颈椎前路手术后硬膜外血肿的发生率和危险因素

doi:10.19723/j.issn.1671-167X.2024.06.018

摘要/Abstract

摘要：

目的: 探讨行颈椎前路手术患者术后脊髓硬膜外血肿(spinal epidural hematoma，SEH)的发生率和危险因素。方法: 回顾性分析2013年3月至2022年2月因颈椎病于北京大学第三医院择期行颈椎前路手术患者的临床资料，将术后出现SEH的患者作为SEH组，将术后未出现SEH的患者以4 ∶ 1的比例随机纳入非SEH组，匹配条件为相同术者、相同性别、相同手术年份和相似年龄(±5岁)。比较两组患者的一般状况、术前合并症、抗凝或抗血小板药物使用情况、术前凝血功能和血小板计数、美国麻醉医师协会体格情况分级、颈椎病分型、术前改良日本骨科学会评分和颈部残障指数评分、手术方式、手术节段、手术节段后纵韧带骨化、手术时间、失血量、术后引流量、术前与术后苏醒期间平均动脉压、住院时间和住院费用等，通过二元Logistic回归筛选出术后发生SEH的独立危险因素，并用受试者工作特征曲线及其曲线下面积(area under curve, AUC)评价指标的准确性。结果: 共有85例患者纳入研究，其中SEH组共17例，非SEH组68例。17例SEH患者均接受了血肿清除术，所有患者均成功治疗并出院。椎体次全切除术(OR=7.247；95%CI：1.962~26.766；P=0.003)和术后苏醒期间最高平均动脉压增高(OR=1.056；95%CI：1.002~1.113；P=0.043)是导致SEH的危险因素，其AUC分别为0.713(95%CI：0.578~0.848)和0.665(95%CI：0.51~0.82)。SEH患者的住院时间更长(P < 0.001)，住院费用更高(P=0.035)。结论: 椎体次全切除术和术后苏醒期间最高平均动脉压增高是颈椎前路手术患者出现术后SEH的危险因素，应在围术期对高风险患者进行密切观察。

关键词: 颈椎前路手术, 脊髓硬膜外血肿, 危险因素

Abstract:

Objective: To investigate the incidence and potential risk factors associated with postoperative spinal epidural hematoma (SEH) following anterior cervical spine surgery (ACSS). Methods: A retrospective analysis was conducted on the clinical data of patients who underwent ACSS for cervical spondylosis at Peking University Third Hospital between March 2013 and February 2022. Patients who developed postoperative SEH were categorized as the SEH group, while those in the cohort without SEH were randomly selected as the non-SEH group by individually matching with the same operator, same gender, same surgery year, and similar age (±5 years) at a ratio of 4 ∶ 1. The general condition, preoperative comorbidities, anticoagulant or antiplatelet therapy, preoperative coagulation and platelet counts, American society of Anesthesiologists physical status classification, cervical spondylosis classification, preoperative modified Japanese Orthopaedic Society score and cervical disability index score, surgical modality, surgical segment levels, ossification of the posterior longitudinal ligament among the surgical level, surgery duration, estimated blood loss, postoperative drainage volume, preoperative mean arterial pressure, mean arterial pressure during postoperative awakening periods, hospital stay and hospitalization cost were compared between the two groups. A bivariate Logistic regression model was applied to screen out the independent risk factors and calculate the odds ratios of indicators associated with SEH. Receiver operating characteristic curve and area under the curve (AUC) were used to describe the discrimination ability of the indicators. Results: A total of 85 patients were enrolled in the study, including 17 patients in the SEH group and 68 patients in the non-SEH group. Seventeen patients with SEH underwent hematoma evacuation, and all of them were successfully treated and discharged from the hospital. Corpectomy (OR=7.247; 95%CI: 1.962-26.766; P=0.003) and the highest mean arterial pressure during awakening (OR=1.056; 95%CI: 1.002-1.113; P=0.043) were independent risk factors for SEH. The AUC values were 0.713 (95%CI: 0.578-0.848) and 0.665 (95%CI: 0.51-0.82) respectively. The patients with SEH had longer hospital stays (P < 0.001) and greater hospitalization costs (P=0.035). Conclusion: Corpectomy and elevated maximum mean arterial pressure during awakening are independent risk factors for the development of postoperative SEH following ACSS. High-risk patients should be closely monitored during the perioperative period.

Key words: Anterior cervical spine surgery, Spinal epidural hematoma, Risk factors

中图分类号:

R681.55

田杨, 韩永正, 李娇, 王明亚, 曲音音, 房景超, 金辉, 李民, 王军, 徐懋, 王圣林, 郭向阳. 颈椎前路手术后硬膜外血肿的发生率和危险因素[J]. 北京大学学报（医学版）, 2024, 56(6): 1058-1064.

Yang TIAN, Yongzheng HAN, Jiao LI, Mingya WANG, Yinyin QU, Jingchao FANG, Hui JIN, Min LI, Jun WANG, Mao XU, Shenglin WANG, Xiangyang GUO. Incidence and risk factors of postoperative epidural hematoma following anterior cervical spine surgery[J]. Journal of Peking University (Health Sciences), 2024, 56(6): 1058-1064.

