持续性植物状态患者颅骨修补手术时间窗的研究
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摘要
目的研究持续性植物状态患者颅骨修补手术的不同时间窗治疗效果及术后并发症。方法收集中国人民解放军第七医学中心神经外科2013年1月—2017年12月行颅骨修补的持续性植物状态患者223例。测评不同手术时间窗患者手术前后修订的昏迷恢复量表(revised coma recovery scale,CRS-R)评分、颅内压力、血红蛋白及血白蛋白含量,分析手术前后的变化;并对不同时间窗患者的并发症进行比较。结果 2个月内颅骨修补(早期组)患者的意识水平评分CRS-R改善最多,为提高2. 3分。晚期修补组血白蛋白水平下降的最多,为(5. 98±3. 21) g/L;而中期修补组下降最少,为(4. 53±2. 66) g/L;表明3～6个月颅骨修补对持续性植物状态患者的血白蛋白水平影响最小。2个月内修补组的血红蛋白水平下降最多,为(4. 96±1. 54)g/L; 6个月以上修补组的血红蛋白水平下降最少,为(2. 51±5. 34) g/L。患者颅内压均在颅骨修补后有所提高,早期组提高了(22. 14±55. 51) mm H2O;中期组提高的最多,为(67. 13±45. 30) mm H2O;晚期组压力提高的最少。晚期修补组的手术并发症最多,早期修补组与中期修补组并发症的差异无统计学意义。结论病情稳定的持续性植物状态患者应在2个月左右尽早行颅骨修补治疗,可较早改善颅骨缺损处的皮层血流动力学,改善脑脊液循环压力的分布,有利于患者意识水平的恢复和功能康复。
Objective To study the effects and complications of cranioplasty in patients with persistent vegetative state (PVS) at different time windows. Methods 223 patients with PVS who underwent decompressive craniectomy (DC) in the department of neurosurgery at the 7 th Medical Center of PLA General Hospital from January 2013 to December 2017 were collected. The recovery of consciousness,intracranial pressure,hemoglobin and albumin were counted before and after the operation at different time windows,the changes before and after the operation were analyzed,and the complications of patients at different time windows were compared. Results The improvement of CRS-R score in patients with cranioplasty (early stage group) was 2. 3 points better than other groups. The decrease of albumin in the blood of late stage repair group (5. 98 ± 3. 21) g/L was the most in the three groups,and the decrease of albumin in the middle stage group was (4. 53 ±2. 66) g/L which was the last in the three groups,indicating that the influence of cranioplasty on albumin in PVS patients was little at 3 to 6 months. The hemoglobin decreased the most in the early stage group,which was (4. 96 ± 1. 54) g/L,whereas the hemoglobin decreased least in the late stage group,which was (2. 51 ± 5. 34) g/L. The patient 's intracranial pressure increased after cranioplasty, (22. 14 ± 55. 51) mm H2 O in the early stage group, (67. 13 ± 45. 30) mm H_2O in the middle stage group and the minimum increase in the late group. The late stage group had the most surgical complications,but there was no statistical difference between the early repair group and the middle repair group. Conclusion PVS patients with stable state should undergo cranioplasty as soon as possible,which can improve the cortical hemodynamics of skull defects and improve the distribution of cerebrospinal fluid circulation pressure, and is beneficial to the recovery of consciousness level and functional recovery of patients.
Objective To study the effects and complications of cranioplasty in patients with persistent vegetative state (PVS) at different time windows. Methods 223 patients with PVS who underwent decompressive craniectomy (DC) in the department of neurosurgery at the 7 th Medical Center of PLA General Hospital from January 2013 to December 2017 were collected. The recovery of consciousness,intracranial pressure,hemoglobin and albumin were counted before and after the operation at different time windows,the changes before and after the operation were analyzed,and the complications of patients at different time windows were compared. Results The improvement of CRS-R score in patients with cranioplasty (early stage group) was 2. 3 points better than other groups. The decrease of albumin in the blood of late stage repair group (5. 98 ± 3. 21) g/L was the most in the three groups,and the decrease of albumin in the middle stage group was (4. 53 ±2. 66) g/L which was the last in the three groups,indicating that the influence of cranioplasty on albumin in PVS patients was little at 3 to 6 months. The hemoglobin decreased the most in the early stage group,which was (4. 96 ± 1. 54) g/L,whereas the hemoglobin decreased least in the late stage group,which was (2. 51 ± 5. 34) g/L. The patient 's intracranial pressure increased after cranioplasty, (22. 14 ± 55. 51) mm H2 O in the early stage group, (67. 13 ± 45. 30) mm H_2O in the middle stage group and the minimum increase in the late group. The late stage group had the most surgical complications,but there was no statistical difference between the early repair group and the middle repair group. Conclusion PVS patients with stable state should undergo cranioplasty as soon as possible,which can improve the cortical hemodynamics of skull defects and improve the distribution of cerebrospinal fluid circulation pressure, and is beneficial to the recovery of consciousness level and functional recovery of patients.
