原位骨瓣联合不同鼻黏膜瓣在神经内镜扩大经鼻手术颅底重建中的应用对比

Comparison of the application of in situ bone flap combined with different nasal mucosa flaps in neuroendoscopic extended transnasal surgery for skull base reconstruction

目的对比原位骨瓣(ISBF)联合带蒂鼻中隔黏膜瓣(PNSF)与联合以游离中鼻甲黏膜瓣(FMTMF)为主的游离黏膜瓣在神经内镜扩大经鼻手术颅底重建中的应用效果。方法回顾性分析2016年1月至2020年9月重庆医科大学附属第一医院神经外科采用ISBF联合PNSF(ISBF+PNSF组,n=86)或FMTMF为主的游离黏膜瓣(ISBF+FMTMF组,n=40)进行颅底重建患者的临床资料。两组患者的性别、年龄、体质量指数、病变最大直径、病理学类型等基线资料比较,差异均无统计学意义(均P>0.05)。所有患者分别于术后3、6个月进行门诊随访,行鞍区增强MRI及鞍区薄层CT检查,观察术后ISBF及黏膜瓣的愈合情况;术后6个月采用鼻腔鼻窦结局测试22(SNOT-22)量表评分评估患者的鼻腔生活质量。比较两组患者的手术时长,术后卧床时间、颅内感染率、脑脊液漏发生率及腰大池置管引流率。结果126例患者均顺利完成颅底重建。术后复查鞍区薄层CT显示ISBF均位置良好。126例患者术后3、6个月的影像学复查结果显示ISBF和黏膜瓣均完全愈合。ISBF+PNSF组与ISBF+FMTMF组患者的手术时长(中位数分别为210 min和190 min)、术后卧床时间(中位数分别为14 d和13 d)、颅内感染率[分别为8.1%(7/86)和5.0%(2/40)]、脑脊液漏发生率[分别为11.6%(10/86)和7.5%(3/40)]、腰大池置管引流率[分别为26.7%(23/86)、22.5%(9/40)]的差异均无统计学意义(均P>0.05)。术后6个月,ISBF+PNSF组患者的SNOT-22评分高于ISBF+FMTMF组,差异有统计学意义(中位评分分别为15分和13分,P=0.029)。结论两种颅底重建方式均能实现颅底解剖重建,ISBF联合FMTMF的鼻腔创伤更小,术后鼻腔生活质量更高,而脑脊液漏和颅内感染的风险相似。

Objective To compare the application effect of in situ bone flap(ISBF)combined with pedicled nasal septum flap(PNSF)and that of ISBF combined with free middle turbinate mucosal flap(FMTMF)in neuroendoscopic extended transnasal surgery for skull base reconstruction.Methods A retrospective analysis was conducted on the clinical data of patients undergoing skull base reconstruction by using ISBF combined with PNSF(ISBF+PNSF group,n=86)or ISBF combined with FMTMF(ISBF+FMTMF group,n=40)at the Department of Neurosurgery,the First Affiliated Hospital of Chongqing Medical University from January 2016 to September 2020.There was no statistically significant difference in the baseline data of the two groups of patients,such as gender,age,body mass index,maximum diameter of the lesion,and pathological type(all P>0.05).All patients underwent outpatient follow-up at 3,6 months after surgery,and re-examination of the sellar area enhanced MRI and sellar area thin-slice CT to observe the postoperative healing of ISBF and mucosal flap.The quality of life in nasal cavity was evaluated by sino-nasal outcome test-22(SNOT-22)at 6 months after operation.The operation time,postoperative bed rest time,intracranial infection rate,cerebrospinal fluid leakage rate,and lumbar cistern drainage rate were compared between the two groups.Results All 126 patients underwent successful skull base reconstruction.The thin-slice CT scan of the sellar area showed that ISBF was in place.The imaging review results of 126 patients at 3,6 months after surgery showed that the ISBF and mucosal flaps healed completely.Patients in the ISBF+PNSF group and ISBF+FMTMF group had no significant differences in the length of operation(median:210 min vs.190 min),postoperative bed rest time(median:14 d vs.13 d),intracranial infection rate[8.1%(7/86)vs.5.0%(2/40)],the incidence of cerebrospinal fluid leakage[11.6%(10/86)vs.7.5%(3/40)],or the rate of lumbar cistern catheterization and drainage[26.7%(23/86)vs.22.5%(9/40)](all P>0.05).At 6 months after surgery,the SNOT-22 score of the ISBF+PNSF group was higher than that of the ISBF+FMTMF group,and the difference was statistically significant(median:15 vs.13,P=0.029).Conclusions Both ISBF+PNSF and ISBF+FMTMF could achieve the anatomical reconstruction of skull base.The method of ISBF+FMTMF is associated with less nasal trauma and better sino-nasal outcomes after surgery.The risks of cerebrospinal fluid leakage and intracranial infection are similar between the two methods.