胸椎管狭窄症术后脑脊液漏继发皮下积液的治疗
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摘要
目的:探讨胸椎管狭窄症术后脑脊液漏继发皮下积液的治疗方法。方法:回顾分析2005年1月至2014年12月北京大学第三医院骨科脊柱组完成手术的胸椎管狭窄症患者,其中术中、术后发生脑脊液漏者186例,选取其中继发皮下积液且规律随访的11例患者作为研究对象,治疗方法依据患者脑脊液漏严重程度以及胸脊髓病恢复情况决定。采取日本骨科协会(Japanese Orthopedic Association,JOA)改良11分评分评价患者术前及术后的脊髓功能,将手术前后的JOA评分进行统计学分析。结果:11例患者均获得随访,其中后纵韧带骨化合并黄韧带骨化者6例,均接受椎管后壁切除及"涵洞塌陷法"360°脊髓环形减压术,单纯黄韧带骨化行椎管后壁切除术者5例。随访时间30~131个月,平均(85±34)个月。术前症状持续时间3个月至8年,中位数18个月;术后引流管拔出时间2~6 d,平均(4.2±1.1)d;围手术期出现发热患者10例,最高体温(37.3~39.7)℃,其中高热患者2例,延长抗生素使用时间。10例患者采取保守治疗,随访发现脑脊液漏全部吸收,其中拔出引流管后加压包扎伤口者8例,局部穿刺抽液后加压包扎伤口者2例;1例患者因保守治疗无效,继发脑脊液假性囊肿而接受再次手术治疗。11例患者的JOA评分从术前的(3.8±1.6)分升高到末次随访时的(8.9±1.2)分,神经功能改善率为70.8%。没有患者出现切口感染、切口不愈合及颅内感染等并发症。结论:胸椎管狭窄症术后脑脊液漏继发皮下积液者多数可以采取保守治疗,只有出现脑脊液假性囊肿压迫脊髓时需要采取手术治疗。
Objective: To investigate the treatment strategy for subcutaneous fistula secondary to cerebrospinal fluid leakage(CSFL) in thoracic spinal stenosis(TSS) cases. Methods: In the study,186 CSFL cases diagnosed with TSS and operated in general spine group of Department of Orthopedics,Peking University Third Hospital from January 2005 to December 2014 were retrospectively reviewed,of which eleven had subcutaneous fistula secondary to CSFL and were regularly followed up. Treatment strategy for subcutaneous fistula depended on the severity of CSFL and the recovery rate of thoracic myelopathy. Japanese Orthopedic Association(JOA) score was utilized to evaluate the neurologic status of these patients preoperatively and postoperatively. Statistical analysis was conducted between preoperative and postoperative JOA scores. Results: All of the 11 patients were regularly followed up for at least 24 months. Six of them had ossification of the posterior longitudinal ligament(OPLL) combined with ossification of ligamentum flavum(OLF),all of them undertook "cave-in"360°circumferential decompression of the spinal cord with instrumentation. Five cases had OLF only,and received En bloc resection of lamina and OLF and fixation. The follow-up period ranged from 30 months to 131 months,and averaged at(85 ± 34) months. Preoperative symptoms lasted from 3 months to 8 years,and the median was 18 months. Drainages were placed for 2-6 days,and averaged at(4. 2 ± 1. 1) days. Ten cases appeared with fever during the perioperative period,the maximum body temperature was(37. 3-39. 7) ℃. Prolonged antibiotics were applied in two cases with high fever. Ten cases were treated with conservative methods,CSFL were completely absorbed during the follow-up time,of which compressive dressing was utilized in 8 cases,and punctures combined with compressive dressing were used in 2 cases. For only 1 case,conservative therapy failed and reoperation was required because of neurological deterioration arising from CSF pseudocyst. For these 11 cases,preoperative JOA score arose from(3. 8 ± 1. 6) preoperatively to(8. 9 ± 1. 2) at the end of the final follow-up,the recovery rate was 70. 8%. No infection of wound or central nerve system were noticed,and neither were unhealing wound. Conclusion: Most TSS cases with subcutaneous fistula secondary to CSFL could be cured by conservative methods,and reoperation is required only if myelopathy caused by cerebrospinal fluid pseudocyst is identified.
