开颅术后切口愈合不良的治疗及预后观察

目的探讨开颅术后切口愈合不良的治疗及预后。方法回顾性分析2014年1月至2020年11月首都医科大学附属北京天坛医院神经外科神经肿瘤六病房行择期手术后发生切口愈合不良的22例患者的临床资料,占同期择期手术患者的0.6%(22/3667)。根据切口愈合不良的累及范围和有无皮肤缺损进行分组,分别为切口愈合不良但无皮肤缺损组(A1组)、切口愈合不良伴脑脊液漏但无皮肤缺损组(A2组)、切口愈合不良且存在皮肤缺损组(B组)、复杂切口愈合不良伴骨髓炎组(C组)、复杂切口愈合不良伴骨髓炎以及硬膜外积脓或脑脓肿组(D组)。A1和A2组给予探查切口并一期缝合;B组给予切口换药并二期缝合;C组和D组给予清创、去骨瓣后缝合切口。定期通过电话或门诊复查的方式随访患者切口愈合情况。结果22例患者中,A1组7例,A2组7例,B组4例,C组1例,D组3例。22例患者中,D组1例复发颅咽管瘤患者因继发皮下积脓、脑脓肿死亡,余21例患者均完成3~60个月的临床随访。A2组1例经枕下远外侧开颅术后患者脑脊液漏持续2个月,因脑积水在外院行脑室-腹腔分流术。至末次随访,21例患者的切口全部愈合,中位愈合时间为14 d(7~42 d)。结论对开颅术后切口愈合不良的患者,根据切口的累及范围和有无皮肤缺损进行个体化治疗,总体预后较好。

Treatment and prognosis observation of poor healing of scalp incision after craniotomy

Objective To discuss the treatment and prognosis of poor healing of scalp incision after craniotomy.Methods A retrospective analysis was conducted on the clinical data of 22 patients with poor healing of scalp incision after elective surgery in the Sixth Ward of Neuro-Oncology,Department of Neurosurgery,Beijing Tiantan Hospital,Capital Medical University from January 2014 to November 2020.Those patients accounted for 0.6%(22/3667)of patients undergoing elective surgery in the same period.According to the scope of poor healing of the incision and the presence or absence of skin defects,the patients were divided into groups:poor healing of scalp incision without scalp defection(Group A1);poor healing of chronic wounds with cerebrospinal fluid leakage rather than defection of scalp(Group A2);poor scalp healing with skin defects(Group B);complex healing defect with osteomyelitis(Group C);complex healing defect,osteomyelitis and epidural abscess or brain abscess(Group D).Group A1 and A2 were given suture after exploring the scalp wound;Group B was given an incision dressing,and then underwent a second stage of suture;Group C and Group D were given debridement,bone flap removal and incision suture.Regular telephone or outpatient follow-up was performed to evaluate the patients′incision healing.Results Among the 22 patients,7 were in group A1,7 were in group A2,4 were in group B,1 was in group C,and 3 were in group D.Among 22 patients,1 patient with recurrent craniopharyngioma in group D died of secondary subcutaneous empyema and brain abscess,and the remaining 21 patients completed the clinical follow-up of 3 to 60 months.One patient in group A2 after suboccipital far-lateral craniotomy had cerebrospinal fluid leakage lasting for 2 months and underwent ventriculoperitoneal shunt at another hospital due to hydrocephalus.By the last follow-up,the incisions of 21 patients were all healed,and the median healing time was 14 days(range:7-42 d).Conclusion Patients with poor incision healing after craniotomy have a generally good prognosis after individualized treatment according to the scope of the incision and the presence or absence of skin defects.