Advances in the Diagnosis and Treatment of Postoperative Meningitis in Neurosurgery
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摘要: 神经外科术后脑膜炎因机制复杂、临床表现不特异、病原谱多样且耐药性突出，诊治难度大。本文围绕其核心病理生理环节：解剖屏障破坏与脑脊液漏、植入物相关生物膜形成、宿主易感性及医院获得性感染，梳理病原学演变特征，重点总结以宏基因组二代测序、多重PCR等快速病原诊断技术进展，以及经验性抗感染、精准用药、脑室内给药等治疗策略的临床应用。同时强调外科源控制（移除感染材料、脑室外引流管理、脑脊液漏修补）与多学科协作在难治性病例中的关键作用，并结合预防体系建设及人工智能、纳米递药等未来方向，提出从经验式处理迈向精准个体化治疗转变的临床路径，为神经外科术后脑膜炎的综合治疗管理提供参考。Abstract: Postoperative meningitis in neurosurgery poses significant challenges in diagnosis and treatment owing to its complex pathogenesis, nonspecific clinical manifestations, a diverse pathogen spectrum, and marked antimicrobial resistance. This review centers on the core pathophysiological mechanisms, including disruption of anatomical barriers and cerebrospinal fluid leakage, implant-associated biofilm formation, host susceptibility, and nosocomial infections. It systematically delineates the evolving etiological characteristics, with particular emphasis on recent advances in rapid pathogen detection technologies—such as metagenomic next-generation sequencing （mNGS） and multiplex PCR—as well as the clinical application of empirical antimicrobial therapy, pathogen-targeted therapy, and intraventricular drug administration. Furthermore, the review highlights the pivotal role of surgical source control （e.g., removal of infected materials, management of external ventricular drains, and repair of cerebrospinal fluid leaks） and multidisciplinary collaboration in refractory cases. Finally, it discusses the development of preventive systems and future directions, including artificial intelligence and nano-based drug delivery, and proposes a clinical pathway transitioning from empirical management to precision individualized therapy, thereby providing a reference for the comprehensive management of postoperative meningitis in neurosurgery.
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图 1 脑脊液漏与术后脑膜炎关系示意图
Figure 1. Schematic diagram of the relationship between cerebrospinal fluid leakage and postoperative meningitis
图 2 细菌生物膜形成、成熟及扩散过程示意图
Figure 2. Schematic diagram of bacterial biofilm formation，maturation，and dispersal process
图 3 生物膜形成与术后脑膜炎机制示意图
Figure 3. Schematic diagram of biofilm formation and postoperative meningitis mechanism
图 4 术后脑膜炎“屏障破坏+病原负荷+宿主脆弱性”机制示意图
Figure 4. Schematic diagram of the mechanism of "barrier disruption+pathogen burden+host vulnerability" in postoperative meningitis
图 5 神经外科术后脑膜炎诊断与治疗决策流程图
Figure 5. Diagnostic and therapeutic decision-making flowchart for postoperative meningitis after neurosurgery
表 1 术后脑膜炎的鉴别诊断
Table 1. Differential diagnosis of postoperative meningitis
疾病 主要特点 鉴别要点 化学性脑膜炎 手术材料刺激、无感染征象 CSF糖正常、mNGS阴性 术后反应性改变 可见轻度脑膜强化 CSF多正常或轻度异常 无菌性CSF激惹 多见于蛛网膜下腔手术 对抗生素反应差 药物相关脑膜炎 多由NSAIDs等引起 停药后症状可逆转 影像结合mNGS可大幅提升鉴别准确率。 
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表 2 脑室内给药常用方案
Table 2. Common protocols for intraventricular drug administration
药物 剂量（脑室内） 适应证 万古霉素 5～20 mg/d G+球菌 庆大霉素 4～8 mg/d G−杆菌 粘菌素 10～12万单位/d MDR / CRAB 关键管理要点：与EVD配合使用；注药后夹闭引流管1～2 h；注意药物相关神经毒性；必要时监测CSF药物浓度等。上述建议以1～2级证据为主。
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