Department of Spine Surgery, Zentralklinik Bad Berka, Bad Berka, Germany.
Department of Spine Surgery, Zentralklinik Bad Berka, Bad Berka, Germany.
World Neurosurg. 2021 Jun;150:e52-e65. doi: 10.1016/j.wneu.2021.02.071. Epub 2021 Feb 25.
Intracranial hemorrhage (IH) after spinal surgery is a rare but potentially life-threatening complication. Knowledge of predisposing factors and typical clinical signs is essential for early recognition, helping to prevent an unfavorable outcome.
A retrospective analysis was performed of patients with IH after spinal surgery treated in our institution between 2012 and 2018. The literature dealing with IH complicating spinal surgery was reviewed.
Our investigation found 10 patients with IH (6 female and 4 male). To the best of our knowledge, this is the largest series reported so far. The assumable incidence of IH after spinal surgery in our population was 0.0657%. Durotomy was noticed in 6 patients, all of whom were treated according to a local standard protocol. In 4 patients, the dural tear was occult. Hemorrhage occurred mostly in the cerebellar compartment. Eight of 10 patients had long-standing arterial hypertension, which seems to be a risk factor (hazard ratio, 1.58). Five patients were treated conservatively, whereas 3 required a cerebrospinal fluid (CSF) diversion procedure. In 2 patients, revision surgery with duraplasty was necessary. Seven patients were discharged with little to no neurologic symptoms, and 3 had significant deterioration. One patient died because of brainstem herniation. Review of the literature identified 54 articles with 72 patients with IH complicating spinal surgery.
Patients with intraoperative CSF loss should be kept under close supervision postoperatively. After opening of the dura, a watertight closure should be attempted. The use of subfascial suction drainage in cases of a dural tear as well as preexistent arterial hypertension seems to be a risk factor for the development of IH. Intracranial bleeding must be considered in every patient with unexplained neurologic deterioration after spinal surgery and should be ruled out by cranial imaging. To ensure early recognition and prevent an unfavorable outcome, a high index of suspicion is required, especially in revision spinal surgery. The treatment is specific to the extent and location of the IH, thus dictating the outcome. In most patients, conservative treatment led to a good outcome. CSF diversion measures may be necessary in patients with compression or obstruction of the fourth ventricle. Large hematomas with mass effect may require decompressive surgery.
脊柱手术后颅内出血（intracranial hemorrhage，IH）是一种罕见但潜在危及生命的并发症。了解其诱发因素和典型临床征象对于早期识别至关重要，有助于预防不良结局。
回顾性分析了 2012 年至 2018 年在我院治疗的脊柱手术后发生 IH 的患者。对脊柱手术后并发 IH 的文献进行了复习。
共发现 10 例 IH 患者（6 例女性，4 例男性）。据我们所知，这是迄今为止报道的最大系列。我们人群中脊柱手术后 IH 的假定发生率为 0.0657%。6 例患者出现硬脊膜切开，均根据当地标准方案进行治疗。4 例患者硬脊膜撕裂为隐匿性。出血主要发生在小脑隔室。10 例患者中有 8 例长期患有动脉高血压，这似乎是一个危险因素（危险比，1.58）。5 例患者接受保守治疗，3 例需要脑脊液（CSF）引流术。2 例患者需要行翻修手术和硬脊膜修补术。7 例患者出院时神经症状轻微或无明显恶化，3 例患者明显恶化。1 例患者因脑干疝死亡。文献复习共纳入 54 篇文章，共计 72 例脊柱手术后 IH 患者。
术中 CSF 丢失的患者术后应密切观察。硬脊膜切开后，应尝试行密闭缝合。筋膜下负压引流以及术前存在动脉高血压似乎是 IH 发展的危险因素。脊柱手术后出现不明原因的神经功能恶化时，必须考虑颅内出血的可能，需通过头颅影像学检查排除。为了早期识别和预防不良结局，需要高度怀疑，尤其是在脊柱翻修手术中。治疗方法取决于 IH 的范围和部位，因此决定了结局。大多数患者经保守治疗后预后良好。对于第四脑室受压或梗阻的患者，可能需要 CSF 引流措施。有占位效应的大血肿可能需要减压手术。
