生物型人工硬脑膜应用的实验研究

OBJECTIVE: To evaluate the safety and efficacy of a dural graft prepared using porcine membrane in duraplasty. METHODS: Eighteen New Zealand rabbits were randomly divided into groups A (n=4), B (n=4), C (n=5), and D (n=5) sacrificed 3, 14, 30 and 90 d after duraplasty, respectively. Each animal underwent bilateral parietal craniectomy behind the coronal suture and beside the midline to expose the dura, which was cut on the right side and substituted with the dural graft. The exposed dura on the left was kept intact as control. The rabbits were observed for WBC counts before the operation and before sacrifice by transcardiac formalin perfusion, respectively. The meninges and brain tissues were histologically examined after sacrifice. RESULTS: The WBC count varied little after the operation (P>0.05). Microscopic examination demonstrated tissue repair on both the implantation side and control side, without graft adhesion to the cortical surface. In group A, a large number of leukocytes were seen gathering on the lateral dura, suggesting acute tissue repair. In group B, endothelial cells covering the inner surface of the graft could be seen. Fibroblasts and fibrocytes were seen in the grafts between collagen fibers in group C, and in group D, fibroblasts and fibrocytes increased between the collagen fibers and the suture healed. CONCLUSION: The dura graft is safe and applicable for dural defect repair.     

生物型人工硬脑膜应用的实验研究

目的 探讨一种生物型人工硬脑膜用于修补缺损硬脑膜的安全性及有效性。方法 将18只新西兰兔分为4组,于冠状缝后、中线两侧用电钻各磨1个骨窗,暴露硬脑膜。右侧剪除自体硬脑膜,取生物型外科补片(硬脑膜)行硬膜修补。左侧硬脑膜作为对照。A组4只,术后3 d处死;B组4只,术后14d处死;C组5只,术后30d处死;D组5只,术后90d处死。取术部脑及脑膜标本进行组织学检查,采集各组术前及处死前静脉血,行白细胞计数,并进行统计学分析;术后对各组动物进行临床观察。结果 各组动物术前、处死前的白细胞总数无显著差异(P>0.05)。各组病理检查植入侧与对照侧均只见修复反应,术后14 d有内皮细胞覆盖植入物内表面;术后30d,人工脑膜内的胶原纤维间有成纤维细胞出现;术后90d,人工硬膜与正常硬膜愈合,人工脑膜内的胶原纤维间可见较多成纤维细胞和纤维细胞。未显示植入人工硬膜的排斥、与脑皮层粘连等不良反应。临床观察各组动物无手术局部感染,伤口愈合好,无局部积液,无脑脊液漏。结论 动物实验证实生物型外科补片(人工硬脑膜)是一种安全、可行的硬脑膜修补材料。     

硬脑膜分阶段切开在特重型额颞部颅脑损伤术中的应用

目的研究硬脑膜分阶段切开、分步清除血肿对特重型额颞部颅脑损伤患者的治疗效果,及对急性脑膨出的预防作用。方法2008年2月-2012年6月间我科收治30例特重型额颞部颅脑损伤患者,减压术中采用三阶段切开硬脑膜、分步清除血肿及坏死脑组织。结果术中均未出现难以控制的急性脑膨出;术后头颅CT：硬膜下及脑挫伤区血肿清除理想,脑移位较术前减轻。伤后6个月至1年随访,根据GOS评分评定患者预后：良好／中残（GOS4-5分）4例;重残／植物状态生存（GOS2-3分）12例;死亡（GOS1分）14例,病死率46．7％。结论应用硬脑膜分阶段切开、分步清除血肿及坏死脑组织的方法,能有效防止特重型额颞部颅脑损伤患者减压术中急性脑膨出的发生,降低病死率。     

