孫祥耀　海涌

Risk factors and research progress in the treatment of incidental durotomy in anterior cervical spine surgery for the patients with ossification of the posterior longitudinal ligament

SUN Xiang-yao, HAI Yong. Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, PRC

. 綜述 Review .

前路手術(shù)治療頸椎后縱韌帶骨化并發(fā)硬脊膜破裂的危險因素及治療進(jìn)展

孫祥耀海涌

Risk factors and research progress in the treatment of incidental durotomy in anterior cervical spine surgery for the patients with ossification of the posterior longitudinal ligament

SUN Xiang-yao, HAI Yong. Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, PRC

頸椎；后縱韌帶骨化；外科手術(shù)；腦脊液漏；危險因素；診斷

硬脊膜破裂 ( incidental durotomy，ID ) 在脊柱外科的整體發(fā)生率為 1%～17%[1]。頸椎手術(shù)硬脊膜破裂的整體發(fā)生率為 0.5%～3%[2-4]，其中頸椎前路減壓手術(shù)引起硬脊膜破裂和腦脊液漏的發(fā)生率為 0.5%～3%[2,5-9]，對于有后縱韌帶骨化的病例，發(fā)生率明顯增高，為 4.3%～32%[1,10-15]。與后路手術(shù)相比，前路手術(shù)可能出現(xiàn)的創(chuàng)傷性操作會增加腦脊液漏發(fā)生的風(fēng)險，這是因為椎板成形術(shù)和椎板切除術(shù)避免了對骨化的后縱韌帶進(jìn)行直接操作；因此，盡管在應(yīng)用頸椎前路手術(shù)治療頸椎管狹窄等疾病時，通過切除骨化的后縱韌帶和前路融合對脊髓進(jìn)行前方減壓能夠比后路手術(shù)取得更加滿意的治療效果，外科醫(yī)生必須考慮到硬脊膜破裂的風(fēng)險[14,16]。

一、頸椎前路手術(shù)并發(fā)硬脊膜破裂概述

( 一 ) 頸椎特殊解剖結(jié)構(gòu)

1. “過渡區(qū)” ( transitional zone ) 的概念：上位頸椎的穩(wěn)定結(jié)構(gòu)十分復(fù)雜，在 C0～2層面的硬脊膜與周圍的韌帶粘連緊密，并通過多層結(jié)締組織進(jìn)行加強；然而，C2椎體下1 / 3 平面以下對應(yīng)的硬脊膜僅有后縱韌帶覆蓋，此結(jié)構(gòu)延續(xù)到樞椎下節(jié)段直到脊髓全長[17]。Beretta 等[18]認(rèn)為，“過渡區(qū)”位于上述 C0～2節(jié)段與樞椎下頸椎節(jié)段之間，為C2～3椎間盤平面與 C3椎體后壁上 1 / 3 之間的區(qū)域。

2. “過渡區(qū)”的意義：樞椎平面以下硬脊膜與上位頸椎平面與硬脊膜粘連的韌帶結(jié)構(gòu)及堅韌的結(jié)締組織所形成的相反的彈性力，使“移行區(qū)”成了頸椎硬脊膜的薄弱區(qū)域，容易受到損傷出現(xiàn)硬脊膜破裂[18]。對于 C0～2復(fù)合體及其硬脊膜的分離，會引起“過渡區(qū)”C3水平硬脊膜薄弱處的破裂，從而將腦脊液引流入硬脊膜外間隙。由于上位頸椎的解剖特點以及“移行區(qū)”的存在，腦脊液漏引起的硬脊膜外間隙腦脊液積聚，較少出現(xiàn)在 C0～2水平，而較易從 C2～3層面向下蔓延，甚至可達(dá)上位胸椎水平硬脊膜外間隙[19]。

