止血海绵覆盖治疗腰椎后路减压术中硬膜囊撕裂的临床疗效观察
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摘要
目的 :观察止血海绵覆盖治疗腰椎后路减压术中硬膜囊撕裂导致显性脑脊液漏的临床疗效,探讨其治疗硬膜囊撕裂的疗效。方法:回顾性分析2014年1月～2016年6月在我院行后路腰椎手术治疗的1896例患者资料(初次手术1850例,翻修手术46例),术中发现硬膜囊撕裂86例(初次手术78例,翻修手术8例),其中男35例,女51例,年龄18～72(53.8±8.3)岁,所有硬膜囊破口术中均行缝合修补。根据是否适用止血海绵覆盖分为两组,A组(46例)术中使用止血海绵覆盖硬膜囊联合明胶海绵加压处理缝合后的硬膜囊破口,B组(40例)术中常规皮下深筋膜覆盖硬膜囊联合明胶海绵覆盖加压处理缝合后的硬膜囊破口。收集患者一般资料、疾病类型、手术时间、硬膜囊撕裂长度、术中失血量,记录两组患者术后脑脊液漏的发生率及其每日引流量、引流管留置时间、起床活动时间、术后脑脊液漏早期并发症情况。术后出现脑脊液漏患者末次随访均复查腰椎MRI,观察术后脑脊液漏远期并发症,是否形成硬膜囊假性囊肿或脑脊液窦道形成。结果 :A组与B组之间性别、年龄、疾病类型、术中硬膜囊撕裂大小、手术时间、术中失血量无统计学差异(P>0.05),A组术后脑脊液漏发生率15.2%(7/46)低于B组35.0%(14/40),两组间有统计学差异(P<0.05);A组中术后出现脑脊液漏患者引流管留置时间(3.5±1.3d)及平均每日脑脊液引流量(125.0±59.3ml)明显低于B组(10.5±2.1d;329.0±103.1ml),两组间有统计学差异(P<0.05);A组中术后出现脑脊液漏患者起床活动时间7.5±1.6d,B组为14.5±2.2d,两组间有统计学差异(P<0.05);末次随访时A组出现低颅压性头痛(2/7)、切口渗漏不愈(0/7)、切口感染(0/7)等早期脑脊液漏并发症低于B组(8/14、2/14、1/14)(P<0.05)。术后出现脑脊液漏患者术后随访复查腰椎MRI,A组未见明确硬膜外脑脊液囊肿或皮下窦道形成,B组存在硬膜外脑脊液囊肿1例,无皮下脑脊液窦道形成。结论:应用止血海绵覆盖硬膜囊治疗后路腰椎减压术中硬膜囊撕裂导致的显性脑脊液漏有效,可减少脑脊液漏引流管留置时间及引流量,降低术后脑脊液漏的发生率及其相关的早期并发症。
Objectives: To observe the clinical effect of hemostatic sponge covering teared dura meter in the treatment of cerebrospinal fluid leakage during lumbar posterior decompression. Methods: From January 2014 to June 2016, clinical and operative records of 1896 patients undergoing spinal surgery in our institute were reviewed retrospectively. Among them, 86 cases of dural tear were found in the posterior decompression, including 35 males and 51 females with an average age of 53.8±8.3 years old, and all the dural tears were repaired. There were 46 patients in group A using hemostatic gauze with gelatin sponge covering pressure. 40 patients in group B using deep fascia covering dural sac combined with gelatin sponge covering pressure treatment. Gender, age, diagnosis, operation time, length of dural tear and intraoperative blood loss were collected. Incidence of cerebrospinal fluid leakage after surgery, drain output, drain duration, time of getting up and the early complications were collected. All patients with cerebrospinal fluid leakage were re-examined with lumbar MRI at the last follow-up to observe long-term complications and dural cyst, pseudocyst or cerebrospinal fluid sinus. Results: There was no significant difference between the experimental group and the control group in gender, age, diagnosis, the size of dural tear, operation time or intraoperative blood loss(P>0.05). The incidence of cerebrospinal fluid leakage in group A was 15.2%(7/46), which was lower than that in group B 35%(14/40), P <0.05. The drainage tube indwelling time(3.5 ±1.3 d) and the average daily cerebrospinal fluid drainage volume(125.0 ±59.3 ml) in the experimental group were significantly lower than those in the control group(10.5±2.1 d; 329.0±103.1 ml), the differences were statistically significant(P<0.05).Time of getting up for patients in the experimental group(7.5 ±1.6 d) significantly earlier than that in the control group(14.5±2.2 d), with statistically significant difference(P<0.05); postoperative intracranial pressure headache(2/7), healing of incision leakage(0/7), wound infection(0/7) and other early complications of cerebrospinal fluid leakage were lower than those in the control group(8/14, 2/14, 1/14), P<0.05. The followup of patients after surgery in group A revealed no cerebrospinal fluid cyst or subcutaneous fistula formation,while in group B there was 1 case of epidural cerebrospinal fluid cyst, there was no subcutaneous CSFL sinus formation. Conclusions: The application of hemostatic sponge dura combined with gelatin sponge compression treatment for cerebrospinal fluid leakage in posterior lumbar decompression is effective. It can reduce the time of drainage, flow of cerebrospinal fluid leakage, the incidence of cerebrospinal fluid leakage after operation and the related early complications.
