改进手术方法治疗额颞部重型颅脑损伤
【关键词】 重型颅脑损伤；额颞部；改进手术方法
Using the improving surgery method to treat heavy craniocerebral trauma of frontal and temporal part
【Abstract】 Objective To study the improving surgery method and effect about plateau heavy craniocerebral trauma of frontal and temporal part.Methods Use of the improving type Kelly question mark shape incision,along the forehead hair center side 3cm,adopt the arc shape back to arrive the mastoid upper part in the parietal bone tubercle anteversion to temporal part,along the border edge after the ear to turn to the front edge to the arcus zygomaticus.Open a window from the scale part of os temporale,take down the expanded bone petal using the skull drill,incise the dura mater,eliminate the haematoma and the broken brain tissue.At the same time get rid of the bone patal to reduce the pressure,soak the bone petal in 55% ethyl alcohol bottle and seal by the low temperature refrigeration.Results This group of 46 patients treated by the surgery survive 36 patients,the good 28 patients,the moderate disabled 6 patients,the heavy disabled 2 patients,died 10 patients.Conclusion 46 patients of heavy craniocerebral trauma of frontal and temporal part used the improving surgery method to expand into the road dura mater forming technique treatment,survived 36 patients,has obtained the good effect.
【Key words】 heavy craniocerbral trauma;frontal and temporal part;the improving surgery method
额颞部重型颅脑损伤在颅脑外科中占比例较高，因损伤重、死亡率高、手术治疗难度比较大。过去手术治疗强调颞肌下充分减压，术后出现较多问题，笔者近年来采用改良式手术方法治疗额颞部重型颅脑损伤46例，取得较好的效果，现报告如下。
1 资料与方法
1.1 一般资料 本组46例，男38例，女8例，平均年龄38岁(18～48岁)。根据GCS评分3～8分，闭合性颅脑损伤39例，开放性颅脑损伤7例；打击伤6例，车祸致伤30例，坠落伤8例，其他原因致伤2例。伤后双侧瞳孔散大者6例，一侧瞳孔散大者15例。头颅CT扫描检查：一侧额颞叶脑挫裂伤，硬膜下血肿伴脑内出血者36例，硬膜外伴硬膜下血肿者10例，硬膜下血肿8例，脑内出血伴硬膜外血肿6例。血肿呈36～160ml,脑内线结构均有移位。伴有下肢骨折4例，腹腔脏器损伤3例。
1.2 手术方法 采用改良Kelly问号形切口［1］，从前额发际内沿正中线旁3cm，向后呈弧形在顶结节前转向颞部直达乳突肌上缘，从耳后发际边缘拐向前缘至于颧弓上耳屏前2cm。翻转皮瓣剥离骨膜，从颞骨鳞部钻孔开窗，直径约3cm，环形切开硬脑膜放出硬膜下血肿以达到暂时减压。经此处理后脑波动常迅速改善。在所取颅骨处行颅骨钻5～6孔，用线锯导板引导下锯开相邻骨孔间骨板。取下骨瓣后用咬骨钳向下扩大骨窗。前至颞窝及额骨隆突，保留额骨隆突及颧弓，后至乳突前方［2］。前下咬出蝶骨嵴外1/3处，向下主要是咬除颞骨鳞部直达中颅窝底，骨窗一般可达8cm×5cm大小［3］，最大者的达15cm×8cm。对广泛挫裂伤无生机的脑组织和血肿应彻底充分清除，经清除后大多数患者均能达到充分内减压。经冲洗后彻底止血，取颞肌筋膜，剔除颞深、浅筋膜之间的脂肪组织，将其分离，翻转后分别与硬脑膜边缘间断缝合成形以扩大硬脑膜表面张力。如果颅内压不高无明显脑组织膨出者，可使骨瓣成浮动放回，将骨膜覆盖之上，对于颅内压高有明显脑膨出者，采用去骨瓣减压。将骨瓣放入55%酒精内密封浸泡冷藏，3个月行颅骨缺损修补术。
2 结果
经改良手术治疗46例，本组存活36例，根据GOS标准：良好28例，中度残废6例，重度残废2例，死亡10例。死亡原因：广泛性脑损伤合并脑干伤6例，腹腔脏器破裂大出血、循环衰竭1例。并发应急性消化道出血、多器官功能衰竭2例，肺感染致呼吸衰竭1例。术后自体颅骨瓣修复26例，用钛板行颅骨修补12例，术中见头皮解剖层次清晰，修补硬脑膜愈合良好。
