Nathoo N, Nadvi S S, Gouws E, van Dellen J R
Department of Neurosurgery, Wentworth Hospital, 4026 Durban, South Africa.
Neurosurgery. 2001 Oct;49(4):872-7; discussion 877-8. doi: 10.1097/00006123-200110000-00017.
Uncertainty regarding the best surgical management for subdural empyemas (SDEs) continues. Our unit has considered craniotomy the preferred method of surgical drainage for all cranial SDEs since 1988. We performed an analysis of our previously published, computed tomography-era, experience with 699 patients.
Two analyses of the database (1983-1997) were performed. First, analysis of the periods from 1983 to 1987 and from 1988 to 1997 was performed. Second, analysis of the composite database was performed. Outcomes were compared for possible outcome predictors by univariate analysis. Multivariate analysis was used to identify variables that contributed independently to outcomes, using stepwise discriminant analysis.
Significant correlations between the analyzed periods with respect to outcome and type of surgery (P = 0.001) were noted. Analysis of the entire database (1983-1997) revealed a significant relationship between outcome and surgery type (P = 0.05). Pairwise comparison of limited procedures such as burr holes or craniectomies with wide-exposure surgical procedures such as primary craniotomies or procedures proceeding to full craniotomies indicated significant correlation with outcomes (P = 0.027). Reoperation and morbidity rates were increased with limited procedures. Stepwise discriminant analyses revealed that the type of surgery was correlated with outcomes (P = 0.0008, partial r(2) = 0.034).
Craniotomy was determined to be the surgical procedure of choice for treatment of cranial SDEs, allowing complete evacuation of the pus and, more importantly, decompressing the underlying cerebral hemisphere. Limited procedures such as burr holes or craniectomies may be performed for patients in septic shock, for patients with parafalcine empyemas, or for children with SDEs secondary to meningitis.
对于硬膜下积脓（SDEs）的最佳手术治疗方案仍存在不确定性。自1988年以来，我们科室一直将开颅手术视为所有颅骨SDEs的首选手术引流方法。我们对之前发表的699例计算机断层扫描时代患者的经验进行了分析。
对数据库（1983 - 1997年）进行了两项分析。首先，对1983年至1987年以及1988年至1997年这两个时间段进行分析。其次，对综合数据库进行分析。通过单因素分析比较可能的预后预测因素的结果。使用逐步判别分析进行多因素分析，以确定独立影响预后的变量。
注意到分析时间段与预后及手术类型之间存在显著相关性（P = 0.001）。对整个数据库（1983 - 1997年）的分析显示，预后与手术类型之间存在显著关系（P = 0.05）。将诸如钻孔或颅骨切除术等有限手术与诸如初次开颅手术或进展为全颅骨切开术的广泛暴露手术进行成对比较，结果表明与预后存在显著相关性（P = 0.027）。有限手术的再次手术率和发病率有所增加。逐步判别分析显示，手术类型与预后相关（P = 0.0008，偏相关系数r(2) = 0.034）。
开颅手术被确定为治疗颅骨SDEs的首选手术方法，它能够彻底清除脓液，更重要的是，对下方的脑半球进行减压。对于感染性休克患者、矢状窦旁积脓患者或脑膜炎继发SDEs的儿童患者，可进行诸如钻孔或颅骨切除术等有限手术。