产前超声对胎儿脑膜膨出及脑膜脑膨出的诊断价值分析

目的 探讨产前超声检查对胎儿脑膜膨出及脑膜脑膨出的临床应用价值.方法 选取2011年1月到2015年6月经该院超声诊断并经引产证实的脑膜膨出及脑膜脑膨出胎儿39例,回顾性分析其临床资料及声像图特征.结果 2011年1月到2015年6月在该院接受超声检查的孕妇共111 620例,检出脑膜膨出及脑膜脑膨出胎儿39例,检出率0.35‰.超声诊断脑膜膨出16例(其中1例膨出部位为两处),脑膜脑膨出23侧.产前超声能清晰显示胎儿颅骨缺损的部位、大小及膨出物的特点,并根据膨出物的特点判断脑膨出的类别.结论 超声检查诊断胎儿脑膜膨出及脑膜脑膨出的准确性高,具有显著的临床价值.     

股前外侧游离皮瓣用于头部创面的修复

目的：修复头部肿瘤和颅骨骨髓炎症灶切除后的较大创面,尤其是合并有颅骨缺损和硬脑膜外露,甚至硬脑膜缺损的病例。方法：肿瘤或感染病地切除后以和颅骨大面积缺损,采用股前外侧游离皮瓣移植覆盖创面,治疗此类患者共９例。结果：术后８例皮瓣全部成活,有１例皮瓣部分坏死。术后外观和功能满意,无１例后期需要进一步进行颅骨的修复。结论：股前外侧以瓣是修复此类缺损的首选皮瓣供区,可以为脑组织提供足够的保护。     

紧急钻颅和顺序脑膜剪开术用于特重型颅脑损伤合并脑疝患者中的临床效果

目的 :研究紧急钻颅和顺序脑膜剪开术在特重型颅脑损伤合并脑疝患者中的临床治疗效果.方法 :30例特重型颅脑损伤合并脑疝患者接受紧急钻颅+顺序脑膜剪开术治疗(治疗组),并将同期27例接受标准大骨瓣减压术+一次性脑膜剪开术治疗的同病症患者作为对照(对照组),分析两组确诊至减颅内压完成时间、术中急性脑膨出、瞳孔恢复情况和术后6月预后情况.结果 :治疗组确诊至减颅内压完成时间、术中急性脑膨出率显著低于对照组;治疗组瞳孔恢复正常率40%,部分缩小率53.33%,无变化率6.67%,而对照组则分别为14.81%,25.93%和59.26%,两组差异显著;术后6月GOS评分显示,治疗组良好率53.33%,中残率20%,重残率10%,植物生存率3.33%,死亡率13.34%,而对照组则分别为11.11%,14.81%,18.52%,7.41%和48.15%,两组差异显著;治疗组术后6月并发症总发生率30%,对照组81.48%,两组差异显著.结论 :紧急钻颅和顺序脑硬膜剪开术可为特重型颅脑损伤合并脑疝患者赢得充分减压时间,显著提高抢救成功率,疗效显著,有效降低术后残疾率和死亡率,减少并发症发生.     

硬脊膜损伤分度及预防脑脊液漏的临床研究

目的探讨硬脊膜损伤的分度及预防脑脊液漏的处理方法。方法回顾性研究1997年1月～2005年12月硬脊膜损伤116例,根据硬脊膜损伤缺损不同程度,采用直接缝合（A组）,深筋膜及各类补片修补缝合（B组）,直接缝合或各类补片修补缝合处理后再覆以生物蛋白胶（C组）。比较各组预后及脑脊液漏发生情况。结果A、B和C组脑脊液漏发生率分别为6.9%、27.3%和5.0%。结论硬脊膜损伤可分不同程度,脑脊液漏的发生与硬脊膜损伤程度有关,硬脊膜损伤修复后再覆以生物蛋白胶能有效降低脑脊液漏的发生。     

颅脑损伤术中急性脑膨出救治分析

目的 探讨颅脑损伤开颅术中急性脑膨出的原因及防治措施.方法 回顾分析86例在开颅手术中出现急性脑膨出的重型颅脑损伤患者的临床资料.结果 迟发性颅内血肿42例,急性脑肿胀38例,大面积脑梗塞及其他原因6例.伤后半年按GOS评估,恢复良好27例,中残15例,重残9例,植物生存7例,死亡28例.结论 术前应综合分析判断发生术中脑膨出的可能性,对迟发性颅内血肿早期诊断,及早清除血肿减压;对急性脑肿胀或大面积脑梗塞引起的脑膨出及早去除病因,迅速减压关颅.     

