Pitskhelauri David, Kudieva Elina, Moshchev Dmitrii, Ananev Evgeny, Shifrin Michail, Danilov Gleb, Melnikova-Pitskhelauri Tatiana, Kachkov Igor, Bykanov Andrey, Sanikidze Alexander
Burdenko Neurosurgery Center, Department of Neuro-oncology, Moscow, Russia.
Burdenko Neurosurgery Center, Department of Anesthesiology and Intensive care, Moscow, Russia.
Acta Neurochir (Wien). 2018 May;160(5):1079-1087. doi: 10.1007/s00701-018-3507-y. Epub 2018 Mar 20.
A pseudomeningocele and an incisional cerebrospinal fluid leak are considered frequent complications following neurosurgical operations. The rate of these complications especially increases following neurosurgical procedures on the posterior cranial fossae. According to some publications, the rate of pseudomeningoceles has been reported as high as 40%, whereas that of incisional cerebrospinal fluid leaks is up to 17%. For the purposes of reducing the risk of these complications after a midline suboccipital craniotomy, we propose suturing the arachnoid membrane of the cisterna magna. In this paper, we present a retrospective analysis of arachnoid membrane suturing.
Seventy patients underwent midline suboccipital craniotomy by the first author between 2012 and 2016 at Burdenko Neurosurgery Institute. In this group was included a consecutive group of patients with posterior fossae tumors where the approach was performed through the cisterna magna arachnoid membrane following midline suboccipital craniotomy and dural opening. The patients were divided into two groups. Group 1 included 38 patients to whom cisterna magna arachnoid membrane suturing was performed with monofilament nonabsorbable suture 7.0., and additionally, the suture was sealed with fibrin adhesive sealant TachoComb®. Group 2 included 32 patients without arachnoid membrane suturing. There was no other significant difference in terms of clinical signs and surgical procedures between these groups. In the postoperative period, the frequency of developing a pseudomeningocele and an incisional cerebrospinal fluid leak was assessed in these two groups. The results were evaluated on the basis of clinical, CT, and MRI data performed in the postoperative period.
In the patients who underwent arachnoid membrane suturing (group I), pseudomeningocele formation was observed in one (2.6%) and CSF leak in one (2.6%) of the 38 patients. In group II, in which patients had no arachnoid membrane suturing, we observed pseudomeningocele formation in 11 (34.4%) patients and a CSF leak in 7 (25.0%) out of 28 patients with known follow-up. Statistical analysis of the data indicates a significantly higher risk of postoperative pseudomeningocele formation and/or an incisional cerebrospinal fluid leak in a group of patients who did not undergo arachnoid membrane suturing (p < 0.05).
Suturing of the arachnoid membrane of the cisterna magna and its further sealing with fibrin adhesive sealant TachoComb® create an additional barrier for preventing cerebrospinal fluid collection in the extradural space. This technique significantly reduces the risk of postoperative pseudomeningocele formation and/or an incisional cerebrospinal fluid leak in patients with midline suboccipital craniotomy.
假性脑脊膜膨出和手术切口脑脊液漏被认为是神经外科手术后常见的并发症。这些并发症的发生率在颅后窝神经外科手术后尤其增加。根据一些出版物，假性脑脊膜膨出的发生率报告高达40%，而手术切口脑脊液漏的发生率高达17%。为了降低枕下正中开颅术后这些并发症的风险，我们建议缝合小脑延髓池蛛网膜。在本文中，我们对蛛网膜缝合进行回顾性分析。
2012年至2016年期间，第一作者在布尔坚科神经外科研究所对70例患者进行了枕下正中开颅手术。该组包括一组连续的颅后窝肿瘤患者，这些患者在枕下正中开颅和硬脑膜切开后通过小脑延髓池蛛网膜进行手术入路。患者分为两组。第1组包括38例患者，用7.0单丝不可吸收缝线缝合小脑延髓池蛛网膜，此外，用纤维蛋白粘合剂TachoComb®密封缝线。第2组包括32例未进行蛛网膜缝合的患者。两组在临床体征和手术操作方面没有其他显著差异。在术后期间，评估这两组患者假性脑脊膜膨出和手术切口脑脊液漏的发生频率。根据术后进行的临床、CT和MRI数据评估结果。
在接受蛛网膜缝合的患者（第1组）中，38例患者中有1例（2.6%）出现假性脑脊膜膨出，1例（2.6%）出现脑脊液漏。在第2组未进行蛛网膜缝合的患者中，在已知随访的28例患者中，我们观察到11例（34.4%）患者出现假性脑脊膜膨出，7例（25.0%）患者出现脑脊液漏。对数据的统计分析表明，未进行蛛网膜缝合的患者组术后假性脑脊膜膨出形成和/或手术切口脑脊液漏的风险显著更高（p < 0.05）。
缝合小脑延髓池蛛网膜并用纤维蛋白粘合剂TachoComb®进一步密封，为防止硬膜外腔脑脊液积聚创造了额外的屏障。该技术显著降低了枕下正中开颅患者术后假性脑脊膜膨出形成和/或手术切口脑脊液漏的风险。
