退变性腰椎疾患后路减压术后脑脊液漏的相关因素分析及处理

Related factors and management of cerebrospinal fluid leakage during degenerative lumbar spine surgery

中文关键词:  腰椎手术  并发症  硬膜撕裂  脑脊液漏

英文关键词:Lumbar spinal surgery  Complications  Dural tears  Cerebrospinal fluid leakage

中文摘要:

  【摘要】 目的：分析退变性腰椎疾患后路减压术后脑脊液漏的相关因素，探讨其处理方法。方法：收集2011年1月～2012年12月在北京大学第三医院骨科腰椎组手术治疗患者的病历资料，纳入因腰椎间盘突出症（LDH）、腰椎管狭窄症（LSS）、腰椎滑脱（LS）、腰椎退变性侧（后）凸（LDS）行腰椎后路减压术的患者，记录患者的性别、年龄、体重指数、诊断、是否翻修手术、手术方法、减压节段数、融合方式、术后引流量、引流管留置时间、脑脊液漏的诊断、术中及术后处理方法。按1∶3配比选择对照组，观察脑脊液漏组术后引流特点和引流管留置时间。结果：共纳入因退变性腰椎疾患行后路减压手术治疗的患者1425例，其中男675例，女750例，年龄16～80岁，平均54.6±13.1岁。LDH 378例，LSS 647例，LS 304例，LDS 96例；初次手术1351例，翻修手术74例；1节段减压635例，2节段减压491例，3节段减压204例，4节段及以上减压95例。术后57例发生脑脊液漏，发生率为4.0%，其中LDH 7例，发生率为1.9%；LSS 30例，发生率为4.6%；LS 13例，发生率为4.3%；LDS 7例，发生率为7.3%。4种疾病脑脊液漏的发生率无显著性差异（P>0.05）。翻修手术发生脑脊液漏9例，发生率为12.2%；初次手术发生脑脊漏48例，发生率为3.6%，差异有显著性（P<0.05）。减压节段数4节段及以上者脑脊液漏的发生率为13.7%，高于1节段（1.9%）、2节段（3.7%）和3节段（6.9%）者。多因素Logistic回归分析结果显示翻修手术和减压节段数≥4是术后并发脑脊液漏的危险因素。脑脊液漏患者采用预防感染、体位调节、引流管留置平均5.6d，卧床休息6～7d，无一例出现伤口不愈合或感染，无一例形成脑脊液囊肿或瘘管，但引流量较对照组大。结论：翻修手术与减压节段数≥4是退变性腰椎疾患后路减压术后脑脊液漏发生的危险因素；发生脑脊液漏患者术后引流管留置5～6d是安全的。

英文摘要:

  【Abstract】 Objectives: To analyze the related factors of the cerebrospinal fluid leakage after degenerative lumbar spine surgery, and to investigate the correpondent management. Methods: From January 2011 to December 2012, clinical and surgery records of patients undergoing spinal surgery in our institute were reviewed retrospectively. Pathogenesis included lumbar disc herniation(LDH), lumbar spinal stenosis(LSS), lumbar spondylolisthesis(LS) and lumbar degenerative scoliosis/kyphosis(LDS). Data of gender, age, body mass index(BMI), diagnosis, revision surgery, surgical method, number of surgical levels, fusion method, amount of drain output, drain duration and management of cerebrospinal fluid leakage(CSFL) were collected. 3 cases as control without CSFL were randomly selected from the same database. Results: A total of 1425 degenerative lumbar spine surgical cases were collected, including 675 males and 750 females, and the mean age at surgery was 54.5±13.1(16-80) years. There were 378 LDH, 647 LSS, 304 LS and 96 LDS; 1351 primary surgery and 74 revision surgery; 635 one-level decompression, 491 two-level decompression, 204 three-level decompression and 95 with decompression of more than three levels decompression. Among these cases, 57(4.0%) cases were complicated with CSFL, including 7 LDH(1.9%), 30 LSS(4.6%), 13 LS(4.3%) and 7 LDS(7.3%), there was no significant difference(P>0.05) among them. The rate of CSFL was 12.2% for revision surgery and 3.6% for primary surgery, which showed significant difference(P<0.05) between them. The incidence of CSFL for decompression of more than three levels was 13.7%, which was higher than 1.9% for one level, 3.7% for two levels and 6.9% for three levels. A multivariate logistic regression analysis demonstrated that revision surgery and more than decompressed 3 levels were risk factors for CSFL. For CSFL patients treated with antibiostic intervention, position adjustment, closed wound drainage for an average of 5.6 days and bed rest for 6-7 days, no case presented with wound infection, pseudomeningocele or cerebrospinal fluid fistula formation. Conclusions: Revision surgery and more than decompressed three levels are the risk factors for post-operative CSFL. It is a safe protocol for post-operative drainage for 5-6 days.