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MODERN TECHNOLOGIES IN SURGICAL TREATMENT OF
THE CONSEQUENCES OF SKULL AND BRAIN TRAUMA
Mansur Aliyev
Samarkand state medical university, Samarkand, Uzbekistan
https://doi.org/10.5281/zenodo.15915291
ARTICLE INFO
ABSTRACT
Received: 08
th
July 2025
Accepted: 14
th
July 2025
Online: 15
th
July 2025
,
The article presents the main surgically significant forms of
post-traumatic pathology in 4136 patients with defects and
deformities of the bones of the arch, base of the skull and facial
skeleton, recurrent liquorrhea, arteriosine fistula, true and false
aneurysms, etc. A classification of the consequences and
complications of traumatic brain injury, as well as a
periodization of its clinical course, has been developed. The
possibilities of modern neuroimaging technologies for
recognizing and investigating the pathogenesis of consequences
and complications of traumatic brain injury are revealed.
Special attention is paid to reconstructive and minimally
invasive surgery, and the method of computer modeling and
subsequent stereolithographic laser reproduction of full-scale
copies of the skull, its defects and implants is described in detail,
which is especially important for extensive and complex
craniobasal and craniofacial injuries. The differentiated use of
intracranial and эндоназальныхendonasal approaches for
closing chronic CSF fistulas is justified. Together with the
method of endovascular reconstruction of main vessels using
balloon catheters developed by F. A. Serbinenko for the first time
at the N. N. Burdenko Research Institute of Neurosurgery, new
approaches based on modern technologies using stents,
microspirals and embolizing compositions are presented.
KEYWORDS
Neurotrauma,
reconstructive
surgery,
computer modeling.
Introduction of the principles of microsurgery, minimally invasive endoscopic and
endovascular interventions, reconstructive operations using computer modeling and
stereolithographic prototyping of damaged structures and implants, as well as the use of
modern methods of neuroimaging, pathogenetically based adequate resuscitation and
intensive care, and programmable CSF bypass systems have made it possible in recent years
not only to reduce the mortality rate in severe traumatic brain injury, but also to reduce the
degree of disabling consequences [1-9]. The main types of post-traumatic pathology were
defects and deformities of the cranial vault and base with damage to the brain and its
membranes, including those accompanied by basal liquorrhea and / or hydrocephalus, as well
as damage to intracranial vessels with the formation of carotid-cavernous fistulas, false
aneurysms, chronic hematomas, etc..
Reconstructive surgery of cranial arch and base defects
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Despite its long history, the problem of restoring the integrity of the skull after depressed
fractures, decompressive trepanations, fire стрельныхwounds, removal of tumors affecting
the bones of the arch and base of the skull, as well as other pathological processes is still
relevant [2, 3, 8, 10-13]. The number of victims with bone defects is constantly increasing due
to the increase in cases of severe traumatic brain injury and surgical activity, the expansion of
indications for decompression trepanation of the skull not only for trauma, but also for vascular
diseases. At the дегерметизацияsame time, skull depressurization, in addition to
complications in the postoperative period, leads to the formation of a new pathological
condition, which is called "trepanated syndrome" [14]. The pathophysiological mechanisms of
the development of this syndrome are quite diverse and are currently being discussed [7, 15].
Improvement of neurological functions after cranioplasty and skull sealing, associated with
changes incerebrospinal fluid and hemodynamics, allows us to consider the reconstruction of
bone defects as a necessary condition in the rehabilitation of patients with the consequences of
severe craniocerebral lesions and decompression operations [2, 3, 15]. It is considered optimal
to perform reconstructive operations in the period from 1 to 6 months after the injury [2, 3,
12]. However, the possibility of performing reconstructive operations at an early stage depends
on many factors: the rate of regression of cerebral edema and intracranial hypertension, the
presence of extra - and intracranial complications, the development of hydrocephalus, etc. In
our study, 186 patients with post-traumatic hydrocephalus, including after decompression
trepanations (Figure 1), underwent bypass surgery followed by closure of the bone defect. In
68 of them, programmable systems were used with a significant reduction in the frequency of
bypass graft dysfunction in the postoperative period. One of the main problems of
reconstructive surgery is the choice of plastic material. The range of materials used for
cranioplasty is huge and constantly expanding. Biological compatibility, lack of tissue reactions,
and high regenerative abilities are the main advantages of auto-materials, but they also have
significant limitations [2, 3, 16]. Modern xenomaterials (polymethylmethacrylates, titanium,
hydroxyapatite, etc.) serve as an alternative to bone implants and in some cases have certain
advantages. The search continues for materials for cranioplastythat can not only provide
sealing of the skull, but also contribute to the processes of osteoconduction and osteoinduction.
In our clinic, the following main types of plastic materials have been used in the reconstruction
of bone defects in the cranial vault in recent years: autocost (split bone, bone fragments, etc.),
allocost (formalized, lyophilized bone tissue) and xenoimplants (methyl methacrylates,
titanium, etc.).