Objective: To investigate the treatment strategy for subcutaneous fistula secondary to cerebrospinal fluid leakage(CSFL) in thoracic spinal stenosis(TSS) cases. Methods: In the study,186 CSFL cases diagnosed with TSS and operated in general spine group of Department of Orthopedics,Peking University Third Hospital from January 2005 to December 2014 were retrospectively reviewed,of which eleven had subcutaneous fistula secondary to CSFL and were regularly followed up. Treatment strategy for subcutaneous fistula depended on the severity of CSFL and the recovery rate of thoracic myelopathy. Japanese Orthopedic Association(JOA) score was utilized to evaluate the neurologic status of these patients preoperatively and postoperatively. Statistical analysis was conducted between preoperative and postoperative JOA scores. Results: All of the 11 patients were regularly followed up for at least 24 months. Six of them had ossification of the posterior longitudinal ligament(OPLL) combined with ossification of ligamentum flavum(OLF),all of them undertook "cave-in"360°circumferential decompression of the spinal cord with instrumentation. Five cases had OLF only,and received En bloc resection of lamina and OLF and fixation. The follow-up period ranged from 30 months to 131 months,and averaged at(85 ± 34) months. Preoperative symptoms lasted from 3 months to 8 years,and the median was 18 months. Drainages were placed for 2-6 days,and averaged at(4. 2 ± 1. 1) days. Ten cases appeared with fever during the perioperative period,the maximum body temperature was(37. 3-39. 7) ℃. Prolonged antibiotics were applied in two cases with high fever. Ten cases were treated with conservative methods,CSFL were completely absorbed during the follow-up time,of which compressive dressing was utilized in 8 cases,and punctures combined with compressive dressing were used in 2 cases. For only 1 case,conservative therapy failed and reoperation was required because of neurological deterioration arising from CSF pseudocyst. For these 11 cases,preoperative JOA score arose from(3. 8 ± 1. 6) preoperatively to(8. 9 ± 1. 2) at the end of the final follow-up,the recovery rate was 70. 8%. No infection of wound or central nerve system were noticed,and neither were unhealing wound. Conclusion: Most TSS cases with subcutaneous fistula secondary to CSFL could be cured by conservative methods,and reoperation is required only if myelopathy caused by cerebrospinal fluid pseudocyst is identified.
引文
[1]中华医学会骨科学分会脊柱外科学组.胸椎管狭窄症诊疗指南[J].中华骨科杂志,2015,35(1):1-4.
[2]刘晓光,刘忠军,陈仲强,等.“涵洞塌陷法”360°脊髓环形减压术治疗胸椎管狭窄症[J].中华骨科杂志,2010,30(11):1059-1062.
[3]Hu P,Yu M,Liu X,et al.Cerebrospinal fluid leakage after surgeries on the thoracic spine:a review of 362 cases[J].Asian Spine J,2016,10(3):472-479.
[4]Khan MH,Rihn J,Steele G,et al.Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery:a review of 3 183 consecutive degenerative lumbar cases[J].Spine,2006,31(22):2609-2613.
[5]Takahata M,Ito M,Abumi K,et al.Clinical results and complications of circumferential spinal cord decompression through a single posterior approach for thoracic myelopathy caused by ossification of posterior longitudinal ligament[J].Spine,2008,33(11):1199-1208.
[6]陈仲强,党耕町,刘晓光,等.胸椎黄韧带骨化症的治疗方法选择[J].中华骨科杂志,1999,19(4):197-200.
[7]孙垂国,陈仲强,齐强,等.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[J].中国脊柱脊髓杂志,2003,13(12):724-726.
[8]Yamazaki M,Okawa A,Fujiyoshi T,et al.Posterior decompression with instrumented fusion for thoracic myelopathy caused by ossification of the posterior longitudinal ligament[J].Eur Spine J,2010,19(5):691-698.
