神经导航和腹腔镜引导脑室腹腔分流插入治疗脑积水
Summary
脑室腹腔 （VP） 分流手术（成人脑积水的主要治疗方法）的患者结局较差，因为分流失败率高。我们使用神经导航和腹腔镜引导提供 VP 分流插入术中录像，目的是分别降低近端和远端分流导管失败的风险。
Abstract
脑积水是一种常见的成人神经外科疾病，通常需要脑脊液 （CSF） 分流术治疗，其中脑室腹腔 （VP） 分流术是最常见的类型。不幸的是，VP分流术的失败率高得惊人，高达50%的患者需要在2年内进行翻修手术。VP 分流失败可能由感染或导管错位、迁移和闭塞引起。我们在一项为期 7 年的前瞻性非随机连续质量改进队列研究中开展了联合神经外科和普通外科合作，以降低三级医疗机构 224 名成年患者的脑室腹腔 （VP） 分流失败的发生率。该倡议结合使用电磁立体定向神经导航来指导近端导管的放置，并结合腹腔镜将远端导管置于直接可视化之下。在腹腔镜的帮助下，远端导管通过畸形韧带上形成的小孔固定，并放置在右侧肝后空间，没有可能阻塞导管尖端的网膜，粘连或肠道。手术使用分流感染预防方案进行，以降低分流感染的风险。在这里，我们展示了外科手术的术中视频。在成人 VP 分流手术中，遵守分流减少策略以及联合使用神经导航和腹腔镜技术，可使总体分流失败的风险降低 44%。在使用这种策略接受VP分流手术的患者中，对无分流的患者结局产生了重大的积极影响，这强调了在VP分流手术期间使用这些现代术中技术和跨专业合作的相关价值。
Introduction
脑积水是一种常见的神经系统疾病，影响全世界约 100，000 名成年人中的 175 人， 其特征是脑室内脑脊液 （CSF） 积聚，这是由于脑中脑脊液生成和摄取过程之间的不平衡2。由于各种非手术疗法均不成功3，脑积水唯一可行的治疗方法是脑脊液从脑室手术转移。成人最常用的方法是放置分流器，将心室脑脊液引流到腹膜腔（脑室腹腔 [VP] 分流）4，5。
VP 分流器有三个皮下位置的组件：通过颅骨毛刺孔插入脑脊液心室的近端心室导管、调节血流的瓣膜和将瓣膜连接到腹膜腔的远端导管，其中脑脊液沉积并重新吸收（图 1）。或者，分流器可以在右心房水平处引流到静脉系统（心室心房 [VA] 分流）6，7 或将脊髓 CSF 从脊柱转移到腹膜腔（隆腹膜 [LP] 分流）8。目前没有证据支持 VP 与 VA 相比优于 LP 分流系统。在成人中，15%-25%9，10，11，12的新VP分流失败，通常在前6个月内，在高危人群中超过50%失败13。VP 分流失败可能继发于近端或远端部位的分流感染、瓣膜故障或导管衰竭12，14，15，16，17。每次分流失败都需要重复手术，这与围手术期并发症的累积风险18，19以及患者和家庭的压力有关，此外还增加了医疗保健基础设施成本20，21，22，23，24。
“传统”VP分流插入技术涉及使用表面解剖标志徒手插入近端导管，并通过小型剖腹手术或穿刺导管25，26，27放置远端导管。这些技术不允许在导管插入期间或之后实时跟踪或直接可视化最终位置。未能达到这些导管的理想位置可导致分流失败，这是与脑积水VP分流治疗相关的最常见的长期并发症10，28。近端导管通常由于错位和/或随后被脉络丛组织或脑室内碎片阻塞而失败。成人远端导管衰竭的主要原因包括导管错位、迁移和/或网膜组织、肠道和节内碎片或粘连的阻塞11，28，29，30，31。
最近的证据表明，通过将近端和远端导管分别置于神经导航和腹腔镜引导下来修改VP分流插入技术，可降低分流失败的风险26，32，33。此外，遵守分流感染减少方案已被证明可以降低继发于感染的分流失败风险34。此外，Svoboda等人描述了一种“假形技术”，其中远端导管固定在假形韧带上，并放置在远离网膜的肝周间隙中，这有助于降低导管迁移和网膜阻塞的风险35。据我们所知，虽然神经导航和腹腔镜的使用已经过独立评估，但它们的综合益处尚未报道，并且文献中也没有充分描述手术技术。
我们最近完成了一项为期7年的前瞻性质量改善研究，该研究结合了神经导航，腹腔镜检查，恶性畸形技术和成年脑积水患者的分流感染减少方案36。通过我们的联合方法，分流失败的总体风险降低了44%36。本文的目的是提供一个手术视频，并附有手术技术的分步指南，以促进使用这些辅助工具的范式转变，以降低成人分流失败的风险。
这里介绍的手术方法可以用于任何VP分流插入手术。我们描述了一名 72 岁男性的病例，他被诊断为特发性正常压力脑积水 （iNPH）， 并符合 VP 分流插入的标准37.患者有 1 年进行性步态和认知障碍病史，伴有间歇性尿失禁。他过去的病史对高血压和膀胱癌的手术治疗具有重要意义。对患者的磁共振成像（MRI）脑部评估显示脑室肿大，Evan指数为0.41。4年前完成的MRI评估未显示脑室肿大，Evan指数为0.29（图2）。他的神经学检查证实，他有一个宽基的洗牌步态，步进页数低，异常缓慢的步态速度为0.83 m/s。他没有脊髓病的迹象。他的蒙特利尔认知评估（MoCA）版本7.1得分为22/30，这证实了他的轻度至中度认知障碍。经过为期3天的腰椎外引流（ELD）试验，每小时取出脑脊液以测试脑脊液切除症状的反应性，他的步态速度提高到1.2 m/s，MoCA评分增加了3分。
Protocol
Representative Results
Discussion
患者对手术耐受性良好，术后立即拔管，适合非急性病房进行过夜监测。我们的实践是第二天早上进行头部的普通CT扫描，以确认近端导管的位置，并作为未来治疗的基线成像。此外，我们获得腹部X射线以确认腹腔导管的术后位置。我们的大多数患者在出院前都通过职业治疗和物理治疗进行评估，并由专职卫生人员认为是安全的。首次出院后评估通常发生在手术后 4 周。
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Divulgations
The authors have nothing to disclose.
Acknowledgements
我们感谢昆廷·科利尔先生协助制作录像。
Materials
| 30-degree angle laparoscope | Stryker | 0502-937-030 | |
| Barium impregnated proximal catheter | Medtronic | 41101 | |
| Bowel grasper | Richard Wolf | 8393.25 | |
| Certas Valve inline | Codman | 82-8800 | |
| Chloraprep | 3M | 355-S10325/103.25 | |
| Electrocautery | Karl Storz | 28160KA | |
| Frameless-based neuronavigation system with magnetic tracking (AxiEM) | Medtronic | 9735428/9734887 | |
| Hasson trocar | Applied Medical Inc | C0R95 | |
| Ioban | 3M | 6661EZ | |
| Monocryl | Ethicon | D8550 | |
| Open barium impregnated proximal catheter | Medtronic | 23092 | |
| Pneumatic surgical drill | Medtronic | PM100 | |
| Steri-Strips | 3M | R1547 | |
| Video System Endoscopy | Stryker | Not Available |
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