本文選題：慢性硬膜下血腫　切入點(diǎn)：鉆顱術(shù)　出處：《南京醫(yī)科大學(xué)》2017年博士論文　論文類型：學(xué)位論文

【摘要】：目的試圖利用前期研究中創(chuàng)建的全新的終點(diǎn)指標(biāo),通過隨機(jī)對照設(shè)計(jì)的臨床病例研究,分析微創(chuàng)鉆顱術(shù)(twist drill craniotomy,TDC)與環(huán)鉆鉆顱術(shù)(burr hole craniotomy,BHC)治療的慢性硬膜下血腫(chronic subdural hematoma,CSDH)患者治愈率及術(shù)前、術(shù)后48小時(shí)、三個(gè)月的mRS評分(modified Rankin Scale),以比較兩者的優(yōu)劣。方法實(shí)驗(yàn)設(shè)計(jì)通過倫理學(xué)審核后,2016年1月至2017年1月,共募集40例頭顱CT確診有慢性硬膜下血腫形成并需要手術(shù)減壓的患者,年齡18歲,性別不限,隨機(jī)分配至TDC組與BHC組,每組20人,使用mRS評分量表,分別記錄各患者術(shù)前、術(shù)后48小時(shí)與3個(gè)月的mRS評分。其中術(shù)后48小時(shí)評分未改善,需要再次手術(shù)者記為手術(shù)失敗(Failure)并進(jìn)行補(bǔ)救手術(shù)(Remedial)。48小時(shí)后評分改善者記為手術(shù)成功(Success),患者癥狀平穩(wěn)后出院,記錄住院時(shí)間(Duration),隨訪3個(gè)月內(nèi)硬膜下血腫再聚集(Recurrence)并出現(xiàn)神經(jīng)功能缺損癥狀(Symptomatic)復(fù)發(fā)需要再次手術(shù)者記為二次手術(shù)(Reoperation),CT檢查完全吸收(Clear)或雖然有殘余(Residual)硬膜下積液但患者神經(jīng)功能缺損癥狀評分無加重者(Asymptomatic)統(tǒng)一記為治愈(Cure)。兩組數(shù)據(jù)計(jì)量資料使用兩獨(dú)立樣本的t檢驗(yàn),對mRS評分及手術(shù)前后評分的差值及其與術(shù)前值的比使用Mann-Whitney U秩和檢驗(yàn),率的比較使用卡方檢驗(yàn)。P0.05認(rèn)為存在顯著差異,有統(tǒng)計(jì)學(xué)意義。結(jié)果40例入組患者中,男33例,女7例,BHC和TDC組性別比分別為17/3與16/4;年齡19～86歲,其中60歲以上34例(85%);26例(65%)有明確外傷史,14例(35%)否認(rèn)外傷史的患者年齡均大于60歲,與有明確外傷史的26例有明顯差異(P=0.03)。兩組患者在一般臨床特征上無明顯差異。TDC組1例行補(bǔ)救手術(shù)(P=0.31)。不能認(rèn)為TDC手術(shù)失敗率明顯高于BHC組。BHC組有3例患者術(shù)前mRS評分5分。其中,兩例分別于出院后32天和45天死亡。TDC組有4例術(shù)前mRS評分5分,1例術(shù)后一月死于癲癇及肺部感染。兩組間死亡率比較無差異(P=0.48)。兩組共有4例患者在3個(gè)月隨訪時(shí)復(fù)查頭顱CT顱內(nèi)血腫完全消失,其中TDC組3例,另1例19歲男性在BHC組(P=0.29)。其余患者術(shù)后3月復(fù)查頭顱CT提示顱內(nèi)均仍有殘留血腫。BHC組有3例首次手術(shù)后30天、40天和47天再次切開引流。TDC組48小時(shí)內(nèi)癥狀改善者,3個(gè)月內(nèi)癥狀均平穩(wěn),未有患者需行二次手術(shù)(P=0.07)。雙變量的相關(guān)性分析發(fā)現(xiàn)患者術(shù)前mRS評分與預(yù)后直接相關(guān),術(shù)前神經(jīng)功能缺損越嚴(yán)重,3個(gè)月后隨訪神經(jīng)功能評分越差(P0.001),死亡率也越高(P0.01)。TDC術(shù)后患者平均住院日9±2.91天,相較于BHC手術(shù)的14.75±5.95天明顯短(P=0.01)。在40例患者的總體樣本中,住院時(shí)間越長,出院后癥狀復(fù)發(fā)需行第二次手術(shù)的風(fēng)險(xiǎn)越高(P0.01)。TDC組術(shù)后3月mRS評分的變化值Vpre-3m、V48h-3m與術(shù)前評分的比值V(pre-3m)/pre、V(48h-3m)/pre較BHC組均有明顯差異(P0.05),提示TDC組患者手術(shù)前后神經(jīng)功能改善較BHC組更明顯。雖然TDC組患者中治愈者有18例(90%),但與BHC組15例(75%)的治愈率相比并無明顯差異(P=0.21)。結(jié)論本研究未發(fā)現(xiàn)經(jīng)兩種手術(shù)治療的慢性硬膜下血腫患者失敗率與治愈率之間存在明顯差異。但TDC組術(shù)后3月的mRS評分改善水平明顯優(yōu)于BHC組,同時(shí)TDC組患者較BHC組總體住院時(shí)間明顯短,可以認(rèn)為TDC方案優(yōu)于BHC方案。
[Abstract]:Objective to use a new index to create end point in the previous research, through the clinical randomized controlled study design, analysis of minimally invasive trepenation (twist drill, craniotomy, TDC) and trephine craniotomy (burr hole, craniotomy, BHC) in treatment of chronic subdural hematoma (chronic subdural, hematoma, CSDH) and the cure rate of patients before the operation, 48 hours after operation, three months mRS score (modified Rankin Scale), to compare the advantages and disadvantages. The experimental design method by ethics review, January 2016 to January 2017, raising a total of 40 cases of cranial CT diagnosed with chronic subdural hematoma and decompression in patients 18 years of age, gender no limit, randomly assigned to TDC group and BHC group, each group of 20 people, the use of mRS score, the patients were recorded before operation, 48 hours after operation and 3 months mRS score. The score did not improve after 48 hours, need another operation record For the failure of operation (Failure) and remedial surgery (Remedial) for.48 hours after the score was improved as successful surgery (Success), patients with stable symptoms after recording, hospitalization time (Duration), within 3 months of follow-up subdural hematoma (Recurrence) and then aggregated symptoms of neurological impairment (Symptomatic) recurrence another operation is two times of surgery (Reoperation), CT (Clear) is completely absorbed or although there are residual subdural effusion (Residual) but the symptoms in patients with neurologic impairment score and weight (Asymptomatic) (Cure) as unified cure. T test of two sets of data measurement data using two independent samples, difference the score of mRS score before and after surgery and preoperative and value than using Mann-Whitney U rank test, were compared using chi square test.P0.05 believes that there are significant differences, with statistical significance. Results 40 patients, male 33渚，

本文編號：1617680