RU2701910C1 - Method for repairing dura mater defect and sealing subdural space within bone defect of cranial vault - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to areas of neurosurgery and operative surgery, and is intended for use in making the defect plasty of a solid cerebral membrane in cerebral surgeries. In the absence of access to the free edge of the dura mater defect located under the bone structures of the cranial vault and adjacent to the venous sinuses of the dura mater, on the corresponding edge of the trephine defect, bone holes are inserted through an external bone plate and spongy substance without drilling an internal bone plate. Graft for replacement of dura mater defect is fixed by continuous suture to available free edge of dura mater, and in area of venous sinus - through bone channels to edge of trephination defect of cranial vault. Bone flap is placed from above, fixing it to the edges of defect of bones of the cranial vault by traditional methods.

EFFECT: method enables higher reliability of the dura mater defects sealing in the absence of access to the free edge in the areas adjoining the venous sinuses, allows to exclude damages of venous sinuses and fatal haemorrhages from them, to avoid expansion of bone defects and their plasty by artificial implants.

5 cl, 4 dwg, 1 ex

Description

Method for plasty of the dura mater defect and sealing of the subdural space in the area of the bone defect of the cranial vault

The invention relates to medicine, in particular to the fields of neurosurgery and operative surgery, and can be used to perform plasty of the defects of the dura mater adjacent to the venous sinuses of the dura mater during brain operations.

Violation of the integrity of the dura mater during planned and emergency surgical interventions on the brain, creating messages of the subdural space with the environment, causes a risk of developing postoperative external and latent cerebrospinal fluid, intracranial infectious complications. The presence of operational defects of the dura mater of the brain increases the risk of cerebrospinal fluid leakage in the postoperative period, prevents the timely healing of the surgical wound, promotes the formation of a meningeal scar, in some cases entails the need for repeated neurosurgical intervention, worsens the quality of life of the patient, increases the length of his stay in hospitalization and increases the cost of treatment. In this regard, the development of methods for plasty of the dura mater remains one of the urgent tasks of modern neurosurgery.

The classic way to restore the integrity of the dura mater is to suture its defect, or use auto-, allo- or xenografts to close the defect, and seal using adhesive compositions. There is a method of plasty of defects of the dura mater at the edge of a bone defect, in which it is recommended to increase the bone defect due to bone resection in order to gain access to the edge of the shell, which appeared under the bone during surgery, to fix the graft to it (Kushel Yu.V., Semin V.E. Kraniotomy. - M: New time, 1998. - 76 p.). The disadvantages of the method: an increase in the area of the trepanation defect exceeding the size of the sawn bone flap, which does not allow cranioplasty to be performed with autobone (due to violation of congruence of the bone flap and the edges of the trepanation defect), an increase in the total duration of the operation, an increase in the risk of damage to the adjacent venous sinuses of the dura mater and the development of menacing blood loss life.

Closest to the claimed is a method of replacing a defect of the dura mater (Old B.C., Ginzburg E.R. RU 2 201 163 C1, 03/27/2003), adopted as a prototype. For transplantation of the dura mater, the brefoticle of the same name is used that is larger than a skull defect. Drilling is carried out in the bone at the edge of the skull defect. A graft is placed under the edge of the bone in the defect. Attach the center of the sheath transplant with threads of a long absorbable material through channels drilled in the center of the plate. Close the bone defect with a plate and fix it with ligatures to the bones through the channels drilled in them. In this case, first a sterile transparent and elastic film is applied to the skull defect in the wound, and marks on the contour of the skull defect and holes of the drilled canals in the bones and in the plate are applied to its surface. Then, the sheath graft, together with the film attached to it, is cut outside the contour and marks on the film. Then, through the marks of the holes on the film and simultaneously through the graft, the threads are carried out, the film is removed, and the graft is fixed with threads through channels in the bones to the inner surface of the skull.

The disadvantages of the prototype: drilling a bone near the edge of the skull defect, bringing the graft under the edge of the bone in the defect and passing the threads through the channels in the bones can lead to a high probability of damage to the venous sinuses of the dura mater and bleeding, the latter requires access to the site of damage to the sinus to stop it due to additional bone resection over the damaged sinus and a significant increase in the bone defect. Damage to the superior sagittal sinus in the middle and posterior thirds and in the area of the sinus flow is especially dangerous. The use of nodal sutures can lead to insufficient sealing of the cranial cavity, the occurrence of postoperative liquorrhea, meningitis.

The invention is directed to the creation of a method for plastics defects in the dura mater of the brain adjacent to the venous sinuses of the dura mater without additional bone resection to access the free edge of the shell.

The technical result of the invention is to increase the reliability of the plastics defects of the dura mater and sealing the cranial cavity. This is achieved by the fact that the drilling of channels in the bone at the edge of the skull defect is carried out at an angle through the outer bone plate and the spongy substance, without damaging the inner bone plate (see illustrations), the graft (2) is placed on the dura mater defect (1) and fixed its continuous suture (3) to the free edge of the dura mater and the lateral surface of the bone at the edge of the skull defect (7). It is the drilling of the bone canals at an angle that avoids damage to the venous sinuses of the dura mater (4), and the imposition of a continuous suture (3) along the entire perimeter of the area of the dura mater defect and laying on top of the bone flap (6) with fixation to the edges of the bone defect (7) make it possible to achieve a tighter fit of the substitute for the dura mater to the bone, the latter allows to level out possible defects of the continuous suture in contact with the bone graft, which provides a more reliable seal cranial cavity. The presence of contact of the graft (2) with the spongy layer of the bones of the cranial vault (7) ensures the formation of a connective tissue scar that extends deep into the bones of the cranial vault. The method is as follows.

