重新考虑老年人颅骨修补术后感染的手术干预：一例病例报告

摘要(中文译文)

颅骨修补术后感染伴头皮破损在老年人中是一个棘手的重建难题，尤其当衰弱和认知障碍可能限制其对分期手术的耐受性时。尽管清创、感染控制和延期颅骨修补通常被视为标准处理方案，但在老年患者中应进行何种程度的重建仍不确定。我们报告一例80多岁晚期女性患者，在急性硬膜下血肿术后行颅骨修补八个月后出现头皮缺损并人工颅骨植入物外露。入院时头颅计算机断层扫描显示无颅内感染，而三维计算机断层扫描血管成像显示颞浅动脉通畅，缺损周围仍有残余血供。由于其高龄、认知障碍以及分期重建预期的负担引发了对反复手术耐受性的担忧，治疗方向定为感染控制和持久创面闭合，而不进行再次颅骨修补。取出植入物后发现硬膜外脓肿，并进行了彻底清创。在感染的人工硬膜下可见形成良好的纤维囊，将其用于硬膜修补。头皮缺损采用游离背阔肌肌皮瓣联合刃厚皮片移植进行重建。尽管术后谵妄限制了康复和功能恢复，但未发生感染复发。本病例提示，对认知脆弱的老年人伤口并发症的延迟识别可使其进展为广泛缺损，并且在部分患者中，当持久的软组织覆盖和感染控制优先于解剖学修复时，省略颅骨修补可能是合理的终点。

Abstract

Post-cranioplasty infection with scalp breakdown in older adults poses a difficult reconstructive problem, particularly when frailty and cognitive impairment may limit tolerance for staged procedures. Although debridement, infection control, and delayed cranioplasty are often considered standard management, the extent of reconstruction that should be pursued in elderly patients remains uncertain. We report the case of a woman in her late 80s who developed scalp loss with exposure of a synthetic cranial implant eight months after cranioplasty following surgery for acute subdural hematoma. On admission, head computed tomography showed no intracranial infection, while three-dimensional computed tomography angiography demonstrated preserved patency of the superficial temporal artery with residual blood supply around the defect. Because her advanced age, cognitive impairment, and the anticipated burden of staged reconstruction raised concern about tolerance for repeated procedures, treatment was directed toward infection control and durable wound closure without repeat cranioplasty. Removal of the implant revealed an epidural abscess, and thorough debridement was performed. Under the infected artificial dura, a well-formed fibrous capsule was identified and used for duraplasty. The scalp defect was reconstructed with a free latissimus dorsi musculocutaneous flap and split-thickness skin grafting. No recurrent infection developed, although postoperative delirium limited rehabilitation and functional recovery. This case highlights that delayed recognition of wound complications in cognitively vulnerable older adults can allow progression to extensive defects and that omission of cranioplasty may be a reasonable endpoint in selected patients when durable soft-tissue coverage and infection control take precedence over anatomical restoration.

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