乙状窦后锁孔入路听神经瘤切除术后脑脊液漏分析及预防(附14例临床分析)
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摘要
目的评价经乙状窦后锁孔入路听神经瘤切除术后脑脊液漏的病因及特点,分析此类并发症的发生原因并预防。方法回顾我科自2008年01月到2018年01月收治桥小脑角区听神经瘤患者相关资料,采用乙状窦后小脑幕下锁孔入路切除肿瘤。术毕严密缝合硬脑膜,修补颅骨并严密缝合肌层,术后局部加压包扎。关注术后切口、鼻腔及外耳道流液情况,明确脑脊液漏者应用加压包扎、腰大池引流及二次修补等方法处理,总结预防及处理脑脊液漏的方法。结果本组手术患者共169例,随访时间1~10年,平均5.4年,共发生脑脊液漏14例(8.28%),其中切口漏11例(6.51%),耳漏2例(1.17%),鼻漏1例(0.59%)。根据不同临床表现针对性处理,切口漏者局部加压包扎后痊愈7例(4.14%),局部处理+腰大池引流后愈合2例(1.17%);上述方法处理后仍有症状者5例(2.96%)最终采用二次手术修补,其中单纯硬脑膜修补3例(2.01%),硬脑膜修补+气房填塞1例(0.59%),硬脑膜修补+内听道修补1例(0.59%)。本组无颅内感染及死亡等并发症发生。结论锁孔技术在乙状窦后入路切除听神经瘤中应用效果确切,脑脊液漏为其并发症之一,内听道磨除、乳突气房填塞不全及硬脑膜缝合不良可能是其发生的重要原因,术后切口加压包扎、腰大池引流及二次修补手术处理疗效确切。
Objective To evaluate the causes and treatments of cerebrospinal fluid leakage following acoustic neuroma resection via retrosigmoid sinus keyhole approach.To explore the effective solutions for this kind of complications.Methods We followed up 169 patients with acoustic neuroma who received tumor resection via retrosigmoid sinus keyhole approach in our department from 2008 to 2018.Retrosigmoid approach was performed in all the patients.Different ways as sewing tightly of endocranium,repairing of skull and pressure bandaging were used to prevent cerebrospinal fluid leakage.Secondary repairing and continued lumbar cerebrospinal fluid drainage were used to treat cerebrospinal fluid leakage.Results A total of 14 cases(8.28%)suffered from the complication,the ratios was 11(6.51%),2(1.17%),and 1(0.59%)for incision leak,otorrhea and rhinorrhea respectively.However,7 cases(4.14%)were cured by pressure bandaging and 2(1.17%)cases by continued lumbar cerebrospinal fluid drainage in addition.Secondary repairing was used in 5(2.96%)cases to cure the complication.3(2.01%)cases received plasty of incision,1(0.59%)received plasty of mastoid cells and 1(0.59%)case received repairment of internal auditory canal.No other complications as intracranial infection or deaths showed in the followingup period(1~10 years,5.4 years on average).Conclusion Cerebrospinal fluid leakage is a kind of complication of acoustic neuroma resection.Proper selection of cutting methods of epidural and pressure bandaging may be effective ways to prevent the complication.Continued lumbar cerebrospinal fluid drainage may be useful to treat the leakage.
Objective To evaluate the causes and treatments of cerebrospinal fluid leakage following acoustic neuroma resection via retrosigmoid sinus keyhole approach.To explore the effective solutions for this kind of complications.Methods We followed up 169 patients with acoustic neuroma who received tumor resection via retrosigmoid sinus keyhole approach in our department from 2008 to 2018.Retrosigmoid approach was performed in all the patients.Different ways as sewing tightly of endocranium,repairing of skull and pressure bandaging were used to prevent cerebrospinal fluid leakage.Secondary repairing and continued lumbar cerebrospinal fluid drainage were used to treat cerebrospinal fluid leakage.Results A total of 14 cases(8.28%)suffered from the complication,the ratios was 11(6.51%),2(1.17%),and 1(0.59%)for incision leak,otorrhea and rhinorrhea respectively.However,7 cases(4.14%)were cured by pressure bandaging and 2(1.17%)cases by continued lumbar cerebrospinal fluid drainage in addition.Secondary repairing was used in 5(2.96%)cases to cure the complication.3(2.01%)cases received plasty of incision,1(0.59%)received plasty of mastoid cells and 1(0.59%)case received repairment of internal auditory canal.No other complications as intracranial infection or deaths showed in the followingup period(1~10 years,5.4 years on average).Conclusion Cerebrospinal fluid leakage is a kind of complication of acoustic neuroma resection.Proper selection of cutting methods of epidural and pressure bandaging may be effective ways to prevent the complication.Continued lumbar cerebrospinal fluid drainage may be useful to treat the leakage.
