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化整为零、步步为“赢”、庖丁解牛式的拆解和剖析神经疾病的指南共识规范。
引经据典，知其然，更知其所以然。
神经内镜经鼻入路颅底重建的主要目的在于分隔颅内、外空间，避免术后发生脑脊液漏和颅内感染，消除死腔和保护正常结构。颅底重建成功的标志是修补材料瘢痕化，成为颅底组织的一部分，从而可以长期有效地支撑颅内组织并抵抗脑脊液的冲击，分隔颅内、外结构。
1．一般修复：
若术中硬膜或蛛网膜保持完整，术中未见明确的脑脊液漏（Kelly分级为0级)[1,2]。
【1】
CongerA, ZhaoF, WangX, et al. Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients[J]. J Neurosurg, 2018，130(3):861-875. DOI: 10.3171/2017.11.JNS172141.
"A graded approach to skull base repair after endonasal surgery remains valid in the endoscopic era. However, the technique has evolved significantly, with further reduction in postoperative CSF leak rates. These data suggest that rigid or soft buttresses are beneficial for repair of most Grade I and II leaks, and all Grade III leaks. Pedicled flaps appear advantageous in repair of all Grade III leaks. CSF diversion was rarely used and offers no apparent value. High BMI is a likely risk factor for repair failure and should prompt an aggressive multilayered repair strategy. Achieving repair failure and meningitis rates of less than 1% is a reasonable goal in endoscopic skull-base tumor surgery."
译文：“经鼻内镜手术后颅底修复的分级方法在内窥镜时代仍然有效。然而，随着术后脑脊液漏率的进一步降低，该技术有了显着的发展。这些数据表明，刚性或软支撑有利于修复大多数 I 级和 II 级泄漏，以及所有 III 级泄漏。带蒂皮瓣似乎有利于修复所有 III 级泄漏。脑脊液转移很少使用并且没有明显的价值。高 BMI 是修复失败的一个可能风险因素，应促使采取积极的多层修复策略。实现修复失败和脑膜炎发生率低于1%是内窥镜颅底肿瘤手术的合理目标。”
【2】
EspositoF, DusickJR, FatemiN, et al. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery[J]. Oper Neurosurg (Hagerstown), 2007，60(4Suppl 2):295-303; discussion 303-304. DOI: 10.1227/01.NEU.0000255354.64077.66.
"A graded repair approach to CSF leaks in transsphenoidal surgery avoids tissue grafts and CSF diversion in more than 60% of patients. Protocol modifications adopted in the last 340 cases have reduced the failure rate to 1% overall and 7% for Grade 3 leaks. Provocative tilt testing before patient discharge is helpful in the timely diagnosis of postoperative CSF leaks."
译文：“在经蝶骨手术中，对脑脊液泄漏采用分级修复方法可避免60%以上患者的组织移植物和脑脊液转移。在过去340例病例中采用的协议修改已将故障率降低到总体1%，3级泄漏的故障率降低到7%。患者出院前的激发性倾斜试验有助于及时诊断术后脑脊液泄漏。”
瘤腔止血后，建议采用人工硬膜覆盖，并用生物胶封闭周边，再放置薄层明胶海绵，最后采用膨胀海绵或纳吸棉填塞鼻腔。如术中见蛛网膜菲薄，或有隐性脑脊液漏的风险，建议硬膜下置入可吸收人工硬膜，将其适当修剪，其面积稍大于颅底缺损，使其周缘嵌入颅底硬膜下，再辅以有效的鼻腔填塞，可均匀分散颅内压力，使其封闭颅底的效果更佳。硬膜或颅底骨质外层再放置一层人工硬膜或游离鼻黏膜，进行多层封闭，可进一步降低脑脊液漏的发生风险。如果颅底硬膜缺损较大，蛛网膜菲薄，建议采用多层复合颅底重建的方法修补。
2．多层复合颅底重建：
适用于术中蛛网膜缺损<1 cm的颅底重建(Kelly分级为2、3级)[3]。
【3】
KimGG, HangAX, MitchellCA, et al. Pedicled extranasal flaps in skull base reconstruction[J]. Adv Otorhinolaryngol, 2013，74:71-80. DOI: 10.1159/000342282.
