Daele J J M, Goffart Y, Machiels S
University of Liege, Belgium.
B-ENT. 2011;7 Suppl 17:47-60.
Over the past two decades, Cerebrospinal Fluid (CSF) leak repair has advanced from open invasive intracranial approaches to transnasal endoscopic ones that avoid the traditional morbidities of frontal craniotomy approaches--such as anosmia, intracranial haemorrhage or oedema, seizures, memory deficiencies, and behaviour disorders--reducing morbidity, reducing hospitalisation times and accelerating return to work, and therefore cutting indirect costs. The diagnosis of CSF rhinorrhoea is both clinical and radiological. The presence of CSF in clear nasal drainage should be established by analysis for CSF markers. Localisation of the leak site involves radiological investigation, mainly Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI). In addition to suppressing symptoms, the main goal of the closure of CSF rhinorrhoea is to prevent ascending meningitis. The operative management of cerebrospinal fluid leak is advised in the following circumstances: persistent, posttraumatic CSF leaks after 4 to 6 weeks of conservative treatment; all cases of spontaneous CSF fistulae; cases with intermittent leaks; delayed posttraumatic leaks; cases of CSF leak with a history of meningitis; false CSF rhinorrhoea coming from the petrous bone via the Eustachian tube. The graft material used depends mainly on the authors' experience and did not significantly influence the success rate. The main steps in the surgical procedures do not differ as much from one author to the other: accurate localisation of the defect; creation of a raw surface around the defect to accept the graft and to help in the formation of synechiae to support the seal later; plugging of the defect with fat covered with fascia lata supported by absorbable gelatin and Merocel. The differences between the authors relate to the use of fluorescein to locate the defect, the importance of prophylactic antibiotherapy, the plugging materials, the technique of underlay or overlay grafting, the use of fibrin glue and the need for lumbar drainage. The success rate for endoscopic repair of CSF rhinorrhoea is high: approximately 90% at the first attempt. Recent reports in the literature highlight the group of patients with spontaneous idiopathic CSF leak as a group with specific attributes and treatment challenges.
在过去二十年中，脑脊液漏修补术已从开放性侵入性颅内手术方法发展为经鼻内镜手术方法，后者避免了传统开颅手术方法的常见并发症，如嗅觉丧失、颅内出血或水肿、癫痫发作、记忆缺陷和行为障碍，从而降低了发病率，缩短了住院时间，加快了恢复工作的速度，进而降低了间接成本。脑脊液鼻漏的诊断包括临床诊断和影像学诊断。清亮鼻漏中脑脊液的存在应通过脑脊液标志物分析来确定。漏口部位的定位需要进行影像学检查，主要是计算机断层扫描（CT）和磁共振成像（MRI）。除了缓解症状外，闭合脑脊液鼻漏的主要目标是预防上行性脑膜炎。在以下情况下建议进行脑脊液漏的手术治疗：保守治疗4至6周后持续存在的创伤后脑脊液漏；所有自发性脑脊液瘘病例；间歇性漏液病例；创伤后延迟性漏液；有脑膜炎病史的脑脊液漏病例；经咽鼓管来自岩骨的假性脑脊液鼻漏。所使用的移植材料主要取决于术者的经验，对成功率没有显著影响。不同术者的手术主要步骤差异不大：准确确定缺损位置；在缺损周围创建一个粗糙面以接纳移植材料，并有助于形成粘连以支持后期封闭；用覆盖有阔筋膜的脂肪堵塞缺损，由可吸收明胶和Merocel支撑。术者之间的差异在于使用荧光素定位缺损、预防性抗生素治疗的重要性、堵塞材料、衬层或覆盖层移植技术、纤维蛋白胶的使用以及是否需要腰椎引流。脑脊液鼻漏内镜修复的成功率很高：首次尝试时约为90%。文献中的最新报道强调了自发性特发性脑脊液漏患者群体具有特定特征和治疗挑战。
