Surgical treatment of mixed cervical spondylosis with spontaneous cerebrospinal fluid leakage: A case report

BACKGROUND Spontaneous cerebrospinal fluid(CSF)leaks associated with cervical spondylosis are rare.To our knowledge,only a few cases have been reported in which treatment is challenging and varies from case to case.Here,we review the literature and describe the surgical treatment of a 70-year-old woman who presented with a CSF leak due to a cervical spine spur.CASE SUMMARY A 70-year-old female patient who was treated for a cerebral infarction,presented with complains of weakness in the right lower extremity and a feeling of stepping on cotton.The patient underwent regular neck massage and presented with neck and right shoulder pain radiating to the right upper extremity one-month ago.Magnetic resonance imaging showed a strip of leaking cerebrospinal fluid posterior to the C1-4 vertebrae,and computed tomography showed a“sickleshaped”disc prolapse with calcification in C4/5.We chose to perform an anterior cervical discectomy.When the prolapsed C4/5 disc was scraped,clear fluid leakage was observed,and exploration revealed a 1 mm diameter rupture in the anterior aspect of the dura mater,which was compressed continuously with cotton patties,with no significant cerebrospinal fluid leakage after 1 h.CONCLUSION Three months after surgery,the patient was asymptomatic and follow-up imaging demonstrated complete resolution.

Comparing surgical efficiencies between phacoemulsification systems: a single surgeon retrospective study of 2000 eyes

AIM: To compare under similar conditions intraoperative surgical efficiencies metrics between an active fluidics and a gravity based phacoemulsification systems.METHODS: Adult patients who were diagnosed with a cataract that compromised visual acuity inferior to 20/40 were included in the study. Patients were excluded from the study if they had a history of severe retinal disorders, clinically significant corneal endothelial dystrophy or history of corneal disease. All phacoemulsification surgeries were performed by a single surgeon. Both phacoemulsification systems used the 0.9 mm 45-degree aspiration bypass system Intrepid Balanced tip and the 0.9 mm Intrepid Ultra infusion sleeve. All cataracts were classified using the Lens Opacities Classification System III, cumulative dissipated energy(CDE) and aspiration fluids were measured in each surgery.RESULTS: Totally 2000 eyes were included in the study. Phacoemulsification was performed in 1000(50%) eyes with an active fluid dynamics system and in 1000(50%) eyes with a gravity-based fluidic system. Mean CDE until fracture of the lens was 1.1 and 1.9 percent-seconds and total mean CDE used was 5.6 and 7.2 percent-seconds using an active fluidics dynamics system and gravity-based fluidic system, respectively(P<0.001). Mean aspiration fluids used were 70 m L using an active fluidics dynamics system and 85 m L using a gravity-based fluidic system(P<0.001).CONCLUSION: This study evidences that surgeries performed under similar conditions(same surgeon, phaco tip and sleeve) with the active fluidics dynamics system required significantly lower CDE and aspiration fluids.

Endoscopic intramural cystogastrostomy for treatment of peripancreatic fluid collection: A viewpoint from a surgeon

Percutaneous or endoscopic drainage is the initial choice for the treatment of peripancreatic fluid collection in symptomatic patients.Endoscopic transgastric fenestration(ETGF)was first reported for the management of pancreatic pseu-docysts of 20 patients in 2008.From a surgeon’s viewpoint,ETGF is a similar procedure to cystogastrostomy in that they both produce a wide outlet orifice for the drainage of fluid and necrotic debris.ETGF can be performed at least 4 wk after the initial onset of acute pancreatitis and it has a high priority over the surgical approach.However,the surgical approach usually has a better success rate because surgical cystogastrostomy has a wider outlet(>6 cm vs 2 cm)than ETGF.However,percutaneous or endoscopic drainage,ETGF,and surgical approach offer various treatment options for peripancreatic fluid collection patients based on their conditions.

Therapeutic interventional endoscopic ultrasound in pancreatobiliary disorders:Does it really replace the surgical/percutaneous approach?