创伤性脑肿胀患者术中术后脑膨出的防治探讨

目的探讨创伤性脑肿胀患者术中术后脑膨出的防治措施。方法将采用大骨瓣减压术治疗的76例创伤性脑肿胀病例分为两组,两组病例术中采用不同方法治疗,观察分析两组病例术中术后发生脑膨出机率。结果第一组40例患者术中脑膨出36例,占90.0%,第二组36例患者术中脑膨出11例,占30.6%。76例患者术后不同阶段不同程度膨出66例,占86.8%。结论创伤性脑肿胀患者,采用＂尽早减压、逐步减压＂、顺序硬脑膜切开法、维持正常脑灌注压和切开硬膜后1小时内开始快速关颅能明显降低术中术后脑膨出发生率,降低致残和死亡率。     

标准外伤大骨瓣开颅术中急性脑膨出96例临床分析

目的：探讨标准外伤大骨瓣开颅术中急性脑膨出的临床特点及救治方法。方法：回顾性分析96例标准外伤大骨瓣开颅术中急性脑膨出患者的临床资料。结果：96例患者中恢复良好21例（21.88%）,中度残疾14例（14.58%）,重度残疾28例（29.17%）,植物生存状态14例（14.58%）,死亡19例（19.79%）,GCS评分越低,术中发生急性脑膨出的程度越高,死亡率越高,组间比较差异有统计学意义（P〈0.05）。结论：迟发性颅内血肿和急性脑肿胀是术中急性脑膨出的主要原因,而GCS评分低的患者更容易出现脑膨出,术中应根据受伤机制,术前GCS评分,脑膨出的特点,尽早采取相应措施,以取得较好疗效,降低患者死亡率。     

Plastic surgery

207684 Surgical correction of craniofacial dysostosis with midface distraction osteotogenesis/ Mu Xiongzheng (穆雄铮,Dept Plast Reconstruct Surg,Shanghai 9th Hosp,Shanghai Jiaotong Univ,Shanghai 200011)…∥ Chin J Plast Surg.-2007 ,23(4) .-277 ~280 Objective Correction of craniofacial dysostosis with midface distraction osteotogenesis.Methods Le Fort Ⅲ osteotomy has been employed through coronal route onpatients with midface craniofacial dysostosis such as Crouzon and Apert syndrome .…     

胸大肌皮瓣与裂层皮片联合修复颈部皮肤黏膜联合缺损

目的 :探讨颈部大面积皮肤黏膜联合缺损的修复方法。方法 :5例因下咽、喉部恶性肿瘤术后颈部大面积皮肤黏膜联合缺损用胸大肌皮瓣与大腿内侧裂层皮片联合修复。结果 :5例均Ⅰ期修复成功 ,外观及功能恢复良好。结论 :用胸大肌皮瓣与裂层皮片联合修复颈部大面积皮肤黏膜联合缺损简便易行 ,血供丰富 ,成活率高 ,值得临床应用及推广     

