外伤性视神经损伤经颅手术时机选择

Operation time selection for traumatic optic nerve injuries

目的分析外伤性视神经损伤后影响视力预后的因素,探讨适宜的手术时机。方法回顾性总结分析231例经颅视神经减压手术治疗外伤性视神经损伤患者的临床资料。根据病人术前视力情况分成2组,A组(无光感)171例;B组(光感以上)60例,每组根据伤后手术间隔时间长短再分为≤48h手术组和>48h手术组。术后随访1个月-6年。结果不同受力部位、术前FVEP检查结果对视力预后有影响(P<0.001);视神经管CT有无骨折对视力恢复影响无统计学意义(P=0.571)。A组伤后48h内手术的患者疗效明显高于48h后者(P=0.001),B组伤后48h内手术患者与48h后者的疗效差异无统计学意义(P=0.5047)。结论对颧骨或眉弓前方受力;视觉诱发电位检查P100潜伏期延长但未消失者应该积极考虑手术治疗;对完全失明患者亦不应放弃治疗,并尽可能争取在48h内手术,以挽救其视力;对有残存视力的患者可适当延长受伤至手术的时间。

Objective To analyze the influential factors on visual prognosis of traumatic optic nerve injuries, discuss the optimal operation time. Methods Retrospective analysis of 231 patients with transcranial decompression of optic canal for optic nerve injury. According to their preoperational visual acuity, patients were divided into 2 groups. Group A （no light perception） included 171 cases. Group B （beyond light perception） included 60 cases. Each group was further divided into 2 subgroups according to the injury time. One was ≤48hour subgroup, the other was 〉48hour subgroup. All patients were followed up for 1-72 months. Results The injured site and preoperational flash visual evoked potential （FVEP） examination results affect the final visual prognosis （ P 〈 0. 001 ）. Optic canal fraction does not have significant impact on the visual recovery（P=0. 571 ）. In group A, the visual prognosis of≤48hour subgroup was better than that of 〉 48hour subgroup （P=0. 001 ）. There is no significant difference between the two subgroups （ P = 0. 5047 ）. Conclusion Early operation is worthy recommending for patients who were hurt at zygoma or medial superciliary arch, or had delay in FVEP. Chances should not be given up for totally blinded patients. On the contrary, operation should be carried out within 48 hours to save their vision. For patients with residual vision, the surgical treatment can be properly delayed.