退变性脊柱侧凸后路长节段固定融合术后早期并发症危险因素分析

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

中文关键词:  退变性脊柱侧凸  早期并发症  长节段固定  危险因素

英文关键词:Adult degenerative scoliosis  Long levels fusion  Early complications  Risk factors

中文摘要:

  【摘要】 目的：探讨成人退变性脊柱侧凸（adult degenerative scoliosis，ADS）后路长节段融合固定术后早期并发症的相关危险因素。方法：收集了216例在我院行后路长节段（≥4节段）固定融合术的ADS患者的临床资料，根据术后6周内是否出现并发症分为早期并发症组和无并发症组。比较两组患者围术期相关资料，一般资料包括性别、年龄、腰腿症状时间、既往内科病病史、是否吸烟、骨质疏松T值、美国麻醉医师学会（American Society of Anesthesiologists，ASA）麻醉风险分级等；手术资料包括手术时间、固定融合节段数、截骨分级、术中失血量等；术后资料包括患者术后是否出现并发症、并发症具体情况、术后引流量、患者术后红细胞计数及血红蛋白量等。比较两组间各指标差异并通过单因素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：89例患者纳入早期并发症组，127例患者纳入无并发症组。腰痛病程（P=0.034）、术后第1天红细胞计数（P=0.017）、麻醉时间（P＜0.001）、手术时间（P＜0.001）、固定融合节段数量（P＜0.001）、术中行截骨术（P=0.027）、不同截骨级别（P=0.002）、截骨节段（P=0.049）、术中失血量（P=0.048）、术中尿量（P=0.022）、术中总输入液体量（P=0.005）、自体血回输量（P=0.022）、术后总引流量（P＜0.001）、住院时间（P＜0.001）两组间存在统计学差异（P＜0.05）。单因素Logistic回归分析显示，固定融合节段长、手术时间长、术中失血量多、术中总输入液体量多、3级及以上截骨术、自体血回输量多、术后总引流量多、术后第1天红细胞计数较低为早期并发症的潜在危险因素，多因素Logistic回归分析显示，较多的术后总引流量、3级及以上截骨为术后早期并发症的独立危险因素。进行3级及以上截骨患者出现早期并发症的风险为进行3级以下截骨或未进行截骨患者的4.577倍（P=0.041）；术后引流量每增加100ml，其出现早期并发症的风险增加12.7%（P＜0.001）。对潜在危险因素应用标准受试者工作特征（receiver operating characteristic，ROC）曲线的曲线下面积值（the area under the ROC curve，AUC）得出，手术时间≥244min，固定融合节段≥6个节段，术后总引流量≥1745ml对术后早期并发症发生的预测具有一定准确性。结论：术后引流量多、进行3级及以上截骨与术后早期并发症密切相关，减少手术时间、选择合适的固定融合节段对减少术后早期并发症有益。

英文摘要:

  【Abstract】 Objectives: To investigate the risk factors of early complications during posterior long-level instrumentation in the treatment of adult degenerative scoliosis(ADS). Methods: The data of 216 patients with ADS who underwent posterior long-segmental instrumentation(≥4 levels) were reviewed retrospectively. According to whether complications occurred within 6 weeks or not after operation, the patients were divided into the early complications group and non-early complications group. The perioperative data of the two groups were compared. General data included gender, age, duration of lumbar and leg symptoms, past medical history, smoking history, T-value of osteoporosis, and preoperative classification by American Society of Anesthesiologists(ASA). The operative data included operation time, number of fixation and fused levels, osteotomy grade, and intraoperative blood loss. Postoperative data included whether there were postoperative complications, the situation of complications, volume of drainage, postoperative red blood cell count, and hemoglobin level. Potential risk factors were identified by univariate logistic regression analysis after comparing the difference of clinical data in the two groups. Multivariate logistic regression analysis was performed to verify the independent risk factors of early complications. Results: There were 89(41.2%) patients enrolled in the early complications group, and 127(58.8%) in the control group. There were statistically significant differences between the two groups(P<0.05) in terms of the duration of low back pain(P=0.034), count of red blood cell on the first day after surgery(P=0.017), anesthesia time(P<0.001), operation time(P<0.001), fixation and fusion levels(P<0.001), intraoperative osteotomy(P=0.027), the osteotomy grade(P=0.002) and level(P=0.049), intraoperative blood loss(P=0.048), intraoperative urinary volume(P=0.022), total intraoperative input liquid(P=0.005), volume of autologous blood transfusion(P=0.022), postoperative drainage volume(P=0.002), and hospital stay(P<0.001). These parameters were analyzed by univariate logistic regression, which showed that the increase of fixation and fusion levels, longer duration of surgery, more intraoperative blood loss, more total intraoperative liquid input, grade 3 and above Osteotomy, more volume of autologous blood transfusion, more postoperative drainage volume, and fewer count of red blood cell on the first day after surgery were the potential risk factors of early complications. Analysis of the multivariate logistic regression showed that more total postoperative drainage volume and grade 3 or above osteotomy were independent risk factors for early postoperative complications. When patients underwent grade 3 or above osteotomy, the risk of early complications was 4.577 times that of those who underwent grade 2 or below or even no osteotomy(P=0.041). The risk of early complications increased 12.7% with every 100ml increase of postoperative drainage volume (P<0.001). The predictive accuracy of the potential risk factors was analyzed using the area under the receiver operating characteristic(ROC) curve(AUC). The result was that the duration of surgery ≥244 minutes, the fixation and fusion levels ≥6 levels, and the total postoperative drainage volume ≥1745ml had certain accuracy in predicting the occurrence of early postoperative complications. Conclusions: High drainage volume and grade 3 or above osteotomy are closely related to early postoperative complications, it is beneficial to reduce the early postoperative complications by reducing the operative time and choosing the appropriate fixation and fusion level.