( 二 ) 頸椎前路手術(shù)硬脊膜破裂危險因素

Epstein 等[20]發(fā)現(xiàn)頸椎手術(shù)引起硬脊膜破裂的整體發(fā)生率為 1%；硬脊膜破裂的重要危險因素為老齡、風(fēng)濕性關(guān)節(jié)炎、后縱韌帶骨化、手術(shù)時間較長、手術(shù)頸椎節(jié)段較多、神經(jīng)功能較差、術(shù)式為椎體次全切除術(shù)以及再次手術(shù)；老齡及后縱韌帶骨化不僅是硬脊膜破裂的重要危險因素，也是硬脊膜破裂直接縫合修補失敗的重要危險因素。其中老齡患者因為硬膜變薄弱，容易出現(xiàn)硬脊膜破裂[19-21]。類風(fēng)濕關(guān)節(jié)炎也是危險因素，可能原因是在炎癥狀態(tài)下會造成硬脊膜與周圍組織更嚴(yán)重的粘連以及使硬脊膜變得更加薄弱；術(shù)前神經(jīng)功能較差也是重要危險因素，這可能是因為其需要進(jìn)行更加復(fù)雜的手術(shù)才能達(dá)到治療目的，從而增加了硬脊膜破裂的風(fēng)險[22]。Hannallah 等[8]報道后縱韌帶骨化是前路減壓手術(shù)后出現(xiàn)腦脊液漏的最重要的危險因素，并且患有后縱韌帶骨化的患者出現(xiàn)腦脊液漏的發(fā)生率是沒有后縱韌帶骨化患者的 13.7 倍。后縱韌帶骨化的病例中，硬脊膜經(jīng)常發(fā)生骨化或鈣化，并與后縱韌帶融合在一起，因此增加了在進(jìn)行去除后縱韌帶骨化塊的手術(shù)操作時出現(xiàn)腦脊液漏和脊髓或神經(jīng)根損傷的可能性[23]。

( 三 ) 頸椎手術(shù)并發(fā)腦脊液漏的預(yù)后

既往文獻(xiàn)描述了多種與頸椎手術(shù)后腦脊液漏相關(guān)的并發(fā)癥，包括腦脊髓膜炎[24]、傷口延遲愈合、氣道阻塞[3-4]、腦脊液皮瘺[23]以及假性硬脊膜膨出[3,25-26]。術(shù)后立即出現(xiàn)的威脅生命的腦脊液漏并不常見，但是其需要早期診斷和迅速干預(yù)。處理得當(dāng)?shù)哪X脊液漏預(yù)后較好，然而 Saxler 等[27]發(fā)現(xiàn)伴有硬脊膜破裂的患者預(yù)后較差 ( 他們會面臨更高的再手術(shù)風(fēng)險，經(jīng)受更嚴(yán)重的疼痛和疼痛相關(guān)的功能受限 )，其他作者報道腦脊液漏產(chǎn)生的長期有害作用有限[9-12]。

二、頸椎前路手術(shù)硬脊膜破裂的治療

頸椎前路硬脊膜破裂的修補技術(shù)包括直接縫合修補，使用吸收性明膠海綿[1]、纖維蛋白膠[4,22,28]、膠原蛋白基質(zhì)[29-30]、脂肪和筋膜移植[31-32]、生物型補片[33]、合成材料[34-35]以及使用硬膜外自體血填充技術(shù)[36]進(jìn)行修補，放置腰部引流[8,37]或腰部－腹腔和傷口－腹腔分流術(shù)[3,33]、腦室引流術(shù)[24,26]、激光技術(shù)[38]和顯微硬脊膜縫合器縫合[15]。筆者將常用的術(shù)中處理方法和術(shù)后特殊處理方法分別進(jìn)行闡述。

( 一 ) 術(shù)中處理策略

1. 硬脊膜直接縫合修補：盡管在整個脊柱區(qū)域，大多數(shù)的硬脊膜破裂引發(fā)腦脊液漏病例中直接縫合修補是最佳的處理方法[39-42]，當(dāng)其出現(xiàn)在頸椎前路手術(shù)治療后縱韌帶骨化時，通常會因為暴露不充分從而使直接縫合修補變得困難[43]。直接修補技術(shù)的主要目的是為硬脊膜破裂提供水密性封閉。如果技術(shù)上允許，提倡使用縫合的方法進(jìn)行直接縫合修補。然而據(jù)報道，這種修補技術(shù)的失敗率為5%～10%[2,44]。當(dāng)硬脊膜發(fā)生骨化并與后縱韌帶出現(xiàn)粘連并不易分離時，硬脊膜破裂將更易發(fā)生；這些硬脊膜破裂產(chǎn)生的組織缺口不適于進(jìn)行直接縫合修補[16]。骨化的硬膜可以通過術(shù)前 CT 進(jìn)行診斷，表現(xiàn)為硬脊膜上均質(zhì)的骨化塊與后縱韌帶粘連或前方及后方骨化邊緣被肥厚的后縱韌帶的高密度區(qū)分開形成雙層征[45]?？赡軐?dǎo)致直接縫合修補失敗的另一個原因是縫合產(chǎn)生的針眼大小的硬脊膜破裂，使腦脊液從硬脊膜漏出[30,46-47]。對較小的硬脊膜破口進(jìn)行一期縫合封閉的潛在風(fēng)險在于，其將低壓力的破口轉(zhuǎn)變?yōu)橛煽p針引起的高壓力針眼[30]。

