RU2640996C1 - Method for valval craniotomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: decompressive craniotomy is performed. The bone flap is maintained, which is vertically split into two valve parts along the geometric center and each valve is fixed in the bone window two bone sutures, fixing against collapsing with titanium Z-shaped fixtures that are attached to the skull bone. One of the devices, 10-20 mm long is screwed to the skull bone on the line of bone flap cutting and intact skull at the valves junction, and one device, 5-10 mm long is fixed to each of the opposite walls of the bone window between the bone sutures. Then the skin-muscle-aponeurotic flap is laid in place and the wound is sutured. Z-shaped fixtures have a wall thickness of 0.5-1.5 mm, height, depending on the thickness of the skull bones at the place of fixation, a working angle, depending on the angle of skull bone cutting and holes on a shelf for the fixture.

EFFECT: method allows to exclude valves blocking through mobile fixation of valves with a turn outside relative to the skull bone, and prevent repeated cranioplasty.

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Description

The invention relates to neurosurgery, and in particular to a method for conducting valvular trepanation of the skull with the elimination of sagging, and can be used for decompressive trepanation of the skull in patients with intracranial hypertension syndrome.

For the treatment of patients with intracranial hypertension refractory syndrome, conservative therapy uses decompressive craniotomy in order to increase intracranial volumes. Standard surgery includes decompressive trepanation of the skull, infratemporal decompression, duraplasty and, in case of a favorable outcome, subsequent cranioplasty.

Despite the significant positive effect of decompressive trepanation of the skull, the postoperative period in most cases is accompanied by the appearance of negative consequences, the main of which is called “trepanirovanny syndrome”, namely skin retraction in the area of the bone defect.

Skin entrapment in the area of the bone defect causes liquorodynamic disturbances, especially in the arachnoid spaces surrounding the vessels. This, in turn, leads to a decrease in brain perfusion and impaired venous outflow, which causes neurological deficiency. The only method of breaking this pathological chain is the timely implementation of cranioplasty - a second operation aimed at eliminating defects and restoring the integrity of the skull.

In order to exclude reoperation, as well as to avoid “trepanirovanny syndrome”, “folding” craniotomy is performed, which allows to ensure mobility (mobility) of bone fragments - “cusps” for the time of increased intracranial pressure, usually within 7-14 days of pronounced intracranial hypertension . Despite all the positive results of carrying out osteoplastic decompression techniques, the issue of fixation of bone fragments - valves is still an open question.

A known method of cranioplasty is to perform trepanation, subsequent placement of the graft in a bone defect in the cranial vault and its fixation to the skull bones using fixing devices (see the description of the invention for USSR copyright certificate No. 1655477, IPC A61B 17/58, publ. 15.06.1991 )

In the known method, the graft is made in the form of a whole plate, and for fastening the graft to the bone defect of the cranial vault, three complex constructional fixation devices made in the form of cotter pins made of porous nickelide are used. Each of the cotter pins has a flattened head with spikes and a trapezoidal rod with a diverging end, for installation of which trapezoidal grooves and diverging channels are formed in the skull bones to the depth of the diverging end of the trapezoidal rod, which complicates the method. In addition, the cotter pin eliminates the mobility of the graft, providing a rigid connection of the graft and the bones of the skull, which is unacceptable with intracranial hypertension syndrome.

There is a method of plasty of skull defects, which consists in performing trepanation, subsequent laying of the graft in a bone defect of the cranial vault and its movable fixation to the bone of the skull with bone sutures (see the description of the invention for USSR copyright certificate No. 1289473, IPC A61B 17/00, publ. 15.02. 1987).

The known method involves the use of a pre-prepared graft, which is placed in a bone defect in the cranial vault, without exfoliating the dura mater, and is sutured with suture threads held U-shaped through openings made in the graft to the aponeurosis, fixing to the bone of the skull movably outward from the brain . Fixation to the aponeurosis does not ensure the cusps to turn outward and does not exclude the graft from falling into the cranial cavity, which is accompanied by the occurrence of postoperative complications. The use of bone sutures can lead to a displacement of the bone flap, including into the cranial cavity after a decrease in intracranial hypertension, which can entail both trauma to intracranial structures and functional disorders in the form of a convulsive syndrome.

, C. Martins, J. C. da Silva, et al. // Advances in the Treatment of Ischemic Stroke, Dr. Maurizio Balestrino (Ed.). - 2012. - P. 227-246.)There is a known method of folding craniotomy, adopted as a prototype, which consists in performing decompressive trepanation, maintaining a bone flap, vertical sawing of a bone flap into two flap parts and then stitching each part with two bone sutures to the bone window in the front and back of it (see An Innovative Technique of Decompressive Craniectomy for Acute Ischemic Stroke / MM

, C. Martins, JC da Silva, et al. // Advances in the Treatment of Ischemic Stroke, Dr. Maurizio Balestrino (Ed.). - 2012. - P. 227-246.)

