neurosurgeryНейрохирургияRussian journal of neurosurgery1683-32952587-7569Издательский дом "МедИНК"10.17650/1683-3295-2021-23-1-91-100neurosurgery-1015Research ArticleОРИГИНАЛЬНАЯ РАБОТАORIGINAL REPORTЭндоскопическая пластика крупных дефектов основания черепа: ретроспективный анализ 30 наблюденийEndoscopic skull base reconstruction of large defects: retrospective analysis of 30 caseshttps://orcid.org/0000-0002-8249-9153ШелескоЕ. В.SheleskoE. V.

Россия, 125047 Москва, 4‑я Тверская-Ямская, 16

16 4th Tverskaya-Yamskaya St., Moscow 125047, Russia

https://orcid.org/0000-0002-4895-233XЧерниковаН. А.ChernikovaN. A.

Надежда Алексеевна Черникова

Россия, 125047 Москва, 4‑я Тверская-Ямская, 16

Nadezhda Alekseevna Chernikova

16 4th Tverskaya-Yamskaya St., Moscow 125047, Russia

chernikhope@gmail.comhttps://orcid.org/0000-0001-5711-3629КравчукА. Д.KravchukA. D.

Россия, 125047 Москва, 4‑я Тверская-Ямская, 16

16 4th Tverskaya-Yamskaya St., Moscow 125047, Russia

https://orcid.org/0000-0003-1295-0612ЗинкевичД. Н.ZinkevichD. N.

Россия, 125047 Москва, 4‑я Тверская-Ямская, 16

16 4th Tverskaya-Yamskaya St., Moscow 125047, Russia

https://orcid.org/0000-0003-0269-2138БеловА. И.BelovA. I.

Россия, 125047 Москва, 4‑я Тверская-Ямская, 16

16 4th Tverskaya-Yamskaya St., Moscow 125047, Russia

ФГАУ «Национальный медицинский исследовательский центр нейрохирургии им. Н. Н. Бурденко» Минздрава РоссииРоссияN.N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of RussiaRussian Federation20210405202123191‑100Copyright © Шелеско Е.В., Черникова Н.А., Кравчук А.Д., Зинкевич Д.Н., Белов А.И., 20212021Шелеско Е.В., Черникова Н.А., Кравчук А.Д., Зинкевич Д.Н., Белов А.И.Shelesko E.V., Chernikova N.A., Kravchuk A.D., Zinkevich D.N., Belov A.I.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.therjn.com/jour/article/view/1015Введение

Введение. Пластика крупных дефектов основания черепа – сложная проблема эндоскопической трансназальной хирургии. Трудности чаще всего связаны с широкой резекцией твердой мозговой оболочки, внутриарахноидальной диссекцией (при удалении менингоцеле или при резекции интракраниально распространяющейся опухоли), наличием неваскуляризированного участка, который подвергается постоянному давлению ликвора со стороны полости черепа, а с другой стороны сообщается с заведомо инфицированной полостью носа, что повышает риск нагноения и отторжения трансплантата.

Цель исследования – проанализировать собственный опыт лечения пациентов с крупными дефектами основания черепа и на основании полученных результатов оптимизировать методику пластики.

Материалы и методы

Материалы и методы. Проведен ретроспективный анализ 30 случаев пластики крупных дефектов основания черепа разной этиологии. Оценивали результаты пластики в раннем и позднем послеоперационном периоде. Статистическую обработку осуществляли с использованием точного критерия Фишера и анализа произвольных таблиц сопряженности с помощью критерия χ2. Выполнен обзор литературы с целью сравнения собственных данных с результатами других исследований.

Результаты

Результаты. В группе пациентов (n = 16), у которых для пластики применяли только свободные трансплантаты, ее эффективность составила 75 %. В группе пациентов (n = 14), у которых последний этап пластики проводили с помощью перемещенного лоскута на питающей ножке, эффективность пластики составила 100 %. Выявлена статистически значимая взаимосвязь между типом трансплантата и степенью герметичности пластики (p <0,05). Использование люмбального дренажа не влияло на вероятность рецидива ликвореи в послеоперационном периоде (p >0,05).

Заключение

Заключение. Эндоскопическая трансназальная пластика эффективна при дефектах основания черепа размером >1,5 см. При крупных дефектах основания черепа предпочтение следует отдавать многослойной пластике с использованием васкуляризированных лоскутов. Использование люмбального дренажа при пластике крупных дефектов оправданно при наличии явных показаний с точки зрения соотношения возможной пользы и риска, обусловленного инвазивностью метода.

Background

Background. Endoscopic skull base reconstruction of large defects is a difficult issue in neurosurgery, as there are problems associated with a wide dural resection, intra-arachnoid dissection (due to removal of the meningocele or resection of an intracranially spreading tumor), and exposure to high-flow cerebrospinal fluid within the cisterns. But perhaps the most significant influence is the larger nonvascularized reconstructive bed – cerebrospinal fluid on one side and sinus cavity (air) on the other.

The study objective is to analyze our own experience in treating patients with large defects of the skull base and, based on the results obtained, to optimize the method of reconstruction.

Materials and methods

Materials and methods. A retrospective analysis of 30 cases of reconstruction of large defects of skull base of various etiologies. The results of surgery in the early and late postoperative period were evaluated. Statistical analysis was carried out using the exact Fisher criterion and the analysis of arbitrary contingency tables using the chi-square criterion. A literature review was conducted to compare the data obtained with the results of other studies.

Results

Results. In the group of patients (n = 16) for whom reconstruction was performed only with free transplants the effectiveness of reconstruction was 75 %. In the group of patients (n = 14) who underwent the last stage of reconstruction using a vascularized pedicled nasoseptal flap, the plastic surgery efficiency was 100 %. According to statistical analysis, there is a relationship between the choice of transplant type and the multilayer technique (p <0.05). The use of lumbar drainage did not affect the recurrence of cerebrospinal fluid leak in the postoperative period (p >0.05).

Conclusion

Conclusion. Endoscopic skull base reconstruction can be effectively used for defects of the skull base >1.5 cm. When choosing the technique of reconstruction of large defects of the skull base, preference should be given to multilayer plastic using vascularized flaps. The use of lumbar drainage for reconstruction of large defects is a justified method in the case of a clear definition of indications for its use, based on a comparison of the possible benefits and risks associated with the invasiveness of the method.

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The authors declare that there are no conflicts of interest present.