| Objective:Craniotomy for decompression of bone flap is a frequently used surgical method in the clinical work of neurosurgeons.After the primary craniocerebral disease cured and the intracranial brain tissue edema restored,the skull defect that originally had therapeutic significance becomes a pathological factor affecting the clinical recovery of patients.The first 3 months after craniocerebral injury are generally considered to be the best time for nerve function and brain tissue recovery.It is generally believed that the repair time of skull defects after craniotomy and decompression is 3 to 6 months.At present,more and more people believe that the cranioplasty should be carried out as soon as possible after the patient’s intracranial condition is stable.The purpose of this study was to compare the effects of cranioplasty at different time intervals on the recovery of nerve function and the incidence of complications in patients with decompression of bone flap,to find the best time for cranioplasty,guide clinical treatment and improve the prognosis of patients.Methods:Patients who underwent craniocerebral trauma and cerebrovascular disease in affiliated hospital of Qingdao university and Rizhao people’s hospital from March 2015 to March 2019 were selected as candidates for cranioplasty after craniotomy for craniocerebral trauma and cerebrovascular disease.According to the inclusion conditions and exclusion conditions,the patients were divided into(1)early group of patients who underwent craniotomy for cranial repair 1-3 months after surgery;(2)patients in the conventional group received cranial repair 3-6 months after craniotomy.(3)patients in the delay group received cranial repair 6-12 months after craniotomy.One month after craniotomy(before skull repair in the early group),2 days before cranioplasty,and 18 months after craniotomy.The scores were based on the National Institutes of Health Stroke Scale(NIHSS)and the Barthle Index(BI).Glasgow Outcome Scale(GOS)was performed 18 months after decompression of the bone flap.The prognosis was poor in 1-3 points;The prognosis was good in 4-5 minutes.There is a special person in charge of grading,and the grading personnel shall implement single-blind management.The patients received routine follow-up after cranioplasty,regular neurological function score,and brain CT reexamination to evaluate the road bone healing.The patients were followed up 1 month,3 months and 6 months after cranioplasty to evaluate the complications(infection after transplantation,bone flap absorption and nonunion,severe subcutaneous fluid).Patients were followed up 18 months after craniotomy,and NIHSS score,BI score and GOS score were obtained.The follow-up was mainly in the form of outpatient follow-up,and some patients with mobility disability were followed up at home.Results:A total of 786 patients underwent craniotomy and cranioplasty during the study.According to the inclusion conditions,185 patients participated in the experiment,and they were divided into the early group(59 cases),the conventional group(78 cases)and the advanced group(48 cases)according to the random number method.There were 21 cases of lost follow-up,7 cases in the early group,9 cases in the conventional group and 5 cases in the late group.Included in the study were 164 cases,93 males and 71 females,aged 18-65 years old,with an average age of 45.36± 5.81 years old.There were 52 patients in the early group,including 30 males and 22 females,aged 18-64 years,with an average age of 44.94±6.23 years.There were 69 patients in the conventional group,including 39 males and 30 females,aged 19-65 years,with an average age of 45.61 ±6.77 years.There were 43 patients in the advanced group,including 24 males and 19 females,aged 18-65 years,with an average age of 45.83±5.98 years.There was no statistically significant difference in the basic data between the three groups(P＞0.05).The cranial repair time of patients in the early group was 43-89 days,with an average of 61.56± 19.28 days.The cranial repair time in the conventional group was 98-176 days,with an average of 132.83±30.95 days.The cranial repair time of patients in the advanced group was 189-360 days,with an average of 267.57±60.45 days.NIHSS score 1 month after craniotomy and osteotomy showed no significant difference between the early group(17.85± 1.89),the conventional group(17.75± 1.38)and the late group(17.72±3.30)(F=0.045,P=0.956).NIHSS score at 18 months after craniotomy and osteotomy was 11.44±3.00 in the early group,12.97±4.42 in the conventional group and 