重型颅脑创伤患者开颅术后远隔部位再次手术的相关因素分析

Risk factors for second operation on remote site of severe traumatic brain injury patients after craniotomy

目的探讨重型颅脑创伤（TBI）患者开颅术后远隔部位再次手术的相关危险因素。方法回顾性分析2010年2月至2014年10月解放军第一。一医院神经外科收治的180例行开颅手术的重型TBI患者的临床资料，其中39例（21．7％）患者远隔部位行二次手术。分析术前格拉斯哥昏迷评分、年龄、性别、着力部位（额颞部、顶部、枕部、多发）、着力部位与血肿位置（同侧、对侧、双侧）、远隔手术部位骨折、术前瞳孔（正常、单侧散大、双侧散大）、环池（清晰、模糊）、中线移位（无、≤5mm、〉5～10mm、≥10mm）、术前缺氧、合并伤、是否放置脑室外引流、术后去骨瓣减压等因素对远隔部位再次手术的影响。结果多因素Logistic回归分析显示，额颞部着力同时血肿位于着力部位同侧是术后远隔部位再次手术的保护因素（OR=0．222，95％CI：0．073～0．674，P=0．008）；而枕部着力同时血肿位于对侧（OR=4．647，95％CI：1．078～20．033，P=0．039）、远隔手术部位骨折（OR=3．133，95％CI：1．247～7．867，P=0．015）、去骨瓣减压（OR=5．684，95％CI：1．759～18．370，P=0．004）是术后远隔部位再次手术的独立危险因素。结论对于重型TBI行开颅手术的患者，枕部着力且血肿位于对侧、手术远隔部位合并骨折、术后去骨瓣减压时，需密切观察病情变化，警惕远隔部位需再次手术。

Objective To explore the risk factors for second operation on remote site of severe traumatic brain injury patients after craniotomy. Methods The clinical data of 180 patients with severe traumatic brain injury were analyzed retrospectively who underwent craniotomy from February 2010 to October 2014 at Department of Neurosurgery, the 101 Hospital of PLA, Craniocerebal Injury Cure Center of PLA. Among them, 39（21.7% ） patients received a second operation on the remote side. The correlation between multiple factors and second operation on remote site was analyzed, which included sex, trauma site （frontal- temporal, parietal, occipital or multiple ）, relationship of trauma site to hematoma location （ipsilateral, contralateral or bilateral）, fracture on remote site, preoperative pupils （normal, unilateral large or bilateral large）, ambient cistern （clear or unclear）, midline shift （no, ≤5 mm, 〉5 -10 mm or ≥10 mm）, preoperative hypoxia, combined injuries, placement of ventricle drainage and decompressive craniotomy. Results It was suggested by multiple logistic regression that the trauma site in frontal-temporal areas with ipsilateral hematoma was the protective factor for re-operation on remote site （ OR = 0.222, 95% CI： 0.073 - 0.674, P=0.008）, while the occipital trauma with contralateral hematoma （OR =4.647, 95% CI： 1. 078 - 20.033, P=0.039）, skull fracture on remote site （OR =3. 133, 95% CI： 1.247 -7.867, P =0.015） and decompressive craniotomy （ OR =5. 684, 95% CI： 1. 759 - 18.370, P =0. 004） were risk factors associated with second operation on remote site in severe traumatic brain injury patients after craniotomy. Conclusion Trauma in the occipital region with contralateral hematoma, skull fracture in distal area and decompressive craniotomy might be related to a larger chance of re-operation on remote site of severe traumatic brain injury patients after craniotomy. Sufficient attention to the patientg conditions are suggested and caution should be warranted.