Objectives: To observe the clinical effect of hemostatic sponge covering teared dura meter in the treatment of cerebrospinal fluid leakage during lumbar posterior decompression. Methods: From January 2014 to June 2016, clinical and operative records of 1896 patients undergoing spinal surgery in our institute were reviewed retrospectively. Among them, 86 cases of dural tear were found in the posterior decompression, including 35 males and 51 females with an average age of 53.8±8.3 years old, and all the dural tears were repaired. There were 46 patients in group A using hemostatic gauze with gelatin sponge covering pressure. 40 patients in group B using deep fascia covering dural sac combined with gelatin sponge covering pressure treatment. Gender, age, diagnosis, operation time, length of dural tear and intraoperative blood loss were collected. Incidence of cerebrospinal fluid leakage after surgery, drain output, drain duration, time of getting up and the early complications were collected. All patients with cerebrospinal fluid leakage were re-examined with lumbar MRI at the last follow-up to observe long-term complications and dural cyst, pseudocyst or cerebrospinal fluid sinus. Results: There was no significant difference between the experimental group and the control group in gender, age, diagnosis, the size of dural tear, operation time or intraoperative blood loss(P>0.05). The incidence of cerebrospinal fluid leakage in group A was 15.2%(7/46), which was lower than that in group B 35%(14/40), P <0.05. The drainage tube indwelling time(3.5 ±1.3 d) and the average daily cerebrospinal fluid drainage volume(125.0 ±59.3 ml) in the experimental group were significantly lower than those in the control group(10.5±2.1 d; 329.0±103.1 ml), the differences were statistically significant(P<0.05).Time of getting up for patients in the experimental group(7.5 ±1.6 d) significantly earlier than that in the control group(14.5±2.2 d), with statistically significant difference(P<0.05); postoperative intracranial pressure headache(2/7), healing of incision leakage(0/7), wound infection(0/7) and other early complications of cerebrospinal fluid leakage were lower than those in the control group(8/14, 2/14, 1/14), P<0.05. The followup of patients after surgery in group A revealed no cerebrospinal fluid cyst or subcutaneous fistula formation,while in group B there was 1 case of epidural cerebrospinal fluid cyst, there was no subcutaneous CSFL sinus formation. Conclusions: The application of hemostatic sponge dura combined with gelatin sponge compression treatment for cerebrospinal fluid leakage in posterior lumbar decompression is effective. It can reduce the time of drainage, flow of cerebrospinal fluid leakage, the incidence of cerebrospinal fluid leakage after operation and the related early complications.
引文
1.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(Phila Pa 1976),2006,31(22):2609-2613.
2.中国医师协会骨科医师分会.中国医师协会骨科医师分会骨科循证临床诊疗指南:脊柱手术硬脊膜破裂及术后脑脊液渗漏的循证临床诊疗指南[J].中华外科杂志,2017,55(2):86-89.
3.张志平,郭昭庆,孙垂国,等.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[J].中国脊柱脊髓杂志2014,24(10):906-911.
