RU2402284C1 - Plasty technique for basicranial defects - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention refers to medicine, namely to neurosurgery. The intracranial and endonasal approaches are applied. At first, a bone basicranial defect is closed by an intracranial technique with an autogenous bone fragment wrapped in an autofascial flap processed by BioGlue; autofatty tissue is laid above the flap. Then the basicranial defect is approached by the endonasal, transsphenoidal, transethmoidal techniques from outside to perform a plasty with an autologous fatty musculofascial flap processed by BioGlue. The edges of the fascial flap of the autograft are brought behind the edges of the bone basicranial defect and additionally fixed with the middle concha which is laterally deepithelialised, mobilised and laterally displaced. ^ EFFECT: technique ensures better surgical results that is reached by the basicranial defect closure both from the nasal cavity, and from the basicranial cavity. ^ 7 dwg, 2 ex

Description

The invention relates to medicine, namely to otorhinolaryngology, neurosurgery, and can be used in the surgical treatment of liquor fistulous passages with defects in the base of the skull.

There is a method of surgical treatment of nasal liquorrhea, which consists in excising the mucous membrane of the fistulous passage and at the same time excising the effect on the tissues adjacent to the fistulous passage by high-intensity laser radiation. The site of exposure is subsequently closed with auto-material. The method is performed endoscopically (RF patent No. 2346667, 2008). The method is less traumatic and effective.

However, the method is not effective in the treatment of nasal liquorrhea with defects in the dura mater (TMT).

Also known is a method of sealing and plasty of defects in the base of the skull (RF patent No. 2174825, 2001; Questions of neurosurgery. - M .: Medicine, 1998, 4, p. 3-9). Plastic surgery of the skull base defect is performed with a free congruent graft (wide fascia of the thigh, musculoskeletal flap, artificial dura mater, hydroxyapatite). In this case, transnasal and / or transoral access is used. The method is used to treat tumors of the base of the skull, while providing reliable sealing and plasticity of the cavity of the skull with large disparate defects of TMT.

However, in the presence of fistulous passage, the method is not effective, fistula passage is not sealed, complications are possible, for example, in the form of postoperative liquorrhea.

Known is a combined method of repairing defects in the base of the skull (application No. 2005111915) with a free autograft using bioglue. The method includes approaching a defect in the base of the skull both from the side of the nasal cavity (endonasally) and from the side of the cranial cavity (intracranially) and sealing the defect.

However, with large or multiple bone defects in the base of the skull, the reliability of fixation of a free autograft is not always sufficient, depressurization of the defect from the side of the cranial cavity and, as a consequence, the occurrence of postoperative complications, such as repeated cerebrospinal fluid, with subsequent meningitis and meningoencephalitis are possible.

The technical task is the qualitative improvement of the results of surgical treatment for large or multiple defects of the base of the skull, elimination of the cerebrospinal fluid fistula and liquorrhea by increasing the reliability of closing the defect of the base of the skull from the side of the nasal cavity and from the side of the skull cavity.

In the method for plasty of skull base defects, including the use of intracranial and endonasal approaches and closing of the skull base defect with free autografts with bioglue fixation, according to the invention, the bone defect of the base of the skull inside is closed first using intracranial access, and autocostomuscular fascial is used as a free autograft then use endonasal, transsphenoidal, transethmoidal access to the defect of the outer base of the skull and akryvayut defect autokostno-musculo-fascial flap outside, wherein the fascial flap plant in the bone defect edges of the skull base and further fixed with deepitelializirovannoy lateral sides, but with the preservation of the bone base of the middle turbinate, which mobilized and displaced laterally.

The use of two approaches to the skull base defect both from the side of the cranial cavity (incranially) and from the side of the nasal cavity (endonasal, transsphenoidal, transetmoidal) allows less severe and more qualitative plasticization of large defects of the base of the skull, covering the defect area with free autologous-muscular -fascial flaps - inside and out. At the same time, the autobone-muscular-fascial flap is fundamentally identical to the natural tissues that form the base of the skull. As a result, the integrity of the natural barriers of the brain and the outer base of the skull is fully restored. Fixation of autobone-muscular-fascial flaps using bioglue, as well as the insertion of a fascial flap beyond the edges of the bone defect in the base of the skull and additional fixation of the flap with the laterolyzed middle nasal concha, increase the reliability of fixation of the flaps, significantly increase the sealing of the defect, and ensure reliable closure of the bone defect of the base of the skull and, accordingly, the elimination of cerebrospinal fistulous course. The outflow of cerebrospinal fluid through the defect of the base of the skull is prevented and the path of infection penetration into the cranial cavity is reliably blocked.