In the absence of access to the free edge of the dura mater defect located under the bony structures of the cranial vault (7) and adjacent to the venous sinuses (4) of the dura mater, holes in the bones are applied along the corresponding edge of the trepanation defect with an equal interval (0.5-0 , 8 cm) at an angle of 30-45 ° through the outer bone plate and the spongy substance without drilling the inner bone plate. A graft (2) is formed that exceeds the area of the dura mater defect. Place the transplant formed.

(2) on the defect of the dura mater, fix it with a continuous suture

(3) along the entire perimeter of this defect to the free edge of the dura mater (1) and through the bone channels to the edge of the trepanation defect of the cranial vault. A bone flap (6) is placed on top, fixing to the edges of the defect bones of the cranial vault with interrupted sutures or titanium fixators.

In FIG. 1 is a schematic general view of a plastics method in a sagittal section.

In FIG. 2 is a diagram of a method with a laid bone flap.

In FIG. 3 - seam diagram - top view.

In FIG. 4 - intraoperative photography.

The inventive method is developed and passed clinical trials in the clinic of neurosurgery of the Military Medical Academy. CM. Kirov MO RF in the treatment of 5 patients. All patients managed to obtain reliable plasty of postoperative defects of the dura mater adjacent to the venous sinuses of the dura mater, to prevent postoperative cerebrospinal fluid, meningitis in the early postoperative period.

Clinical example.

Patient C, 53 years old, was admitted to the neurosurgery clinic of VMedA them. CM. Kirov 11/28/2017, with complaints of constant headache, memory impairment. MRI revealed parasagittal meningioma in the left parietal region measuring 5 × 4 × 3 cm.

Clinical diagnosis: parasagittal meningioma in the left parietal region.

November 30, 2017 the operation was performed: Osteoplastic trepanation of the skull in the parietal region on the left, removal of the parasagittal meningioma of the parietal region on the left.

Surgical protocol: Under general multicomponent anesthesia with tracheal intubation in the patient position lying on the back with a raised head end, head rotation to the right and fixing it to the operating table using the Mayfield-Keyes bracket, an arcuate incision of soft tissues was made in the left parietal region, about 17 in length see. Left parietal bone partially skeletonized. A bone window about 8 × 7 cm in size is formed from two milling holes by sawing.

An altered dura mater with a germinating tumor matrix was visualized in the projection of a trepanation window. The TMT is dissected along the perimeter of the tumor within the unchanged tissue, while along the medial side of the trepanation window, the TMT section is made along the edge of the bone defect to achieve radical removal of the tumor. The tumor is gradually separated from the brain tissue together with the matrix of pathologically altered TMT and removed in a single block. Hemostasis using diathermocoagulation. Control of a wound on foreign bodies - no, hemostasis is steady.

Plastic surgery of the resulting TMT defect was performed as described using a fragment of the broad fascia of the femur fixed from the medial side to the edge of the trepanation window (Fig. 4). The bone flap is laid in place and fixed with three titanium plates. The aponeurotic skin flap is in place. Layer wound closure tightly. The postoperative period was satisfactory.

In neurological status without negative dynamics.

During the control CT scan (December 1, 2017) and MRI (December 5, 2017): the tumor was radically removed, there were no hemorrhagic complications, and there were no signs of pathological accumulations of cerebrospinal fluid in the area of surgical intervention.

The patient was discharged 7 days after surgery.

Using the proposed method for plasty of defects of the dura mater allows you to increase the reliability of sealing defects of the dura mater in the absence of access to the free edge in the areas adjacent to the venous sinuses of the dura mater due to drilling of bone channels at an angle through the outer bone plate and the spongy substance without damaging the internal bone plate, and graft fixation with a continuous suture along the entire perimeter of this defect to the free edge of the dura mater bone and through the channels to the edge of the burr calvarial defect, avoids damage to the venous sinuses of the dura mater and fatal hemorrhages of them avoid the expansion of bone defects and their plastic artificial implants, reoperation, postoperative and inflammatory complications liquorrhea.

Claims (5)

1. The method of plasty of the dura mater defect and sealing of the subdural space in the area of the bone defect of the cranial vault, including the formation of a graft exceeding the area of the dura mater defect, placing the formed graft on the dura mater defect, suturing it along the entire perimeter of this defect to the free edge of the dura mater and to the edge of the trepanation defect of the cranial vault, characterized in that before being placed in the area of the defect of the dura mater the grafts of the graft are drilled through the corresponding edge of the trepanation defect into the bones with an equal interval of 0.5-0.8 cm at an angle of 30-45 ° through the outer bone plate and the spongy substance without drilling the inner bone plate, and then the graft is fixed with a continuous suture, separate from above a bone flap is fixed with interrupted sutures, pressing the graft along the perimeter of the bone defect, contributing to additional sealing of the subdural space. 2. The method according to p. 1, provides for the use of an automaterial as a transplant. 3. The method according to p. 1, characterized in that as the transplant use allomaterial, for example, decellulated cadaveric dura mater. 4. The method according to p. 1, characterized in that the non-resorbable artificial polymeric materials, for example polytetrafluoroethylene, polyesterurethane, are used as the graft. 5. The method according to p. 1, characterized in that as the graft use resorbable biosynthetic materials, for example collagen, polylactide.

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