成人退变性脊柱侧凸长节段内固定术后内科相关并发症的危险因素分析

Risk factors for complications after fusion in the treatment of adult degenerative scoliosis

中文关键词:  成人脊柱侧凸  退变性脊柱侧凸  内科并发症  危险因素

英文关键词:Adult spinal deformity  Degenerative scoliosis  Medical complications  Risk factors

中文摘要:

  【摘要】 目的：分析成人退变性脊柱侧凸长节段内固定术后的内科并发症的相关危险因素。方法：回顾性分析2012年1月~2016年1月于我院行后路长节段（内固定融合节段≥3个）椎弓根螺钉内固定矫形术治疗的成人退行性脊柱侧凸的患者资料82例，其中男24例，女58例，年龄55~71（63.9±4.6）岁。根据有无内科并发症分为无内科并发症组（58例）和有内科并发症组（24例）。内科并发症包含肺炎、脓血症、尿路感染、中枢神经病变、周围神经病变、充血性心力衰竭、深静脉血栓、心肌梗死、心律失常、胸腔积液、凝血功能障碍、胃肠道并发症和肾功能异常等。比较两组术前和末次随访的侧凸Cobb角、骨盆投射角与腰椎前凸角之差（PI-LL）和矢状面垂直轴（SVA）等影像学差异。术前、术后4周、52周和104周使用Oswestry功能障碍指数（Oswestry disability index，ODI），日本骨科协会（Japanese Orthopaedic Association，JOA）评分和视觉模拟量表（visual analogue scale，VAS）对患者临床症状进行评分。使用单因素分析对性别、年龄、BMI、术前贫血、糖尿病、高血压病史以及吸烟情况、心脏病史、症状持续时间、手术固定节段数量、椎板减压节段数量、手术时间、术中出血量情况和术后住院时间等潜在危险因素进行检测。采用多元Logistics回归分析内科并发症的独立危险因素。结果：出现内科并发症的患者29.3％。高血压、糖尿病和贫血的发病率分别为30.5%、20.7%和9.8%。术后并发症中感染14例（17.1%），心肺功能异常9例（11.0%），胃肠道疾病11例（13.4%），肾功能异常1例（1.2%）。无内科并发症组脑脊液漏的发病率显著低于内科并发症组（19.0% vs 54.2%，P=0.001），术前两组影像学参数中Cobb角、PI-LL和SVA无统计学差异（P＞0.05）；术后两组影像学参数比较Cobb角、PI-LL和SVA无统计学差异（P＞0.05）。在多因素Logistic回归模型中确定的独立危险因子包括BMI（OR 1.127，P=0.011），吸烟（OR 3.15，P=0.032）、住院时间（OR 1.16，P=0.047）和症状持续时间较长的患者（OR 1.33，P=0.025）。内科并发症组的患者末次随访ODI、JOA评分和VAS与术前相比均有显著改善（P＜0.05），但两组间差异无统计学意义（P＞0.05）。结论：成人退变性脊柱侧凸患者长节段椎弓根螺钉内固定术后内科并发症相关危险因素包括心脏病史、糖尿病、吸烟和住院时间。

英文摘要:

  【Abstract】 Objectives: To analyze the risk factors for medical complications in adult patients with adult degenerative scoliosis(ADS) who underwent long fusion. Methods: This was a retrospective study that analyzed adult degeneration scoliosis patients who underwent long fusion with posterior pedicle screw fixation in our hospital between January 2012 and January 2016. All patients were divided into no medical complications group(n=58) and medical complications group(n=24). The radiographic parameters including Cobb′s angle, PI-LL and SVA were compared between the two groups at preoperation and the final follow-up. Internal medical complications in this study included intra- and perioperative complications such as deep and superficial wound infection, pneumonia, sepsis, nerve root injury with weakness, neuropathy or sensory deficit, pain(radiculopathy), peripheral nerve palsy, congestive heart failure, deep vein thrombosis, myocardial infarction, pleural effusion, arrhythmia, coagulopathy, pneumothorax, gastrointestinal complications and renal dysfunction. Potential risk factors were identified by using univariate analysis. Multivariate Logistics regression was used to analyze the independent risk factors for medical complications. The clinical functional scores were assessed by using the Oswestry disability index(ODI), Japanese Orthopaedic Association(JOA) scores and visual analogue scale(VAS) at preoperation, 4 weeks, 52 weeks and 104 weeks of postoperation. Functional scores were tested by using multivariate repeated measured mixed models. Results: Eighty-two ADS patients who underwent long fusion were included. The incidence of patients with medical complications was 29.3%. The incidence of hypertension, diabetes and anemia were 30.5%, 20.7% and 9.8%, respectively. Among the postoperative complications, 14(17.1%) cases were infected, 9(11.0%) cases were complicated with cardiopulmonary dysfunction, 11(13.4%) cases were complicated with gastrointestinal disease, and 1 patient was with abnormal renal function(1.2%). The incidence of cerebrospinal fluid leakage in the no medical complications group was significantly lower than that in the medical complications group(19.0% vs. 54.2%, P=0.001). There were no significant differences in Cobb angle, PI-LL and SVA between the two groups at preoperation(P＞0.05). Cobb angle, PI-LL and SVA used in the radiographic parameters of the two groups were not significantly different at postoperation(P＞0.05). Independent predictors identified on multivariate Logistics regression modeling included BMI(OR 1.127, P=0.011), smoking(OR 3.15, P=0.032), length of hospital stay(OR 1.16, P=0.047), and duration of symptoms(OR 1.33, P=0.025). Despite experiencing medical complications, patients presented significant improvements at the final follow-up clinical functional scores ODI(P=0.0001), JOA(P=0.0001) and VAS(P=0.0001) after operation. However, there was no statistically significant difference in clinical scores between the two groups. Conclusions: Risk factors of postoperative medical complications after surgery of ADS include diabetes, smoking and hospital stay.