2. 化學(xué)密封劑和生物材料移植：常用的化學(xué)密封劑有吸收性明膠海綿[44]、纖維蛋白膠[48]、膠原蛋白基質(zhì)[33]，水明膠[68]等?；瘜W(xué)封閉劑可以被用來克服針眼處出現(xiàn)腦脊液漏的問題[30]。

吸收性明膠海綿為有孔材料，水密性差，但是可以與直接縫合相配合修補破口[44]。使用時可以使用甲潑尼龍浸泡防止與周圍組織粘連[25]。相關(guān)研究表明，頸椎前路手術(shù)致硬脊膜破裂腦脊液漏的患者，術(shù)中采用吸收性明膠海綿聯(lián)合縫合修補可以達(dá)到較好的療效，并且有效防止感染的發(fā)生[49]。

纖維蛋白膠被證明在防止直接修補引起的腦脊液漏方面有效[28]。實驗數(shù)據(jù)表明，經(jīng)單純縫合的方法修補的硬脊膜破裂會在生理壓力下出現(xiàn)腦脊液漏，然而使用纖維蛋白膠等密封劑輔助修補后的硬脊膜破裂能在術(shù)后承受更高的壓力[28,31,48]。由于纖維蛋白密封劑在被吸收之前只能保持性狀 5～7 天，它應(yīng)當(dāng)與硬脊膜移植修補術(shù)合用，從而保證術(shù)后早期的水密性封閉。

Narotam 等[30]報道了在硬脊膜破裂修補中使用膠原蛋白基質(zhì)外置非縫合移植物，并取得了成功。膠原蛋白基質(zhì)不需要縫合固定，黏附能力較好，能降低局部反應(yīng)，在2～3 個月被自身組織取代[20]。

水凝膠修補硬脊膜破口的成功率可達(dá) 98.2%[50]。水凝膠在使用后體積會增大 50%，因此其禁用于神經(jīng)結(jié)構(gòu)豐富的狹小骨性區(qū)域中，以避免對周圍結(jié)構(gòu)造成壓迫[51]。國內(nèi)報道了對無明顯硬脊膜缺損的患者，使用氰基丙烯酸酯醫(yī)用膠[52]和人工硬脊膜聯(lián)合生物蛋白膠[53]治療腦脊液漏，療效較好。

常用于移植修補的生物材料包括脂肪組織[54]、肌肉組織[55]、自體筋膜[54]以及牛心包膜[44]等。脂肪移植是最早應(yīng)用于硬脊膜破裂的移植物，其不透水，容易獲得，不易與周圍神經(jīng)結(jié)構(gòu)粘連，并且能夠有效預(yù)防瘢痕的產(chǎn)生；最常應(yīng)用的筋膜移植物包括闊筋膜和切口周圍的筋膜[54]。最常用于頸椎前路手術(shù)的肌肉組織移植方法為帶蒂胸鎖乳突肌皮瓣移植[55-56]。該皮瓣用途極為廣泛，Benazzo 等[56]曾經(jīng)使用這種皮瓣治療頸椎前路手術(shù)造成的食管破裂，并取得了成功。牛心包膜為常用的異體組織移植物，有相關(guān)研究表明，硬膜環(huán)形撕裂使用自體闊筋膜移植或牛心包膜進(jìn)行聯(lián)合修補，治療效果較好[44]。Epstein[15,33]描述了一項使用縫合或顯微硬膜縫合器來確保心包膜移植到硬脊膜破口處的技術(shù)，均在應(yīng)用中取得成功；這項技術(shù)通常需要使用纖維蛋白密封劑和硬膜基質(zhì)移植以及傷口－腹腔或腰部－腹腔分流術(shù)進(jìn)行輔助治療。

