| 王会旺,陈仲强,李危石,姜 帅,赵春霞,梅雅男,孙垂国.胸椎管狭窄症术后脑脊液漏继发低颅压症状的临床特点及处理策略[J].中国脊柱脊髓杂志,2022,(8):696-703. |
| 胸椎管狭窄症术后脑脊液漏继发低颅压症状的临床特点及处理策略 |
| 中文关键词: 胸椎管狭窄症 脑脊液漏 术后并发症 低颅压症状 治疗策略 |
| 中文摘要: |
| 【摘要】 目的：探讨胸椎管狭窄症术后脑脊液漏继发低颅压症状的临床特点及处理策略。方法：回顾性分析2021年8月～2022年3月于北京大学第三医院骨科行胸椎后路手术且术后并发脑脊液漏的38例胸椎管狭窄症患者的资料，其中男7例，女31例，年龄30～78岁（56.6±11.1岁）。根据术后是否出现低颅压症状分为低颅压症状组和非低颅压症状组，低颅压症状组15例，男1例，女14例，年龄43～78岁（58.9±11.0岁），非低颅压症状组23例，男6例，女17例，年龄30～72岁（55.1±11.2岁）。采用疼痛视觉模拟评分（visual analogue scale，VAS）评估头痛，按照WHO规定标准对恶心呕吐进行分级，头晕按患者的主观感受分为：轻度、中度和重度，对比两组患者的手术时间、术中出血量、术后补液量及引流量；采用二元Logistic分析低颅压症状的危险因素；总结低颅压症状的具体表现、严重程度、出现时间、持续时间；评价补液、调整体位、改变引流方式等治疗措施对低颅压症状的疗效。结果：15例出现低颅压症状的患者中，头痛11例（73.3%），恶心呕吐9例（60.0%），头晕5例（33.3%），其中7例（46.7%）为单一症状，6例（40.0%）合并2种症状，2例（13.3%）合并3种症状。头痛VAS评分为2～6分（4.0±1.0分），恶心呕吐程度：Ⅱ级1例，Ⅲ级7例，Ⅳ级1例，头晕程度均为轻度。患者出现低颅压症状时间为术后24～96h（41.3±25.5h）。低颅压症状持续天数为1～4d（2.2±0.9d）。低颅压症状治疗方法包括补液、调整体位及改变引流方式，拔除引流管时间为3～5d，平均为3.9d。15例患者低颅压症状经保守治疗后均完全缓解，顺利出院。脑脊液漏继发并发症情况，非低颅压症状组颅内出血1例、蛛网膜下腔-胸膜腔瘘1例，低颅压症状组伤口裂开1例。患者胸椎管狭窄症术后并发脑脊液漏患者出现低颅压症状比例为39.5%（15/38），低颅压症状组和非低颅压症状组在手术时间、术中出血量、术后补液量及引流量无统计学差异（P＞0.05）。Logistic回归分析显示年龄、性别、体重、身高、BMI、手术时间、手术节段、术中总入量、术中总出量、术中出血量、术后第1天血钠、平均每日引流量、平均每日引流量/体重、平均每日补液量、平均每日补液量/体重与低颅压症状无显著相关性（P＞0.05）。结论：胸椎管狭窄症术后并发脑脊液漏患者出现低颅压症状的比例较高；低颅压症状的常见临床表现为头痛、恶心呕吐、头晕，半数患者会合并出现两种或两种以上症状；补液、调整体位及改变引流方式等综合处理方案能够有效地缓解低颅压症状或缩短其持续时间。 |
Clinical characteristics and treatment of symptoms of intracranial hypotension secondary to cerebrospinal fluid leakage after thoracic spinal stenosis surgery |
| 英文关键词:Thoracic spinal stenosis Cerebrospinal fluid leakage Post-operative complication Symptoms of intracranial hypotension Treatment |
| 英文摘要: |
| 【Abstract】 Objectives: To investigate the clinical characteristics and treatment plan of symptoms of intracranial hypotension (SIH) secondary to cerebrospinal fluid leakage(CSFL) after symptomatic thoracic spinal stenosis surgery. Methods: A retrospective cohort study was conducted to analyze the data of 38 patients with thoracic spinal stenosis complicated with postoperative CSFL who underwent thoracic posterior approach surgery in Peking University Third Hospital from August 2021 to March 2022. There were 7 males and 31 females, aged 56.6±11.1(30-78) years old. According to whether occurred postoperative symptoms of intracranial hypotension, the patients were divided into SIH group of 15 patients including 1 male and 14 females, aged 58.9±11.0(43-78) years, and non-SIH group of 23 patients including 6 males and 17 females, aged 55.1±11.2(30-72) years old. The operation time, intra-operative blood loss, post-operative fluid infusion, and drainage volume were compared between the two groups. Risk factors for SIH were analyzed by binary logistic analysis. Headache was assessed by visual analogue scale (VAS), nausea and vomiting were graded according to WHO standards, and dizziness was classified as mild, moderate and severe according to patients′ subjective feelings. The clinical manifestations, severity, occurrence time and duration of SIH were summarized; the efficacy of fluid infusion, postural adjustment, and drainage mode changes in the treatment of SIH was evaluated. Results: 15 patients developed SIH, among which, 11 cases (73.3%) had headache, 9 cases (60.0%) had nausea and vomiting, and 5 cases (33.3%) had dizziness. Of these 15 cases, 7 cases (46.7%) had single symptom, 6 cases (40.0%) had two symptoms, and 2 cases(13.3%) had three symptoms. The VAS score of headache ranged from 2 to 6, with an average of 4.0±1.0. The severity of nausea and vomiting fell in grade Ⅱ(1 case), Grade Ⅲ(7 cases), and grade Ⅳ(1 case). The degree of dizziness was all mild. Postoperative SIH lasted from 24 hours to 96 hours, with an average of 41.3±25.5h. The duration of SIH averaged 2.2±0.9(1-4) days. SIH were treated with fluid infusion, postural adjustment and drainage regulation. The duration of epidural drainage was between 3-5 days, with an average of 3.9 days. After conservative treatment, the SIH in 15 patients were all completely relieved. There were 3 complications secondary to CSFL, including 1 case of intracranial hemorrhage and 1 case of subarachnoid-pleural fistula in non-SIH group and 1 case of wound dehiscence in SIH group. The proportion of SIH in CSFL patients after thoracic spinal stenosis surgery was 39.5%(15/38). And there was no statistical significance in operation time, intra-operative blood loss, post-operative fluid infusion and drainage volume between the two groups(P>0.05). Logistic regression analysis showed that age, gender, weight, height, BMI, operation time, operation segment, total intraoperative input, total intraoperative output, intraoperative blood loss, serum sodium on the first day after operation, average daily drainage volume, average daily drainage volume/body weight, average daily fluid infusion volume, and average daily fluid infusion volume/body weight were not significantly associated with symptoms of hypotension(P>0.05). Conclusions: Patients with CSFL after thoracic spinal stenosis surgery had a relative high proportion of SIH. The main clinical manifestations of SIH were headache, nausea and vomiting, dizziness, and almost half cases might have two symptoms or above. The comprehensive treatment including fluid infusion, body position adjustment and drainage regulation could effectively relieve the SIH or shorten its duration. |
| 投稿时间：2022-04-06 修订日期：2022-07-17 |
| DOI： |
| 基金项目:国家自然科学基金面上项目（编号：81874031）；北京大学第三医院人才孵育基金（编号：Y77477-03） |
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