Spine:颈椎术后并发症的危险因素分析

2013-03-04 Spine Dxy

明确脊柱术后患者的并发症发生的危险因素对患者和医生而言都非常重要,目前已有的脊柱术后并发症发生危险因素大部分研究均未将手术创伤程度考虑在内,可以预见的是手术节段较多、创伤较大的手术,其术后并发症发生率会处于较高水平。并且目前大部分研究仅和腰椎手术相关,很少有文献报道颈椎术后并发症的危险因素,近期来自美国的学者lee对颈椎术后的并发症危险因素进行了较大样本的回顾性研究,并创造性的将脊柱手术创伤程度(

明确脊柱术后患者的并发症发生的危险因素对患者和医生而言都非常重要,目前已有的脊柱术后并发症发生危险因素大部分研究均未将手术创伤程度考虑在内,可以预见的是手术节段较多、创伤较大的手术,其术后并发症发生率会处于较高水平。并且目前大部分研究仅和腰椎手术相关,很少有文献报道颈椎术后并发症的危险因素,近期来自美国的学者lee对颈椎术后的并发症危险因素进行了较大样本的回顾性研究,并创造性的将脊柱手术创伤程度(spinal surgical invasiveness,SSI)纳入了研究变量中进行了统计分析,相关结论发表在近期出版的spine杂志上。
研究数据来源于2003年1月1日至2004年12月31日两年间在两家地区医院进行脊柱手术的患者,研究除外标准:年龄小于18岁,非颈椎手术,未进行颈椎部位开放手术等.
依据患者术后并发症累及器官不同,将患者并发症分为六大类:心脏,肺部,消化道,神经,泌尿系统,血液系统。纳入评估的危险因素包括:年龄,性别,吸烟状态,酒精使用,药物使用,糖尿病,BMI,内科疾病情况,既往脊柱手术病史,最初诊断,手术入路等。
研究结果:共582例患者符合研究纳入标准,人口统计学数据如表1,每个脏器累计并发症发病率:心脏 8.4%,肺部 13%,胃肠道 3.9%,神经 7.35%,血液系统10.75%,泌尿系统 9.18%。单因素及多因素方差分析统计结果如表2-4。表2,3所示单因素方差分析中和并发症显著相关的危险因素在进行多因素方差分析后只剩余部分显著相关危险因素。
研究者总结:年龄大于65岁(RR,9.44;95% CI 3.15-34.66)及既往有心脏病事件(RR,3.79;95% CI 1.38-10.41)是颈椎术后2年内死亡的危险因素;当患者发生心脏或肺部并发症时其死亡风险最高。
[译者注]:脊柱手术创伤程度(spinal surgical invasiveness):2006年有Mirza等人在脊柱不良时间评估方法一文中提出。评分范围0-48分,分数越高,代表手术节段越多,创伤越大。评分由6个手术权重指标组成:前路减压(anterior decompression,AD),前路融合(anterior fusion,AF),前路器械固定(anterior instrumentation,AI), 后路减压(posterior decompression,PD),前路融合(posterior fusion,PF),后路器械固定(posterior instrumentation,PI),每个椎体节段对应1分,如C5-C6前路椎间盘切除术计分:5分=前路减压2分(C5,C6)+前路融合1分(C5-C6)+前路内固定2分(C5,C6)。但译者认为该方法仍存在缺陷,前路减压的不同方式创伤不同,在该计量方法中未得到体现。如患者行前路C4椎体切除+C3-C5节段融合内固定术,其计分为:6分=前路减压1分(C4)+前路融合2分(C3-C4,C4-C5)+前路内固定3分(C3-C5),和单纯前路C5-6椎间盘切除减压融合内固定术的评分接近,而事实上该手术创伤要远大于后者。译者认为在该计分基础上对每个计分选项进行系数调整,从而拉开计分差距。

Objective
Using multivariate analysis to determine significant risk factors for medical complication after cervical spine surgery.
Summary of Background Data
Several studies have examined the occurrence of medical complication after spine surgery. However, many of these studies have been done using large national databases. While these allow for analysis of thousands of patients, potentially influential covariates are not accounted for in these retrospective studies. Furthermore, the accuracy of these retrospective data collection in these databases has been called into question.
Methods
The Spine End Results Registry (2003–2004) is a repository of prospectively collected data on all patients who underwent spine surgery at our 2 institutions. Extensive demographic and medical information was prospectively recorded. Complications were defined in detail a priori and were prospectively recorded for at least 2 years after surgery. We analyzed risk factors for medical complication after lumbar spine surgery, using univariate and multivariate analyses.
Results
We analyzed data from 582 patients who met our inclusion criteria. The cumulative incidences of complication after cervical spine surgery per organ system are as follows: cardiac, 8.4%; pulmonary, 13%; gastrointestinal, 3.9%; neurological, 7.4%; hematological, 10.8%; and urologic complications, 9.2%. The occurrence of cardiac or respiratory complication after cervical spine surgery was significantly associated with death within 2 years (relative risk, 4.32, 6.43, respectively). Relative risk values with 95% confidence intervals and P values are reported.
Conclusion
Risk factors identified in this study can be beneficial to clinicians and patients alike when considering surgical treatment of the cervical spine. Future analyses and models that predict the occurrence of medical complication after cervical spine surgery may be of further benefit for surgical decision making.

作者:Spine



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