急性自发性椎管内硬膜外血肿的临床特征及治疗

Clinical characteristics and early treatment of acute spontaneous spinal epidural hematoma

中文关键词:  急性自发性硬膜外血肿  脊髓压迫  显微手术  疗效

英文关键词:Acute spontaneous spinal epidural hematoma  Spinal cord compression  Microsurgery  Outcomes

中文摘要:

  【摘要】 目的：总结急性自发性椎管内硬膜外血肿（acute spontaneous spinal epidural hematoma，ASSEH）的临床和影像学特征，探讨其治疗方法及预后。方法：收集我院2005年1月～2020年12月收治的27例ASSEH患者的临床和影像学资料，回顾性分析病因、临床表现、影像学特征、治疗过程、手术时机、手术方式等相关资料，治疗前后和末次随访时进行VAS评分、ASIA分级及JOA评分，对神经功能改善情况及预后进行评估。结果：27例患者中，男15例，女12例；年龄15～81岁（31.3±15.9岁）。血肿位于颈椎15例，胸椎10例，腰椎2例，累及2～5个节段（2.3±0.9个节段）。24例首发症状为相应节段的疼痛，进而出现脊髓功能障碍；3例突发肢体神经功能障碍。入院时，27例患者VAS评分6.7±1.9分，ASIA分级A级16例，B级6例，C级4例，D级1例；颈胸段患者JOA评分0～15分（4.1±4.4分）。1例ASIA分级A级、3例C级、1例D级患者行保守治疗，其余22例患者在发病后4h～7d行后路椎板切除减压、显微镜下血肿清除、可疑畸形血管切除并椎板复位手术。保守治疗患者出院时1例A级患者恢复至B级，C级患者2例恢复至D级、1例无改变，1例D级患者恢复至E级；VAS评分由入院前4.6±1.1分降至1.4±1.1分；颈胸椎患者JOA评分由术前11.3±2.5分改善至13.6±3.1分，改善率为40.3%。手术患者出院时15例A级患者4例无变化，6例恢复至B级，5例恢复至C级；6例B级患者1例无恢复，3例恢复至C级，2例恢复至D级；VAS评分由术前7.2.±1.7分减少至1.0±1.2分；JOA评分由术前2.8±3.2分改善至7.3±3.9分，改善率为31.7%。随访6～54个月（21.8±10.5个月），保守治疗A级患者恢复至D级，C级患者1例恢复至D级，其余均恢复至E级；VAS评分0.20±0.44分；颈胸椎患者JOA评分15.0±2.0分，改善率为64.9%。手术治疗A级患者2例无变化，1例恢复至B级，1例恢复至C级，3例恢复至D级，8例恢复至E级；B级患者1例恢复至C级，5例恢复至E级，C级患者恢复至E级；VAS评分0.3±0.6分；JOA评分12.1±5.3分，改善率为67.7%。结论：ASSEH患者以颈肩胸背部疼痛和脊髓神经功能障碍为首发症状，早期诊治至关重要，对于脊髓压迫症状重、进展明显的患者及早行显微手术治疗预后较好。

英文摘要:

  【Abstract】 Objectives: To summarize the clinical and radiological features of acute spontaneous spinal epidural hematoma(ASSEH), and to explore different treatments and their outcomes and prognoses. Methods: The clinical and radiological data of 27 patients with ASSEH treated in our department from January 2005 to December 2020 were collected, and the etiology, clinical feature, imaging manifestation, therapeutic strategy, therapeutic process, operation timing and method were analyzed. The visual analogue scale(VAS), American Spinal Injury Association(ASIA) grade, and Japanese Orthopaedic Association(JOA) score before and after operation and at the final follow-up were compared to assess the improvement of neurological function and prognosis. Results: Of all the patients, there were 15 males and 12 females, aged 31.3±15.9 years(15 to 81 years). The imaging data revealed that the hematoma sizes extended across 2-5 vertebral levels(averaged 2.3±0.9), including 15 cases in cervical segment, 10 in thoracic segment, and 2 in lumbar segment. And in 24 cases, the initial symptoms were pain, followed by spinal cord dysfunction, while in the other 3 cases, the patients had sudden onset of limb numbness or paralysis. On admission, the VAS score of all the patients was 6.7±1.9; 16 cases were of ASIA grade A, 6 of grade B, 4 of grade C, and 1 of grade D; and JOA score for cervicothoracic patients was 4.1±4.4(0-15). 5 cases(1 ASIA grade A, 3 grade C, and 1 grade D) received conservative treatments, and the other 22 cases underwent microsurgery within 4h to 7d, including posterior laminectomy, removal of hematoma under microscope, and resection of suspected abnormal vessels and lamina reduction. On discharge, among the 5 cases with conservative treatments, 1 of ASIA grade A recovered to grade B; 2 of the 3 grade C cases recovered to D, and the other 1 remained grade C; 1 of grade D recovered to E; VAS score decreased from 4.6±1.1 to 1.4±1.1; JOA score improved from 11.3±2.5 to 13.6±3.1, with an improvement rate(IR) of 40.3%. Of the 22 cases undergone surgery, 4 of the 15 ASIA grade A patients remained grade A, 6 recovered to B and 5 recovered to C; and 1 case of the 6 grade B patients remained grade B, 3 recovered to C, and the other 2 recovered to D; VAS score dropped from preoperative 7.2±1.7 to 1.0±1.2, JOA score improved from 2.8±3.2 to 7.3±3.9, with an IR of 31.7%. All the patients were followed up for 6-54 months(averaged 21.8±10.5 months). Of the 5 cases with conservative treatments, VAS was 0.20±0.44, and JOA was 15.0±2.0, with an IR of 64.9％; 1 of grade A recovered to D, 1 of the 3 grade C recovered to D, and the other 2 recovered to E. Of the 22 cases undergone surgery, VAS score was 0.3±0.6, and JOA score was 12.1±5.3, with an IR of 67.7%; 2 of the 15 grade A patients remained grade A, 1 recovered to B, 1 to C, 3 to D, 8 to E; 1 of the 6 grade B patients recovered to grade C, 5 to E; 1 grade C patient recovered to grade E. Conclusions: The initial symptoms of ASSEH patients are sudden pain in neck, shoulder, chest and back as well as spinal nerve dysfunction, and early diagnosis and therapy are crucial. For patients with severe symptoms of spinal cord compression and with obvious progression, early microsurgery intervention provides promising outcomes.