Esposito Felice, Dusick Joshua R, Fatemi Nasrin, Kelly Daniel F
Division of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA.
Oper Neurosurg (Hagerstown). 2007 Apr;60(4 Suppl 2):295-303; discussion 303-4. doi: 10.1227/01.NEU.0000255354.64077.66.
A graded approach to cerebrospinal fluid (CSF) leak repair after transsphenoidal surgery is presented.
Patients undergoing endonasal tumor removal during an 8-year period were reviewed. Intraoperative CSF leaks were classified as Grade 0, no leak observed; Grade 1, small leak without obvious diaphragmatic defect; Grade 2, moderate leak; or Grade 3, large diaphragmatic/dural defect. Cranial base repair was tailored to the leak grade as Grade 0, collagen sponge; Grade 1, two-layered collagen sponge repair with intrasellar titanium mesh buttress; Grade 2, intrasellar and sphenoid sinus fat grafts with collagen sponge overlay and titanium buttress; and Grade 3, same as Grade 2 with CSF diversion in most cases. A provocative tilt test was performed before patient discharge to assess the integrity of the CSF leak repair. Protocol modifications adopted in 2003 included an intrasellar fat graft in Grade 1 leaks with a large intrasellar dead space, frequent use of BioGlue (CryoLife, Inc., Atlanta, GA) in Grade 1, 2, and 3 leaks, and CSF diversion for all Grade 3 leaks.
Among 668 cases in 620 patients (475 pituitary adenomas and 145 other lesions), an intraoperative CSF leak was observed in 57% of the cases: 32.5% Grade 1, 15% Grade 2, and 8.7% Grade 3. Postoperative repair failures occurred in 17 cases (2.5%), including 0.7, 3, 1, and 12% of Grade 0, 1, 2, and 3 CSF leaks, respectively. Bacterial meningitis occurred in three patients (0.45%). After protocol modifications in 2003, repair failures decreased from 4 to 1.2% (P = 0.02).
A graded repair approach to CSF leaks in transsphenoidal surgery avoids tissue grafts and CSF diversion in more than 60% of patients. Protocol modifications adopted in the last 340 cases have reduced the failure rate to 1% overall and 7% for Grade 3 leaks. Provocative tilt testing before patient discharge is helpful in the timely diagnosis of postoperative CSF leaks.
介绍一种经蝶窦手术后脑脊液（CSF）漏修补的分级方法。
回顾了8年间接受鼻内肿瘤切除术的患者。术中脑脊液漏分为0级，未观察到漏液；1级，小漏且无明显膈膜缺损；2级，中度漏液；3级，大的膈膜/硬脑膜缺损。颅底修补根据漏液分级进行调整，0级用胶原海绵；1级，用两层胶原海绵修补并在鞍内放置钛网支撑；2级，鞍内及蝶窦脂肪移植，覆盖胶原海绵并使用钛支撑；3级，多数情况下与2级相同，但需进行脑脊液分流。在患者出院前进行激发性倾斜试验以评估脑脊液漏修补的完整性。2003年采用的方案调整包括在1级漏液且鞍内死腔较大时进行鞍内脂肪移植，在1、2、3级漏液时频繁使用生物胶（CryoLife公司，佐治亚州亚特兰大），以及对所有3级漏液进行脑脊液分流。
在620例患者的668例手术中（475例垂体腺瘤和145例其他病变），57%的病例术中观察到脑脊液漏：32.5%为1级，15%为2级，8.7%为3级。术后修补失败17例（2.5%），分别占0、1、2、3级脑脊液漏的0.7%、3%、1%和12%。3例患者发生细菌性脑膜炎（0.45%）。2003年方案调整后，修补失败率从4%降至１.2%（P = 0.02）。
经蝶窦手术中脑脊液漏的分级修补方法可使60%以上的患者避免组织移植和脑脊液分流。在最后340例病例中采用的方案调整使总体失败率降至1%，3级漏液的失败率降至7%。患者出院前的激发性倾斜试验有助于及时诊断术后脑脊液漏。
