颅底探查和重建在急性颅脑损伤开颅术中的意义

Significance of skull base exploration and reconstruction in craniotomy of acute traumatic brain injury

目的探讨颅底探查和重建对防治合并前颅底粉碎性骨折的急性颅脑损伤(TBI)患者脑脊液漏及颅内感染的作用。方法回顾性分析浙江湖州解放军第九八医院及浙江湖州南太湖医院神经外科自2013年1月至2019年3月收治的37例急性TBI患者的临床资料,根据伤后24 h内是否行前颅底探查及颅底重建分为一期颅底探查重建组(研究组,18例)和非一期颅底探查重建组(对照组,19例)。研究组均在伤后24 h内行颅脑清创和/或颅内血肿清除+颅底探查+颅底重建,对照组的皮瓣设计及颅脑清创和颅内血肿清除术同研究组,但不行颅底探查和颅底重建。比较2组患者术后并发脑脊液漏、颅内积气和颅内感染的发生率。结果研究组患者术后并发脑脊液漏并感染1例,并发症发生率为5.6%。对照组患者并发脑脊液漏和/或颅内积气12例,其中单纯脑脊液漏4例,单纯颅内积气1例,脑脊液漏同时颅内积气3例,脑脊液漏并颅内感染3例,脑脊液漏同时颅内积气并颅内感染1例,并发症发生率为63.2%。2组患者的并发症发生率比较差异有统计学意义(P<0.05)。13例脑脊液漏/颅内积气患者(包括研究组一期术后并发脑脊液漏1例和对照组12例)在合适时期行二期颅底重建后脑脊液漏、颅内积气均消失,颅内感染均得到有效控制。结论对合并有前颅底粉碎性骨折的急性TBI患者在急性开颅术中行颅底探查并重建可有效防止脑脊液漏、颅内积气和颅内感染的发生。

Objective To investigate the effects of skull base exploration and reconstruction on cerebrospinal fluid leakage and tracranial infection in patients with acute traumatic brain injury(TBI)complicated with anterior skull base comminuted fracture.Methods The clinical data of 37 patients with acute TBI with anterior skull base comminuted fracture were analyzed retrospectively from January 2013 to March 2019.Patients were divided into two groups based on if they accepted skull base exploration and reconstruction on the first stage,i.e.,the test group(skull base exploration and reconstruction)and the control group(non-skull base exploration and reconstruction),and 18 cases in the test group,19 cases in the control group.The test group underwent craniocerebral debridement and/or intracranial hematoma removal+skull base exploration+skull base reconstruction within 24 h after injury.The flap design,craniocerebral debridement and intracranial hematoma removal in the control group were the same as those in the test group,but skull base exploration and skull base reconstruction were not performed.The incidence of postoperative cerebrospinal fluid leakage,intracranial pneumatosis and intracranial infection were compared between the two groups.Results There were 1 case of cerebrospinal fluid leakage accompanied by intracranial infection in the test group,and the incidence of complication rate was 5.6%.Twelve cases of cerebrospinal fluid leakage and/or intracranial pneumatosis in the control group,including 4 cases of cerebrospinal fluid leakage,1 case of intracranial pneumatosis,3 cases of cerebrospinal fluid leakage and intracranial pneumatosis,3 cases of cerebrospinal fluid leakage and intracranial infection,1 case of cerebrospinal fluid leakage accompanied by intracranial pneumatosis and intracranial infection,and the incidence of complication was 63.2%.The difference of incidence of complication between the two groups was statistically significant(P<0.05).After skull base reconstruction,13 patients with cerebrospinal fluid leakage and/or intracranial pneumatosis(including 1 case of cerebrospinal fluid leakage in the first stage of the test group and 12 patients in the control group)were cured,patients with intracranial infection were controlled before the second stage operation.Conclusion For patients with acute TBI complicated with anterior skull base comminuted fracture,skull base exploration and reconstruction in acute craniotomy can effectively prevent cerebrospinal fluid leakage,intracranial pneumatosis and intracranial infection.