【作者】 薛亚轲；

【导师】 魏新亭；

【作者基本信息】 郑州大学 ， 外科学， 2007， 硕士

【摘要】 背景和目的颅骨缺损大都继发于开放性颅脑损伤、手术颅内减压及肿瘤切除、先天畸形和进行性骨骼疾病等所致的病变颅骨切除术后，是颅脑术后较常见的后遗症。由于脑组织失去了正常颅骨的屏障作用而易受伤，且颅骨缺损能引起各种症状和影响外观。通常颅骨缺损除了直径小于3cm，以及颞肌下和枕下的颅骨缺损由于有肥厚的肌肉及筋膜覆盖并在缺损区形成的坚韧纤维性愈合层起到对脑的保护作用外，其余的多有临床症状，常需积极进行颅骨缺损修复。颅骨缺损直径大于3cm，可能会引起如头昏、头痛、忧郁、易激怒、自制力差和焦躁不安等躯体、心理各方面的症状；大面积的颅骨缺损会造成病人头颅严重畸形并影响颅内压的生理性平衡，大气压的长期直接作用于缺损区的局部脑组织可导致该部脑组织萎缩，加重脑损伤症状；小儿的颅骨缺损，随着发育缺损变大、边缘外翻，突出的脑组织呈进行性萎缩及囊变。颅骨成形术可以避免脑的再次损伤，外观上达到整形效果，还能增加大脑血流量，改善脑组织的能量代谢促进脑组织的功能恢复，治疗脑膨出，改善颅骨缺损患者神经、认知及精神方面的症状。目前尚没有理想的技术和材料使颅骨缺损从形态、结构和功能上完整地得到修复，组织工程特别是骨组织工程的出现和发展，给理想向现实的转变带来了希望。在临床工作中发现，对颅骨缺损患者进行修补不仅有整形及保护颅内容物的作用，而且对患者的神经及认知功能的改善也有帮助。虽然国内也有颅骨修补前后患者神经功能和轻中度认知能力的改善的报道。但对颅骨缺损患者神经及认知功能改善的原因尚缺乏具体分析，本研究对我院自2005年7月-2007年1月行颅骨修补患者进行前瞻性研究，观测颅骨修补患者手术前后神经、认知及颅内血流速率的变化，探讨患者手术前后神经及认知功能的变化及其原因。方法共计32例。其中男27例，女5例，年龄13-65岁，平均31岁。其中2例为自体缺损颅骨修补，其余30例为钛网修补，皮瓣切口应尽量利用原手术切口，另行切口时，需考虑到原手术切口疤痕对皮瓣血运的影响，以防术后血运差而延缓切口愈合；剥离皮肌瓣时，应避免头皮过薄出现血供不足而坏死，同时也尽量不要损伤硬脑膜，以减少术后切口脑脊液外漏的发生。钛网的多孔状结构便于引流皮下及硬膜外的积液，组织长入后有铆合固定作用，加快组织愈合。骨缺损周边无需修整，骨衣不必切开，将大于缺损处的金属钛网覆盖在缺损处，四周螺钉固定。钛网植入位置应在原位，即硬膜外颞肌下，不可将颞肌置于钛网下，以避免颞肌反复运动产生牵拉痛，要充分暴露骨缺损区，将金属钛网塑形后与缺损区吻合后牢固固定。若颅骨缺损较大，需用丝线将缺损中央的硬脑膜悬吊固定在金属钛网上，以减少死腔，防止术后血肿或积液的发生，若有皮下积液时需穿刺抽吸并加压包扎。分别于术前2d和术后10d左右对患者的神经功能和认知功能进行评价，神经功能评价用NIHSS(美国国立卫生研究院卒中量表)，认知功能采用MMSE(简明智能量表)。颅内血流分别于术前2d和术后10d左右行经颅多普勒超声(TCD)检测。结果1．其中30例用钛网进行颅骨修补的患者只有一例术后发生皮下积液、一例术后发生癫痫。其中部分采用电脑塑形，术后患者修补效果满意，并发症少。两例用自体颅骨瓣进行颅骨修补，均采用医用乙醇保存，术后无骨瓣下陷等明显并发症。2．颅骨修补后，患者的认知功能与术前相比有明显改善(P＜0.05)3．颅骨修补后，患者的神经功能与术前相比有明显改善(P＜0.05)4．颅骨修补患者手术前患侧血流速率与健侧相比明显降低，两侧血流速率不对称(P＜0.05)，修补后患者颅骨缺损侧血流有明显提高(P＜0.05)，术前两侧血流不对称性得到改善。结论1．颅骨修补可以明显改善患者的认知功能。2．颅骨修补可以明显改善患者的神经功能。3．颅骨修补可以提高患者缺损侧的血流速率，这在一定程度上可以解释颅骨修补对患者神经及认知功能的改善。更多还原

