颈椎后路手术后有症状硬膜外血肿及其危险因素

Incidence and risk factors of symptomatic epidural hematoma in posterior cervical surgery

中文关键词:  硬膜外血肿  颈椎后路手术  危险因素

英文关键词:Epidural hematoma  Posterior spine surgery  Risk factors

中文摘要:

  【摘要】 目的：探讨颈椎后路手术后有症状硬膜外血肿（symptomatic epidural hematoma，SEH）的发生情况及危险因素，为预防硬膜外血肿提供依据及处理措施。方法：回顾性分析2012年9月~2017年9月在我院接受颈椎后路椎管扩大椎板成形术或椎板切除术的患者（除外骨折、脱位、感染及肿瘤），找出术后发生SEH的患者（SEH组），并从相同时间段内未发生SEH的患者中按照1∶4的比例随机抽取对照组，收集患者性别、年龄、体重指数BMI、是否合并后纵韧带骨化（ossification of posterior longitudinal ligament，OPLL）、有无外伤、是否合并高血压、糖尿病或动脉粥样硬化性疾病、是否服用抗血小板药物、血小板计数、凝血酶原时间（PT）、部分凝血酶原活化时间（APTT）、国际标准比值（INR）、血清总蛋白、白蛋白、血钙、手术节段数、内固定节段数、是否行椎板切除、手术时间及术中失血量等可能对SEH发生有影响的因素。应用t检验、卡方检验以及多因素Logistic回归分析，分析其与SEH发生的相关性。结果：共有3859例患者接受颈椎后路手术，其中19例患者术后发生SEH，发生率为0.49%。术后出现血肿中位时间为120min（30min~15d）。2例患者以躯体或四肢麻木为首发症状，17例患者首要表现为四肢肌力明显下降，后随时间推移，所有患者均出现肌力下降，神经功能Frankel分级B级4例，C级13例，D级2例。出现临床症状后，7例患者接受MRI检查，明确诊断为SEH，另12例患者通过临床症状确诊。19例均接受急诊手术探查、硬膜外血肿清除术。术后患者肌力均有恢复，所有患者经血肿清除术后神经功能Frankel分级均恢复至少1级。两组比较，合并OPLL比例、手术节段数、内固定长度、手术时间、术中出血量等有显著性差异（P<0.05）；多因素Logistic回归分析显示，手术节段数和合并OPLL与术后SEH的发生具有显著相关性（P<0.05）。结论：手术节段数以及合并OPLL是颈椎后路手术后发生SEH的危险因素，对于有相关危险因素的患者术后应密切观察神经功能，保证引流通畅。

英文摘要:

  【Abstract】 Objectives: To explore the incidence and risk factors of symptomatic epidural hematoma(SEH) in posterior cervical surgery, and to provide evidence and intervention for clinical prevention. Methods: Retrospective review of patients who received posterior cervical laminoplasty or laminectomy was made from September 2012 to September 2017(exclude patients with fractures, dislocation, infections or tumors), and all the patients with SEH were identified as SEH group. The control group was randomly chosen from patients without hematoma, with quantity four times of SEH group. Factors which might affect SEH occurrence were collected: gender, age, body mass index, ossification of posterior ligament(OPLL), trauma, hypertension, diabetes, vascular atherosclerotic diseases, anti-platelet drugs, platelet count, prothrombin time, activated partial thromboplastin time, international normalized ratio, serum total protein, serum albumin, blood calcium, segments, instrumental fixation, laminectomy, duration of surgery and estimated blood loss. t-test, Chi-square test and multifactor logistic regression analysis were used to investigate the correlation of factors and SEH. Results: A total of 3859 patients received posterior cervical surgery, among whom 19 cases suffered from SEH with the incidence of 0.49%. The median time of SEH occurrence was 120min(range, 30min to 15d). 2 cases firstly presented with numbness, other 17 cases firstly presented with paralysis, and all cases suffered from paralysis before hematoma evacuation. Frankel grade was B in 4 cases, C in 13 cases and D in 2 cases. 7 cases were radiologically diagnosed by MRI, the other 12 cases were diagnosed by clinical manifestation. All 19 patients received emergent hematoma evacuation and recovered at least one grade after evacuation. There were significant differences of OPLL, surgical segments, instrumental length, duration and estimated blood loss between the two groups in univariable test(P<0.05). Multifactor logistic regression showed that surgical segments and OPLL were the risk factors of postoperative SEH(P<0.05). Conclusions: Segments and OPLL are the risk factors of postoperative SEH. For patients with these risk factors, neurological functions should be under restrict surveillance, and drains obstruction should be prevented.