单侧双通道内镜下腰椎融合术后隐性失血的危险因素分析

Analysis of risk factors for hidden blood loss in unilateral biportal endoscopic transforaminal lumbar interbody fusion

中文关键词:  腰椎退行性疾病  内镜下融合术  单侧双通道  隐性失血  危险因素

英文关键词:Lumbar degenerative diseases  Endoscopic fusion  Unilateral biportal endoscopic  Hidden blood loss  Risk factors

中文摘要:

  【摘要】 目的：观察单侧双通道内镜下腰椎融合术（unilateral biportal endoscopic transforaminal lumbar interbody fusion，UBE-TLIF）术后的隐性失血情况，并对其相关危险因素进行分析。方法：回顾性分析2020年1月~2021年6月在我院行UBE-TLIF治疗的59例腰椎退行性疾病患者的临床资料，收集患者一般资料如年龄、性别、体质指数（body mass index，BMI）、学习曲线、疾病类型以及是否合并有高血压、糖尿病；手术相关资料如病变节段、手术时间、显性失血量、美国麻醉师协会麻醉分级（American Society of Anesthesiologists，ASA）；实验室检查如凝血酶原时间、活化部分凝血活酶时间、血小板计数、纤维蛋白原、血红蛋白（hemoglobin，Hb）和红细胞压积（hematocrit，Hct）。根据Gross公式计算总失血量，并由此计算患者的术后隐性失血量，采用单因素方差分析和Pearson相关性检验探讨患者的特征与术后隐性失血之间的相关性，采用多元线性回归分析确定术后隐性失血的独立危险因素，构建危险因素的受试者工作特征（receiver operating characteristic，ROC）曲线以分析危险因素的预测价值。结果：手术时间为128.22±22.88min，总失血量为607.32±186.78ml，隐性失血量为393.83±173.42ml，占总失血量的（62.13±11.73）%。术后Hb、Hct均较术前明显降低（P<0.05）。单因素方差分析中性别、高血压、糖尿病、手术节段、疾病类型与隐性失血无明显相关性（P>0.05），学习曲线和ASA分级与隐性失血具有相关性（P<0.001）。Pearson相关性分析显示，年龄、BMI、凝血酶原时间、活化部分凝血活酶时间、血小板计数与隐性失血无相关性（P>0.05），手术时间、纤维蛋白原与隐性失血具有相关性（P<0.001）。多元线性回归分析显示，手术时间（B=2.236，P<0.01）、学习曲线（B=-109.781，P<0.01）、ASA分级（B=77.589，P<0.01）和纤维蛋白原（B=81.762，P<0.01）是隐性失血的独立危险因素。ROC曲线显示手术时间预测严重隐性失血的ROC曲线下面积（area under curve，AUC）为0.813（95%CI：0.688~0.938，P<0.001），最佳截点为139.5min；纤维蛋白原的AUC为0.794（95%CI：0.654~0.934，P<0.001），最佳截点为2.65g/L。结论：UBE-TLIF治疗腰椎退行性疾病存在较大的术后隐性失血，手术时间、学习曲线、ASA分级和纤维蛋白原是术后隐性失血的独立危险因素。

英文摘要:

  【Abstract】 Objectives: To observe the hidden blood loss after unilateral biportal endoscopic transforaminal lumbar interbody fusion(UBE-TLIF) and analyze its related risk factors. Methods: The clinical data of 59 patients who underwent UBE-TLIF for lumbar degenerative diseases(LDD) in our hospital from January 2020 to June 2021 were retrospectively analyzed. Data of general information such as age, gender, body mass index(BMI), learning curve, type of disease, and presence of hypertension and diabetes; surgery-related information such as lesion segment, operative time, visible blood loss, and American Society of Anesthesiologists(ASA) classification; and laboratory test data such as prothrombin time, activated partial thromboplastin time, platelets, fibrinogen, hemoglobin(Hb), and hematocrit(Hct) were collected. The total blood loss was calculated according to the Gross formula, and the hidden blood loss was calculated accordingly. One-way analysis of variance and Pearson correlation test were used to explore the correlation between patient characteristics and postoperative hidden blood loss. Multivariate linear regression analysis was used to determine the independent risk factors for postoperative hidden blood loss, and the receiver operating characteristic(ROC) curve of risk factors was constructed to analyze the predictive values of risk factors. Results: The operative time was 128.22±22.88min, total blood loss was 607.32±186.78ml, and the hidden blood loss was 393.83±173.42ml, accounting for (62.13±11.73)% of the total blood loss. Postoperative Hb and Hct were significantly lower than those before operation(P<0.05). One-way analysis of variance showed gender, (with or without)hypertension, (with or without)diabetes, surgical segment, and disease type were not significantly correlated with hidden blood loss(P>0.05), and the learning curve and ASA calssification were correlated with hidden blood loss(P<0.001). Pearson correlation analysis showed that age, BMI, prothrombin time, activated partial thromboplastin time, and platelets had no correlations with hidden blood loss(P>0.05), while operative time, and fibrinogen had correlations with hidden blood loss(P<0.001). Multiple linear regression analysis indicated that operative time(B=2.236, P<0.01), learning curve(B=-109.781, P<0.01), ASA classification(B=77.589, P<0.01), and fibrinogen(B=81.762, P<0.01) were independent risk factors for hidden blood loss. ROC curve displayed that the area under the ROC curve(AUC) of operative time for predicting severe hidden blood loss was 0.813(95%CI: 0.688-0.938, P<0.001), and the best cut-off point was 139.5min. The AUC of fibrinogen was 0.794(95%CI: 0.654-0.934, P<0.001), and the optimal cut-off point was 2.65g/L. Conclusions: There is a large hidden blood loss risk in the treatment of LDD by UBE-TLIF, which should be paid attention to in clinical practice. Operative time, learning curve, ASA classification, and fibrinogen are independent risk factors for postoperative hidden blood loss.