14.44±3.40 in the late group.The difference between the three groups was statistically significant(F=8.473,P=0.000).NIHSS score at 18 months after craniotomy and osteotomy:the early group was lower than the conventional group(11.44±3.00 vs.12.97±4.42,t=2.119,P=0.036).The early group was significantly lower than the late group(11.44 ± 3.00 vs.14.58 ± 3.30,t=4.854,P=0.000).The conventional group was lower than the advanced group(12.97±4.42 vs.14.58±3.30,t=2.037,P=0.044).One month after craniotomy and osteotomy,there was no statistically significant difference in BI score between the early group(59.42± 12.42),the conventional group(60.13±12.33)and the late group(58.42±11.55)(F=0.259,P=0.772).Eighteen months after craniotomy and bone-flap removal,the BI score of the early group(69.58± 10.25),the conventional group(65.78±9.40)and the late group(62.07±8.99)was statistically significant(F=7.260,P=0.001).BI score 18 months after craniotomy and osteotomy:the early group was significantly higher than the conventional group(69.58± 10.25 vs.65.78±9.40,t=3.199,P=0.002).The early group was significantly higher than the late group(69.58±10.25 vs.62.07±8.99,t=5.125,P=0.000).The conventional group was significantly higher than the advanced group(65.78±9.40 vs.62.07±8.99,t=3.827,P=0.000).GOS score 18 months after craniotomy and bone-flap removal,the early group(3.9810.896),the conventional group(3.609 1.046)and the late group(3.326 1.085)showed statistically significant differences(F=5.045,P=0.007).GOS score 18 months after craniotomy and osteotomy:the early group was higher than the conventional group(3.981±0.896 vs.3.609± 1.046,t=2.057,P=0.042).The early group was significantly higher than the late group(3.981 ±0.896 vs.3.326±1.085,t=3.224,P=0.002).The conventional group was higher than the advanced group,but the difference was not statistically significant(3.609±1.046 vs.3.326± 1.085,t=1.373,P=0.173).Among the 164 patients included in the study,a total of 29 cases of postoperative complications after skull repair occurred,with an incidence rate of 17.68%.Among them,6 cases were infected after transplantation,8 cases were bone flap absorption nonunion(excluding nonunion caused by infection),and 15 cases were severe subcutaneous effusion.In the early group,there were 5 cases of complications:1 cases of infection after transplantation,1 case of bone flap absorption nonunion,and 3 cases of severe subcutaneous effusion.In the conventional group,there were 9 cases of complications:2 cases of infection after transplantation,1 cases of bone flap absorption nonunion,and 6 cases of severe subcutaneous effusion.In the late stage group,there were 15 cases of complications:3 cases of infection after transplantation,6 cases of bone flap absorption nonunion,and 6 cases of severe subcutaneous effusion.After cranioplasty,there was a statistically significant difference between the three groups(2=12.086,P=0.002).Complications in the late group were higher than those in the early group(2=7.585,P=0.006).Complications in the advanced group were higher than those in the conventional group(2=6.264,P=0.012).There was no significant difference in complications between the conventional group and the early group(2=0.341,P=0.559).There was no significant difference between the three groups(x2=3.684,P=0.159).The difference of bone flap absorption and nonunion after skull repair in three groups was statistically significant(x2=10.359,P=0.006).The absorption and nonunion of bone flap after skull repair were higher in the late group than in the early group(χ2=4.991,P=0.025)and the conventional group(χ2=7.069,P=0.008).There was no significant difference between the three groups in the comparison of severe subcutaneous effusion after skull repair(x2=1.926,P=0.382).The severe subcutaneous effusion after skull repair in the late group was higher than that in the early group,but the difference was not statistically significant(χ2=1.008,P=0.315).Conclusions:Early cranioplasty can significantly promote the recovery of neurological function and improve the clinical prognosis.Early cranioplasty can significantly reduce the incidence of complications such as severe subdural effusion and nonunion of bone flap repaired by deep cryopreservation autologous skull orthotopic transplantation.The patient’s general condition permits,should strive for three months after the operation of bone flap removal to perform early cranioplasty;In the absence of contraindications,delay cranioplasty over 6 months should be avoided. |
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