引文
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[3]Ikeda H,Kurisu K,Kihira K.Vancomycin ointment for MRSAinfection at a cranioplasty site[Z].Ann Pharmacother,2004,38:70.
[4]Jho DH,Neckrysh S,Hardman J,et al.Ethylene oxide gas sterilization:a simple technique for storing explanted skull bone[J].J Neurosurgery,2007,107:440.
[5]刁新峰.颅骨缺损修补术80例临床总结[J].中国实用神经疾病杂志,2010,13:封3.
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[8]Khader BA,Towler MR.Materials and techniques used in cranioplasty fixation:A review[J].Mater Sci Eng C mater,2016,66:315.
[9]Kim H,Sung SO,Kim SJ,et al.Analysis of the factors affecting graft infection after cranioplasty[J].Acta Neurochir(Wien),2013,155:2171.
[10]Kuleshova LL,Gouk SS,Hutmacher DW.Vitrification as a prospect for cryopreservation of tissue-engineered constructs[J].Biomaterials,2007,28:1585.
[11]Lee BS,Min KS,Lee MS,et al.Comparison with subcutaneous abdominal preservation and cryoconservation using autologous bone flap after decompressive craniectomy[J].Korean J Neurotrauma,2012,8:21.
[12]Lee SH,Yoo CJ,Lee U,et al.Resorption of autogenous bone graft in cranioplasty:Resorption and reintegration failure[J].Korean JNeurotrauma,2014,10:10.
[13]Lemée JM,Petit D,Splingard M,et al.Autologous bone flap versus hydroxyapatite prosthesis in first intention in secondary cranioplasty after decompressive craniectomy:a French medicoeconomical study[J].Neurochirurgie,2013,59:60.
[14]Lethaus B,Bloebaum M,Koper D,et al.Interval cranioplasty with patient-specific implants and autogenous bone grafts-success and cost analysis[J].J Craniomaxillofac Surg,2014,42:1948.
[15]Wen L,Yang XF,Liu WG,et al.Cranioplasty of large cranial defect at an early stage after decompressive craniectomy performed for severe head trauma[J].J Craniofac Surg,2007,18:526.
[16]段国升,朱诚.手术学全集神经外科卷[M].北京:人民军医出版社,1994:108.
[2]Barthélemy EJ,Melis M,Gordon E,et al.Decompressive craniectomy for severe traumatic brain injury:a systematic review[J].World Neurosurg,2016,88:411.
[3]Ikeda H,Kurisu K,Kihira K.Vancomycin ointment for MRSAinfection at a cranioplasty site[Z].Ann Pharmacother,2004,38:70.
[4]Jho DH,Neckrysh S,Hardman J,et al.Ethylene oxide gas sterilization:a simple technique for storing explanted skull bone[J].J Neurosurgery,2007,107:440.
[5]刁新峰.颅骨缺损修补术80例临床总结[J].中国实用神经疾病杂志,2010,13:封3.
[6]Joaquim AF,Mattos JP,Chaddad F,et al.Bone flap management in neurosurgery[J].Rev Neurocienc,2009,17:133.
[7]Kaku M,Koseki H,Kojima S,et al.Cranial bone regeneration after cranioplasty using cryopreserved autogenous bone by a programmed freezer with a magnetic field in rats[J].Cryo Letters,2014,35:451.
[8]Khader BA,Towler MR.Materials and techniques used in cranioplasty fixation:A review[J].Mater Sci Eng C mater,2016,66:315.
[9]Kim H,Sung SO,Kim SJ,et al.Analysis of the factors affecting graft infection after cranioplasty[J].Acta Neurochir(Wien),2013,155:2171.
[10]Kuleshova LL,Gouk SS,Hutmacher DW.Vitrification as a prospect for cryopreservation of tissue-engineered constructs[J].Biomaterials,2007,28:1585.
[11]Lee BS,Min KS,Lee MS,et al.Comparison with subcutaneous abdominal preservation and cryoconservation using autologous bone flap after decompressive craniectomy[J].Korean J Neurotrauma,2012,8:21.
[12]Lee SH,Yoo CJ,Lee U,et al.Resorption of autogenous bone graft in cranioplasty:Resorption and reintegration failure[J].Korean JNeurotrauma,2014,10:10.
[13]Lemée JM,Petit D,Splingard M,et al.Autologous bone flap versus hydroxyapatite prosthesis in first intention in secondary cranioplasty after decompressive craniectomy:a French medicoeconomical study[J].Neurochirurgie,2013,59:60.
[14]Lethaus B,Bloebaum M,Koper D,et al.Interval cranioplasty with patient-specific implants and autogenous bone grafts-success and cost analysis[J].J Craniomaxillofac Surg,2014,42:1948.
[15]Wen L,Yang XF,Liu WG,et al.Cranioplasty of large cranial defect at an early stage after decompressive craniectomy performed for severe head trauma[J].J Craniofac Surg,2007,18:526.
[16]段国升,朱诚.手术学全集神经外科卷[M].北京:人民军医出版社,1994:108.