翻转颞深筋膜在幕上开颅减压中的应用

The application of turning down the deep temporal fascia to mend the dura mater in the operation of intracranial supratentorial decompression in skull trauma

目的探讨在颅脑损伤幕上开颅减压手术中,采用翻转颞深筋膜修补硬脑膜的可行性及实用价值。方法我院收治的36例颅脑损伤手术的患者,以减速伤为主,病灶主要位于额颞部或交界处,采用冠状切口、扩大翼点入路或标准大骨瓣减压入路,进行去骨瓣减压、硬脑膜作倒“T”形切开、血肿清除或内减压手术,硬脑膜用翻转颞深筋膜进行修补。结果出现脑脊液漏合并切口感染1例,皮下积液4例；死亡3例,生存33例。生存者均行1～6月随访,没有出现颅脑损伤术后所具有的头痛和神经系统体征等以外的症状和体征。术后有一部分患者来院行颅骨修补手术,再次手术发现：头皮解剖层次清楚,颞深筋膜与硬脑膜之间愈合良好。进一步病理(显微镜、电镜)证实：颞深筋膜无变性、坏死等改变。结论翻转的颞深筋膜是自体同部位组织,位于头皮与颞肌之间,与硬脑膜组织结构相同,有足够大的面积和较好的血运。在不损伤颞肌的情况下,用翻转的颞深筋膜修补硬脑膜,恢复了头皮的基本结构层次．起到充分缓解颅内高压和维持颅内环境稳定作用；经过再次手术、病理证明翻转的颞深筋膜成活、无变性,与硬脑膜愈合良好；翻转颞深筋膜修补硬脑膜为颅骨修补提供良好的组织解剖基础,减少对脑的损伤,也缩短下次手术时间,减少医疗成本和患者经济负担。采用本术式治疗病灶主要位于额颞部或交界处的颅脑损伤,可行、实用,并发症少,对患者损伤小,没有潜在的危害,值得应用和推广。

Objective To explore the feasibility and practical value of turning down the deep temporal fascia to mend the dura mater in the operation of intracranial supratentorial decompression in skull trauma. Methods 36 patients with cranial trauma were admitted into our hospital from March 2000 to December 2004 because of cranial contrecoups, the focus of which were located in frontal and temporal lobes. The coronal incision, enlarged pterion approach and standard large bone flap approach were adopted to cut open the dura mater like downfallen ＂T＂ in order to remove the hematoma or to finish intracerebral decompression. The open dura mater was finally mended by the turned deep temporal fascia. Results Postoperational cerebral spinal fluid leakage and incision infection occurred in l case. Subcutaneous hydrops occurred in 4 cases. 3 cases died. Follow-up of 1 to 6 months indicated none of the survivors complained about additional headache or neural symptoms. Some of them returned to have the skull defect amended and in the second operation calp levels and good concrescence between deep temporal fascia and dura mater were cleady seen. Pathological check （microscope and electron microscope） proved that no degeneration or necrosis of the deep temporal fascia was found. Conclusion The turned deep temporal fascia, as autologous tissue has a structure similar to dura mater. Turned deep temporal fascia is used to mend dura mater, which can recover the structural lays of scalp. Dura mater mended by turned deep temporal fascia can maintain desired anatomic structure and stability of internal environment so that the time to following surgical operation is shortened. On the other hand, it can cut down the medical cost for patients. The approach applied to the cranial trauma located in the frontal and temporal lobes is worth popularizing because it produces few complications and injuries.