【Abstract】 ObjectiveMost of the skull defect caused by the open head injury, surgical decompression and intracranial tumor resection, congenital malformations, continual bone disorders and other disease , is the more common side effect of the brain surgery. The brain can be easily injured because of the losing of normal skull barrier, and skull defect can cause a variety of symptoms and effects of appearance. Generally if the skull defects smaller than 3 cm in diameter and the temporal and occipital muscle under the skull defect due to muscle and anadesma cover the skull defects in the formation of fibrous more tenacity played with skull-brain protection have no clinical symptoms, the rest often have clinical symptoms which need reconstruction. The defect which more than 3 cm in diameter, probably cause dizziness, headaches, depression, irritability, poor discipline and restlessness physical, psychological aspects of the symptoms; Large areas of the skull defect will cause serious cranium malformation and damage the physiological balance of intracranial pressure, atmospheric pressure of the long-term directly affect the brain tissue of the defect area can lead to the telatrophy of the brain, increasing symptoms of brain damage; The skull defects in children with developmental defect in turn, marginalized valgus, a prominent brain atrophy was conducted and cystic degeneration .Cranioplasty can avoid the recurrence of brain injury, can achieve the plastic effect ,also increase the brain blood flow, can improve the brain energy metabolism and promote the resumption of brain tissue, treat the enencephalocele skull defects patients with neurological cognition and mental syndrome. At present, there is no ideal technology and materials so that the skull defect from the shape, structure and function to be completely restored, engineering tissue especially the bone engineering tissue’s emergence and development bring hope for ideals to the reality.At present, due to various reasons the skull defect repair is the main purpose for the protection of plastic and cranial contents needs. In clinical found that cranioplasty also can affect the neurological and cognitive function of the patients. Although in domestic there are some reports of the improvement of the effect of cranioplasty to neurological and moderate cognitive patients. But there are not analysis of the reason for the improvement of neurological and cognitive of the skull defect patients. This test summed up the clinical data of the cranioplasty patients of our hospital since July 2005 to January 2007 .Observing cranioplasty patient’s neurolocal, cognitive and intracranial blood flow velocity changes before and after surgery, discuss the changes of neurological and cognitive function and analysis its reason.MethodsThere are 32 patients .27 of them are men ,the rest are women, the ages 13-65,average 31 years old. Two cases of autologous reconstruction skull defects, 30 cases of titanium mesh ,the skin flap should make full use of the original incision, if take a seperately incision, taking into account the influence of the original incision scar on the flap revascularization, prevent poor revascularization delayed wound healing; when decoherence skin Flap, should avoid emerging too thin scalp lead necrosis because of poor blood, also advised not to injury dura, in order to reduce the recurrence of cerebrospinal fluid leakage . The porous titanium mesh structure to facilitate drainage subcutaneous fluid and the epidural, after the organization grew into a riveting stationary, accelerate tissue healing. The peripheral of the bone defect need not repair, bone clothing need not open ,covering the metal titanium mesh to the defect, screw around. Titanium mesh implant in situ, that is, epidural temporalis muscle, the temporalis muscle will not be placed under the titanium mesh, to avoid the repeatedly movement of temporalis muscle cause pulling pain, fully exposed bone defects, the metal titanium mesh should be firmly fixed if it cover the skull defect. The large skull defect required a central thread fix the dura to metal titanium mesh to reduce dead space. Prevent postoperative hematoma and fluid, if needed subcutaneous hydrops should be punctured and compression bandaging. On the 2nd day before surgery and 10 days after surgery for patients with neurological and cognitive function evaluation, the evaluation of neurological function with NIHSS (National Institutes of Health Stroke Scale). Cognitive function using MMSE (mini-mental state examination). On the 2d pre-operative and 10d post-operative days via transcranial Doppler ultrasound (TCD) to detection intracranial blood flow.Results1. Thirty patients with titanium mesh for the cranioplasty with only one occurred subcutaneous fluid after surgery, and one patient had epilepsy. Some titanium mesh molding with computer, and the patient satisfacty with the repair effects, have fewer complications. 2 patients use autologous bone flap for cranioplasty, the skull flaps are preserved through medical alcohol, there was no skull flap subsidence and other significant complications.2. After cranioplasty, cognitive function of the patients showed a significant improvement compare with preoperative evaluation (P<0.05)3. After cranioplasty, neurological function of the patients showed a significant improvement compare with preoperative evaluation (P<0.05)4. Before Cranioplasty ,the blood flow of the injuried side lower than the uninjuried side ,the blood flow of the two side not at the same level(P<0.05).After cranioplasty , the blood flow of the injuried side have a significant increase(P<0.05), the blood flow of the two side are at the same level with.Conclusion1. Cranioplasty can significantly improve the cognitive function of the patients. 2. Cranioplasty can significantly improve the neurological function of the patients.3. Canioplasty can increase the brain blood flow of the injuried side, this can partly explain the improvement of cranioplasty to neurological and cognitive function of the patients.更多还原