前颅底骨折合并脑脊液漏手术治疗80例分析

Analysis of 80 surgical cases of cerebrospinal fluid fistulae complicated with anterior cranial base fractures

目的探讨前颅底骨折合并脑脊液漏患者的手术治疗。方法回顾性分析我科1998年1月至2008年12月收治的前颅底骨折合并脑脊液漏并经手术治疗的80例患者的临床资料，对其诊治和术后结局进行分析。所有患者均采用硬膜外或硬膜内手术入路修补硬脑膜。结果80例患者中，首次手术治愈72例（90％），术后出现脑脊液漏8例（10％）。对这8例患者采用经蝶窦人路或二次颅内入路手术治疗，术后均未再发。4例发生脑膜炎，经静脉应用抗生素后治愈；3例术后死亡。42例并发颅神经损伤，2例运动功能障碍，13例脑外伤后综合征。随访2—36个月，结局良好者69例（86．3％），中度残疾7例（8．8％），重度残疾1例（1．3％），术后死亡3例（3．8％）。结论选择颅内入路还是颅外入路需根据患者骨折特征来决定。颅内入路可使术者采用硬膜外和硬膜下联合入路精确修补破损硬脑膜。这一入路常适用于伴有颅底广泛骨质缺损的脑脊液漏、筛骨多处骨折、额窦后壁骨折，也适用于伴有颅神经损伤、颅内血肿或伤后颅内感染的脑脊液漏患者。内镜经鼻入路更适用于简单的脑脊液漏修补。

Objective To investigate the surgical treatment of patients of cerebrospinal fluid fistulae complicated with multiple anterior cranial base fractures. Methods Between January 1998 and December 2008, eighty surgical casesof anterior cranial base fractures complicated with CSF fistulae were retrospectively reviewed. All patients underwent the same surgical prodedure of combined extradural and intradural closure of the dural tear. Results Of the 80 patients, 72 patients （90%） were cured after the first operation. Persistent postoperative CSF rhinorrhea occurred in 8 patients （ 10% ）, necessitating an early complementary surgery via transsphenoidal approa ch or a second-look intracranial approach. Conclusion The choice of an intracranial versus extracranial approach depends on the characteristics of the fracture. The intracranial approach enables the surgeon to perform all necessary extradual and intradural dissections to precisely identify the dural tear. This approach is indicated for patients with extensive bone defects in the cranial base, multiple fractures of the ethmoid bone and the posterior wall of the frontal sinus, cranial nerve injury and associated lessions such as intracranial hematomas and posttranmatic intracranial infection. The endonasal endoscopic approach is effective for the closure of uncomplicated CSF fistulae.