颅脑病变术中急性脑膨出分析

目的:分析颅脑病变手术中急性脑膨出的形成原因及有效的防治措施。方法:对重型颅脑损伤、脑肿瘤、脑AVM术中的脑膨出21例患者进行回顾性分析,总结其形成原因及防治措施。结果:脑外伤出血,脑组织缺氧充血,急性弥漫性脑肿胀,迟发性颅内血肿形成,脑肿瘤组织及周边高度水肿,脑AVM术中阻断回流静脉急性脑充血,均为引起术中急性脑膨出的主要原因。彻底清除颅内血肿,大骨瓣减压,脱水降低颅内压,术中过度换气,控制性降低收缩压,巴比妥类药物应用等是防止术中急性脑膨出的主要措施。结论:术中急性脑膨出由多方面引起,针对不同的病因采取相应措施防治,可减轻脑组织损害,减少死亡率。     

耳廓复合组织修复鼻翼缺损

目的 探索大于1．5cm耳廓复合组织块修复较大鼻翼、鼻尖缺损的可行性。方法 手术保留耳廓复合组织插入部的真皮下血管网,扩大供受区接触面积,常规术后丹参、低分子右旋糖苷用药,应用耳廓复合组织修复较大鼻翼、鼻尖缺损。结果 共修复较大鼻翼、鼻尖缺损7例,移植耳廓复合组织块最大宽径2．5cm,最小宽径2．0cm,手术均获成功。结论 手术方式改进,结合扩血管用药,宽径大于1．5cm的大块耳廓复合组织移植修复鼻翼缺损能够获得满意效果。     

Diagnostic approach to recurrent bacterial meningitis in children

Recurrence of bacterial meningitis in children is not only potentially life-threatening, but also involves or induces psychological trauma to the patients through repeated hospitalization and multiple invasive investigations if the underlying cause remains undetected. Bacteria migration, along congenital or acquired pathways from the skull or spinal dural defects, gains entrance into the central nervous system (CNS) and should be taken into consideration when children face recurrent bacterial meningitis, however, symptoms and signs of cerebrospinal fluid (CSF) rhinorrhea or otorrhea are rare in such patients. Without evidence of CSF leakage, a cranial symptom/sign or coccygeal cutaneous stigmata may suggest the approximate lesion site, diagnosis and detection remains difficult. To detect an occult dural lesion along the craniospinal axis, such as basal encephalocele, dermal sinus tract, or neurenteric cyst, a detailed clinical evaluation and the use of the modern diagnostic imaging methods is necessary. Because of the possibility of concomitant occurrence of more than one malformation, both the frontal and the lateral skull base should be carefully evaluated. Precise localization of the dural lesion is a prerequisite for successful surgical repair. In addition, the bacteria specificity could leave significant clues: Pneumoccocus or Hemophilus suggests cranial dural defects, E. coli or other gram negative bacilli suggests spinal dural defects, and meningococci suggest immunologic deficiency. Asplenia or immunodeficiency such as complement or immunoglobulin deficiency rarely causes recurrent meningitis without a history of frequent infection of non-CNS areas. Salmonella meningitis or brain abscess should not be treated incompletely or inadequately and could lead to recrudescence, relapse or recurrence of bacterial meningitis. Antibiotic (penicillin or trimethoprim-sulfamethoxazole) induced meningitis may repetitively occur on occasion.     

重型颅脑损伤开颅术中急性脑膨出原因及防治

目的探讨重型颅脑损伤开颅术中急性脑膨出原因及防治。方法对术中出现急性脑膨出的46例病人进行回顾性分析。结果导致脑膨出的主要原因有迟发性颅内血肿、急性弥漫性脑肿胀、低血压、低血氧及较大回流静脉的损伤。结论术中出现急性脑膨出的病因是多方面的，针对不同的病因采取相应的措施，可以减轻脑组织的损害，降低病死率。     

