人工硬脊膜防治胸腰椎骨折脱位并发脑脊液漏的疗效分析

The therapeutic effect of artificial dura mater on the prevention and treatment of cerebrospinal fluid leakage associated with thoracolumbar fracture and dislocation

目的探讨利用人工硬脊膜防治胸腰椎骨折脱位并发脑脊液漏的疗效。方法选择2011年1月—2016年12月西南医科大学附属医科收治的58例胸腰椎骨折脱位合并硬脊膜损伤脑脊液漏患者,其中男30例,女28例;年龄15~86岁,平均(51.8±16.3)岁。所有患者均采用后路椎弓根钉棒系统进行减压、复位固定融合,探查硬脊膜及脊髓损伤情况,回纳外露神经根或马尾神经;同时分别进行单纯硬脊膜缝合修复后局部覆盖明胶海绵(A组,24例)、硬脊膜缝合修复后覆盖人工硬脊膜和明胶海绵(B组,34例)。对两种不同处理方法的疗效和并发症进行评价。结果手术均顺利完成,手术时间110~340 min,平均(195.0±10.4)min,术中出血量200~2 800 m L,平均(845.0±26.5)m L。A组中13例(54.1%)切口愈合,术后引流平均(13.4±1.6)d脑脊液漏消失,其中3例合并假性硬膜囊肿。A组11例(45.9%)治疗失败,其中6例引流超过10 d脑脊液渗漏无减少趋势,经腰部经皮蛛网膜下腔脑脊液引流后,脑脊液渗漏于术后15 d左右消失;3例(12.5%)合并切口感染,手术切口清创,硬膜囊再次修复后腰部经皮蛛网膜下腔脑脊液引流,结合全身用抗菌药物等对症处理,术后16 d左右治愈;2例(8.3%)合并脊膜炎,经蛛网膜下腔引流及注入抗菌药物,脑脊液漏于术后14 d消失。B组中27例(79.4%)切口愈合,术后引流平均(9.1±1.7)d脑脊液漏消失,其中4例合并假性硬膜囊肿。B组7例(20.6%)治疗失败,其中5例引流超过10 d脑脊液渗漏无减少趋势,经处理后脑脊液漏于术后12 d左右消失;1例(2.9%)合并切口感染,经处理后治愈;1例(2.9%)合并脊膜炎,同A组处理后治愈。结论硬脊膜缝合修复结合人工硬脊膜覆盖修补可以更有效地修复胸腰椎骨折脱位合并的硬脊膜撕裂,减少脑脊液漏的发病率。

Objective To investigate the therapeutic effect of artificial dura mater on the prevention and treatment of cerebrospinal fluid（CSF） leakage associated with thoracolumbar fracture and dislocation. Methods A total of 58 patients with thoracolumbar fracture and dislocation combined with dura mater injury and CSF leakage were treated in Affiliated Hospital of Southwest Medical University from January 2011 to December 2016, including 30 males and 28 females, aged from 15 to 86 years, with an average of（51.8±16.3） years. All patients were treated with posterior pedicle screw system for decompression, reduction fixation and fusion, dura mater and spinal cord injury were investigated, and external nerve roots or caudate nerves were exposed. At the same time; the dura mater was sutured and repaired and partially covered with gelatinous sponge（group A, 24 cases）, or after dura mater was sutured and repaired, the artificial dura mater was partially covered（group B, 34 cases）. The curative effect and complications of the two different treatment methods were evaluated. Results All operations were successfully completed. The operative time was 110–340 minutes,with an average of（195.0±10.4） minutes; the intraoperative blood loss was 200–2 800 m L, with an average of（845.0±26.5）m L. In group A, 13 patients（54.1%） acquired wound healing, and the average CSF leakage duration was（13.4±1.6） days postoperatively, among whom 3 cases were complicated with pseudomeningocele; 11 cases（45.9%） failed and necessitated additional management. Among the 11 cases, 6 case had no decreasing tendency of CSF leakage after 10-day drainage, and after subarachnoid drainage was performed, CSF leakage disappeared about 15 days after operation; 3（12.5%） with wound infection underwent operative incision debridement, after the repair of the dura sac, the subarachnoid CSF was drainage at the lumbar part combined with the systemic situation with antibiotics and other symptomatic treatment, and the patients were cured about 16 days after the operation; 2（8.3%） with spinal meningitis underwent subarachnoid CSF drainage and administration of antibiotics, and the CSF leakage ceased about 14 days after operation. In group B, 27 patients（79.4%）acquired wound healing, and the average CSF leakage duration was（9.1±1.7） days postoperatively; among whom, 4 cases were complicated with pseudomeningocele; 7 cases（20.6%） failed and necessitated additional management. Among the7 cases, 5 cases had no decreasing tendency of CSF leakage after 10-day drainage, and CSF leakage disappeared around 12 days after treatment; 1 case（2.9%） with wound infection and 1 case（2.9%） with spinal meningitis, both were cured after the treatment as in group A. Conclusion Dural suture repair combined with artificial dura mater mulch repair can more effectively repair the dura tears associated with thoracolumbar vertebral fracture dislocation and reduce the incidence of CSF leakage.