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参考文献 23

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Case number	Symptom	Symptom onset time	Diagnostic method	Time from symptom onset to evacuation	Outcome
1	Quadriplegia	2 h	Clinical examination	0.5 h	Resolved
2	Quadriplegia	1 h	MRI	2.5 h	Resolved
3	Quadriplegia	1 h	Clinical examination	1 h	Resolved
4	Numbness	7 d	MRI	6 d	Resolved
5	Significant pain in left hand	1 h	CT	0.5 h	Resolved
6	Numbness	2 h	MRI	8 h	Resolved
7	Quadriplegia	3 h	Clinical examination	2 h	Resolved with residual neurologic deficits (mild motor weakness)
8	Quadriplegia	12 h	Clinical examination	1 h	Resolved
9	Sensory disorder and weakness in right upper limb	5 d	MRI and CT	2 d	Unresolved
10	Quadriplegia	3 h	MRI and CT	2.5 h	Resolved
11	Quadriplegia	4 h	Clinical examination	0.5 h	Resolved with residual neurologic deficits (mild motor weakness)
12	Paraplegia	2 h	Clinical examination	2.5 h	Resolved with residual neurologic deficits (mild motor weakness)
13	Quadriplegia	2 h	Clinical examination	1 h	Resolved
14	Weakness in left upper limb	20 h	MRI	8 h	Resolved with residual neurologic deficits (mild motor weakness)
15	Paraplegia	3 h	Clinical examination	1 h	Resolved
16	Paraplegia	1 h	Clinical examination	2 h	Resolved with residual neurologic deficits (mild motor weakness)
17	Paraplegia	0.5 h	Clinical examination	0.5 h	Resolved

Characteristic	SEH group (n=17)	Non-SEH group (n=68)	χ²/Z/t	P value
Gender, n (%)			χ²=0.000	>0.999
Male	13 (76.5)	52(76.5)
Female	4 (23.5)	16(23.5)
Age/years, $\bar x \pm s$	53±10	53±9	t=0.116	0.908
Hypertension, n (%)	4 (23.5)	21(30.9)	χ²=0.089	0.766
Body mass index/(kg/m²), $\bar x \pm s$	26.2±3.2	24.9±3.8	t=-1.239	0.219
Smoking history, n (%)	7 (41.2)	21(30.9)	χ²=0.652	0.419
Anticoagulant or antiplatelet therapy, n (%)	1 (5.9)	6(8.8)	χ²=0.000	>0.999
ASA classification, n (%)				>0.999^#
Ⅰ-Ⅱ	17 (100.0)	65 (95.6)
≥Ⅲ	0 (0)	3 (4.4)
Preoperative blood index
Prothrombin time/s, $\bar x \pm s$	10.9±0.9	10.9±0.7	t=0.039	0.969
International normalized ratio, $\bar x \pm s$	1.02±0.79	1.02±0.06	t=0.176	0.860
Fibrinogen/(g/L)，$\bar x \pm s$	3.11±0.63	2.91±0.53	t=-1.329	0.187
Activated partial thromboplastin time/s, $\bar x \pm s$	33.2±4.1	31.7±3.1	t=-1.615	0.109
Thrombin time/s, $\bar x \pm s$	14.0±1.2	14.0±0.9	t=-0.098	0.921
Platelet counts/(×10⁹/L), M (IQR)	255 (58)	220 (67)	Z=1.719	0.086

Characteristic	SEH group (n=17)	Non-SEH group (n=68)	χ²/Z/t	P value
Classification of cervical spondylosis, n (%)			χ²=5.379	0.146
Cervical spondylotic myelopathy	14 (82.4)	39 (57.4)
Cervical spondylotic radiculopathy	0 (0)	14 (20.6)
Mixed cervical spondylosis	3 (17.6)	13 (19.1)
Other types	0 (0)	2 (2.9)
m-JOA score, M (IQR)	13.5 (3.9)	14.5 (3.5)	Z=-1.292	0.196
Neck disability index score, M (IQR)	10.5 (15.8)	10.0 (17.3)	Z=-0.049	0.961
Surgical segments, M (IQR)	2 (0.5)	2 (1.0)	Z=1.305	0.192
OPLL among the surgical level, n (%)	9 (52.9)	22 (32.4)	χ²=2.488	0.115
Corpectomy, n (%)	13 (76.5)	23 (33.8)	χ²=8.460	0.004
Surgery duration/min, M (IQR)	95 (40)	86 (52)	Z=0.868	0.385
Estimated blood loss/mL, M (IQR)	60 (95)	20 (35)	Z=2.889	0.004
Drain volume/mL, M (IQR)	18 (50)	30 (35)	Z=-1.063	0.288
Preoperative MAP/mmHg, ±s	97±9	95±10	t=-0.848	0.399
Maximum MAP during awakening/mmHg, M (IQR)	116 (18)	103 (21)	Z=2.101	0.036
Length of stay/d, M (IQR)	7 (4)	4 (2)	Z=3.536	< 0.001
Cost/yuan, M (IQR)	69 949 (28 116)	60 007 (21 208)	Z=2.104	0.035

Variable	B	SE	P value	OR	95%CI
Corpectomy	1.981	0.667	0.003	7.247	1.962-26.766
Maximum MAP during awakening	0.054	0.027	0.043	1.056	1.002-1.113
Constant	-8.335	3.057	0.006	0

Variable	AUC	SE	P value	95%CI
Corpectomy	0.713	0.069	0.007	0.578-0.848
Maximum MAP during awakening	0.665	0.079	0.036	0.510-0.820