【摘要】：目的：探討早期顱骨修補(bǔ)并腦室腹腔分流治療應(yīng)用于顱腦損傷患者中的臨床療效,并評(píng)價(jià)該手術(shù)方案應(yīng)用于腦外傷治療中的安全性以及可行性,同時(shí)分析影響顱骨修補(bǔ)并發(fā)癥的相關(guān)因素。方法：選擇2008年1月～2012年1月在我院神經(jīng)外科住院治療的72例需行腦室腹腔分流術(shù)的顱骨缺損患者為研究對(duì)象,按照顱骨修補(bǔ)手術(shù)時(shí)間分為A組和B組。其中A組采取腦室腹腔分流術(shù)合并早期(2個(gè)月內(nèi))顱骨修補(bǔ)術(shù)治療,共40例患者；B組采取先行腦室腹腔分流術(shù),在2個(gè)月后再行顱骨修補(bǔ)術(shù),共32例患者。對(duì)兩組患者進(jìn)行為期6月到1年的追蹤隨訪,采用格拉斯哥昏迷(GCS)評(píng)分系統(tǒng)評(píng)價(jià)兩組患者術(shù)后昏迷程度；利用Barthel指數(shù)評(píng)價(jià)兩組患者日常生活能力；利用Fugl-Meyer法評(píng)價(jià)兩組患者肢體運(yùn)動(dòng)功能和神經(jīng)缺損程度,記錄數(shù)據(jù)并做好對(duì)比。另外,再觀察兩組患者并發(fā)癥情況,并分析影響并發(fā)癥的相關(guān)因素。結(jié)果：(1)A組行早期顱骨修補(bǔ)術(shù)能輕松游離皮瓣,平均手術(shù)時(shí)間為95.34±4.73min,游離皮瓣平均時(shí)間為15.4士1.25mmin,平均術(shù)中出血量為336.68±24.73m1；B組行晚期顱骨修補(bǔ)術(shù),平均手術(shù)時(shí)間為133.68±5.14min,游離皮瓣平均時(shí)間為40.68±3.12min,平均術(shù)中出血量為574.32±26.59m1,兩組患者的上述指標(biāo)之間的差異均存在明顯統(tǒng)計(jì)學(xué)差異(P0.01)。(2)A組患者術(shù)后恢復(fù)良好36例(90.00%)、中度殘疾4例(10.00%)、重度殘疾0例(0.00%)；B組術(shù)后恢復(fù)良好22例(68.75%)、中度殘疾5例(15.63%)、重度殘疾5例(15.63%),兩組手術(shù)中無死亡病例,兩組恢復(fù)情況比較差異不具有統(tǒng)計(jì)學(xué)意義(P0.05)。(3)術(shù)前,兩組GCS評(píng)分差異不具有統(tǒng)計(jì)學(xué)意義(P0.05),術(shù)后及隨訪期間A組GCS評(píng)分明顯優(yōu)于B組(P0.05)；兩組患者術(shù)后ADL、肢體運(yùn)動(dòng)功能和神經(jīng)功能和術(shù)前相比都有一定程度恢復(fù)(P0.05),但是A組各項(xiàng)指標(biāo)改善情況明顯優(yōu)于B組(P0.05)。(4)B組有1例并發(fā)分流管堵塞、有3例出現(xiàn)感染、皮下積液2例,顱內(nèi)血腫1例、頭皮壞死1例、腦脊液漏2例、并發(fā)癥發(fā)生率為31.25%；而A組術(shù)中無分流管堵塞,2例出現(xiàn)感染,1例皮下積液,未發(fā)生腦脊液漏、頭皮壞死、修補(bǔ)材料外露、顱骨骨瓣吸收、修補(bǔ)材料塌陷移位等,并發(fā)癥發(fā)生率為7.50%,兩組之間差異具有統(tǒng)計(jì)學(xué)意義(X2=6.78,P0.05)。(5)患者的年齡和缺損程度均為導(dǎo)致并發(fā)癥的主要因素,老年患者并發(fā)癥發(fā)生率明顯高于青年患者(P0.05),損傷面積大的患者并發(fā)癥發(fā)生率明顯高于損傷面積小的患者(P0.05)。結(jié)論：對(duì)于顱腦損傷患者,行早期顱骨修補(bǔ)并腦室腹腔分流手術(shù),不僅能滿足患者外形美觀的要求,同時(shí)還能有效地提高其生活質(zhì)量,并能有效地促進(jìn)腦組織局部血流量的恢復(fù),預(yù)防缺損部位腦組織再度損傷,進(jìn)而恢復(fù)和改善患者的神經(jīng)功能。該手術(shù)方案療效滿意,并發(fā)癥發(fā)生率低,主要的影響因素為年齡和缺損面積大小。所以,開展早期顱骨修補(bǔ)術(shù)聯(lián)合腦室腹腔分流術(shù)治療顱腦外傷是一種安全有效的治療方式,值得在臨床上進(jìn)一步推廣和應(yīng)用。
[Abstract]:Objective: To study the clinical effect of early skull repair and intraventricular shunt treatment in patients with head injury, and to evaluate the safety and feasibility of the operation in the treatment of head injury. Methods: From January 2008 to January 2012,72 cases of skull defect with ventriculoperitoneal shunt were divided into group A and group B according to the time of skull repair. In group A, a total of 40 patients were treated by intraventricular shunt and early (2-month) skull repair. Two groups of patients were followed up for a period of 6 months to 1 year. The Glasgow Coma (GCS) scoring system was used to evaluate the degree of coma of the two groups, and the daily life of the two groups was evaluated by the Barthel index. The function of limb movement and the degree of nerve defect in the two groups were evaluated by the Fugl-Meyer method. Record the data and make a comparison. In addition, the