颈椎严重后纵韧带骨化症前路手术脑脊液漏的预防和处理

Prevention and treatment of cerebrospinal fluid leakage in anterior cervical surgery for severe ossification of posterior longitudinal ligament

目的探讨前路手术治疗颈椎严重后纵韧带骨化症过程中，预防和处理脑脊液漏（cere—brospinal fluid leakage，CSFL）的经验。方法回顾性分析2008年1月至2011年5月行前路手术治疗的47例颈椎严重后纵韧带骨化症（骨化厚度〉5mm，椎管狭窄率〉50％）患者资料，其中15例患者术中出现硬膜缺损，男11例，女4例；年龄40~68岁，平均55．6岁。术前认真分析CT影像，行针对性的减压准备；术中应用直接切除、间接漂浮等技巧减少硬膜损伤，采用缝线修补、肌肉覆盖等方法处理硬膜缺损；术后给予卧床、引流等措施治疗CSFL。结果术后15例患者均获得随访，随访时间为12-18个月，平均14．8个月。10例患者伤口愈合，术后未发生CSFL；5例患者确诊出现CSFL，其中4例经加压包扎、引流等治疗4-6d后脑脊液漏出停止；1例形成脑脊液囊肿，经反复穿刺后3周内囊肿消失。所有患者伤口均完全愈合，无一例发生椎管内及颅内感染、气道阻塞等并发症，且无一例行二次修补或转流手术，术后神经功能恢复良好。结论颈前路手术治疗严重后纵韧带骨化过程中，术前分析CT片并行充分减压准备，术中避免硬膜损伤及有效修补缺损，术后给予卧床、引流等措施能有效预防和处理CSFL。

Objective To investigate prevention and treatment of cerebrospinal fluid leakage （CSFL） in anterior cervical spine surgery for severe ossification of posterior longitudinal ligament （OPLL）. Methods A retrospective analysis of 47 patients with severe cervical OPLL （thickness of the ossified mass 〉 5 mm, spinal stenosis 〉50%）, who had undergone anterior cervical surgery between January 2008 and May 2011, was conducted. Fifteen cases of dural defect were found intraoperatively, including 11 males and 4 females, aged from 40 to 68 years （average, 55.6 years）. Preoperative CT scans were carefully analyzed. During the operation, the ossified mass was excised or floated and the araehnoid was reserved in order to reduce dural damage. Dural defects were repaired by suturing or covering with muscle. After surgery, patients were con- fined to bed rest to allow for drainage or puncture. Results All 15 patients were followed up for 12 to 18 months （average, 14.8 months）. After operation, 10 patients recovered fully without CSFL. Five patients developed CSFL, including 4 cases of spinal dural mater injury that healed within 4-6 days with bed rest and pressure dressing, and 1 case of cerebrospinal fluid pseudocyst that disappeared within 3 weeks with repeat puncture and aspiration treatment. No cases required secondary operations or shunt placement. All cases ex- hibited good neurological improvement. Conclusion During anterior surgical treatment for severe cervical OPLL, CSFL can be effectively prevented through careful analysis of preoperative CT images, meticulous operative technique, reasonable handling of the ossified mass and positive repair of dural damage. Moreover, postoperative bed rest and drainage are effective to treat CSFL.