目的 分析重型颅脑创伤患者开颅术后远隔部位二次手术的危险因素,为围手术期监测及治疗提供参考。方法 采用回顾性分析,收集2016年1月—2019年3月163例重型颅脑创伤（TBI）患者资料,根据远隔部位是否二次手术分为二次手术组（n=37）和对照组（n=126）,比较两组创伤着力部位、血肿位置、术前格拉斯哥昏迷评分（GCS） 等可能导致远隔部位二次手术的相关因素,对有统计学意义的因素根据权重赋值,采用多因素logistic回归分析。结果 二次手术组良好、中残率为45.94%,低于对照组的65.87%,差异有统计学意义（P<0.05）。二次手术组受伤时枕部着力、血肿位置在对侧或双侧、有合并伤、去骨瓣减压、术前PLT<80×10⁹/L、中线移位、远隔部位骨折患者的构成比例高于对照组,差异有统计学意义（P<0.05）。Logistic回归分析显示,枕部着力+对侧血肿（OR=0.704,95%CI：0.517~1.296）、术前PLT水平<80×10⁹/L（OR=1.573, 95%CI：1.106~4.821）、去骨瓣减压（OR=4.251,95%CI：2.592~6.281）及远隔部位骨折（OR=5.092, 95%CI： 3.702~13.173）是重型TBI患者远隔部位二次手术的危险因素。结论 枕部着力+对侧血肿、术前PLT水平<80×10⁹/L、去骨瓣减压及远隔部位骨折是重型TBI患者远隔部位二次手术的危险因素,对于合并上述危险因素的患者在开颅术后应密切观察病情变化,一旦出现颅内压升高或意识状态变化,及时行头颅CT检查,符合远隔部位二次手术指征及时手术治疗。

Objective To analyze the risk factors for secondary surgery at distant sites after craniotomy in patients with severe craniocerebral trauma, so as to provide reference for perioperative monitoring and treatment. Methods A retrospective analysis was conducted. A total of 163 cases of severe traumatic brain injury （TBI） were selected from from January 2016 to March 2019, and according to whether secondary surgery was performed at distant sites, they were divided into a secondary surgery group （n=37） and a control group （n=126）. Comparisons were made in trauma site, hematoma site, preoperative Glasgow Coma Scale （GCS） score, and other factors may cause secondary surgery at distant sites, and significant factors were assigned a value based on weight. A multiple logistic regression analysis was also conducted. Results In the secondary surgery group, the good and moderate disability rate was 45.94%, lower than 65.87% in the control group, and the difference was statistically significant （P<0.05）. In the secondary surgery group, the proportions of patients with occipital impact, hematoma on the contralateral or bilateral position, associated injury, decompression by bone flap removal, preoperative PLT < 80×10⁹/L, midline displacement, and distal fracture were higher than those in the control group, and the differences were statistically significant （P<0.05）. Logistic regression analysis results showed that occipital impact + contralateral hematoma, preoperative PLT < 80×10⁹/L, decompression by bone flap removal, and distal fracture were risk factors for secondary surgery of distal part in patients with severe TBI （OR=0.704, 1.573, 4.251, 5.092; 95%CI： 0.517-1.296, 1.106-4.821, 2.592-6.281, 3.702-13.173）. Conclusion Occipital impact + contralateral hematoma, preoperative PLT < 80×10⁹/L, decompression by bone flap removal, and distal fracture are risk factors for secondary surgery at distant sites in patients with severe TBI. Patients with a combinition of these factors should be closely monitored after craniotomy. Once there is an increase in intracranial pressure or change in consciousness, a cranial CT examination should be performed promptly, and an operation should be performed promptly if the indication for secondary surgery in the distal compartment is met.