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Aliev Mansur Abdukholikovich, Samarkand State Medical Institute, Senior researcher, Department of Neurosurgery E-mail: [email protected] Mamadaliev Abdurakhmon Mamatkulovich, Doctor of Medical Sciences, Professor, Department of Neurosurgery
E-mail: [email protected] Mamadalieva Saodat Abdurakhmonovna, Neurosurgeon, Clinic of Neurosurgery E-mail: [email protected]
The study of the improved complex neurosurgical treatment in patients with posttraumatic chronic subdural hematomas and hygromas
Abstract: The article about improved complex neurosurgical treatment in patients with posttraumatic chronic subdural hematomas and hygromas use of endolumbally insufflation of ozone after operation. Received the positive results — improved clinical and neurological status in GOSE.
Keywords: chronic, subdural, hematoma, hygroma, ozone, GOSE.
For the present time among general traumatism cranio-cere-bral traumas (CCT) make 30-50 % and according to World Health Organization data every year this index has been on average in 2 %. The disability index after cranio-cerebral traumas has been examined in 25-30 % of patients and this index shows the actuality of the problem [8; 9; 11]. Among the consequences of CCT under acute and chronic subdural hematomas (CSH), also hygromas have a separate neurosurgical importance as nosologic unit.
Based on the literature data in the development of chronic subdural hematomas it requires time from 1 week to 4 months [5; 18; 1; 12; 13; 14; 19]. As a result of the received materials during surgical operations and morphologic investigations CSH-s have been developed after capsulated traumas or spontaneous rupture of blood vessels during the period of two weeks and exactly this period gives us the opportunity to divide hematomas into under acute and chronic forms [9; 12; 13]. To determine the formation period of CSH capsule is very difficult, because this process depends on the many individual features, such as premorbid status and properties of reactivity. It should been separately emphasized that after formation
of capsule, development and evolution process of this one require several months and several years [17; 6; 14].
According to the data of some investigators the probability of CSH development after CCT is 1.1-8 % i. e. in every 100 000 of population it has been occurred in 1.72 cases [2; 7]. Among all subdural hematomas chronic forms have been occurred in 8-63 % of cases and besides that among all intracranial chronic hematomas CSH has been occurred in 82-86 % of cases [2; 15]. Among all intracranial hemorrhages bilateral CSH-s have been occurred in 0.57 % of cases and only among CHS-s this index is 5-18 % [15; 16].
The aim of the scientific investigation was to improve the methods and results of complex treatment of posttraumatic subdural hematomas and subdural hygromas.
Material and methods of investigations. Scientific investigations have been carried out on the basis of assessment of 167 patients with the diagnosis of posttraumatic chronic and under acute subdural hematomas and hygromas (Fig. 1) who had surgical operations in the neurosurgical clinic of Samarkand State Medical Institute for the period of2003-2014 years.
Fig. 1. a) Bilateral chronic posttraumatic hygroma in the fronto-temporal regions of the brain (MRI);
b) Chronic posttraumatic chronic hematoma in the left fronto-temporal region of the brain (CT);
c) Chronic posttraumatic common subdural hematoma in the left hemisphere of the brain (MRI)
The study of the improved complex neurosurgical treatment in patients with posttraumatic chronic subdural hematomas...
142 patients (85 %) were men and 25 patients (15 %) were women. The most investigated patients were young and efficient people which it has been seen from Fig. 2.
For the last years the amount of patients with chronic subdural hematomas and hygromas who had surgical operations have been gradually increased (Fig. 3).
Fig. 2. Distribution of the patients due to age
Fig. 3. Distribution of the patients due to the years of suffering
Hematomas 70-100 ml. in size evacuated after surgical operations have been in the most concentration during dividing groups of patients due to the size of the evacuated hematomas (Fig. 4.).
Fig. 4. Distribution of the patients due to the amount of hematomas evacuated after surgical operation
In order to prevent the probability of complications (cerebral arachnoiditis, arachnoid cysts, atrophic-glioz processes) caused by the development of liquorodynamic and hemodynamic disorders in the postoperative period in the 8-9 days of treatment we used endo-lumbal insufflations and these patients (49) have been included in the first group. 118 patients have been treated by the traditional methods without using endolumbal procedures in the postoperative period and they have been included in the control group.
There are several approaches in the surgery of chronic subdural hematomas regarding drainage of subdural cavity after surgical operation. Some group of researchers consider that there is no need drainage of subdural cavity after surgical operation and the others consider the necessity of using drainage of subdural cavity after surgical operation. In 155 patients (92.8 %) it has been carried out removing of chronic subdural hematomas by miniinvasive method of surgical treatment with the put of milling holes or milling chinks and removing of chronic subdural hematomas by the use of bone-plastic trepanation has been carried out in 12 patients (7.2 %). In 65 patients (38.9 %) after surgical operations in the subdural cavity it
has been placed one chlorvinile drainages, in 9 patients (5.4 %) it has been fixed two incoming and out coming chlorvinile drainages, also in 86 patients (51.5 %) it has been placed only rubber drainages and in the rest 7 patients (4.2 %) after surgical operation has been determined that subdural cavity left without drainage.
In 49 patients of the basic investigated group after surgical operation in the last 8-9 days after primary healing of the operational wound and after removing sutures in the dressing room under
aseptic conditions after suitable processing of the lumbar-sacral area of patient it has been carried out lumbar puncture between VLIIIIV with evacuation of 20 ml. of liquor, then it has been carried out en-dolumbal insufflations of 15-25 sm 3 of ozone.