3. 傷口引流：使用筋膜下引流處理術(shù)中出現(xiàn)的腦脊液漏尚有爭議。采用這種引流方式能夠在術(shù)后早期將積聚的漿液性滲出液、創(chuàng)面出血或腦脊液引流出來，并消除無效腔；當(dāng)患者術(shù)后活動時，腦脊液內(nèi)靜水壓力的增加促進(jìn)腦脊液在短時間內(nèi)溢出到筋膜下的空隙；當(dāng)使用如膠原蛋白基質(zhì)等有孔的移植材料時，腦脊液的溢出風(fēng)險會增加，這在術(shù)后化學(xué)封閉形成和移植物與周圍組織接合之前的幾天中尤為明顯[30]。盡管有學(xué)者不建議使用引流[25]，大多數(shù)的研究表明，硬脊膜－皮膚瘺管的形成的發(fā)生率不會隨引流的使用而增加[5,57]。

( 二 ) 術(shù)后處理方法

術(shù)中修補硬脊膜破口雖然是首選方法，但是由于其操作難度大，往往不易完成，因此硬脊膜破裂引起腦脊液漏的術(shù)后處理十分重要[23]。筆者將其分為蛛網(wǎng)膜下腔閉式引流術(shù)、傷口－腹腔分流術(shù)或腰部－腹腔分流術(shù)、硬脊膜外間隙自體血填充技術(shù)等特殊治療方法分別進(jìn)行闡述。

1. 蛛網(wǎng)膜下腔閉式引流術(shù)：采用將腦脊液進(jìn)行分流的方法在治療腦脊液漏方面有較為全面的文獻(xiàn)記錄。據(jù)報道成功率為 83%～100%[12,37]；將頸椎前路減壓治療后縱韌帶骨化引起腦脊液漏，在術(shù)中放置腰部蛛網(wǎng)膜下腔閉式引流或分流術(shù)，以及不作處理的患者進(jìn)行治療效果的比較，發(fā)現(xiàn)采用腰部蛛網(wǎng)膜下腔閉式引流及或分流術(shù)的患者沒有出現(xiàn)腦脊液瘺管或假性脊膜膨出形成，也沒有出現(xiàn)需要再次手術(shù)治療的病例。采用腦脊液分流治療硬脊膜破裂的原理為通過將腦脊液優(yōu)先從引流管引出，降低破口處腦脊液的壓力差，或者通過降低硬脊膜破口邊緣的張力，促進(jìn)破口的愈合[37,44]。

在放置引流管時，應(yīng)當(dāng)在無菌的條件下采用側(cè)臥位進(jìn)行操作，在 L2及 L3之間進(jìn)行穿針；在引流時可以預(yù)防性靜脈滴注頭孢類抗生素或哌拉西林；引流量控制在 5～15 ml / h 或 12～360 ml / 天；使用硅膠引流管防止引流管閉塞，保留引流管 5～10 天[44]。

對于在術(shù)后處理過程中診斷腦脊液漏的患者 ( 例如患者引流管流出腦脊液或出現(xiàn)腦脊液皮膚瘺管形成 )，單純的臥床休息往往療效不佳[25]。盡管直接縫合修補是有效的治療方法，但是其需要二次手術(shù)，從而使其應(yīng)用受到限制。很多學(xué)者建議使用腰部蛛網(wǎng)膜下腔閉式引流術(shù)而不采用二次手術(shù)進(jìn)行硬脊膜破口的直接修補[37]。其它的方法，如腦脊液漏區(qū)域直接持續(xù)加壓等方法療效較差[16]。盡管腰部蛛網(wǎng)膜下腔閉式引流在治療腦脊液漏的治療方面有效，但是據(jù)報道其感染的發(fā)生率為 5%[58-60]。除此之外，腰部蛛網(wǎng)膜下腔閉式引流是重力依賴型系統(tǒng)，患者體位的改變會引起腦脊液的大量引出[61]。有報道指出引流后會出現(xiàn)顱內(nèi)積氣伴腦干受壓；其它與過度引流相關(guān)的并發(fā)癥包括頭痛、惡心，嘔吐[62]。此外，為防止因患者體位變化出現(xiàn)過度引流而采取長期制動處理，會增加術(shù)后深靜脈血栓形成和肺栓塞的風(fēng)險[63]。流量控制型腦脊液引流系統(tǒng)的應(yīng)用可以克服以上所述的潛在問題，該系統(tǒng)使用一個容量泵設(shè)備控制腦脊液的引流速度[30,51-52,55,64-66]，一個低壓力控制閥[29]，或者聯(lián)合使用容量和壓力控制系統(tǒng)。