Pancreato-biliary disorders are still incredibly challenging in the field of gastroenterology,as they would sometimes require multi-approach interventional procedures.Recently,therapeutic interventional endoscopic ultrasound(EUS)has emerged as a potential alternative to surgical or percutaneous approaches.Unfortunately,considering the high cost of EUS,lack of facility and expertise,most gastroenterologists still often refer cases to undergo surgical interventions without contemplating the possibility of utilizing EUS first.EUS-guided biliary drainage has become one of the best choices for establishing access to biliary system,given the clear visualization of pancreas,gallbladder,and common bile duct.Although there are still only a few studies which directly compare EUSguided and surgical approaches for biliary drainage,current evidence demonstrated the superiority of EUS-guided approach in terms of adverse events and reintervention rates,with similarly high technical and clinical success rates compared to percutaneous and surgical approaches,especially in patients with history of failed endoscopic retrograde cholangiopancreatography attempt.Comparable success rates with shorter length of hospital stay between endoscopic and surgical approaches have also been exhibited for pancreatic pseudocysts and walled-off necrosis.Recent findings about the progress of EUS approach in gastroenterostomy/jejunostomy also indicated a promising potential of EUS,as a less invasive approach,for managing gastric outlet obstruction.

Genomic profile concordance between pancreatic cyst fluid and neoplastic tissue

BACKGROUND DNA mutational analysis of pancreatic cystic fluid (CF) is a useful adjunct to the evaluation of pancreatic cysts. KRAS/GNAS or RAF/PTPRD/CTNNB1/RNF43 mutations are highly specific to precancerous or advanced neoplasia. Several studies recently demonstrated the ability of next-generation sequencing (NGS)analysis to detect DNA mutations in pancreatic CF, but few studies have performed a systematic comparative analysis between pancreatic CF and neoplastic surgical tissue (NT). The value of CF-NGS analysis indicators for determining surgical resection necessitates evaluation. AIM To confirm whether CF genomic profiles are a reliable malignancy predictor by comparing NGS mutational analyses of CF and NT. METHODS Patients requiring surgery for high-risk pancreatic cysts were included in a multicenter prospective pilot study. DNA from CF (collected by endoscopic ultrasound-guided fine needle aspiration (known as EUS-FNA)) and NT (collected by surgery) were analyzed by NGS. The primary objective was to compare the mutation profiles of paired DNA samples. The secondary objective was to correlate the presence of specific mutations (KRAS/GNAS, RAF/ PTPRD/CTNNB1/RNF43/POLD1/TP53) with a final cancer diagnosis. Sensitivity and specificity were also evaluated. RESULTS Between December 2016 and October 2017, 20 patients were included in this pilot study. Surgery was delayed for 3 patients. Concordant CF-NT genotypes were found in 15/17 paired DNA, with a higher proportion of mutated alleles in CF than in NT. NGS was possible for all pancreatic CF collected by EUS-FNA. In 2 cases, the presence of a KRAS/GNAS mutation was discordant between CF and NT. No mutations were found in 3 patients with NT or pancreatic cysts with high-grade dysplasia. The sensitivity and specificity of KRAS/GNAS mutations in CF to predict an appropriate indication for surgical resection were 0.78 and 0.62, respectively. The sensitivity and specificity of RAF/PTPRD/CTNNB1 /RNF43/POLD1/TP53 mutations in CF were 0.55 and 1.0, respectively. CONCLUSION Mutational analyses of CF and NT were highly concordant, confirming the value of NGS analysis of CF in the preoperative malignancy assessment. However, these results need to be confirmed on a larger scale.

