内镜经鼻手术后脑脊液漏的分层重建策略

A Multilayer Reconstruction Strategy for Cerebrospinal Fluid Leak after Endoscopic Endonasal Surgery

摘要: 脑脊液漏(Cerebrospinal fluid leak)是神经内镜经鼻手术后最受关注且最具临床影响的并发症之一，其发生可增加脑膜炎、再次手术、住院时间延长及医疗成本上升等风险。随着经鼻颅底外科的适应证由鞍区逐渐扩展至鞍结节、鞍平面、前颅底和斜坡等更复杂区域，单纯按修补材料罗列经验的综述框架，已难以满足当前临床决策的需要。近年研究的关注点，正由“选什么材料”转向“如何依据漏流量、缺损解剖及局部承压条件实施分层重建”。现有证据显示，低流量漏多数可通过游离移植物联合多层覆盖获得可靠封闭，关键在于精准修补并尽量减少不必要的供区损伤；高流量漏则更强调以内层封闭、过渡层构建、血供瓣覆盖，以及必要时辅以机械支撑和选择性脑脊液分流的标准化多层重建链条。与此同时，水密硬脑膜闭合、聚乙醇酸类材料、羟基磷灰石辅助重建等新技术和新材料不断出现，但其临床价值仍需放在具体适应证与证据等级中审慎评估。本文围绕低流量与高流量脑脊液漏的处理原则、不同解剖区域的重建差异、鼻中隔黏膜瓣和腰大池引流等核心争议，以及新材料的真实临床定位展开综述。总体而言，经鼻手术后脑脊液漏的最佳防治策略并不依赖单一材料，而依赖基于漏流量、解剖区域和风险因素的个体化分层重建；其中高流量漏应优先考虑标准化多层重建，低流量漏则应避免不必要的过度修补。

Abstract: Cerebrospinal fluid (CSF) leak is one of the most closely watched and clinically significant complications after endoscopic endonasal surgery. Its occurrence increases the risks of meningitis, reoperation, prolonged hospitalization, and higher medical costs. As the indications for endonasal skull base surgery have gradually expanded from the sellar region to more complex areas, including the tuberculum sellae, planum sphenoidale, anterior skull base, and clivus, conventional review frameworks that merely catalogue repair materials are no longer sufficient to meet current clinical decision-making needs. In recent years, the focus of research has shifted from “which material to choose” to “how to perform stratified multilayer reconstruction according to leak flow, defect anatomy, and local pressure-bearing conditions.” Available evidence indicates that most low-flow leaks can be reliably sealed with free grafts combined with multilayer coverage, with the key being precise repair while minimizing unnecessary donor-site morbidity. In contrast, high-flow leaks require greater emphasis on a standardized multilayer reconstruction sequence consisting of inner-layer closure, construction of an intermediate layer, coverage with a vascularized flap, and, when necessary, adjunctive mechanical support and selective cerebrospinal fluid diversion. Meanwhile, emerging techniques and materials, such as watertight dural closure, polyglycolic acid-based materials, and hydroxyapatite-assisted reconstruction, continue to evolve; however, their clinical value should still be interpreted cautiously in the context of specific indications and levels of evidence. This review focuses on the management principles for low-flow and high-flow CSF leaks, reconstructive differences across anatomical regions, major controversies surrounding the nasoseptal flap and lumbar drainage, and the actual clinical role of novel materials. Overall, the optimal strategy for the prevention and management of postoperative CSF leak after endonasal surgery does not depend on any single material, but rather on individualized, stratified reconstruction based on leak flow, anatomical region, and risk factors. Standardized multilayer reconstruction should be prioritized for high-flow leaks, whereas unnecessary over-reconstruction should be avoided for low-flow leaks.