去骨瓣减压术中人工硬脑膜松弛缝合的临床研究

目的通过在去骨瓣减压手术中比较应用新型生物人工硬膜松弛缝合与常规硬膜敞开减压的预后,探讨人工硬膜松弛缝合在神经外科去骨瓣减压术中的应用价值。方法将2005年5月至2007年5月因重型颅脑损伤行去骨瓣减压术的126例患者分为两组,其中分组条件即在去骨瓣减压中采用常规硬膜敞开式方法和人工硬膜松弛缝合方法,对其资料进行回顾性分析研究。结果两组术后CT表现及颅内压监测,均能达到减压目的,其颅内压变化两组之间差异无统计学意义。其中,常规硬膜敞开组62例,发生并发症46例。Ⅱ期颅骨修补过程中见硬膜外组织粘连程度重,分离创面出血多,分离后易发生纤维破损,甚至脑组织受损。人工硬膜修补组64例,发生并发症9例。Ⅱ期颅骨修补过程中见修补材料表面可见毛细血管,周边缝合的硬膜已完全愈合,粘连程度轻,分离创面出血少,分离纤维膜完整,脑组织无损伤。两组经统计学处理,差异有统计学意义(P<0.05)。结论人工硬膜松弛缝合在去骨瓣减压术中能够充分发挥有效的减压作用,基本保持原有解剖层次,显著降低去骨瓣减压术后的并发症发生率,值得临床推广。     

潮式椎管引流术防治开颅去骨瓣术后脑膨出

目的 研究早期应用潮式椎管引流术防治开颅去骨瓣术后脑膨出的治疗效果。方法 将所有开颅去骨瓣术后病人随机分为防治组（335例）和对照组（176例）,防治组除了常规治疗外还早期应用潮式椎管引流术,而对照组只行常规治疗,以术后一个月时骨窗脑膨出情况作出比较。结果 防治组脑膨出17例（5％）,对照组脑膨出52例（29．5％）,防治组发病率明显降低,统计学上有显著性差异（p〈0．01）。结论早期应用潮式椎管引流术可以有效地防治开颅去骨瓣术后脑膨出。     

Prevalence and prenatal diagnosis of neural tube defects in Nova Scotia in 1980-84.

A survey of the records of all hospitals with obstetric services in Nova Scotia revealed that during 1980-84 there were 122 pregnancies involving a neural tube defect. The mean rate was 2/1000 births. Of the affected fetuses or infants 54% had spina bifida, 35% had anencephaly and 11% had encephalocele. The records showed that in the early part of the period studied at least one prenatal ultrasonographic examination had been performed in 60% of the pregnancies; in 1984 the rate was 74%. When examinations done before 16 weeks' gestation were excluded, the overall detection rates at the first ultrasonographic examination were 100% for anencephaly and 73% for spina bifida and encephalocele; the rates improved toward the end of the study period.     

Reconstruction of large limb bone defects with a double-barrel free vascularized fibular graft

Background The use of a free, vascularized fibular graft is an important technique for the reconstruction of large defects in long bones. The technique has many advantages in strong, tubular bones; a more reliable vascular anatomy with a large vascular diameter and long pedicle is used, minimizing donor-site morbidity. Due to limitations in both fibular anatomy and mechanics, they cannot effectively be used to treat large limb bone defects due to their volume and strength.
Methods From 1990 to 2001, 16 clinical cases of large bone defects were treated using vascularized double-barrel fibular grafts. Patients were evaluated for an average of 10 months after surgery.
Results All the patients achieved bony union; the average bone union took 10 months post surgery, and no stress fractures occurred. Compared with single fibular grafts, the vascularized double-barrel fibular grafts greatly facilitate bony union and are associated with fewer complications, suggesting that the vascularized double-barrel fibular graft is a valuable procedure for the correction of large bone defects in large, long bones in addition to enhancing bone intensity.
Conclusions The vascularized double-barrel fibular graft is superior to the single fibular graft in stimulating osteogenous activity and biological mechanics for the correction of very large bone defects in large, long bones. Free vascutarized folded double-barrel fibular grafts can not only fill up large bone defects, but also improve the intensity margin. Therefore, this study also widens its application and enlarges the treatment targets. However, in the case of bone deformability, special attention should be paid to bone fixation and protection of donor and recipient sites.