The method is introduced into clinical practice by the Department of ENT diseases of the Ural State Medical Academy on the bases of the ENT and I neurosurgical departments of the Municipal Clinical Hospital No. 40 of Yekaterinburg. The proposed method operated on more than 80 patients, in the postoperative period, complications and relapses were not observed in any patient.

Thus, the proposed method of plastic surgery of the cerebrospinal fluid fistulous course allows a better quality surgical operation for large defects of the base of the skull.

The method is as follows.

The operation is performed in one intervention, using transcranial and transnasal approaches. As a free autograft, autobone-muscular-fascial flaps are used. Autologous bone is cut out from the bones of the cranial vault or from the iliac wing, muscle, fascia and adipose tissue are secreted and taken from the soft tissues of the lateral surface of the thigh or from the temporal muscle.

First, craniotomy is performed, which makes it possible to approach the structures of the base of the skull from the inside (intracranially). Under the control of the optics, the dura mater is mobilized, a bone defect is isolated and it is revised with refreshing edges. The defect is closed with an autocostal fragment wrapped in an autofascial flap treated with bioglue, and an autogyro tissue is placed on top of this flap (to the dura mater).

Then, endonasally, transsphenoidally, transetmoidally, using optics and endovideoscopic equipment, an access to the defect of the external base of the skull is made. From the side of the nasal cavity, the defect is audited, followed by plastic surgery with an auto-fat-muscle-fascial flap treated with bioglue. In this case, the edges of the fascia are wound beyond the edges of the bone defect of the base of the skull. Deepithelialization of the lateral surface of the middle nasal concha is performed, followed by mobilization and lateral displacement, thereby additionally fixing the free autologous fat-muscle fascial flap. The endonasal stage is completed with the usual anterior nasal tamponade, the turunds are completely removed on the 3rd day after the operation.

As a result of plastic surgery of nasocranial cerebrospinal fluid fistulas, this method provides reliable closure of the bone defect in the base of the skull and, therefore, elimination of the cerebrospinal fluid fistula.

Figure 1 presents a diagram of the plastic defect of the base of the skull in this way, where 1 is a layer of autogyro tissue; 2 - autobone wrapped in fascia, 3 - fascia, 4 - muscle tissue, 5 - lateral-pexated middle turbinate deepithelialized from the lateral side.

Figure 1 shows that the autocostal-muscular-fascial flaps on both sides cover the defect of the base of the skull, sealing it and thereby preventing the recurrence of cerebrospinal fluid and the development of meningoencephalitis. Autogyro tissue resorbs cerebrospinal fluid released from the defect of the dura mater, thereby contributing to the engraftment of the fascial-muscle flap and sealing the defect of the base of the skull.

Thus, the proposed method allows to achieve a significant qualitative improvement in the results of surgical treatment of defects in the base of the skull, which leads to a decrease in relapse of cerebrospinal fluid, prevention of meningitis and encephalitis, reduction of hospital stay days, reduction in the morbidity of surgical intervention, reduction of cases of disability, and It also reduces the risk of surgery and anesthesia, and, accordingly, has a pronounced economic effect.

Clinical example 1. Patient N., 18 l, was admitted to the neurosurgical department of the City Clinical Hospital No. 40 of Yekaterinburg with a diagnosis of neoplasm of the anterior cranial fossa, nasal liquorrhea. Complaints of headaches, periodic, liquid, colorless discharge from the nose. Sick for 3 years, she was not treated on her own.

The clinic conducted additional examinations: 1) CT with 3D and VRT reconstruction of the brain and paranasal sinuses: there is a volumetric neoplasm of the base of the skull with germination in the anterior cranial fossa, ethmoid labyrinth and sphenoid sinus. Diagnosis: neoplasm of the base of the skull.

Figure 2 - intraoperative photograph. An extensive defect (16 × 34 mm) of the base of the skull is visible after removal of the neoplasm (marked by an arrow).

Figure 3 - control CT study. At the site of the skull base defect, an autologous musculoskeletal-fascial flap (marked by an arrow) is visible.