[9]Matsumoto M,Toyama Y,Chikuda H,et al.Outcomes of fusion surgery for ossification of the posterior longitudinal ligament of the thoracic spine:a multicenter retrospective survey:clinical article[J].J Neurosurg Spine,2011,15(4):380-385.
[10]Yamazaki M,Mochizuki M,Ikeda Y,et al.Clinical results of surgery for thoracic myelopathy caused by ossification of the posterior longitudinal ligament:operative indication of posterior decompression with instrumented fusion[J].Spine,2006,31(13):1452-1460.
[11]Sun X,Sun C,Liu X,et al.The frequency and treatment of dural tears and cerebrospinal fluid leakage in 266 patients with thoracic myelopathy caused by ossification of the ligamentum flavum[J].Spine,2012,37(12):E702-E707.
[12]Papavero L,Engler N,Kothe R.Incidental durotomy in spine surgery:first aid in ten steps[J].Eur Spine J,2015,24(9):2077-2084.
[13]Mc Mahon P,Dididze M,Levi AD.Incidental durotomy after spinal surgery:a prospective study in an academic institution[J].J Neurosurg Spine,2012,17(1):30-36.
[14]Guerin P,El Fegoun AB,Obeid l,et al.Incidental durotomy during spine surgery:incidence,management and complications.A retrospective review[J].Injury,2012,43(4):397-401.
[15]Song D,Park P.Primary closure of inadvertent durotomies utilizing the U-Clip in minimally invasive spinal surgery[J].Spine,2011,36(26):E1753-E1757.
[16]Stendel R,Danne M,Fiss l,et al.Efficacy and safety of a collagen matrix for cranial and spinal dural reconstruction using different fixation techniques[J].J Neurosurg.2008,109(2):215-221.
[17]Thavarajah D,de Lacy P,Hussain R,et al.Postoperative cervical cord compression induced by hydrogel(Dural Seal):a possible complication[J].Spine(Phila Pa 1976),2010,35(1):E25-E26.
[18]Jankowitz BT,Atteberry DS,Gerszten PC.Effect of fibrin glue on the prevention of persistent cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery[J].Eur Spine J,2009,18(8):1169-1174.
[19]李波,陈喜安.腰大池置管持续引流治疗脊柱术后脑脊液漏的疗效分析[J].中国脊柱脊髓杂志,2011,21(6):456-458.
[20]Fang Z,Jia YT,Tian R,et al.Subfascial drainage for management of cerebrospinal fluid leakage after posterior spine surgery:a prospective study based on Poiseuille’s law[J].Chin J Traumatol,2016,19(1):35-38.
[21]Hu P,Yu M,Liu X,et al.A circumferential decompressionbased surgical strategy for multilevel ossification of thoracic posterior longitudinal ligament[J].Spine J,2015,15(12):2482-2492.
[22]Wang YQ,Liu XG,Jiang L,et al.Intraoperative ultrasonography in“cave-in”360°circumferential decompression for thoracic spinal stenosis[J].Chin Med J(Engl),2011,124(23):3879-3885.
[23]Desai A,Ball PA,Bekelis K,et al.Surgery for lumbar degenerative spondylolisthesis in Spine Patient Outcomes Research Trial:does incidental durotomy affect outcome?[J].Spine,2012,37(5):406-413.
[2]刘晓光,刘忠军,陈仲强,等.“涵洞塌陷法”360°脊髓环形减压术治疗胸椎管狭窄症[J].中华骨科杂志,2010,30(11):1059-1062.
[3]Hu P,Yu M,Liu X,et al.Cerebrospinal fluid leakage after surgeries on the thoracic spine:a review of 362 cases[J].Asian Spine J,2016,10(3):472-479.
[4]Khan MH,Rihn J,Steele G,et al.Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery:a review of 3 183 consecutive degenerative lumbar cases[J].Spine,2006,31(22):2609-2613.
