Abstract】Objective: To summarize the selection of surgical method and improvement of surgical approach for cranioplasty. The results showed that all 17 patients had good surgical results. The patients recovered satisfactorily after surgery. Conclusion: Different surgical timing and surgical methods can significantly improve the postoperative symptoms of patients according to different patients. Improve the quality of life of patients.
Cranioplasty is a routine procedure in neurosurgery and is not difficult to perform. Some patients can be repaired in one stage, so that patients can avoid two operations and aggravate patients’ pain, and if the operation is too simple, patients may be left with some complications, such as: patients’ postoperative chewing pain, fluid under the surgical flap, easy to cause infection, and even surgical failure. Now the experience in surgery is summarized as follows:
Clinical data
1.1 General information
There were 17 patients in this group, including ten males and seven females, with an average age of 32 years,
1.2 Clinical performance
Thirteen patients were admitted with consciousness, the rest were coma patients, GCS score: 8-15 points in 13 cases, 5-8 points in 4 cases. There were 8 cases with mild cranial hypertension after craniocerebral injury without brain herniation, 6 cases with severe brain swelling and cranial defect after debridement and decompression, and 3 cases with craniocerebral penetrating injury after thorough debridement and foreign body infection.
1.3 Auxiliary examination
The cranial CT examination showed 8 cases of mild cranial hypertension, 6 cases of severe brain swelling and cranial defects after debridement and decompression, and 3 cases of intracerebral changes after thorough debridement after cranial penetrating injury.
1.4 Surgical treatment
According to the current data, autologous cranial bone should be used as the first choice of repair material, and for those who cannot be reset by autologous cranial bone, the most ideal foreign body repair material is three-dimensional plastic titanium mesh and plastic polymer material. If there is mild high cranial pressure after craniocerebral trauma, it is feasible to perform cranioplasty external decompression surgery, that is, the skull fragments are neatly arranged along the dura, and the fragments are basically formed when the cranial pressure is applied after 2 weeks, and it is better to place drainage tubes in the epidural after surgery. For patients whose recovery may be affected by cranial defects, cranioplasty can be performed as soon as possible after 2 weeks of normal cranial pressure. For patients with cranial penetrating injuries, second-stage cranioplasty must be performed after 3 months of thorough debridement and foreign body infection, and for patients with intracranial infection, second-stage cranioplasty must be performed after 1 year of thorough debridement and infection control.
2.Conclusion:
Comminuted skull fractures caused by closed or open craniocerebral injury are feasible in patients with surgical indications except for obvious local infection of the incision, and stage I debridement and cranioplasty are feasible in patients with severe cerebral contusion. Patients with malignant intracranial hypertension who underwent debridement and decompression should undergo second-stage cranioplasty during the recovery period.
3. Discussion:
It is generally believed that autologous bone is the best clinical repair material. However, for patients whose autologous bone cannot be replanted or is not suitable for replantation, only repair materials can be used instead. Although three-dimensional malleable titanium mesh is an ideal material for cranioplasty, a slight foreign body reaction can still occur. My experience in the application of titanium plates for cranioplasty is as follows:
3.1 In some patients, one-stage cranial repair is feasible, such as open cranial injury or surgical cranial defect with good wound condition and low contamination, it is possible to apply titanium plate for one-stage cranial repair at the same time of initial thorough debridement or other surgery without increasing complications. They are becoming more and more widely accepted. The indications for one-stage debridement are: (1) closed craniocerebral injury without cranial hypertension; (2) open craniocerebral injury with no foreign body in the cranium, light contamination of the wound, no skin necrosis or defects, and no cranial hypertension; in addition, the indications for surgery can be relaxed for pediatric patients.
3.2 For severe brain swelling. In patients with cranial defects after debridement and decompression, second-stage surgery is usually performed during the recovery period (usually 3 to 6 months after injury). The most ideal material for foreign body repair is currently a three-dimensional malleable polymer or titanium mesh.
3.3 During surgery, the scalp should be lifted along the original incision as much as possible, and the flap should be separated from under the capillary R membrane. The injection of anesthetic or saline under the flap is beneficial to the flap separation, and the dural layer should be avoided to break during the separation process leading to cerebrospinal fluid leakage.
3.4 The temporalis muscle should be free when the field involves the temporalis muscle, only in this way can the bone edge of the deep side of the temporalis muscle be exposed to avoid the postoperative chewing pain caused by the compression of the temporalis muscle by the repair flap.
3.5 The titanium mesh should be constantly plasticized during the fixation process, so that the titanium mesh should conform to the original cranial morphology as much as possible, avoiding warping around the titanium mesh, and suspending the dura mater with multiple needles on the titanium mesh, and because of the sharp edge of the titanium mesh hole, the knot should be tied gently to avoid breaking the silk thread.
3.6 The temporalis muscle is sutured to the surface of the titanium mesh, and then the flap is sutured layer by layer and wrapped with an elastic bandage to reduce the occurrence of subcutaneous exudate and effusion. However, if the bandage is too tight, it will aggravate the patient’s pain and have an effect on the blood supply to the skin edge, my experience is that it is better to place a thin drainage tube and remove it for 24 hours, which will not cause postoperative incisional infection and will not affect the patient.