微创钻颅治疗慢性硬膜下血肿的疗效研究

发布时间：2018-03-16 01:16

  本文选题：慢性硬膜下血肿　切入点：钻颅术　出处：《南京医科大学》2017年博士论文　论文类型：学位论文

【摘要】：目的试图利用前期研究中创建的全新的终点指标,通过随机对照设计的临床病例研究,分析微创钻颅术(twist drill craniotomy,TDC)与环钻钻颅术(burr hole craniotomy,BHC)治疗的慢性硬膜下血肿(chronic subdural hematoma,CSDH)患者治愈率及术前、术后48小时、三个月的mRS评分(modified Rankin Scale),以比较两者的优劣。方法实验设计通过伦理学审核后,2016年1月至2017年1月,共募集40例头颅CT确诊有慢性硬膜下血肿形成并需要手术减压的患者,年龄18岁,性别不限,随机分配至TDC组与BHC组,每组20人,使用mRS评分量表,分别记录各患者术前、术后48小时与3个月的mRS评分。其中术后48小时评分未改善,需要再次手术者记为手术失败(Failure)并进行补救手术(Remedial)。48小时后评分改善者记为手术成功(Success),患者症状平稳后出院,记录住院时间(Duration),随访3个月内硬膜下血肿再聚集(Recurrence)并出现神经功能缺损症状(Symptomatic)复发需要再次手术者记为二次手术(Reoperation),CT检查完全吸收(Clear)或虽然有残余(Residual)硬膜下积液但患者神经功能缺损症状评分无加重者(Asymptomatic)统一记为治愈(Cure)。两组数据计量资料使用两独立样本的t检验,对mRS评分及手术前后评分的差值及其与术前值的比使用Mann-Whitney U秩和检验,率的比较使用卡方检验。P0.05认为存在显著差异,有统计学意义。结果40例入组患者中,男33例,女7例,BHC和TDC组性别比分别为17/3与16/4;年龄19～86岁,其中60岁以上34例(85%);26例(65%)有明确外伤史,14例(35%)否认外伤史的患者年龄均大于60岁,与有明确外伤史的26例有明显差异(P=0.03)。两组患者在一般临床特征上无明显差异。TDC组1例行补救手术(P=0.31)。不能认为TDC手术失败率明显高于BHC组。BHC组有3例患者术前mRS评分5分。其中,两例分别于出院后32天和45天死亡。TDC组有4例术前mRS评分5分,1例术后一月死于癫痫及肺部感染。两组间死亡率比较无差异(P=0.48)。两组共有4例患者在3个月随访时复查头颅CT颅内血肿完全消失,其中TDC组3例,另1例19岁男性在BHC组(P=0.29)。其余患者术后3月复查头颅CT提示颅内均仍有残留血肿。BHC组有3例首次手术后30天、40天和47天再次切开引流。TDC组48小时内症状改善者,3个月内症状均平稳,未有患者需行二次手术(P=0.07)。双变量的相关性分析发现患者术前mRS评分与预后直接相关,术前神经功能缺损越严重,3个月后随访神经功能评分越差(P0.001),死亡率也越高(P0.01)。TDC术后患者平均住院日9±2.91天,相较于BHC手术的14.75±5.95天明显短(P=0.01)。在40例患者的总体样本中,住院时间越长,出院后症状复发需行第二次手术的风险越高(P0.01)。TDC组术后3月mRS评分的变化值Vpre-3m、V48h-3m与术前评分的比值V(pre-3m)/pre、V(48h-3m)/pre较BHC组均有明显差异(P0.05),提示TDC组患者手术前后神经功能改善较BHC组更明显。虽然TDC组患者中治愈者有18例(90%),但与BHC组15例(75%)的治愈率相比并无明显差异(P=0.21)。结论本研究未发现经两种手术治疗的慢性硬膜下血肿患者失败率与治愈率之间存在明显差异。但TDC组术后3月的mRS评分改善水平明显优于BHC组,同时TDC组患者较BHC组总体住院时间明显短,可以认为TDC方案优于BHC方案。
[Abstract]:Objective to use a new index to create end point in the previous research, through the clinical randomized controlled study design, analysis of minimally invasive trepenation (twist drill, craniotomy, TDC) and trephine craniotomy (burr hole, craniotomy, BHC) in treatment of chronic subdural hematoma (chronic subdural, hematoma, CSDH) and the cure rate of patients before the operation, 48 hours after operation, three months mRS score (modified Rankin Scale), to compare the advantages and disadvantages. The experimental design method by ethics review, January 2016 to January 2017, raising a total of 40 cases of cranial CT diagnosed with chronic subdural hematoma and decompression in patients 18 years of age, gender no limit, randomly assigned to TDC group and BHC group, each group of 20 people, the use of mRS score, the patients were recorded before operation, 48 hours after operation and 3 months mRS score. The score did not improve after 48 hours, need another operation record For the failure of operation (Failure) and remedial surgery (Remedial) for.48 hours after the score was improved as successful surgery (Success), patients with stable symptoms after recording, hospitalization time (Duration), within 3 months of follow-up subdural hematoma (Recurrence) and then aggregated symptoms of neurological impairment (Symptomatic) recurrence another operation is two times of surgery (Reoperation), CT (Clear) is completely absorbed or although there are residual subdural effusion (Residual) but the symptoms in patients with neurologic impairment score and weight (Asymptomatic) (Cure) as unified cure. T test of two sets of data measurement data using two independent samples, difference the score of mRS score before and after surgery and preoperative and value than using Mann-Whitney U rank test, were compared using chi square test.P0.05 believes that there are significant differences, with statistical significance. Results 40 patients, male 33渚，

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