不同术中冲洗策略对后路单节段腰椎融合患者围手术期预后的影响

Assessment of surgical site infection after different intraoperative irrigation strategies in single-segment transforaminal lumbar interbody fusion

目的:评估不同术中冲洗策略对行后路单节段腰椎融合患者围手术期预后的影响,为临床工作中合理选择术中局部冲洗方式提供参考依据。方法:回顾性分析139例行后路单节段腰椎融合内固定的患者,依不同术中冲洗策略分为仅行终末生理盐水冲洗的A组(49例)、术中行持续生理盐水冲洗+终末生理盐水冲洗的B组(49例)和术中行抗生素生理盐水持续冲洗+终末生理盐水冲洗的C组(41例),所有病例均依据疾病控制和预防中心(Centre for Disease Control and Prevention,CDC)术后切口感染标准随访满1年。收集术中失血量、手术时间、术后住院时间、术后24h切口引流量、切口感染情况、VAS评分、白细胞计数、肌酸激酶同工酶(CKMB)、C反应蛋白(CRP)及单核细胞主要组织相容性抗原-DR(HLA-DR)变化情况等指标。分别对三组间正态及非正态指标行单因素ANOVA检验及Kruskal-Wallis H(K-W)检验,计数和等级资料的评估使用K-W检验。结果:B、C组与A组比较,术中失血量(185ml vs 240ml,P=0.001;185ml vs 240ml,P=0.008)、术后24h引流量(90ml vs 160ml,P=0.036;100ml vs 160ml,P=0.029)均显著减少;术后血白细胞升高程度[术后24h数据相比术前提升的百分比:(66.42±8.7)%vs(83.06±9.60)%,P=0.028;(65.91±11.2)%vs(83.06±9.60)%,P=0.032]均显著降低;术后住院时间明显缩短(7 vs 10.5,P<0.001;6 vs 10.5,P=0.001);B、C组术后24h术区VAS评分改善程度较A组更明显,B、C组间上述指标无差异。A组切口感染3例,感染率为6.12%;B组感染1例,感染率为2.04%;C组未发现感染阳性证据病例。所有感染病例都行切开引流及术后抗生素治疗并获得治愈。B组及C组的切口感染率低于A组,但无显著性差异。B组及C组的术前及术后CRP、CK及HLA-DR等指标的变化幅度均较A组小,但未见统计学差异。结论:术中伴随电刀使用的局部持续冲洗能有效减少术中失血、术后引流,减轻患者术后切口疼痛,并可缩减患者术后住院天数;抗生素生理盐水伴随冲洗策略可能是降低术后炎症反应的有效手段。

Objectives： To evaluate three strategies of intraoperative irrigation and their effects on control of postoperative surgical site infections. Methods： 139 consecutive patients in our ward undertaking single segment transforaminal lumbar interbody fusion（TLIF） were collected, and all the cases were categorized into three groups according to different methods of irrigation： group A, simple irrigation before closure; group B, continuous intraoperative irrigation with normal saline; group C, continuous intra-operative irrigation with antibiotic solutions. The Centre for Disease Control and Prevention （CDC） definition of surgical site infection （SSI） was used. All patients were followed up for 1 year. For data analysis, ANOVA test was used to analyze normally distributed variables and K-W test for abnormal distribution. K-W test was also used to analyze enumeration and ranked data. Results： Significant differences were found amongst parameters between group B and A, and group C and A, such as blood loss （185ml vs 240ml, P=0.001; 185ml vs 240ml, P=0.008）,postoperative drainage for the first 24 hours （90ml vs 160ml, P=0.036; 100ml vs 160ml, P=0.029） and postoperative hospital stay（7 vs 10.5, P〈0.001; 6 vs 10.5, P=0.001）. The increase in white blood cell count was found to be significantly different in group B and C compared to group A （66.42-＋8.7% vs 83.06_＋9.60%, P=0.028; 65.91-＋11.2% vs 83.06-＋9.60%,P=0.032）. Groups B and C showed a more significant decrease in VAS score compared to group A. 3 eases in group A （6.12%）, 1 case （2.04%） in group B and no case in group C showed positive evidence of SSI. All the infected cases were cured after irrigation and antibiotic treatment. SSI rates were found to be lower in group B and C compared to group A, but no significant differences between any two of the three groups were found. Pre and postoperative changes of CRP, CK and monoeyte HLA-DR expressions in group B and C were less than those of group A at 24 hours after surgery, but there were no significant differences. Conehlsions： Continuous lavage with normal saline or antibiotic solution can significantly decrease the amount of intraoperative blood loss and postoperative drainage as well as shorten the postoperative hospital stay. Thus, continuous irrigation alone with use of eleetrotome may have a positive effect in controlling the SSI risk.