神经内镜扩大经鼻入路手术中原位骨瓣联合不同黏膜瓣颅底重建的骨愈合效果分析

Efficacy analysis of bone healing using in situ bone flap combined with different mucosal flaps for skull base reconstruction in neuroendoscopic surgery through expanded transnasal approach

目的探讨神经内镜扩大经鼻入路(EETA)手术中,采用原位骨瓣(ISBF)联合带血管蒂鼻中隔黏膜瓣(PNSF)与游离中鼻甲黏膜瓣(FMTMF)进行颅底重建的骨愈合效果。方法回顾性分析2016年1月至2020年12月于重庆医科大学附属第一医院神经外科接受EETA手术并采用ISBF联合PNSF或FMTMF颅底重建患者(106例)的临床资料。于术后当日、1周、1个月、3个月、6个月、1年、2年进行鞍区薄层CT扫描,应用全息三维影像模型/医学图像分析软件进行骨性结构三维重建,测量观察ISBF与骨窗面积比值的变化。根据术中采用的黏膜瓣类型,将患者分为ISBF+PNSF组(简称PNSF组,n=62)与ISBF+FMTMF组(简称FMTMF组,n=44)。比较两组患者在术后不同时间节点ISBF与骨窗面积的比值以及术后2年该比值>90%的患者占比。结果106例患者的颅底重建术均顺利完成。随着术后时间的延长,PNSF组和FMTMF组患者ISBF与骨窗面积的比值均呈增长趋势(F=588.62,P<0.001);但两组患者比较,术后当日、1周、1个月、3个月、6个月、1年、2年ISBF与骨窗面积比值的差异均无统计学意义(F=0.20,P=0.659);PNSF组与FMTMF组比较,术后2年ISBF与骨窗面积的比值>90%患者占比的差异无统计学意义[46.77%(29/62)对比50.00%(22/44),χ2=0.11,P=0.743]。结论EETA手术中采用ISBF联合PNSF与FMTMF进行颅底重建的骨愈合效果均良好,两种黏膜瓣均能保证ISBF的存活、生长及愈合。

Objective To investigate the bone healing effect of skull base reconstruction using an in situ bone flap(ISBF)combined with pedicled nasoseptal flap(PNSF)versus free middle turbinate mucosal flap(FMTMF)in surgery via endoscopic extended transnasal approach(EETA).Methods A retrospective analysis was conducted on the clinical data of 106 patients who underwent EETA surgery with ISBF combined with PNSF or FMTMF for skull base reconstruction at the Department of Neurosurgery,the First Affiliated Hospital of Chongqing Medical University from January 2016 to December 2020.Thin-layer CT scans of the saddle area were performed on the operation day,1 week,1 month,3 months,6 months,1 year,and 2 years after surgery,the holographic 3D image modeling/medical image analysis software was applied to perform 3D reconstruction of the bony structures,and measurements were taken to observe the changes in the ratio of the ISBF to the bone window area.Based on the type of mucosal flap used intraoperatively,patients were categorized into the ISBF+PNSF group(referred to as the PNSF group,n=62)versus the ISBF+FMTMF group(referred to as the FMTMF group,n=44).The ratio of ISBF to bone window area at different postoperative time points and the percentage of patients with this ratio>90%at 2 years postoperatively were compared between the two groups.Results Skull base reconstruction was successfully completed in 106 patients.With the prolongation of postoperative time,the ratio of ISBF to bone window area tended to increase in the patients of both PNSF group and FMTMF group(F=588.62,P<0.001).However,the differences in the ratios of ISBF to bone window area were not statistically significant on the day of operation,1 week,1 month,3 months,6 months,1 year and 2 years post operation when comparing patients in the two groups(F=0.20,P=0.659);The difference in the percentage of patients with a ratio of ISBF to bone window area>90%at 2 years postoperatively was not statistically significant in the PNSF group compared with the FMTMF group[46.77%(29/62)vs.50.00%(22/44),χ2=0.11,P=0.743].Conclusion Bone healing in EETA surgery using ISBF combined with PNSF or FMTMF for skull base reconstruction seems favorable,and both mucosal flaps ensure survival,growth,and healing of the ISBF.