Modified big bone valve decompression reduces intracranial pressure and improves prognosis following craniocerebral injury

摘要

BACKGROUND: Conventional big bone valve decompression is used for treatment of craniocerebral injury, but postoperative therapeutic effects are not ideal in some patients. Therefore, a better method of big bone valve decompression should be searched.OBJECTIVE: To observe the effects of modified standard big bone valve decompression on craniocerebral injury.DESIGN: A controlled observation experiment.SETTING: Department of Neurosurgery, First Hospital Affiliated to Lanzhou University. PARTICIPANTS: Eighty-eight patients with craniocerebral injury admitted to Department of Neurosurgery, First Hospital Affiliated to Lanzhou University from October 1998 to October 2001 were involved in this experiment. The involved patients, including 60 male and 28 female, aged 16 to 67 years, were confirmed as craniocerebral injury by skull CT and MRI examination. They are all in the treatment range of standard big bone valve decompression. Informed consents of operation items were obtained from all the patients. The involved patients were randomized into modified operation group (n =48) and conventional operation group (n =40). METHODS: ①In the modified operation group, bone valve was removed as big as possible. Bone valve was properly enlarged near the base of skull and sphenoidal crest was removed; Periosteum was reserved as possible. Dura mater was cut from the center of bone window to peripheral area in the shape radiation; When temporalis was sewed up, its fascia would be separated from its root and the scalp cut would be sewed up layer and layer. After hematoma and injured brain tissue were cleared away, the cut dura matter in the shape of radiation covered the brain surface again. Dura mater was not sewed up, and the uncovered brain tissue was covered with gelatin sponge. Subepicranial aponeurosis was bluntly dissected along the peripheral edge of incision. The lower part of epicranical aponeurasis , with a width of 3 - 5 cm, was bluntly dissected along the peripheral edge of incision, which was for loosing the tension of scalp and sewing it. ②In the conventional operation group, standard big bone valve decompression was performed in all the patients, and intracranial pressure was monitored. At postoperative 3, 5, 7 and 15 days, intracranial pressure of patients in two groups was measured. Meanwhile, prognosis of patients in two groups were compared and analyzed. MAIN OUTCOME MEASURES: Comparison of intracranial pressure and prognosis of patients between two groups at postoperative different time points.RESULTS: Eighty-eight involved patients with craniocerebral injury participated in the final analysis. ①At postoperative 3, 5, 7 and 15 days, intracranial pressure of patients in the modified operation group was (2.39±0.53), (2.13±0.53), (1.86±0.53) kPa, which was significantly lower than that in the conventional operation group [ (2.66±0.53), (2.39±0.66), (2.13±0.53) kPa, P ＜ 0.01]. ②In the conventional operation group, 8 (17%) patients died, 3 (6%) patients presented vegetative state, which was respectively less than that in the conventional operation group [4 (10%) and 3(6%), P ＜ 0.01]; In the conventional operation group, 6(13%) and 3(6%) patients suffered from moderate and severe disability, respectively, which was significantly less than that in the conventional operation group [4 (10%) ,5 (12%) ,P＜0.01], 12(26%) and 16 (35%) patients suffered from mild disability and turned better, respectively, which was more than that in the conventional operation group [6 (15%), 13 (32%), P ＜ 0.01].CONCLUSION: Modified big bone valve decompression fundamentally changes from conventional big bone valve decompression. It fully decompresses and improves prognosis of patients.