Preliminary Evaluation of Hemodynamic Effects of Fontan Palliation on Renal Artery Using Computational Fluid Dynamics

Background:The assessment of renal function is important to the prognosis of patients needing Fontan palliation due to the reconstructed compromised circulation.To know the relationship between the kidney perfusion and hemodynamic characteristics during surgical design could reduce the risk of acute kidney injury(AKI)and the postoperative complications.However,the issue is still unsolved because the current clinical evaluation methods are unable to predict the hemodynamic changes in renal artery(RA).Methods:We reconstructed a three-dimensional(3D)vascular model of a patient requiring Fontan palliation.The technique of computational fluid dynamics(CFD)was utilized to explore the changes of RA hemodynamics under different possible blood flow rates.The relationship between the kidney perfusion and hemodynamic characteristics was investigated.Results:The calculated results indicated the declined tendency of the pressure and pressure drop as the flow rate decreased.When the flow rate decreased to two-thirds of its baseline,both the pressure of left renal artery(LRA)and the pressure of right renal artery(RRA)dipped below 50%,and the pressure of RRA fell more quickly than that of LRA.Uneven distribution of WSS was observed on the trunk of RA,and the lowest WSS was found at the distal of RA.The average WSS in RA dropped to around 50%as the flow rate reached one-third of its baseline.Conclusions:As a promising approach,CFD can be utilized to quantitatively evaluate the hemodynamic characteristics of RA and contribute to offsetting the drawbacks of clinical assessments of renal function,to help realize better prognosis for the patients with Fontan palliation.

Surgical Repair and Detection of Cerebrospinal Fluid Rhinorrhea using Magnetic Resonance Cisternography and Skull Base Coronal Thin-section Computed Tomography Scan

INTRODUCTION Cerebrospinal fluid （CSF） rhinorrhea is a common condition managed by neurosurgeons. The accurate identification of the site of leak plays a key role in facilitating successful surgical repair. We reported two surgery-proven cases of CSF rhinorrhea examined by magnetic resonance （MR） cisternography （Siemens, Berlin, Germany） and skull base coronal thin-section computed tomography （CT） scan （Siemens, Berlin, Germany） before surgical treatment.

耳廓假性囊肿治疗研究进展

耳廓假性囊肿是耳鼻喉科常见病,好发于我国人群,有多种致病因素,无统一的治疗方法,临床上有穿刺抽液加压、囊液引流、囊内注药、手术、物理治疗等多种治疗方式,本文将对近年来的治疗研究进展作一综述。

控制性与非控制性失血性休克早期液体复苏的对比研究

目的比较在失血已控制及失血未控制两种状态下常规液体复苏治疗失血性休克的效果,探索早期液体复苏对策。方法健康雄性SD大鼠28只,随机分为对照组(n=8)、失血已控制休克组(CHS组,n=10)及失血未控制休克组(UHS组,n=10)。CHS组及UHS组大鼠股动脉放血,使血压在15min内降至30mmHg,然后截断3组大鼠尾根部,对照组及CHS组立即结扎止血,UHS组不予处理使其自然流血。模拟战创伤实际情况,将动物分为院前期(30～90min)、医院救治期(90～150min)及康复期(150min～72h)3个阶段。院前期通过输液将大鼠血压维持在60mmHg;医院救治期结扎出血灶,输血、输液维持大鼠血压至90mmHg;康复期观察至72h。监测平均动脉压(MAP)、中心静脉压(CVP)、心功能、血气分析及血细胞比容(Hct)、血乳酸水平等,观察记录出血量、补液量及动物存活时间。结果根据实验设计,通过液体复苏使CHS组及UHS组大鼠院前期及医院救治期MAP分别维持在60mmHg及90mmHg。CHS组及UHS组同一时相MAP及CVP均无显著差异。院前期UHS组大鼠Hct明显低于CHS组。自院前期开始,UHS组大鼠血乳酸水平即持续性升高,而医院救治期以后CHS组血乳酸水平升高不明显。从医院救治期开始UHS组心率及最大心室内压上升速度明显低于CHS组。液体复苏后CHS组动物酸中毒及低氧血症得到明显纠正,但UHS组仍持续处于低氧血症及酸中毒状态。CHS组院前期补液量(44.5±10.1ml/kg)明显低于UHS组(74.5±11.4ml/kg,P<0.01)。CHS组及UHS组72h死亡率分别为30%及80%。结论较失血已控制的休克而言,对失血未控制的休克进行快速复苏可导致出血量增加、血液稀释、心功能损害及死亡率增加。