"Cerebrospinal fluid (CSF) leaks most commonly arise during or after skull base surgery, although they occasionally present spontaneously. Recent advances in the repair of CSF leaks have enabled endoscopic endonasal surgery to become the preferred option for management of skull base pathology. Small defects (<1 cm) can be repaired by multilayered free grafts. For large defects (>3 cm), pedicled vascular flaps are the repair method of choice, resulting in much lower rates of postoperative CSF leaks. The pedicled nasoseptal flap (NSF) constitutes the primary reconstructive option for the vast majority of skull base defects. It has a large area of potential coverage and high rates of success. However, preoperative planning is required to avoid sacrificing the NSF during resection. In cases where the NSF is unavailable, often due to tumor involvement of the septum or previous resection removing or compromising the flap, other flaps may be considered. These flaps include intranasal options – inferior turbinate or middle turbinate flaps – as well as regional pedicled flaps: pericranial flap, temporoparietal fascial flap, or palatal flap. More recently, novel alternatives such as the pedicled facial buccinator flap and the pedicled occipital galeopericranial flap have been added to the arsenal of options for skull base reconstruction. Characteristics of and appropriate uses for each flap are described."
译文：“脑脊液（CSF）渗漏最常出现在颅底手术期间或之后，但偶尔会自发出现。脑脊液泄漏修复的最新进展使内镜鼻内手术成为颅底病理学管理的首选。小缺陷（<1cm）可以通过多层游离移植物修复。对于大的缺损（>3cm），椎弓根血管瓣是首选的修复方法，导致术后脑脊液泄漏率大大降低。带蒂鼻中隔皮瓣（NSF）是绝大多数颅底缺损的主要重建选择。它具有大范围的潜在覆盖范围和高成功率。然而，术前计划是必要的，以避免在切除过程中牺牲NSF。在NSF不可用的情况下，通常是由于鼻中隔的肿瘤受累或先前的切除或损害皮瓣，可以考虑其他皮瓣。这些皮瓣包括鼻内选择-下鼻甲或中鼻甲皮瓣-以及区域性椎弓根皮瓣：颅周皮瓣，颞顶筋膜瓣或腭瓣。最近，诸如椎弓根面部布奇纳特皮瓣和带蒂枕高气脑皮瓣之类的新替代品已被添加到颅底重建的选择库中。描述了每个皮瓣的特征和适当用途。”
先将人工硬膜置于硬膜缺损下方，再于硬膜下置入脂肪组织，缺损硬膜外采用自体阔筋膜、游离鼻腔黏膜或人工硬膜贴敷加固。脂肪、人工硬膜、阔筋膜的放置顺序可以根据具体情况进行调整，也可只采用1～2种修补材料[4]。
【4】
FandiñoM, MacdonaldK, SinghD, et al. Determining the best graft-sealant combination for skull base repair using a soft tissue in vitro porcine model[J]. Int Forum Allergy Rhinol, 2013，3(3):212-216. DOI: 10.1002/alr.21085.
"Discussion The surgical approach and repair technique in SB repairs depends on several factors including etiology of the leak, elevated ICP, the presence of a meningocele or meningoencephalocele, and localization and size of the defect. The basic principles of endoscopic CSF leak repairs rely on accurate documentation of the leak site, careful preparation of the area, and precise placement of the materials used in the repair.8 The use of a multilayer repair technique and vascularized flaps for the closure of large SB defects has been described and recommended by many authors in order to decrease postoperative CSF leaks in patients with large SB defects.3, 9–12 The use of autologous avascular grafts and/or synthetic dural grafts in combination with synthetic dural sealants to support the grafts is common in anterior SB repairs and has shown high success rates regardless of the material used (meta-analysis of retrospective reviews)."
译文：“内窥镜脑脊液漏修补的基本原则依赖于对漏点的详细记录，对该区域的仔细准备，以及在修补中使用的材料的精确放置许多作者已经描述和推荐，使用多层修复技术和带血管的皮瓣来闭合大的矢状面区缺损，以减少大矢状面区缺损患者的术后脑脊液漏。3,9 - 12使用自体无血管移植物和/或合成硬脑膜移植物结合合成硬脑膜密封胶来支持移植物在前路SB修复中很常见，且无论使用何种材料都显示出很高的成功率(回顾性回顾的meta分析)。”
采用生物胶或自体肌肉浆封闭修补材料边缘，最外层采用薄层明胶海绵或氧化再生纤维素隔开鼻腔填塞，最后可采用球囊或纱条支撑。
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