外側後頭下アプローチにおける硬膜一次閉鎖の工夫—フィブリン糊コーティングによる硬膜の保湿

Modified Technique for Primary Dural Closure in the Lateral Suboccipital Approach:Dural Moisturizing with Fibrin Glue Coating

Ⅰ．はじめに

　外側後頭下アプローチでは，閉頭時にしばしば硬膜面積が不足し一次閉鎖が困難となるため，自家組織や人工硬膜による補塡を要する．これは同部の硬膜が薄く，空気への曝露や顕微鏡の照明により乾燥・収縮しやすいためであり，綿片による被覆や頻回の洗浄を行っても回避は困難である．

　この硬膜の乾燥・収縮を防ぎ，縫合による簡便な一次閉鎖を可能とする，硬膜へのフィブリン糊コーティングを考案・試行したので報告する．

　Objective:When employing the lateral suboccipital approach, the thin dura shrinks due to the drying effect of illumination and air exposure, and dural substitutes are often needed for closure. We developed a new technique involving dural moisturizing with fibrin glue coating that facilitates primary dural closure.

　Patients and Methods:We used this technique in 12 adults who underwent the lateral suboccipital approach for 5 hemifacial spasms, 3 trigeminal neuralgias, 2 cerebellopontine meningiomas, 1 vestibular schwannoma, and 1 vertebral artery aneurysm. Fibrin glue was sprayed on the outer surface before opening the dura, and additionally sprayed on the inner surface of the reflected dural flap after opening the dura. After the intradural procedures the dura was closed with the usual knotted sutures.

　Results:Dural closure was performed 65-340 minutes（mean:161.9 minutes）post-durotomy. This technique resulted in primary dural closure with a sufficient area of preserved dura in all but one patient. In this patient, the dura shrank due to coagulation of the dural attachment to the meningioma for which a small autologous substitute was required. There were no procedure-related complications such as cerebrospinal fluid leakage and meningitis.

　Conclusions:Dural moisturizing with fibrin glue coating is simple, protects the dura from drying and shrinkage, and facilitates primary dural closure in patients undergoing the lateral suboccipital approach.