脊柱手术中硬脊膜损伤及术后脑脊液漏的处理

目的探讨脊柱外科手术的常见并发症——术中硬脊膜损伤及术后脑脊液漏的外科处理措施,并观察其疗效。方法回顾性分析2002年6月-2006年3月接受脊柱手术的405例患者资料。其中男298例,女107例;年龄11～78岁,平均46.2岁。病程3个月～5年。术中硬脊膜损伤或切开者28例(6.91%),其中颈椎3例,胸椎和腰椎19例,骶椎6例;28例中术后有6例发生脑脊液漏。术中未发现硬脊膜损伤而术后发生脑脊液漏2例。术后脑脊液漏的总发生率为1.98%。采用修复硬脊膜裂口、严密缝合切口各层、卧床休息和伤口加压包扎等综合措施处理。观察并记录处理疗效。结果所有患者获随访3个月～4年,平均1年5个月。术前症状获不同程度缓解。8例术后脑脊液漏患者均获临床治愈,其中6例硬脊膜囊背侧瘘主要通过卧床休息、伤口加压包扎和再次手术缝合治愈,2例硬脊膜囊腹侧和侧方瘘尚需附加持续腰椎蛛网膜下腔引流。并发中枢神经系统感染1例,经多科协作治疗而愈合。结论及时、正确地进行术中干预和术后处理,可有效治疗脊柱手术中硬脊膜损伤并预防术后脑脊液漏形成。

神经内镜下经鼻-蝶窦入路术中、术后脑脊液鼻漏的处理

目的探讨神经内镜下经鼻-蝶窦入路术中、术后脑脊液鼻漏的处理策略。方法回顾性分析27例神经内镜下经鼻-蝶窦入路术中、术后发生脑脊液鼻漏病人的临床资料。其中鞍结节脑膜瘤2例,脊索瘤、视神经胶质瘤、上斜坡转移性腺瘤各1例,垂体腺瘤22例。内镜下发现脑脊液鼻漏后,根据漏口大小予以简单修补,或自体脂肪组织、人工硬脑膜及生物蛋白胶等多层材料修补鞍底。术后3~5 d若再漏,予以药物脱水降颅压或持续腰大池引流等处理。结果术中发现小漏口21例,予以简单修补;较大漏口6例,予以分层修补。修补术后再次发生脑脊液鼻漏3例,2例保守治疗,1例持续腰大池引流10 d后治愈。随访5~10个月,未再发生脑脊液鼻漏。结论在神经内镜视野下,术者可及时发现脑脊液漏口,术中多层严密封堵,术后有效对症处理,可明显改善脑脊液鼻漏的预后。

外伤性颅底骨折致脑脊液漏的发生及处理

目的:探讨脑脊液漏在颅底骨折时的发生率、部位、时间及治疗方法。方法:回顾分析近18年来收治的358例颅底骨折患者的临床资料。结果:脑脊液漏的发生率为24.58%(88/358)。发生于前颅窝56例,中颅窝23例,前中颅窝9例。57例在外伤后48 h内发病,占63.64%,最迟者外伤后28年才发病。88例脑脊液漏中,73例经保守治疗痊愈,11例经一次手术痊愈,3例经二次手术痊愈,1例经三次手术后,因颅内感染呼吸循环衰竭死亡。15例手术治疗中,4例在鼻内窥镜下经鼻行脑脊液漏修补一次成功。结论:颅底骨折部位及脑脊液漏发生时间决定了治疗方案的选择,并与疗效直接相关。鼻内窥镜下手术具有副损伤小,瘘孔定位准确,手术反应轻等优点,值得推广。

Beagle犬脑脊液(CSF)多次采集手术模型的建立

目的通过建立一种新的手术模型,实现对脑脊液(CSF)的多次采集。方法研究Beagle犬头颅结构,定位手术钻孔,手术穿刺、埋管采集脑脊液。结果动物手术存活率为80%,模型成功率为60%。结论新模型设计合理,有利于多次采集,此方法可成为Beagle犬脑脊液采集新手段。