2. 傷口－腹腔分流術(shù)或腰部－腹腔分流術(shù)：很多復(fù)雜硬脊膜破裂需要進(jìn)一步切除周圍骨質(zhì)才能顯露破口、完成直接修補；這往往需要加用閉合的傷口－腹腔或腰部－腹腔分流系統(tǒng)[29]。Epstein[33]報道了對接受多節(jié)段頸椎前路椎體次全切除、椎間植骨融合術(shù)治療后縱韌帶骨化，術(shù)中出現(xiàn)腦脊液漏的患者采用一期硬脊膜修補，聯(lián)合傷口－腹腔分流和腰部－腹腔分流置入的復(fù)雜方法治療，最終表明放置腰部－腹腔分流能夠有效防止傷口－腹腔引流失敗或阻塞。

分流術(shù)是一種有創(chuàng)性治療方法，會給患者帶來很多問題，如引流過度或不足，近端或遠(yuǎn)端分流管道移位或阻塞，感染以及分流器故障，隨著時間的推移，這些問題需要翻修手術(shù)來解決[67]。因此，在其它方法都失敗的情況下才放置永久性分流進(jìn)行治療。

3. 硬脊膜外間隙自體血填充技術(shù)：硬脊膜外間隙自體血填充技術(shù)通過自體血的填充作用可以降低硬脊膜破口處的壓力差，從而使腦脊液流入顱內(nèi)，進(jìn)而升高顱內(nèi)腦脊液的壓力；同時腦脊液的移位改變了腦部血流狀態(tài)，進(jìn)而使靜脈擴張減輕；自體血能夠覆蓋在硬脊膜破口處，腦脊液漏停止，并且通過自身纖維化進(jìn)行修復(fù)[49,68-74]。

應(yīng)用于治療頸椎前路手術(shù)硬脊膜破裂引發(fā)腦脊液漏的硬脊膜外間隙自體血填充技術(shù)包括：徒手硬脊膜外間隙自體血填充技術(shù)[70]、X 線引導(dǎo)下硬脊膜外間隙自體血填充技術(shù)[71]、CT 引導(dǎo)下硬脊膜外間隙自體血填充技術(shù)[70]、超聲引導(dǎo)下硬脊膜外間隙自體血填充技術(shù)[72]。徒手硬膜外間隙自體血填充因為定位不準(zhǔn)確，操作風(fēng)險較大，現(xiàn)在已被影像學(xué)定位后穿刺自體血填充技術(shù)取代[70]。X 線引導(dǎo)下硬脊膜外間隙自體血填充技術(shù)可以通過局部麻醉，在 X 線引導(dǎo)下，使用 18-G 或 20-G 圖伊針經(jīng)椎間孔入路到達(dá)脊髓前方的硬脊膜破口處，將與造影劑混合的自體靜脈血進(jìn)行注入填充[71]；其自體血使用劑量尚無標(biāo)準(zhǔn)，往往患者癥狀明顯緩解，注射局部稍有膨脹感即可，一般 10～35 ml[73]。CT 引導(dǎo)下硬脊膜外間隙自體血填充技術(shù)中可以應(yīng)用 CT 脊髓造影技術(shù)，從而將穿刺針頭準(zhǔn)確引導(dǎo)到硬脊膜破裂部位，從而減少了損傷脊髓的風(fēng)險，并且可以在保證填充效果的前提下，適量減少自體血的注入量[70]。X 線等放射檢查方法在穿刺定位中發(fā)揮了重要的作用，但是這些方法會帶來輻射風(fēng)險。隨著超聲檢查技術(shù)的發(fā)展，超聲引導(dǎo)下硬脊膜外間隙自體血填充技術(shù)已經(jīng)開始應(yīng)用，該技術(shù)通過在操作中觀察硬脊膜外間隙的空間變化從而確定進(jìn)針部位以及自體血注入劑量[72]。