For the present time in the practice of the world neurosurgeons patients' general health and neurological status has been assessed by the widely used "Glasgow Extended Scale of the Outcomes of the Traumatic Brain Injury" (GOSE) [20] (Table 1).
Table 1. - The results of assessing patients' general health and neurological status by the use of "Glasgow Extended Scale of the Outcomes of the Traumatic Brain Injury" [20]
Points Category Group № 1 Group № 2
1 point The death of the first hours (D1) 0 0
2 point Death after the first hours (D2) 0 0
3 point Vegetative state (VS) 2 (4.1 %) 3 (2.5 %)
4 point Lower Severe disability (LSD) 1 (2.1 %) 14 (11.9 %)
5 point Upper Severe disability (USD) 3 (6.1 %) 17 (14.4 %)
6 point Lower Moderate disability (LMD) 27 (55.1 %) 43 (36.4 %)
7 point Upper Moderate disability (UMD) 11 (22.4 %) 27 (22.9 %)
8 point Lower Good recovery (LGR) 5 (10.2 %) 14(11.9 %
9 point Upper Good recovery (UGR) 0 0
Total 49 (100 %) 118 (100 %)
As you can see from table 1 in the preoperative period during assessment of patients' general health and neurological status by the use of GOSE in the 1 group of patients chronic vegetative status (VS) has been observed in 2 patients (4.1 %), lower severe disability has been observed in 1 (2.1 %) patient (LSD), in 3 patients (6.1 %) it has been observed upper severe disability (USD), in 27 patients (55.1 %) it has been observed lower moderate disability (LMD), in 11 (22.4 %) patients it has been observed upper moderate disability (UMD) and in 5 patients (10.2 %) it has been observed lower good recovery (LGR), in the 2 group ofpatients the assessment results of patients' general health and neurological status were the following — in 3 patients (2.5 %) it has been observed VS, in 14 patients (11.9 %) it has been observed LSD, in 17 patients (14.4 %) it has been observed USD, in 43 patients (36.4 %) it has been observed LMD, in 27 patients (22.9 %) it has been observed UMD and at last in 14 patients (11.9 %) it has been observed LGR.
General health and neurological status of the investigated patients in 3-6 months after surgical operations has been reassessed by the use of GOSE and we received the following results: in the 1 group of patients after surgical removing of subdural hematomas and hygromas and as a result of complex treatment with using ozone insufflations after surgical operation in 2 patients with vegetative status general health condition and the presented neurological deficits have temporary recovered and in 1 patient it has been observed the improvement of the changes until lower severe disability (LSD), and also in 1 patient his condition has been improved until 8 scale (LGR) "lower good recovery". In the other contingent of the basic group we have been received the positive results, i. e. patients who had 5 scale (USD) "upper severe disability condition" have been decreased in 1 time and patients who had 6 scale (LMD) "lower moderate disability condition" have been decreased in 5 times. The amount of patients' contingent who has been assessed as 7 scale (UMD) "upper moderate disability condition" the recoveries in their general health status and neurological deficits have been determined in 3 times less cases. The amount of patients' contingent who has been assessed as 8 scale "lower good recovery" (LGR) in the contrast of the other patients' contingent who had lower scale it has been observed the improvement of the general health status which has been increased in 2 times, and the amount of
patients' contingent who had 9 scale (UGR) "upper good recovery" was 28 (57.1 %) which we have not observed before performing complex treatment (Fig. 5).
During the analyses of the treatment results of the control group of patients treated with usual methods we received the following data: from 3 patients with vegetative status in 2 ones general condition and presented neurological deficit have been changed in better way and this group of patients transferred in high score contingent of patients. In the control group patients who had 4 scale of LSD "lower severe disability" general amount of patients have been decreased from 14 to 9 patients, in the group of patients who had 5 scale (USD) "upper severe disability" general amount of patients have been decreased from 17 to 13 patients, in the group of patients who had 6 scale (LMD) "lower moderate disability condition" general amount of patients have been decreased in 2 times and in the group of patients who had 7 scale (UMD) "upper moderate disability condition" general amount of patients have been decreased in 3 times. "Lower good recovery" (LGR) contingent (8 scale) of patients as mentioned before like the other lower contingent of patients have been increased in 3 times, the contingent of patients who 9 scale (UGR) "upper good recovery" have not been determined before treatment, but after having suitable their amount have been increased in 13.6 % and this data in the comparison of the basic group contingent have been decreased in 5 times (Fig. 6).
During the differential assessing of the Fig. 7 we could see that in group patients with posttraumatic chronic and under acute hematomas and hygromas in the early period after surgical operation complex treated by endolumbal insufflations of ozone the general health condition and neurological status in the comparison with the group ofpatients treated by the ordinary method the positive results of the assessment by the use of GOSE were seen.
Conclusions
• Posttraumatic chronic subdural hematomas and hygromas should been removed by the use of miniinvasive surgical operation with the put of milling holes or milling chinks;
• After surgical operation of the big hematomas and hygromas it should been carried out chlorvinile drainage of subdural cavity and evacuation step by step;
The study of the improved complex neurosurgical treatment in patients with posttraumatic chronic subdural hematomas.
The use of complex endolumbal ozone insufflations procedure which performed step by step in 8-9 days after
surgical operation have got positive results and patients' working ability have been restored in the early stages.
Fig. 5. The differential results of the assessment of general condition and neurological status of the patients in the basic group with the use of GOSE before and after treatment
Fig. 6. The differential assessment results of general condition and neurological status before and after treatment of the 2nd group patients by the use of GOSE
Fig. 7. The differential assessment results of general condition and neurological status after treatment of the basic and control groups patients by the use of GOSE
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