引文
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[11]Lim S L,Wong S H A.Review of an 11-year experience in retrosigmoid approach for treatment of acoustic neuromas[J].The Medical journal of Malaysia,2013,68(3):253~258.
[12]Zhang X,Shen W,Dai P.Causal analysis and management strategies of cerebrospinal fluid leakage following translabyrinthine approach for acoustic neuromas[J].Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi.2014,49(3):200~204.
[13]Arlt F,Trantakis C,Krupp W,et al.Cerebrospinal fluid leak after microsurgical surgery in vestibular schwannomas via retrosigmoidal craniotomy[J].Neurological Research,2011,33(9):947~952.
[14]Bayazit Y A,Celenk F,Duzlu M,et al.Management of cerebrospinal fluid leak following retrosigmoid posterior cranial fossa surgery[J].ORL,2009,71(6):329~333.
[15]徐武,梁维邦,陆天宇.微血管减压术治疗颅神经疾病1982例临床分析[J].立体定向和功能性神经外科杂志,2016,29(1):9~12.
[2]Sun H.Lee,Thomas O.Willcox,William A.Current results of the surgical management of acoustic neuroma[J].Skull Base,2002,12(4):189~195.
[3]Lim S L,Wong S H A.Review of an 11-year experience in retrosigmoid approach for treatment of acoustic neuromas[J].The Medical journal of Malaysia,2013,68(3):253~258.
[4]Copeland W R,Mallory G W,Neff B A,et al.Are there modifiable risk factors to prevent a cerebrospinal fluid leak following vestibular schwannoma surgery[J].Journal of Neurosurgery,2015,122(2):312~316.
[5]Scheich M,Ginzkey C,Ehrmann-Müller,Desiree,et al.Management of CSF leakage after microsurgery for vestibular schwannoma via the middle cranial fossa approach[J].European Archives of Oto-Rhino-Laryngology,2016,273(10):2975~2981.
[6]Mangus B D,Rivas A,Yoo M J,et al.Management of cerebrospinal fluid leaks after vestibular schwannoma surgery[J].Otology&Neurotology,2011,32(9):1525~1529.
[7]Shew M1,Muelleman T1,Harris M,et al.Petrous apex pneumatization:influence on postoperative cerebellopontine angle tumor cerebrospinal fluid fistula[J].Ann Otol Rhinol Laryngol,2018,127(9):604~607.
[8]Luryi AL,Schutt CA,Michaelides E,Hydroxyapatite cement cranioplasty for translabyrinthine surgery:Asingle institution experience[J].Laryngoscope,2019,3(1):7~15.
[9]Volsky P G,Hillman T A,Stromberg K J,et al.Hydroxyapatite cement cranioplasty following translabyrinthine approach:Long-term study of 369cases[J].The Laryngoscope,2017,127(9):177~180.
[10]Crowson M G,Rd C C,Moses H,et al.Preoperative lumbar drain use during acoustic neuroma surgery and effect on CSF leak incidence[J].Annals of Otology Rhinology&Laryngology,2015,125(1):1~6.
[11]Lim S L,Wong S H A.Review of an 11-year experience in retrosigmoid approach for treatment of acoustic neuromas[J].The Medical journal of Malaysia,2013,68(3):253~258.
[12]Zhang X,Shen W,Dai P.Causal analysis and management strategies of cerebrospinal fluid leakage following translabyrinthine approach for acoustic neuromas[J].Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi.2014,49(3):200~204.
[13]Arlt F,Trantakis C,Krupp W,et al.Cerebrospinal fluid leak after microsurgical surgery in vestibular schwannomas via retrosigmoidal craniotomy[J].Neurological Research,2011,33(9):947~952.
[14]Bayazit Y A,Celenk F,Duzlu M,et al.Management of cerebrospinal fluid leak following retrosigmoid posterior cranial fossa surgery[J].ORL,2009,71(6):329~333.
[15]徐武,梁维邦,陆天宇.微血管减压术治疗颅神经疾病1982例临床分析[J].立体定向和功能性神经外科杂志,2016,29(1):9~12.
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