Bone sutures provide the leaflets with the possibility of mobility, namely, the possibility of a limited rotation of the leaflets out of the skull by an angle determined by the tension of the surface tissues (muscles, aponeurosis, subcutaneous fat and skin) with increased intracranial pressure, but do not exclude the sash in the skull cavity along the cut line after normalization of intracranial pressure.

The entrapment of the valves in the cranial cavity entails both trauma to the intracranial structures and functional disturbances in the form of a convulsive syndrome, which is a disadvantage of the known method.

The technical task and the result of the proposed method is the possibility of movable fixation of the valves with the turn outward relative to the bone of the skull, excluding both the leaflet retraction and the second operation on the skull plastic - cranioplasty, which allows to accelerate the implementation of rehabilitation measures.

The technical problem is solved in that in the method of leaf trepanation of the skull of the sash before laying the skin-muscle-aponeurotic flap is additionally fixed from being absorbed by titanium devices of a Z-shape with a wall thickness of 0.5-1.5 mm, a height depending on the thickness of the skull bone in place fixation, working angle, depending on the angle of cut of the bone of the skull, and holes on one shelf for fasteners, while one of the devices 10-20 mm long is screwed to the bone of the skull on the cut line of the bone flap and intact skull in place with yka flaps and one device 5-10 mm - on opposite sides of the bone between the bone window seams.

The use of bone sutures provides the possibility of a limited rotation of the valves outside the skull with an increase in intracranial pressure, the magnitude of which depends on the tension of the surface tissues (muscles, aponeurosis, subcutaneous fat and skin), and the installation of Z-shaped devices between the bone sutures and on the cut line of the bone flap and the intact skull at the junction of the cusps eliminates the retraction of the cusps into the cranial cavity when the cusps move in the opposite direction with a decrease in intracranial pressure.

The proposed method eliminates the occurrence of postoperative complications and reoperation - cranioplasty.

The proposed method is illustrated by drawings, where in FIG. 1 shows the valves fixed in the bony window of the skull; in FIG. 2 is a section AA in FIG. one; in FIG. 3 - general view of the fixing device, isometry.

The invention consists in the following. First, decompressive trepanation of the skull is performed with preservation of the bone flap, which is cut in half into two parts, the leaves 1 and 2 vertically along the line of the geometric center. Then, each leaf 1 and 2 is sutured with two bone sutures 3 and 4 in the front and rear parts of the bony window of the skull, respectively, made with threads, using a non-absorbable thread from lavsan or lye. The fastening of the flaps 1 and 2 by bone sutures 3 and 4, made of threads, form a movable articulation of the flaps 1 and 2 with the bone of the skull, which allows for a limited rotation of the flaps 1 and 2 both outward and inward of the skull. In order to prevent the junction of the flaps 1 and 2 from getting inside the skull, along the cut line of the bone flap, at the junction of the flaps 1 and 2 and the intact skull, one titanium fixation device 5 is installed, and one more device 6 and 7 respectively between the bone sutures 3 and 4, respectively .

The fixtures 5, 6 and 7 are made of Z-shaped titanium with a wall thickness (s) of not more than a cut of skull bones of 0.5-1.5 mm and with a working angle (α) of 90-140 °, depending on the direction of the cut line of the bone skulls. The width (a) of the shelves of devices 5, 6 and 7 is 6-8 mm, and the length (l) of devices 5, 6 and 7 is 10-20 mm and 5-10 mm, respectively. The height (h) of devices 5, 6 and 7 depends on the thickness of the skull bone at the installation site and is equal to 6-10 mm. One shelf of devices 5, 6 and 7 is performed with holes 8 for fasteners, for example titanium screws (screws are not shown in the drawing).

One shelf with the holes of devices 5, 6 and 7 is placed on the surface of the skull bone and fastened to the skull with screws through the holes 8, and on the other shelf they are installed with the lower surface of the edges of the cusps 1 and 2, placing them at the level of the skull bone and not allowing them to sink inside the skull . Then the skin-muscle-aponeurotic flap is placed in place and the wound is sutured in layers, while the bone sutures 3, 4 and Z-shaped devices 5, 6 and 7 provide mobility of the bone cusps 1 and 2 to normalize the intracranial pressure and the moment of occurrence of bone fusion.

With an increase in intracranial pressure, the flaps 1 and 2 have the possibility of limited rotation under the skin-muscle-aponeurotic flap on the bone sutures 3 and 4 to the outside of the skull, with a decrease in intracranial pressure, they can move in the opposite direction, with an emphasis on the corners of the flaps 1 and 2 on the shelf of the device 5 , excluding their retraction, preventing compression of the brain in the postoperative period, and devices 6 and 7 exclude the retraction of the valves 1 and 2 at the place of their attachment with bone sutures 3 and 4.

Example 1

Patient K. was hospitalized in the Department of Neuroresuscitation 07.07.2016, 2 hours later after a road injury in a coma. After a general clinical and X-ray examination (computed tomography of the brain), the diagnosis was established: Closed head injury, severe brain contusion with compression of an acute subdural hematoma with a volume of 100 cm ³ on the left, cerebral edema, dislocation syndrome. Injuries of the soft tissues of the head, face. An emergency operation was performed under combined anesthesia: Valvular trepanation in the fronto-parietal-temporal region on the left, removal of acute subdural hematoma, and dura mater.