POU3F4基因突变致内耳畸形人工耳蜗术后脑脊液漏的观察及处理

目的探讨POU3F4基因突变导致的IP-Ⅲ型内耳畸形患者人工耳蜗植入术后脑脊液漏并发其他并发症的护理观察与处理。方法收集解放军总医院第一医学中心耳鼻咽喉头颈外科收治的8例IP-Ⅲ内耳畸形患儿。入院后行基因检测明确分子病因,经颞骨CT及颅脑核磁检查后均提示内耳结构异常,发育畸形,按Sennarolu内耳畸形分类符合IP-Ⅲ型,排除各项绝对禁忌症后在全麻下行人工耳蜗植入+编程术,术后根据患者病情变化给予相对应处置措施。结果8例患者除一例未行基因检查外,7例均在POU3F4基因上明确了致病突变。6例患者术中均发生镫井喷,1例患者术后出现脑脊液漏、肺部感染、脑膜炎等严重并发症。结论POU3F4基因突变导致的内耳畸形IP-Ⅲ患者接受人工耳蜗植入术时脑脊液漏的发生率高,术中修补及术后早期发现都是避免严重并发症发生的要素。针对此类患者,临床护理中需对患者术后的体温变化、隐匿性脑脊液漏及脑脊液漏并发脑膜炎进行更严密的观察,降低脑脊液漏及其他相关并发症的发生率。

不同晶胶比例目标导向液体治疗对老年食管癌根治术患者围术期血管外肺水指数及血乳酸的影响

目的探讨不同晶胶比例目标导向液体治疗(goal-directed fluid therapy,GDFT)对老年食管癌根治术患者血管外肺水指数及血乳酸的影响。方法选择择期行食管癌根治术患者50例,所有患者术中均行单肺机械通气且术式相同,以晶胶比例3∶1为界,随机分为低晶胶比例组(A组,n=25)和高晶胶比例组(B组,n=25)。术中液体治疗以维持正常范围内的胸内血容量指数(intrathoracic blood volume index,ITBVI)为目标,通过脉搏指示连续心排出量(pulse indicator continuous cardiac output,Pi CCO)监护仪记录术前(T0)、气管插管后5 min(T1)、双肺通气15 min(T2)、单肺通气15 min(T3)、肺复张后双肺通气15 min(T4)和术毕(T5)时患者的心率(heart rate,HR)、平均动脉压(mean artery pressure,MAP)、心脏指数(cardiac index,CI)、血管外肺水指数(extravascular lung water index,EVLWI)、ITBVI等指标。记录所有患者术前、术毕和术后6 h血乳酸含量以及术中使用糖皮质激素、血管活性药物及呋塞米情况,输液总量,失血量,尿量,手术时间。结果术中两组无一例应用糖皮质激素,A组术中1例应用去氧肾上腺素,1例应用呋塞米,B组术中2例应用去氧肾上腺素。共46例纳入统计分析,其中A组23例、B组23例。术中各组GDFT均能维持血流动力学稳定。与T0时比较,两组T1时MAP、CI均显著降低(P<0.05);A组在T5时CI显著高于T0时(P<0.05),且显著高于B组(P<0.05)。B组T5时EVLWI显著高于T0时,且显著高于A组(P<0.05)。两组在各时点血乳酸含量与术前比较差异均无统计学意义(P>0.05),术毕时A组血乳酸含量明显低于B组(P<0.05)。结论食管癌根治术患者术中GDFT应用低晶胶比例补液方案,有利于维持血流动力学稳定、改善组织灌注,且不增加肺水肿的风险。

