退行性脊柱侧凸长节段固定融合手术早期并发症的危险因素分析

Risk factors analysis of early complications in long-level fusion and instrumentation for adult degenerative scoliosis

中文关键词:  退行性脊柱侧凸  手术  并发症  危险因素

英文关键词:Adult degenerative scoliosis  Surgery  Complications  Risk factors

中文摘要:

  【摘要】 目的：探讨成人退行性脊柱侧凸（ADS）后路长节段固定融合手术早期并发症的危险因素。方法：回顾性分析2011年12月~2018年12月我院收治的行后路长节段固定融合手术ADS患者的临床资料，按术中和术后6周内是否出现早期并发症（肺部感染、泌尿系感染、切口感染、胃肠道反应或不完全性肠梗阻、硬脊膜破裂、胸腔积液、心律失常、肝功能损害和休克）分为早期并发症组和无早期并发症组。收集患者基本资料，包括性别、年龄、骨密度、合并症；术前风险评估指标，包括麻醉风险分级、营养风险筛查、深静脉血栓风险分级、手术风险评估；术前影像学测量指标，包括主弯冠状面Cobb角、冠状面平衡距离、脊柱失状位轴；术中相关指标，包括患者手术时间、手术固定节段数、手术椎间融合节段数、减压节段数、术中截骨分级、术中失血量和输血量；术后相关指标，包括患者住院输血总量、住院输血次数、术后血红蛋白最低值、术后白蛋白最低值、住院时间。比较两组间各指标差异和单因素Logistic回归分析来发现潜在危险因素，多因素Logistic回归分析筛选发生早期并发症的独立危险因素。结果：纳入研究的64例患者，男性23例，女性41例，平均年龄60.8±7.9（50～78）岁，早期并发症发生率32.8%（21/64）。有合并症（57.1% vs 25.6%）、术前营养风险筛查≥1分（42.9% vs 16.3%）、手术风险评估≥2分（52.4% vs 25.6%）和手术时间（279.3±97.8min vs 238.8±59.3min）、手术固定节段数（8.1±1.6 vs 6.9±2.1）两组间比较存在统计学差异（P＜0.05）；性别、年龄、骨密度、冠状面Cobb角、CBD、SVA、术前麻醉风险分级、深静脉血栓风险分级和术中失血量、术中输血量、椎间融合节段个数、减压节段个数、截骨等级以及术后血红蛋白最低值、术后白蛋白最低值、住院时间、住院输血总量、住院输血两组间比较无统计学差异（P＞0.05）。将有统计学差异的参数进行单因素Logistic回归分析显示术前营养风险筛查分值、术前手术风险评估分值、手术时间、手术固定节段数是早期并发症的潜在危险因素，多因素Logistic回归分析显示，术前营养风险筛查分值和手术时间是ADS长节段固定融合手术早期并发症的独立危险因素。术前营养风险筛查分值每增加1分（OR=3.114，P=0.032）、手术时间每增加1min（OR=1.010，P=0.033），发生手术早期并发症的风险分别增加2.11倍和0.01倍。结论：改善患者营养状况，降低术前营养风险筛查分值、缩短手术时间，对降低退行性脊柱侧凸患者长节段固定融合手术相关早期并发症有益。

英文摘要:

  【Abstract】 Objectives: To investigate the risk factors of early complications in long-level fusion and instrumentation for adult degenerative scoliosis(ADS). Methods: This retrospective study included patients with ADS who underwent posterior long-level fusion and instrumentation from December 2011 to December 2018. Patients were divided into two groups according to the occurrence of intra- and post-operative complications in 6 weeks. Early complications included pneumonia, urinary tract infection, wound infection, gastrointestinal discomfort or incomplete ileus, dural tear, pleural effusion, arrhythmia and shock. Patients′ demographics characteristics included gender, age, bone mineral density(BMD) and comorbidities. Preoperative assessment data included American society of anesthesiologists(ASA) risk grade, nutritional risk screening, deep vein thrombosis(DVT) risk grade and operative risk assessment. Radiographic parameters included coronal Cobb angle, coronal balance distance(CBD) and sagittal vertebral axis(SVA). Intraoperative data included operation time, intraoperative blood loss and transfusion, level of decompression, number of instrumented and fusion vertebrae. Postoperative data included hospital stay, the times and amount of blood transfusion, the minimum value of postoperative hemoglobin and albumin. Potential risk factors were identified by univariate logistic regression analysis after comparing the difference of clinical data in two groups. Multivariate logistic regression analysis was performed to verify the independent risk factors of early complications. Results: 64 patients was enrolled, 23 males and 41 females, the mean age was 60.8±7.6(50-78) years. Early complications were developed in 21 of 64 patients until 6 weeks after operation, the incidence rate is 32.81%(21/64). There were significant difference in parameters including comorbidities(57.1% vs 25.6%), preoperative nutritional risk screening≥1 score(42.9% vs 16.3%, P=0.021), operative risk assessment≥2 score(52.4% vs 25.6%, P=0.034), operation time(279.3±97.8 min vs 238.8±59.3 min, P=0.034), and levels of instrumentation(8.1±1.6 vs 6.9±2.1, P=0.016). There were no significant difference in parameters including gender, age, bone mineral density(BMD), coronal Cobb angle, coronal balance distance(CBD), and sagittal vertebral axis(SVA), preoperative American society of anesthesiologists(ASA) risk grade, deep vein thrombosis(DVT) risk grade, intraoperative blood loss and transfusion, level of decompression, number of instrumented and fusion vertebrae, the minimum value of postoperative hemoglobin and albumin, hospital stay, the times and amount of blood transfusionbetween two groups. These parameters with significant difference between the two groups were analysised by using univariate logistic regression, it showed that preoperative nutritional risk screening score, operative risk assessment score, operation time and levels of instrumentation were the potential risk factors of early complications. Analysis of the multivariate logistic regression showed that for every 1 point(OR=3.114, P=0.032) increase in preoperation nutritional risk screening score and 1 minute(OR=1.010, P=0.033) increase in operative time, the risk of early complications increased 2.11 times and 0.01 times respectively. Preoperative nutritional risk screening score and operation time were two independent factors of early complications after long-level fusion and instrumentation in ADS. Conclusions: By improving preoperative nutritional status, lower nutritional risk score and shortening the operation time are benefit to reduce early complications in long-level fusion and instrumentation for ADS.