4.孙祥耀,海涌.脊柱手术硬脊膜破裂的诊断及治疗进展[J].中国脊柱脊髓杂志,2015,25(9):860-864.
5.王飞,关凯,文天林,等.退行性腰椎滑脱术后脑脊液漏的发生率及原因分析[J].中国脊柱脊髓杂志,2016,26(7):609-612.
6.Wang JC,Bohlman HH,Riew KD.Dural tears secondary to operations on the lumbar spine:management and results after a two-year-minimum follow-up of eighty-eight patients[J].JBone Joint Surg Am,1998,80(12):1728-1732.
7.Tafazal SI,Sell PJ.Incidental durotomy in lumbar spine surgery:incidence and management[J].Eur Spine J,2005,14(3):287-290.
8.Stromqvist F,Jonsson B,Stromqvist B.Dural lesions in lumbar disc herniation surgery:incidence,risk factors,and outcome[J].Eur Spine J,2010,19(3):439-442.
9.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.
10.Joo JD,Yoon SH,Kim KJ,et al.Isolated abducens nerve palsy due to cerebrospinal fluid leakage following lumbar discectomy:a rare clinical entity[J].Eur Spine J,2013,22(Suppl 3):S421-423.
11.Jankowitz BT,Atteberry DS,Gerszten PC,et al.Effect of fibrin glue on the prevention of cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery[J].Eur Spine J,2009,18(8):1169-1174.
12.丁淼,江晓冰,姚珍松,等.氰基丙烯酸酯医用胶预防脑脊液漏的疗效观察[J].中国修复重建外科杂志,2013,27(12):1471-1474.
13.Leggat PA,Smith DR,Kedjarune U.Surgical application of cyanoacrylate adhesives:a review of toxicity[J].ANZ J Surg,2007,77(4):209-213.
14.汪向飞,张晓丹,周汉新.生物医用可吸收止血材料的研究与临床应用[J].中国组织工程研究与临床康复,2010,6(21):3973-3976.
15.巴根,赵贵成,傅强.可吸收止血材料的安全性与临床应用[J].第二军医大学学报,2011,32(8):911-914.
16.Yao HH,Hong MK,Drummond KJ.Haemostasis in neurosurgery:what is the evidence for gelatin-thrombin matrix sealant[J].J Clin Neurosci,2013,20(3):349-356.
17.于滨生,郑召民,庄新明,等.脊柱手术后脑脊液漏的治疗[J].中国脊柱脊髓杂志,2009,19(2):113-116.
18.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.
19.程增银,马文海,崔建平,等.延长引流时间并间断夹闭引流管治疗脊柱术后脑脊液漏的疗效观察[J].中国脊柱脊髓杂志,2010,20(12):985-987.
20.Yi HJ,Kim DW.Reversible unilateral blindness after lumbar spine surgery:a role for cerebrospinal fluid leakage?[J].JNeurosurg Anesthesiol,2004,16(4):322-323.
21.Friedman JA,Ecker RD,Piepgras DG,et al.Cerebellar hemorrhage after spinal surgery:report of two cases and literature review[J].Neurosurgery,2002,50(6):1361-1363.
22.Huang PH,Wu JC,Cheng H,et al.Remote cerebellar hemorrhage after cervical spinal surgery[J].J Chin Med Assoc,2013,76(10):593-598.
23.Nowak R,Maliszewski M,Krawczyk L.Intracranial subdural hematoma and pneumocephalus after spinal instrumentation of myelodysplastic scoliosis[J].J Pediatr Orthop B,2011,20(1):41-45.
24.Pirris SM,Nottmeier EW.Symptomatic pneumocephalus associated with lumbar dural tear and reverse trendelenburg positioning:a case report and review of the literature[J].Case Rep Neurol Med,2013,21(2):34-39.
25.Narotam PK,Jose S,Nathoo N,et al.Collagen matrix(DuraGen)in dural repair:analysis of a new modified technique[J].Spine,2004,29(24):2861-2869.
2.中国医师协会骨科医师分会.中国医师协会骨科医师分会骨科循证临床诊疗指南:脊柱手术硬脊膜破裂及术后脑脊液渗漏的循证临床诊疗指南[J].中华外科杂志,2017,55(2):86-89.