From our point of view, auto-tissues have the greatest advantage, but structural changes
in bone tissue, its frequent resorption (with an auto-tissue size of more than 30.0 cm2, the risk
of resorption is significantly higher), and technical difficulties of sampling, especially large bone
flaps, limited their use. The use of auto-tissues is most preferable in children, as well as in small
bone defects. The use of allogeneic materials is currently being reviewed due to the risk of
transmission of vector-borne infections [2]. Computer modeling and laser stereolithography
An important task of cranioplasty is the aesthetic perfection of reconstructive surgery,
especially for extensive defects of complex fronto-orbital and craniobasal localization. Rapid
development of neuroimaging methods with the construction of three-dimensional virtual
models and the possibility of computer simulation of operations has radically changed the
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technology and quality of reconstructive surgery for traumatic, tumor, and congenital cranial
defects and deformities, as well as after resection and decompression operations. The first
systematic three-dimensional computed tomography (CT) studies at the N. N. Burdenko
Research Institute of Neurosurgery began in the 90s in patients with craniobasal and
craniofacial injuries in order to plan operations to remove foreign bodies of complex
configuration and virtual modeling of reconstruction of cranial defects[2, 3, 17, 18]. Computer
modeling allows you to edit CT models with the restoration of missing fragments and the
creation of virtual individual implants. Implants are manufactured using various methods of
prototyping three-dimensional objects based on CAD / CAM technologies [15, 19-21]. In Russia,
this method was developed at the Institute of Laser and Information Technology Problems of
the Russian Academy of Sciences (IPLIT, Shatura, Moscow Region) under the supervision of
Academician of the Russian Academy of Sciences V. Ya. Panchenko, it was first used in forensic
medical practice to verify the remains of the Romanov family [1-3, 19, 21]. Computer modeling
and laser stereolithography in reconstructive operations at the N. N. Burdenko Research
Institute of Neurosurgery has been used since the late 90s, and the first publications date back
to the early 2000s [3, 7, 16]. From 1999 to 2011, in the Department of neurotrauma of the N. N.
Burdenko Research Institute of Neurosurgery, this technology was used in 445 patients with
extensive defects in the bones of the arch and base of the skull, as well as the facial skeleton of
a complex configuration (mainly fronto-orbital localization). Planning of reconstructive
operations includes several stages: direct data collection based on the developed CT scanning
protocols; data processing with modeling of three-dimensional models and detailed study of
bone fragments of the skull to be restored. The complex geometry of bone defects in the skull
and their large size require the use of CT scans with a slice thickness of 1 mm or less. The results
of CT data stored in DICOM medical image files and / or standard BMP graphic format are sent
to IPLIT via an electronic network. Received tomograms Using the 3DView software package
developed at IPLIT, they are converted into a three-dimensional computer model in STL format,
which is the basis for the software operation стереолитографииof the LS-250/E laser
stereolithography unit (Fig. 2). For unilateral bone defects, modeling and construction of
implants is carried out using the "mirror symmetry"method. When locating defects along the
midline, the "virtual donor" method is used. This method is based on the created database of
3D reconstructions of skulls of various configurations. From the database, a 3D model of the
skull is selected that is close to the parameters of the patient's skull, and on its basis all the
stages of prototyping are carried out with the creation of an implant model. An important
advantage of the domestic technology in contrast to foreign analogues is not only the modeling
of the implant, but also the development of a model of the implant mold and full-scale
prototyping of skull models from photopolymerizing solutions on a stereolithograph. The
duration of" growing " models is from 4 to 12 hours. Plastic models are delivered to the Institute
of Neurosurgery, where they are subjected to gas sterilization (ethyleneoxide). Implants are
made from biocompatible modern polymethylmethacrylates (R. Polacos, acetone G-40 Heraeus
Kulzer, Germany). The presence of a mold allows you to make an implant both intraoperatively
in sterile conditions, and before the operation with subsequent sterilization. In the latter case,
the operation time is shortened and, most importantly, the polymerization of the implant with
an exothermic reaction occurs outside the wound, thereby eliminating the possibility of
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thermal damage to the brain, its membranes and bone structures. Manufacturing an implant
using a mold requires some experience due to the rapidly changing fluidity and plasticity of the
material. During the manufacturing process, it is possible to pre-modify the implant on a plastic
model of the skull and finally fit it using high-speed cutters. An exact plastic copy of the patient's
skull also allows you to make an implant from a titanium mesh before surgery, which reduces
the operation time and improves its quality. In our series of observations, when using all stages
of the technological process, 95.3% of patients received good functional and cosmetic results.
Unsatisfactory results (3.9% of patients) were due to a combination of consequences of
combined craniofacial trauma and atrophic changes in the scalp, and purulent-inflammatory
complications were noted in 3 (0.8%) cases. To further improve the quality of reconstructive
operations, it is necessary to take into account changes in the soft tissues of the head, primarily
due to scar-atrophic changes in the temporal muscle, the possibility of contact of the implant
with the air-bearing sinuses, the presence of inflammatory processes in the area of damage and
risk factors for their occurrence, and an adequate choice of plastic material [2, 3, 8]. The use of
computer modeling technology and laser stereolithography has brought new opportunities to
reconstructive neurosurgery and significantly improved the quality of operations in complex
configuration and localization of craniocerebral and craniofacial diseases. damage.
