluid (CSF) leakage. Of these, 6 required a second operation; in the other 4, the CSF collection diminished spontaneously. There were no other complications such as allergic reaction, adhesion, or infection. CONCLUSION: In combination with CSF diversion, the PGA-fibrin sheet is a viable alternative method for dural repair in spinal surgery.     

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.     

A novel method of dural repair using polyglycolic acid non-woven fabric and fibrin glue: clinical results of 140 cases

This paper presents a report based on the results obtained from clinical applications of a biocompatible dural substitute made of polyglycolic acid non-woven fabric and fibrin glue. The cases subjected to this study were the ones needing reconstruction of dura mater which had become defective due to injury or brain tumor and the ones in which primary suture of the dura mater was considered to be too difficult or inadequate with ordinary methods. The dural substitute was used in 140 cases during the period between June, 2001 and July, 2005. The operations were performed using the supratentorial approach in 66 cases and infratentorial approach in 74 cases. Among these procedures, 39 cases were indicated for microvascular decompression, the commonest operation performed, then cranial base surgery in 27 cases and tumor resection in 24 cases, and so on. Lumber spinal fluid drainage or re-operation was required in 3 cases (2.1%) due to formation of post-operative cerebrospinal fluid leakage or subcutaneous accumulation of cerebrospinal fluid. With the dural substitute no infection was observed as a complication in any of the cases. Among the 140 cases presented this time, 27 cases were cranial base surgery and 74 cases were performed, using the infratentorial approach. Nevertheless, the study showed that the closing ability of the dural substitute was adequate even in actual clinical settings it is reported above that the incidence rate of post-operative cerebrospinal fluid leakage or subcutaneous accumulation of cerebrospinal fluid which require additional intervention was only 2.1%.     

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.     

A New Absorbable Synthetic Substitute With Biomimetic Design for Dural Tissue Repair

Dural repair products are evolving from animal tissue–derived materials to synthetic materials as well as from inert to absorbable features; most of them lack functional and structural characteristics compared with the natural dura mater. In the present study, we evaluated the properties and tissue repair performance of a new dural repair product with biomimetic design. The biomimetic patch exhibits unique three‐dimensional nonwoven microfiber structure with good mechanical strength and biocompatibility. The animal study showed that the biomimetic patch and commercially synthetic material group presented new subdural regeneration at 90 days, with low level inflammatory response and minimal to no adhesion formation detected at each stage. In the biological material group, no new subdural regeneration was observed and severe adhesion between the implant and the cortex occurred at each stage. In clinical case study, there was no cerebrospinal fluid leakage, and all the postoperation observations were normal. The biomimetic structure and proper rate of degradation of the new absorbable dura substitute can guide the meaningful reconstruction of the dura mater, which may provide a novel approach for dural defect repair.     

Patch technique for repair of a dural tear in microendoscopic spinal surgery

A dural tear is a common but troublesome complication of endoscopic spinal surgery. The limitations of space make repair difficult, and it is often necessary to proceed to an open operation to suture the dura in order to prevent leakage of cerebrospinal fluid. We describe a new patch technique in which a small piece of polyglactin 910 is fixed to the injured dura with fibrin glue. Three pieces are generally required to obtain a watertight closure after lavage with saline. We have applied this technique in seven cases. All recovered well with no adverse effects. MRI showed no sign of leakage of cerebrospinal fluid.     

Safety and efficacy of the porcine small intestinal submucosa dural substitute: results of a prospective multicenter study and literature review

OBJECT. Dural substitutes are often needed after neurosurgical procedures to expand or replace dura mater resected during surgery. A new dural repair material derived from porcine small intestinal submucosa (SIS) was evaluated in a prospective multicenter clinical study. METHODS. Between 2000 and 2003, 59 patients at five different institutions underwent dural reconstruction with the SIS dural substitute, with a minimum follow up of 6 months. The primary goals of the study were to assess the efficacy and safety of the SIS dural substitute according to the rate of cerebrospinal fluid (CSF) leakage, infection, and meningitis. Chiari malformation Type I decompression (32 patients) and tumor resection (18 patients) were the most common procedures performed, with 81% of SIS grafts implanted in the posterior fossa or spine. There was one case of a CSF leak (1.7%), two cases of wound infection (3.4%), and no cases of bacterial meningitis (0%) in the 58 patients available for follow up. In both cases of wound infection, the SIS graft acted as a barrier to infection and was not removed. Intraoperatively, a watertight seal was achieved in all 59 cases. On follow-up imaging available in 27 patients there was no evidence of any adverse reaction to the graft or of cerebral inflammation. CONCLUSIONS: The SIS dural substitute demonstrated substantial efficacy in these patients after a mean follow up of 7.3 +/- 2.2 months. Rates of infection, CSF leakage, and meningitis were comparable to those reported for other dural substitute materials. A lack of adverse reactions to the graft, favorable safety profile, and clinical efficacy all point to the utility of this material as an alternative for dural repair.     