Figure 4 - control CT study. At the site of the defect of the base of the skull, an autologous musculoskeletal-fascial flap is seen, fixed from the side of the nasal cavity with a lateropex-mediated nasal concha (marked by an arrow).

5 is a control CT study with 3D and VRT reconstruction. At the site of the skull base defect, an autologous musculoskeletal-fascial flap (marked by an arrow) is visible.

The operation was performed by the claimed method: under ETN with mechanical ventilation trepanation of the skull in the frontotoparietal region and traction of the frontal lobes of the brain, access was provided to the inner base of the skull in the region of the anterior cranial fossa. The intracranial part of the neoplasm was removed by lumping (Figure 2), the dura mater and bone defect were revised, and an autobone-girofacial flap treated with bioglue was placed in place of the defect (Figure 3). Fascia and adipose tissue were previously taken from the lateral surface of the thigh; the autobone was cut from a trepanized frontal bone. Tumor tissue within healthy tissue was removed endonasally transetmoidal-transfenoidally. After the audit, in place of an extensive defect in the base of the skull, an automuscular-fascial flap was placed (Figure 4), also previously taken from the lateral surface of the thigh. Deepithelialization of the lateral surface of the middle nasal concha on the right was made, the latter is lateropexed. Front nasal swab. The postoperative period proceeded without features and complications. Received antimicrobial therapy, activities aimed at normalizing cerebrospinal fluid pressure. Liquorrhea was not observed. The patient was discharged in satisfactory condition. At the control examination after 3 months, there is no data for liquor.

Clinical example 2. Patient T., 17 years old, was admitted to the I neurosurgical department of City Clinical Hospital No. 40 with a diagnosis of the consequences of a traumatic brain injury (TBI), nasal liquorrhea. From the anamnesis it is known that the patient suffered a severe head injury and after 1.5 months began to notice clear discharge from the nose, in connection with which he was then hospitalized in the I neurosurgical department of the City Clinical Hospital No. 40, where surgical treatment was performed: under ETN with transcranial access a plastic defect in the base of the skull was produced. Discharged on recovery. However, after several months, nasal liquorrhea resumed. In addition, he transferred two purulent meningitis one after another, in connection with which he was again hospitalized in the I neurosurgical department.

The clinic conducted additional studies, including CT of the base of the skull, on which a bone defect is again visualized.

Figure 6 - CT scan of patient T. before surgery. Defects of the walls of the trellis labyrinth and the sieve plate on the left are visible (marked by an arrow).

Figure 7 - Control MRI study. At the site of the skull base defect, an autologous musculoskeletal-fascial flap (marked by an arrow) is visible.

Performed operation: plastic defect of the base of the skull of the claimed method. A skin scar in the frontal region was excised under ETN with mechanical ventilation, the soft tissues of the aponeurotic flap, periosteum were exfoliated, the bone flap was removed, and hemostasis was removed. The dura mater was exfoliated in the region of the sieve plate, its defects 1.5 × 1.5 cm in size were identified. In addition, a linear defect in the cerebral wall of the frontal sinus was detected. After identifying and refreshing the edges of the defects, musculoskeletal flaps covered by fascia were laid on the latter. The dura mater is hemmed to the edges of the wound. A bone flap was placed in place, hemostasis, sutures on the wound. Then, transnasally under the control of rigid optics, a left-sided bullotomy, ethmoid sphenotomy was performed. A sieve plate defect has been identified. The defect is covered by a muscle flap, which is covered by a lateratexed middle nasal concha. Front nasal swab. Postoperative treatment without features. Liquorrhea has stopped. Discharged in satisfactory condition with recovery. During the control examination for the entire period, there is no data for liquor.

Claims (1)

A method for plasty of defects in the base of the skull, including the use of intracranial and endonasal approaches and closing of the defect of the base of the skull with free autografts with fixation with bioglue, characterized in that they first intracranially cover the bone defect of the base of the skull with an autocostal fragment wrapped in an autofascial flap, and the autoclaved glue is applied over the top with a bio-adhesive tissue, then endonasal, transsphenoidal, transethmoidal access to the skull base defect is used from the outside and plastic surgery is carried out with an auto-fat-muscle-fascial flap treated with bioglue, while the edges of the fascial autograft flap are inserted beyond the edges of the bone defect of the base of the skull and additionally fixed with the middle nasal concha, which is depepithelialized from the lateral side, mobilized and displaced laterally.

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