三、硬脊膜破裂的預(yù)防

前路漂浮技術(shù)：“前路漂浮法”和它的改良技術(shù)已被用來降低后縱韌帶骨化患者進(jìn)行前路手術(shù)時出現(xiàn)硬脊膜破裂的發(fā)生率[75-76]。總的來說，這些方法保留了已經(jīng)變薄的椎體后壁中部和骨化的后縱韌帶，而圍繞它進(jìn)行側(cè)方減壓，因此骨化的后縱韌帶成為硬脊膜上“自由漂浮”的團塊。Epstein[77]指出，在使用磨鉆進(jìn)行鉆削的過程中，應(yīng)當(dāng)保證后縱韌帶骨化塊與椎體次全切缺損的邊緣相連，從而保證骨化塊的穩(wěn)定，直到后縱韌帶的中部已被處理得足夠薄。當(dāng)后縱韌帶骨化塊從骨性邊緣分離以后，必須小心謹(jǐn)慎地使后縱韌帶骨化塊進(jìn)一步變薄。少數(shù)與硬脊膜粘連緊密的骨化塊保留在原處，從而降低了腦脊液漏的發(fā)生率[25]。一組研究報道了標(biāo)準(zhǔn)前路全切法治療后縱韌帶骨化出現(xiàn)術(shù)后腦脊液漏的發(fā)生率為 16%～25%[77]，而與之相比前路漂浮法的發(fā)生率只有 5.1%[76]。

四、總結(jié)

因為上位頸椎“過渡區(qū)”的存在，需要手術(shù)醫(yī)生在此區(qū)域進(jìn)行頸椎前路手術(shù)操作時提高警惕，防止操作不當(dāng)引起硬脊膜破裂。多節(jié)段、廣泛的后縱韌帶骨化增加了硬脊膜骨化的風(fēng)險，因而增加了硬脊膜破裂的發(fā)生率。頸椎前路手術(shù)硬脊膜破裂診斷需根據(jù)術(shù)中及術(shù)后表現(xiàn)進(jìn)行綜合評價。在治療過程中除非骨化的后縱韌帶能與下面的硬脊膜分離，否則應(yīng)當(dāng)采用術(shù)前放置腰部蛛網(wǎng)膜下腔閉式引流并在術(shù)中采取前路漂浮技術(shù)預(yù)防硬脊膜破裂。當(dāng)發(fā)生硬脊膜破裂時，可以將多種輔助修補材料聯(lián)合使用進(jìn)行直接修補。直接縫合修補適用于硬脊膜破口較小，破口顯露充分的病例。如果腦脊液漏無法在術(shù)中通過使用輔助修補材料進(jìn)行有效控制，建議在手術(shù)結(jié)束之前放置腰部蛛網(wǎng)膜下腔閉式引流。在上述治療方法都失敗的情況下才放置永久性分流進(jìn)行治療。

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( 本文編輯：王萌 )

Anterior cervical spine surgery is commonly performed with low complication rates. One potentially serious complication is incidental durotomy ( ID ), which may cause cerebrospinal fluid ( CSF ) leak. Compared with posterior cervical spine surgery, anterior cervical spine surgery may increase the risk of ID by traumatic procedures. Direct operation on ossificated longitudinal ligament can be avoided due to posterior laminoplasty or laminectomy. The risk factors for ID in anterior cervical spine surgery include peculiar anatomical structure, transitional zone, old age, rheumatoid arthritis, longer operative time and so on. The complications related to CSF leak after cervical spine surgery include cerebrospinal meningitis, delayed wound healing, airway obstruction, cerebrospinal fluid fistula and pseudomeningocele. There is no consensus on the treatment principle of ID in anterior cervical spine surgery. The treatment methods include intraoperative suture technique without adjuncts, implantation with chemical sealants and biological materials, intraoperative wound drainage, lumbar subarachnoid drainage, wound-enterocoelia shunt or lumbar-enterocoelia shunt, epidural blood patch and general symptom management in the postoperative period. Simultaneously, anterior floating method can also help to prevent the appearance of ID in the operation.

Cervical vertebrae; Ossification of posterior longitudinal ligament; Surgical procedures, operative; Cerebrospinal fluid leak; Risk factors; Diagnosis

10.3969/j.issn.2095-252X.2016.11.009

R681.5

100020 北京，首都醫(yī)科大學(xué)附屬北京朝陽醫(yī)院骨科

2016-04-11 )