Reconstructive surgery of cranioorbital injuries
One of the urgent problems of modern neurotraumatology is the diagnosis and treatment
of craniofacial trauma and its most common variant — cranioorbital injuries, which are
characterized by a violation of the differentiation of the cranial cavities, orbit, paranasal
sinuses; displacement of the eyeball, visual and oculomotor disorders that determine functional
and cosmetic deficiencies [1, 22-24]. Planning and evaluation of the effect of operations were
carried out on the basis of the results of clinical examination and spiral computed tomography
data. In patients with the most complex defects and deformities, preoperative planning was
performed using computer modeling and stereolithographic models [1]. Depending on the
location and extent of the injury, reconstructive interventions have different goals: restoring
the shape of the face, contours and volume of the orbit, eliminating herniated protrusion of the
medulla into the orbit and disconnecting the contents of the orbit from the cranial cavity and/or
paranasal sinuses, sealing the dura mater, reconstructing the anterior cranial fossa, eliminating
displacement of the eyeballs, restoring their position in the mobility, elimination of diplopia, as
well as preparation of the orbit for subsequent ophthalmoplastic interventions [1, 22]. In our
clinic, first of all, intracranial interventions are performed, after which reconstructive
operations are performed on the skull and facial skeleton (craniofacial osteosynthesis; Fig. 3)
using the basic principles of craniofacial surgery, including: a) wide subcostal exposure of the
fracture zone to accurately assess the extent of damage and the nature of displacement of bone
fragments; b) open reposition of bone fragments in an anatomically correct position and their
stable internal fixation using titanium micro -and mini-plates; c) primary bone autoplasty for
irreversible bone loss with the formation of defects. Out of 374 patients with cranioorbital
trauma hospitalized at the N. N. Burdenko Research Institute of Neurosurgery from 1998 to
2010, 288 (77%) underwent reconstructive surgery on the skull and facial skeleton. In 254
(88%) patients out of 288, interventions were performed on the anterior base of the skull,
upper and/or middle zones of the facial skeleton with the restoration of various parts of the
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orbit, in 48 (16.7%) — with the reconstruction of the base and plasty of cerebrospinal fluid
fistulas. In 167 (65.7%) out of 254 patients, the cranioorbital region reconstruction was
performed to correct displacement of the eyeballs (enophthalmos, hypophthalmos, or a
combination of them, less often exophthalmos). With fractures of the thin walls of the orbit
(mainly lower and medial), it is almost impossible to compare fragments due to the high degree
of fragmentation. That is why bone autotransplants, less often titanium implants, were used to
restore their integrity. After restoration of the contours and volume of the bone orbit, a
thorough reposition of soft tissues, including the medial and lateral canthal ligaments, was
performed (if necessary). Reconstruction of the cranioorbital This procedure resulted not only
in cosmetic improvement and repositioning of the eyeball, but also in regression or significant
reduction of oculomotor disorders and diplopia.
Reconstructive endovascular surgery of intracranial vascular injuries in craniobasal
trauma
In craniocerebral trauma, the main extra-and intracranial vessels are often damaged, for
the treatment of which the endovascular method is the most adequate. Initially, it was
developed by F. A. Serbinenko in the late 60s-early 70s of the XX century for reconstructive
operations using balloon catheters in traumatic carotid-cavernous fistulas (CCS) [28].
Currently, the scope of minimally invasive endovascular interventions has expanded
dramatically, and the methods have changed significantly (the use of spirals, stents, and modern
adhesive compositions should be highlighted) [6]. The N. N. Burdenko Research Institute of
Neurosurgery has accumulated extensive experience (1314 patients with CCS) in the treatment
of vascular consequences of craniocerebral trauma, and in 99% of cases the fistula was
completely occluded by the endovascular method, and in 80% of cases blood flow through the
internal carotid artery was preserved [2]. Endovascular treatment has also been used
successfully for traumatic hard артерио -shell arteriovenous fistulas in the sinus region,
arteriovenous fistulas in the cerebral vessels and extracranial sections of the main vessels. In
case of false aneurysms of the internal carotid artery in the sphenoid sinus and profuse
nosebleeds (64 cases), it is necessary to resort to balloon occlusion of the internal carotid artery
at the level of its rupture. катамнезаNo recurrence of nosebleeds was observed during the
period of catamnesis from 1 year to 10 years. Thanks to the developments of the Research
Institute of Neurosurgery, highly effective, mainly reconstructive endovascular treatment of
surgically significant vascular consequences of craniocerebral trauma has been introduced into
practice [2, 6, 28]. Among other vascular consequences of trauma, a special place is occupied
by chronic subdural hematomas, in the treatment of which in recent years the clinical
effectiveness of sparing, minimally invasive methods has been proven [2, 3, 9, 29].
Conclusion
The developed and tested modern methods of reconstructive interventions using
computer planning, stereolithographic models, as well as reconstructive endovascular
operations were included in the approved list of standards for providing high-tech medical care
to victims with craniofacial and combined craniocerebral injuries.
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