Physical and histologic properties of substitutes used for the anterior fossa region dural repair

During the last 10 years, 41 patients with dural tear caused by anterior cranial fossa bone fracture were treated surgically. Those treated conservatively were not included in this series. The patients' mean age was 36 years. The average time of postoperative observation was 15 months. Traffic accidents, as well as wounds caused by missiles (shell fragments or bullets), blows, and falls were the mechanisms of injury. An autogenous graft, followed by homologous (lyodura) and most recently by heterologous (lyoplant; B. Braun Melsungen AG, Melsungen, Germany) implants, was used to repair the dural lacerations. Fibrin adhesive was used to seal the sutures inserted between graft and dural defect margins in a majority of cases. The following criteria are required for the best dural substitute: uncontaminated tissue, histologic similarity to the local dura mater, adaptability, quick rehidratation, waterproof closure and the dural margins fast healing, and tensile strength easily resisting cerebrospinal fluid pressurization in physiological and pathological conditions. To define the effects of different tissue that could meet the above-mentioned criteria, we have undertaken a mechanical testing of the dural substitutes' tensile strength followed by histologic examination, and comparison with the dura mater of the anterior fossa region. Finally, we have paid particular attention to the clinical results of these substitutes.     

应用明胶海绵野三明治冶法在硬脊膜缝合后预防脑脊液漏的作用

 目的 探讨明胶海绵“三明治”法(医用胶+明胶海绵+医用胶)在加强硬脊膜后方裂口缝合预防脑脊液漏的作用。方法 回顾性分析2007年2月至2011年6月收治的54例椎管内硬脊膜下肿瘤患者资料,根据修复硬脊膜的方法将患者分成两组。常规修复组23例,男16例,女7例;年龄24～69 岁,平均(45.2±7.2)岁;“三明治”组31例,男19例,女12例;年龄22～67 岁,平均(44.2±6.4)岁。患者在切除椎管内硬脊膜下的肿瘤后,常规修复组采用连续锁边缝合硬脊膜后覆盖大小合适的明胶海绵;“三明治”组在连续锁边缝合硬脊膜后,加用医用胶喷涂缝合口及周缘硬脊膜,而后覆盖大小合适的明胶海绵,最后再次在明胶海绵表面及周缘喷涂医用胶。结果 与常规修复组比较,“三明治”组术后当天、第1天、第2天、第3天引流量均明显下降。常规修复组在引流管拔除后7～10 d仍有3例出现切口积液,经穿刺抽液、沙袋加压、俯卧体位等治疗后切口愈合。两组患者均获随访,随访时间12~63个月,平均26.5个月。常规组3个月后有5例伤口发生深部积液;“三明治”组未见明显异常。结论 应用“三明治”法修复硬脊膜背部损伤裂口可明显提高缝合修复效果,有效减少术后引流量,降低脑脊液漏发生率。     

Subdural patch graft technique for watertight closure of large dural defects in extended transsphenoidal surgery

OBJECTIVE: The most common postoperative complication of the transsphenoidal approach is cerebrospinal fluid (CSF) rhinorrhea. If the dura is widely opened beyond the sellar floor and massive intraoperative CSF leakage is encountered, then the conventional packing method, in which the sella turcica is filled with pieces of fat or muscle, demonstrates a relatively high incidence of CSF rhinorrhea. For more reliable prevention of postoperative CSF leakage, we developed a method for watertight closure of large dural defects. METHODS: For 34 consecutive patients with suprasellar tumors, we performed tumor resection via an extended transsphenoidal approach, in which the surgical window in the sellar floor was extended to the planum sphenoidale to expose the suprasellar cistern. The patients were retrospectively divided into three groups according to the dural defect closure technique used. Group I consisted of the first two patients, whose large dural openings were closed with a conventional fat-packing method. Group II consisted of the next 10 patients, whose large dural defects were patched with fascia and sutured with 5-0 nylon, in a watertight manner. Group III consisted of the last 22 patients, who underwent watertight dural closure with a new knot-tying technique and a double-layer patch graft, which generously covered the dural defect of the cranial base with subdural placement. In Group III, intracranial CSF compressed the patch graft against the cranial base and sealed the gap between the patch graft and the cranial base in a watertight manner. The double-layer patch graft was composed of autologous fascial membrane and a commercially available, expanded polytetrafluoroethylene dural substitute. RESULTS: Postoperative CSF leakage was noted for 50% of the patients in Group I, 30% of the patients in Group II, and 9% of the patients in Group III. The time required for dural closure for Group III was approximately 50% shorter than that required for Group II (45.9 +/- 12.4 min versus 93.5 +/- 19.1 min, P < 0.001). CONCLUSION: The subdural double-layer patch graft technique is simple and reliable for the prevention of CSF rhinorrhea after transsphenoidal surgery associated with a widely opened dura.