Surgical protocol: After processing the surgical field under combined anesthesia in the left parietal-temporal region, an incision was made according to the Trauma flap type. A skin-muscle-aponeurotic flap was formed, with the base allotted to the ear, fixed, processed. Along the perimeter of the bone section intended for resection, 7 milling holes were made. A jigley saw was brought into the epidural space through a conductor through milling holes. Sliced bones at a distance of 0.5 cm from the edges of the milling holes are cut. The bone is removed. The dura mater is sharply tense, swells out, does not transmit the pulsation of the brain, is opened horseshoe-shaped, blood clots of up to 100 ml are found under it, which were gradually removed with a spatula and by washing with physiological saline. A revision of the subdural space was made, the source of bleeding was revealed - the cortical vessel, the latter coagulated. The surgical field is washed with physiological saline, a distinct pulsation and expansion of the substance of the brain are noted. Dura mater periosteum and temporal muscle aponeurosis. The bone flap is sawn vertically, fixed anteriorly and posteriorly with two sutures from Dacron on each side. In the parietal region of the intact skull, a fixing Z-shaped device was installed against the sinking of the valves for life. The musculocutaneous aponeurotic flap was put in place, the wound was sutured with the removal through a separate incision of polyvinyl chloride drainage installed in the subaponeurotic space. 35 days after the complex treatment, the patient was discharged for outpatient aftercare and medical examination at a neurologist at the place of residence. Rehabilitation treatment was carried out.

On the control computed tomogram after 2 weeks: satisfactory standing of the flap of the bone flap without entrapment in the cranial cavity.

Example 2

Patient P. was hospitalized in the intensive care unit for patients with cerebrovascular accident 11.11.2016, 2 hours after the onset of the disease with right-sided hemiparesis, sensorimotor aphasia. After a general clinical and radiological examination (computer brain), the diagnosis was established: Ischemic stroke in the pool of the left middle cerebral artery. Conservative treatment has been prescribed. During treatment, a patient with negative dynamics in the form of oppression of consciousness to stun. On the control computer tomogram - hemispheric ischemic stroke in the basin of the left middle cerebral artery, cerebral edema, dislocation of the median structures. In an emergency, under combined anesthesia, an operation was performed: Valvular trepanation in the fronto-parietal-temporal region on the left, dura mater.

Surgical protocol: After treatment of the surgical field under combined anesthesia, local infiltration anesthesia with 0.5% novocaine 30.0 in the temporal parietal region on the left made an incision according to the Trauma flap type. A skin-muscle-aponeurotic flap was formed, with the base allotted to the ear, fixed, processed. Along the perimeter of the bone section intended for resection, 7 milling holes were made. A jigley saw was brought into the epidural space through a conductor through milling holes. Sliced bones at a distance of 0.5 cm from the edges of the milling holes are cut. The bone is removed. The dura mater is sharply tense, swells out, does not transmit the pulsation of the brain, is opened like a horseshoe, under it is an edematous brain. A revision of the subdural space was performed. The surgical field is washed with physiological saline, a distinct pulsation and expansion of the substance of the brain are noted. Dura mater periosteum and temporal muscle aponeurosis. The bone flap is sawn vertically, fixed anteriorly and posteriorly with two sutures from Dacron on each side. In the parietal region of the intact skull, a fixation device is installed against the sash retraction. The musculocutaneous aponeurotic flap was put in place, the wound was sutured with the removal through a separate incision of polyvinyl chloride drainage installed in the subaponeurotic space. 35 days after the complex treatment, the patient was discharged for outpatient aftercare and medical examination at a neurologist at the place of residence. Rehabilitation treatment was carried out.

On control computed tomograms after 2 weeks: satisfactory standing of the flap of the bone flap without retraction into the cavity of the skull.

Conclusion: 5 patients were operated on with this method in the neuroresuscitation department, all received good functional, therapeutic and cosmetic results, there were no complications during surgical treatment of this category of patients with the developed method.

Claims (1)

The method of valve trepanation of the skull, which consists in performing decompressive trepanation, maintaining a bone flap, cutting a bone flap into two flap parts vertically along the line of the geometric center and stitching each part in the bone window with two bone sutures, followed by laying the musculoaponeurotic flap in place and suturing the wound, characterized in that the sashes before laying the skin-muscle-aponeurotic flap are additionally fixed from being absorbed by titanium devices of a Z-shaped thickness wall 0.5-1.5 mm, height, depending on the thickness of the skull bone at the place of fixation, working angle, depending on the angle of cut of the skull bone, and holes on one shelf for fasteners, while one of the devices is 10-20 mm long fasten with screws to the skull bone on the cut line of the bone flap and intact skull at the junction of the valves and one device with a length of 5-10 mm on opposite walls of the bone window between the bone sutures.

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