[5]Takahata M,Ito M,Abumi K,et al.Clinical results and complications of circumferential spinal cord decompression through a single posterior approach for thoracic myelopathy caused by ossification of posterior longitudinal ligament[J].Spine,2008,33(11):1199-1208.
[6]陈仲强,党耕町,刘晓光,等.胸椎黄韧带骨化症的治疗方法选择[J].中华骨科杂志,1999,19(4):197-200.
[7]孙垂国,陈仲强,齐强,等.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[J].中国脊柱脊髓杂志,2003,13(12):724-726.
[8]Yamazaki M,Okawa A,Fujiyoshi T,et al.Posterior decompression with instrumented fusion for thoracic myelopathy caused by ossification of the posterior longitudinal ligament[J].Eur Spine J,2010,19(5):691-698.
[9]Matsumoto M,Toyama Y,Chikuda H,et al.Outcomes of fusion surgery for ossification of the posterior longitudinal ligament of the thoracic spine:a multicenter retrospective survey:clinical article[J].J Neurosurg Spine,2011,15(4):380-385.
[10]Yamazaki M,Mochizuki M,Ikeda Y,et al.Clinical results of surgery for thoracic myelopathy caused by ossification of the posterior longitudinal ligament:operative indication of posterior decompression with instrumented fusion[J].Spine,2006,31(13):1452-1460.
[11]Sun X,Sun C,Liu X,et al.The frequency and treatment of dural tears and cerebrospinal fluid leakage in 266 patients with thoracic myelopathy caused by ossification of the ligamentum flavum[J].Spine,2012,37(12):E702-E707.
[12]Papavero L,Engler N,Kothe R.Incidental durotomy in spine surgery:first aid in ten steps[J].Eur Spine J,2015,24(9):2077-2084.
[13]Mc Mahon P,Dididze M,Levi AD.Incidental durotomy after spinal surgery:a prospective study in an academic institution[J].J Neurosurg Spine,2012,17(1):30-36.
[14]Guerin P,El Fegoun AB,Obeid l,et al.Incidental durotomy during spine surgery:incidence,management and complications.A retrospective review[J].Injury,2012,43(4):397-401.
[15]Song D,Park P.Primary closure of inadvertent durotomies utilizing the U-Clip in minimally invasive spinal surgery[J].Spine,2011,36(26):E1753-E1757.
[16]Stendel R,Danne M,Fiss l,et al.Efficacy and safety of a collagen matrix for cranial and spinal dural reconstruction using different fixation techniques[J].J Neurosurg.2008,109(2):215-221.
[17]Thavarajah D,de Lacy P,Hussain R,et al.Postoperative cervical cord compression induced by hydrogel(Dural Seal):a possible complication[J].Spine(Phila Pa 1976),2010,35(1):E25-E26.
[18]Jankowitz BT,Atteberry DS,Gerszten PC.Effect of fibrin glue on the prevention of persistent cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery[J].Eur Spine J,2009,18(8):1169-1174.
[19]李波,陈喜安.腰大池置管持续引流治疗脊柱术后脑脊液漏的疗效分析[J].中国脊柱脊髓杂志,2011,21(6):456-458.
[20]Fang Z,Jia YT,Tian R,et al.Subfascial drainage for management of cerebrospinal fluid leakage after posterior spine surgery:a prospective study based on Poiseuille’s law[J].Chin J Traumatol,2016,19(1):35-38.
[21]Hu P,Yu M,Liu X,et al.A circumferential decompressionbased surgical strategy for multilevel ossification of thoracic posterior longitudinal ligament[J].Spine J,2015,15(12):2482-2492.
[22]Wang YQ,Liu XG,Jiang L,et al.Intraoperative ultrasonography in“cave-in”360°circumferential decompression for thoracic spinal stenosis[J].Chin Med J(Engl),2011,124(23):3879-3885.
[23]Desai A,Ball PA,Bekelis K,et al.Surgery for lumbar degenerative spondylolisthesis in Spine Patient Outcomes Research Trial:does incidental durotomy affect outcome?[J].Spine,2012,37(5):406-413.