腰椎与间盘手术致脑脊液漏的防治.doc

腰椎间盘手术致脑脊液漏的防治 王培增　桑仲亮　苏炜　郭少华 　　【摘要】　目的：分析腰椎间盘手术中硬脊膜损伤的原因， 探讨术后脑脊液漏的防治。方法：回顾1990年至1998年间43例腰椎间盘手术致硬脊膜损 伤的临床资料。结果：经切口放置引流管的12例病人，有8例于拔管术后发生了切口脑脊液漏，经切口旁皮肤，椎旁肌置管的31例病人，拔管后无一例发生切口脑脊液漏。结论：硬脊膜损伤的主要原因是手术操作误伤，防止术后发生切口脑脊液漏的主要措施是保护或修复脊膜，经切口旁椎旁肌放置引流管，并严密缝合腰背筋膜。　　【关键词】　腰椎间盘手术　硬脊膜损伤　脑脊液漏　预防 Prevention and Treatment of Cerebrospinal Fluid Leakage in Lumbar Disc Surgery Wang Peizeng,Sang Zhongliang Su Wei et al.Department of Surgery,Qingzhou Branch of The 401th Hospiaal,PLA,Shandong 262500. 　　【Abstract】　Aim:To analyze the causes of dural damages during lumbar disc surgery and to probe the prevention and management of cerebrospinal fluid leakage after operation.Methods:Clinical materials of 43 p atients who had dural damages during lumbar disc surgery form 1990 to 1998,were retrospectively analyzed.Results:Eight out of 12 patients,who had dr ainage tube set from incision, had cerebrospinal fluid leakage after decannulati on,while none of 31 patients ,who had drainage tube set through para-incision,h ad cerebrospinnal fluid leakage after decannulation.Conclusions:Dama ges to dura were mainly caused during operation.It is very important to protect or repair dura during operation,to set drainage tube through para-incision and to suture lumbodosal fasia tigytly in the prevention of cerebrospinal fluid leak age.　　【Key words】　Lumbar disc surgery Dural damage Cerebrospinal fluid Leakage Prevention 　　硬脊膜损伤是腰椎间盘手术的并发症之一〔1，2〕，由此而发生 的脑脊液漏，不仅给手术者带来了操作上的困难，而且可能给病人带来低颅压性头痛、切口延迟愈合或感染、蛛网膜囊肿等并发症。作为一种神经结构损伤，硬脊膜损伤的同时，潜在着马尾神经或神经根损伤的危险性，因此术中应注意神经结构的识别和保护。我院自1990年至1998年期间，共实施1013例腰椎间盘手术，其中有43例发生了硬脊膜损伤，并有8例于拔管术后发生了切口脑脊液漏。作者对有关硬脊膜损伤的原因，术后脑脊液漏的防治等问题介绍如下： 1　临床资料 1.1　一般资料　男23例，女20例。年龄21岁～71岁，平均48.5岁。初次手术37例，再次手术6例，病变节段：L4，516例，L5L110例，L3.4+L 4.57例，L4.5+L5S18例，L3.4+L4.5+L5S12例。手术方式：全椎板切除术18例，左半椎板切除术7例，右半椎板6例，左开窗6例，右开窗6例。椎间盘突出病理分型：突出型28例，游离型8例，脱出型4例，钙化型3例。合并症情况：合并椎管狭窄32例，腰椎软骨板破裂2例，黄韧带钙化3例。1.2　术中硬膜损伤情况　(1)初次手术，切除椎板、黄韧带致硬脊膜咬破 伤18例，骨片刺破硬脊膜3例，因术前腰穿刺致硬脊膜损伤未愈6例，分离神经根与髓核粘连时致硬脊膜裂伤10例，(2)二次手术分离硬脊膜与其周围疤痕粘连致伤硬脊膜6例。术中均