Culley D J, Berger M S, Shaw D, Geyer R
University of Washington School of Medicine, Seattle.
Neurosurgery. 1994 Mar;34(3):402-7; discussion 407-8. doi: 10.1227/00006123-199403000-00003.
The authors retrospectively reviewed 117 pediatric patients with posterior fossa tumors treated at The Children's Hospital and Medical Center, Seattle, Washington, between 1976 and 1990, in an attempt to determine what perioperative and intraoperative factors influenced the need for postoperative shunts. The ages of the patient population ranged from 4 months to 16 years 9 months. The factors evaluated included age at diagnosis, duration of symptoms, extent of hydrocephalus, tumor location, extent of tumor resection, presence and duration of an external ventricular drain, flow of cerebrospinal fluid (CSF) through the fourth ventricle after tumor resection, presence of hemostatic cavity linings, method of dural closure, tumor type, CSF infection, CSF leak, and pseudomeningocele formation. Of these variables, young age at diagnosis, tumors affecting midline structures, subtotal tumor resection as determined by immediate postoperative scans, prolonged requirement of an external ventricular drain, cadaveric dural grafts, pseudomeningocele formation, and CSF infections were statistically significant factors associated with the need for postoperative shunt placement, which was required in 36% of all patients. Therefore, considering the pertinent factors that may influence the need for postoperative shunt placement, a radical tumor resection should be done when possible, especially for midline lesions, and closure of the operative wound should be meticulous to avoid a CSF leak and subsequent infection. Foreign body dural substitutes as a cause of an inflammatory response in the CSF should also be avoided. Persistence of a pseudomeningocele despite serial taps and time will eventually require placement of a shunt after posterior fossa tumor surgery.
作者回顾性研究了1976年至1990年间在华盛顿州西雅图市儿童医院和医疗中心接受治疗的117例小儿后颅窝肿瘤患者，试图确定哪些围手术期和术中因素会影响术后分流的需求。患者年龄范围为4个月至16岁9个月。评估的因素包括诊断时的年龄、症状持续时间、脑积水程度、肿瘤位置、肿瘤切除范围、外部脑室引流管的存在及持续时间、肿瘤切除后脑脊液通过第四脑室的流量、止血腔衬里的存在、硬脑膜闭合方法、肿瘤类型、脑脊液感染、脑脊液漏和假性脑膜膨出形成。在这些变量中，诊断时年龄小、影响中线结构的肿瘤、术后立即扫描确定的肿瘤次全切除、外部脑室引流管的长期需求、尸体硬脑膜移植、假性脑膜膨出形成和脑脊液感染是与术后分流放置需求相关的统计学显著因素，所有患者中有36%需要进行分流。因此，考虑到可能影响术后分流放置需求的相关因素，应尽可能进行根治性肿瘤切除，尤其是对于中线病变，手术伤口的闭合应细致，以避免脑脊液漏和随后的感染。还应避免使用异物硬脑膜替代物作为脑脊液中炎症反应的原因。尽管进行了多次穿刺和长时间观察，但假性脑膜膨出持续存在最终将需要在后颅窝肿瘤手术后放置分流管。
