Santiago Gabriel, Wolff Amir, Huang Judy, Weingart Jon, Brem Henry, Gordon Chad R
Department of Neurosurgery, Multidisciplinary Adult Cranioplasty Center.
Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
J Craniofac Surg. 2019 Mar/Apr;30(2):326-329. doi: 10.1097/SCS.0000000000004895.
Patients requiring cranioplasty reconstruction with customized cranial implants may unexpectedly present with cerebrospinal fluid (CSF) leaks and durotomies following previous neurosurgical procedures. As such, multiple factors influence the type of dural reconstruction chosen at this time, which are essential for achieving long-term success. Overall, the most common material used for duraplasty is currently an "off-the-shelf" xenograft construct. However, some believe that they are not suitable for large-sized defects and accompany a higher incident of complications. Therefore, based on our success and experience with scalp augmentation using rectus fascia grafts, the authors herein present our preliminary experience with duraplasty using autologous rectus fascia grafts (ARFGs).
A retrospective review of our database, consisting of 437 cranial reconstructions from 2012 to 2017, was performed under institutional review board approval. Selection criteria included all adult patients (n = 6) requiring dural reconstruction (duraplasty) with ARF grafting for an active CFS leak with concomitant skull defect. Cadaver study and patient illustrations are also presented to demonstrate clinical applicability. All outcomes, including complications, were reviewed and are presented here.
A total of 6 patients underwent autologous duraplasty with either unilateral or bilateral ARFGs. All patients (6/6) of large-sized (>3 cm) defect repair with ARFGs were indicated for repair of secondary CSF leaks following previous craniotomy by neurosurgery. To date, none have demonstrated recurrent leaking and/or dura-related complications. At this time, all 6 patients were reconstructed using customized cranial implants with a mean follow-up of 10 months.
Based on our preliminary experience presented here, the use of rectus fascia grafts for autologous dural reconstruction appears to be both safe and reliable. This new technique adds another tool to the neurosurgical armamentarium by reducing the additional risk of "off-the-shelf" dural substitutes.
需要使用定制颅骨植入物进行颅骨成形重建的患者，在先前的神经外科手术后可能会意外出现脑脊液（CSF）漏和硬脑膜切开。因此，多种因素会影响此时选择的硬脑膜重建类型，而这些因素对于取得长期成功至关重要。总体而言，目前用于硬脑膜成形术最常用的材料是“现成的”异种移植构建物。然而，一些人认为它们不适用于大尺寸缺损，且并发症发生率较高。因此，基于我们使用腹直肌筋膜移植进行头皮增大术的成功经验，本文作者介绍我们使用自体腹直肌筋膜移植（ARFG）进行硬脑膜成形术的初步经验。
在机构审查委员会批准下，对我们的数据库进行了回顾性分析，该数据库包含2012年至2017年的437例颅骨重建病例。选择标准包括所有因活动性脑脊液漏合并颅骨缺损而需要使用ARF移植进行硬脑膜重建（硬脑膜成形术）的成年患者（n = 6）。还展示了尸体研究和患者插图以证明临床适用性。对所有结果，包括并发症进行了审查并在此呈现。
共有6例患者接受了单侧或双侧ARFG自体硬脑膜成形术。所有接受ARFG修复大尺寸（>3 cm）缺损的患者（6/6）均因先前神经外科开颅术后继发性脑脊液漏而接受修复。迄今为止，无一例出现复发性漏液和/或与硬脑膜相关的并发症。此时，所有6例患者均使用定制颅骨植入物进行了重建，平均随访10个月。
基于我们在此介绍的初步经验，使用腹直肌筋膜移植进行自体硬脑膜重建似乎既安全又可靠。这项新技术通过降低“现成的”硬脑膜替代物的额外风险，为神经外科手术增添了另一种工具。