3.张志平,郭昭庆,孙垂国,等.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[J].中国脊柱脊髓杂志2014,24(10):906-911.
4.孙祥耀,海涌.脊柱手术硬脊膜破裂的诊断及治疗进展[J].中国脊柱脊髓杂志,2015,25(9):860-864.
5.王飞,关凯,文天林,等.退行性腰椎滑脱术后脑脊液漏的发生率及原因分析[J].中国脊柱脊髓杂志,2016,26(7):609-612.
6.Wang JC,Bohlman HH,Riew KD.Dural tears secondary to operations on the lumbar spine:management and results after a two-year-minimum follow-up of eighty-eight patients[J].JBone Joint Surg Am,1998,80(12):1728-1732.
7.Tafazal SI,Sell PJ.Incidental durotomy in lumbar spine surgery:incidence and management[J].Eur Spine J,2005,14(3):287-290.
8.Stromqvist F,Jonsson B,Stromqvist B.Dural lesions in lumbar disc herniation surgery:incidence,risk factors,and outcome[J].Eur Spine J,2010,19(3):439-442.
9.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.
10.Joo JD,Yoon SH,Kim KJ,et al.Isolated abducens nerve palsy due to cerebrospinal fluid leakage following lumbar discectomy:a rare clinical entity[J].Eur Spine J,2013,22(Suppl 3):S421-423.
11.Jankowitz BT,Atteberry DS,Gerszten PC,et al.Effect of fibrin glue on the prevention of cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery[J].Eur Spine J,2009,18(8):1169-1174.
12.丁淼,江晓冰,姚珍松,等.氰基丙烯酸酯医用胶预防脑脊液漏的疗效观察[J].中国修复重建外科杂志,2013,27(12):1471-1474.
13.Leggat PA,Smith DR,Kedjarune U.Surgical application of cyanoacrylate adhesives:a review of toxicity[J].ANZ J Surg,2007,77(4):209-213.
14.汪向飞,张晓丹,周汉新.生物医用可吸收止血材料的研究与临床应用[J].中国组织工程研究与临床康复,2010,6(21):3973-3976.
15.巴根,赵贵成,傅强.可吸收止血材料的安全性与临床应用[J].第二军医大学学报,2011,32(8):911-914.
16.Yao HH,Hong MK,Drummond KJ.Haemostasis in neurosurgery:what is the evidence for gelatin-thrombin matrix sealant[J].J Clin Neurosci,2013,20(3):349-356.
17.于滨生,郑召民,庄新明,等.脊柱手术后脑脊液漏的治疗[J].中国脊柱脊髓杂志,2009,19(2):113-116.
18.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.
19.程增银,马文海,崔建平,等.延长引流时间并间断夹闭引流管治疗脊柱术后脑脊液漏的疗效观察[J].中国脊柱脊髓杂志,2010,20(12):985-987.
20.Yi HJ,Kim DW.Reversible unilateral blindness after lumbar spine surgery:a role for cerebrospinal fluid leakage?[J].JNeurosurg Anesthesiol,2004,16(4):322-323.
21.Friedman JA,Ecker RD,Piepgras DG,et al.Cerebellar hemorrhage after spinal surgery:report of two cases and literature review[J].Neurosurgery,2002,50(6):1361-1363.
22.Huang PH,Wu JC,Cheng H,et al.Remote cerebellar hemorrhage after cervical spinal surgery[J].J Chin Med Assoc,2013,76(10):593-598.
23.Nowak R,Maliszewski M,Krawczyk L.Intracranial subdural hematoma and pneumocephalus after spinal instrumentation of myelodysplastic scoliosis[J].J Pediatr Orthop B,2011,20(1):41-45.
24.Pirris SM,Nottmeier EW.Symptomatic pneumocephalus associated with lumbar dural tear and reverse trendelenburg positioning:a case report and review of the literature[J].Case Rep Neurol Med,2013,21(2):34-39.
25.Narotam PK,Jose S,Nathoo N,et al.Collagen matrix(DuraGen)in dural repair:analysis of a new modified technique[J].Spine,2004,29(24):2861-2869.