Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
Department of Orthopaedic Surgery, Toyonaka Municipal Hospital, Osaka, Japan.
Bone Joint J. 2019 Sep;101-B(9):1115-1121. doi: 10.1302/0301-620X.101B9.BJJ-2019-0381.R1.
The aim of this study was to explore risk factors for complications associated with dural tear (DT), including the types of DT, and the intra- and postoperative management of DT.
Between 2012 and 2017, 12 171 patients with degenerative lumbar diseases underwent primary lumbar spine surgery. We investigated five categories of potential predictors: patient factors (sex, age, body mass index, and primary disease), surgical factors (surgical procedures, operative time, and estimated blood loss), types of DT (inaccessible for suturing/clipping and the presence of cauda equina/nerve root herniation), repair techniques (suturing, clipping, fibrin glue, polyethylene glycol (PEG) hydrogel, and polyglycolic acid sheet), and postoperative management (drainage duration). Postoperative complications were evaluated in terms of dural leak, prolonged bed rest, headache, nausea/vomiting, delayed wound healing, postoperative neurological deficit, surgical site infection (SSI), and reoperation for DT. We performed multivariable regression analyses to evaluate the predictors of postoperative complications associated with DT.
In total, 429/12 171 patients (3.5%) had a DT. Multivariable analysis revealed that PEG hydrogel significantly reduced the incidence of dural leak and prolonged bed rest, and that patients treated with sealants (fibrin glue and PEG hydrogel) significantly less frequently suffered from headache. A longer drainage duration significantly increased the incidence of headache, nausea/vomiting, and delayed wound healing. Headache and nausea/vomiting were significantly more prevalent in younger female patients. Postoperative neurological deficit and reoperation for DT significantly depended on the presence of cauda equina/nerve root herniation. A longer operative time was the sole independent risk factor for SSI and was also a risk factor for dural leak, prolonged bed rest, and nausea/vomiting.
Sealants, particularly PEG hydrogel, may be useful in reducing symptoms related to cerebrospinal fluid leakage, whereas prolonged drainage may be unnecessary. Younger female patients should be carefully treated when DT occurs. Cite this article: 2019;101-B:1115-1121.
本研究旨在探讨与硬脊膜撕裂（DT）相关并发症的危险因素，包括 DT 的类型以及 DT 的术中及术后处理。
2012 年至 2017 年，12171 例退行性腰椎疾病患者接受了原发性腰椎手术。我们研究了五类潜在的预测因素：患者因素（性别、年龄、体重指数和原发性疾病）、手术因素（手术程序、手术时间和估计失血量）、DT 类型（无法缝合/夹闭和马尾/神经根疝出）、修复技术（缝合、夹闭、纤维蛋白胶、聚乙二醇（PEG）水凝胶和聚乙醇酸片）以及术后管理（引流时间）。术后并发症根据硬脊膜漏、延长卧床休息、头痛、恶心/呕吐、伤口愈合延迟、术后神经功能缺损、手术部位感染（SSI）和 DT 再次手术进行评估。我们进行了多变量回归分析，以评估与 DT 相关的术后并发症的预测因素。
共有 429/12171 例患者（3.5%）出现 DT。多变量分析显示，PEG 水凝胶显著降低了硬脊膜漏和延长卧床休息的发生率，使用密封剂（纤维蛋白胶和 PEG 水凝胶）治疗的患者头痛发生率显著降低。引流时间延长显著增加了头痛、恶心/呕吐和伤口愈合延迟的发生率。年轻女性患者头痛和恶心/呕吐更为常见。术后神经功能缺损和 DT 再次手术明显取决于马尾/神经根疝出的存在。手术时间较长是 SSI 的唯一独立危险因素，也是硬脊膜漏、延长卧床休息和恶心/呕吐的危险因素。
密封剂，特别是 PEG 水凝胶，可能有助于减少与脑脊液漏相关的症状，而延长引流可能是不必要的。发生 DT 时，应谨慎处理年轻女性患者。引用本文：2019；101-B：1115-1121。
