Predictive factors for dural tear and cerebrospinal fluid leakage in patients undergoing lumbar surgery
Predictive factors for dural tear and cerebrospinal fluid leakage in patients undergoing lumbar surgery
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DOI：
10.3171/spi.2006.5.3.224
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发表时间：
2006-09-01
影响因子：
2.8
通讯作者：
Nanda, Anil
中科院分区：
文献类型：
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作者：
Sin, Anthony H.;Caldito, Gloria;Nanda, Anil
Object.硬膜撕裂导致脑脊液（CSF）漏是腰椎手术的一种众所周知的风险。作者假设，在涉及重复手术的病例中，CSF漏的发生率较高，并且外科医生进行手术的经验较少;然而，他们假设患者的总体结局不会受到硬脑膜撕裂的不利影响。2003年8月，在路易斯安那州立大学健康科学中心（什里夫波特）启动了一项机构审查委员会批准的方案，以前瞻性比较腰椎手术期间发生CSF泄漏的患者（A组）和未发生CSF泄漏的患者（B组）的数据。比较两组患者的基本人口统计学信息、关于撕裂的描述性结果、其他手术史、住院时间（LOS）和出院时的立即处置。一名患者拒绝参加。76例患者中有12例（15.8%）发生脑脊液漏。在3例患者中，对撕裂的存在提出质疑，并对患者进行了临床治疗，就像撕裂一样。A组患者的年龄大于B组（分别为59.8 ± 16.9岁和49.4 ± 13.6岁; p = 0.02，Fisher精确检验）。在有手术史的患者中，有和无脑脊液漏的患者之间无显著差异（12例患者中的3例[25%][A组]与64例患者中的28例[43.8%][B组]; p = 0.34，双样本t检验）。在12例硬脑膜撕裂患者中，9例（75%）是由实习医生造成的，Kerrison打孔器是当时最常用的器械（55%）。这在5%水平下显著大于50%（p = 0.044，二项式检验）。除了1名患者外，作者能够主要用缝线修复所有患者的撕裂，该患者的撕裂沿着神经根袖。在所有病例中，使用纤维蛋白胶和肌肉/脂肪移植物覆盖撕裂，所有患者均在术后24至48小时卧床休息。在A组中，1例患者在出院时需要康复。A组的LOS大于B组（中位数5 d比3 d），但未观察到额外的并发症。脑脊液漏发生率为16%，无其他并发症。年龄大、外科医生的培训水平高是影响其发生率的因素，而手术史与此无关。
Object. A dural tear resulting in a cerebrospinal fluid (CSF) leak is a well-known risk of lumbar spinal procedures. The authors hypothesized that the incidence of CSF leakage is higher in cases involving repeated operations and those in which the surgeon performing the surgery is less experienced; however, they postulated that the overall outcome of the patient would not be adversely affected by a dural tear.Methods. An institutional review board-approved protocol at Louisiana State University Health Sciences Center, Shreveport, was initiated in August 2003 to allow prospective comparison of data obtained in patients in whom a CSF leak occurred (Group A) and those in whom no CSF leak occur-red (Group B) during lumbar surgery. Basic demographic information, descriptive findings regarding the tear, history of other surgeries, hospital length of stay (LOS), and immediate disposition at the time of discharge were compared between the two groups.Seventy-seven patients were eligible for this study. One patient refused to participate. In 12 (15.8%) of 76 patients CSF leakage developed. In three patients the presence of a tear was questioned, and the patients were clinically treated as if a tear were present. The patients in Group A were older than those in Group B (59.8 +/- 16.9 and 49.4 +/- 13.6 years of age, respectively; p = 0.02, Fisher exact test). In terms of those with a history of surgery, there was no significant difference between patients with and patients without a CSF leak (three [25%] of 12 patients [Group A] compared with 28 [43.8%] of 64 patients [Group B]; p = 0.34, two-sample t-test). In the 12 patients with dural tears, nine (75%) were caused by a resident-in-training, and the Kerrison punch was the instrument most often being used at the time (55%). This is significantly greater than 50% at the 5% level (p = 0.044, binomial test). The authors were able to repair the tear primarily with suture in all but one patient, whose tear was along the nerve root sleeve. In all cases fibrin glue and a muscle/fat graft were used to cover the tear, and all patients were assigned to bed rest from 24 to 48 hours after the operation. In Group A one patient required rehabilitation at discharge. The LOS in Group A was greater than that in Group B (median 5 days compared with 3 days), but no additional complication was noted.Conclusions. The incidence of CSF leakage was 16% in 76 patients, and there were no other complications. Older patient age and higher level of the surgeon's training were factors contributing to the incidence, but the history of surgery was not.