CHIARI畸形伴脊髓空洞症的脑脊液动力学

目的探讨脑脊液动力学在Ｃｈｉａｒｉ畸形伴脊髓空洞症的发生、发展中的作用，提出本病脑脊液动力学异常的早期指标及相应的手术治疗方法。方法全组２２例病人经ＭＲＩ和ＣＴ检查，伴脑积水者进行颅内压监护，其他患者行颈部不同体位的术前和术后的脑脊液动力学研究，按其异常程度分别行脑室腹腔分流术、后颅＋颈１－２椎板减压术和硬膜减张。结果全部病人均有不同程度的脑脊液动力学的改善，术后１６例获得随访，其中１２例复查ＭＲＩ，空洞缩小９例，３例同术前。３例临床症状完全缓解，９例有不同程度改善，２例同术前，２例加重。结论脑脊液动力学的异常在Ｃｈｉａｒｉ畸形伴脊髓空洞症的发病和病程演变中有重要意义，而纠正其异常应是手术治疗的主要目的。合并颅内压增高者，脑室腹腔分流术同样可使空洞缩小。

脑脊液鼻漏的诊断及手术治疗28例临床分析

目的探讨脑脊液鼻漏的诊断及手术治疗方法。方法回顾性分析潍坊市人民医院与聊城市人民医院2005-2010年收治的28例脑脊液鼻漏患者资料,其中男性18例,女性10例,年龄18~59岁,平均年龄38岁,病程7d^2年;外伤性脑脊液鼻漏20例,自发性6例,医源性2例。结合生化检查、CT/MRI及鼻内窥镜检查明确诊断,修复材料为鼻中隔黏膜(18例)、颞肌筋膜(8例)、额部带蒂骨膜瓣(2例)。结果 28例均在鼻内镜下修补成功,其中1次修补成功26例,2例经再次修补成功,2例术后嗅觉明显减退,1例治疗后好转,1例无效;所有患者无鼻塞及鼻腔干燥等并发症,随访6~36个月未见复发。结论脑脊液鼻漏的准确诊断及修补方式和修补材料的正确选择是手术成功的关键。

脑脊液鼻漏的手术治疗与护理30例

目的总结脑脊液漏患者的手术治疗与护理经验。方法对手术治疗的 3 0例脑脊液鼻漏病例进行回顾性研究。结果外伤性脑脊液鼻漏 12例 ,肿瘤致脑脊液鼻漏 17例 ,自发性脑脊液鼻漏 1例。一次手术修补成功者 2 3例。 7例行第 2次手术修补。术后并发脑积水 1例 ,脑室炎 1例 ,硬膜下积液 1例 ,给予相应治疗均治愈。结论漏口精确定位诊断 ,同时注重手术中对漏口的探察与定位 ,是手术成功的关键。防止感染是手术成功、降低手术并发症的重要保证。

鼻内镜下修补脑脊液鼻漏19例并文献复习

目的探讨鼻内镜下脑脊液鼻漏修补术的瘘口定位、材料选择及修补方法。方法回顾性分析19例脑脊液鼻漏修补术病例资料，其中骨折发生在筛窦预壁14例、筛预和对侧额窦后壁1例、蝶窦4例，瘘口0．8～2．5cm，搔刮创面后用生物胶肌浆填塞瘘口，覆盖筋膜，再填塞鼻腔填充物。结果19例患者均在鼻内镜下一次手术修补成功，其中出现局限性脑膜炎1例、局部真菌感染1例。结论鼻内镜下脑脊液鼻漏修补方法简单，损伤小，成功率高，并发症少。

持续性脑脊液耳漏的诊断与治疗

目的 :探讨持续性脑脊液耳漏的发病原因、临床表现、诊断及手术处理方法。方法 :分析 1987年 6月～ 2 0 0 0年 12月收治 2 6例持续性脑脊液耳漏的临床资料 ,男 16例 ,女 10例。成人 18例 ,儿童 8例。结果 :2 6例中自发性脑脊液耳漏 14例 ,因乳突及侧颅底手术引起的 12例。 15例伴有复发性脑膜炎。 2 6例中 2 5例在我院 1次手术修补成功 ,1例听神经瘤术后脑脊液鼻漏行 2次手术修补成功。结论 :手术是主要的治疗方法 ,术中应注意颅底的修复 ,尤其对内听道、鼓室、咽鼓管、乳突尖等重要部位的处理 ,以预防术后脑脊液耳漏的发生。