complications of the two groups were observed and the related factors of the complications were analyzed. Results: (1) The average operation time was 95.34-4.73min, the average operation time was 95.34-4.73min, the mean time of free-skin flap was 15.4-1.25 mmin, the average operation time was 336.68-24.73ml, and the average operation time was 133.68-5.14min. The mean time of free flap was 40.68-3.12 min, the amount of intraoperative blood loss was 574.32-26.59 ml, and there was a significant difference in the difference between the two groups (P0.01). (2) There were 36 cases (90.00%) in group A,4 (10.00%) with moderate disability,0 (0.00%) with severe disability,22 (68.75%) in group B,5 (15.63%) with moderate disability and 5 (15.63%) with severe disability. The difference between the two groups was not statistically significant (P0.05). (3) The GCS scores of the two groups were not statistically significant before and after operation (P0.05). The GCS scores of group A in group A after operation and follow-up were significantly better than that of group B (P0.05). However, that improvement of the index in group A was better than that of group B (P0.05). (4) There were 1 case complicated with shunt in group B. There were 3 cases of infection,2 cases of subcutaneous effusion,1 case of intracranial hematoma,1 case of scalp necrosis,2 cases of cerebrospinal fluid leakage, and 31.25% of complication rate. The incidence of complications was 7.50%, and the difference between the two groups was statistically significant (X2 = 6.78, P0.05). (5) The age and defect of the patients were the main factors leading to the complications. The complication rate of the old patients was significantly higher than that of the young (P0.05). The complication rate of the patients with large injury area was significantly higher than that of the patients with small injury area (P0.05). Conclusion: For the patients with head injury, the early-stage skull repair and the intraventricular shunting operation can not only meet the requirements of the appearance of the patients, but also can effectively improve the quality of life of the patients, and can effectively promote the recovery of the local blood flow in the brain tissue. The brain tissue of the defect part is prevented from being damaged again, and the neurological function of the patient is recovered and improved. The result of the operation is satisfactory, the complication rate is low, and the main influencing factors are age and defect area size. Therefore, it is a safe and effective way for the treatment of head injury with the combination of the early skull repair and the intraventricular shunt. It is worth further promotion and application in clinic.
【學(xué)位授予單位】：中南大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2013
【分類號(hào)】：R651.15

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