自发性脊髓硬膜外血肿的治疗策略和预后

Treatment strategies and outcomes of spontaneous spinal epidurai hematomas

目的探讨自发性脊髓硬膜外血肿（SSEH）的治疗策略及其神经功能预后。方法回顾性纳入2004年6月至2016年3月天津医科大学总医院神经外科收治的42例SSEH患者，其中手术组24例，保守治疗组18例。根据发病至手术的时间，将手术组分为〈12h组（13例）、12～24h组（7例）以及〉24h组（4例）。分别采用日本骨科协会（JOA）脊髓功能评分表（简称JOA评分）和美国脊髓损伤协会（ASIA）损伤分级（简称ASIA分级）评价患者的神经功能状况。根据JOA评分评估神经功能恢复率。随访时间为4～34个月，平均（18±6）个月。结果无论是手术组或保守治疗组，不同ASIA分级的患者其神经功能恢复率的差异均有统计学意义（均P〈0．05）。ASIA分级同为C级的手术组与保守组间神经功能恢复率的差异有统计学意义[（64．1±31．5）％对比（34．1±17．6）％，P〈0．05]；而ASIA分级同为D级的手术组与保守组间神经功能恢复率的差异无统计学意义[（100．0±0．0）％对比（91．9±18．7）％，P〉0．05]。〈12h组的术后神经功能恢复率[（79．8±26．1）％]高于12～24h组[（53．9±13．9）％]以及〉24h组[（20．0±21．3）％]（均P〈0．05）。结论对于ASIA分级为A、B、C级或神经功能障碍进行性加重的SSEH患者，应尽早行手术治疗；对于ASIA分级为D级或E级，或短期内神经功能有好转趋势的患者，可选择保守治疗。行手术治疗的患者术前ASIA分级越高，发病至手术的时间间隔越短，则预后越佳。行保守治疗的患者治疗前ASIA分级越高，则预后越佳。

Objective To investigate the treatment strategies and neurological outcomes of spontaneous spinal epidural hematomas （SSEH）. Methods From June 2004 to March 2016, a total of 42 patients with SSEH were admitted to Department of Neurosurgery, Tianjin Medical University General Hospital and were retrospectively reviewed in this study. All patients were divided into the surgery group （24 cases） and conservative treatment group （ 18 cases）. Based on the time interval from inital symptoms to surgery, the patients in surgery group were further separated into 〈 12 h group, 12 -24 h group and 〉24 h group. The neurological functions of patients were assessed by the Japanese Orthopedics Association （JOA） scale and American Spinal Injury Association （ASIA） impairment scale. The 3OA scores were used to determine the recovery rate of neurological functions. The follow-up period ranged from 4 to 34 months, with an average of 18 ---6 months. Results There were significant differences in the recovery rate of neurological functions between patients with different ASIA scales either in the surgery group or conservative treatment group （ all P 〈 0.05 ）. Significant difference was identified in the neurological function recovery rate between ASIA grade C patients in the surgery group and those in the conservative treatment group （64.1±31.5% vs. 34.1±17.6%,P〈0.05）. The patients of ASIA grade D in the two groups had no statistical difference （100.0±0.0% vs. 91.9±18.7% , P 〉 0.05 ）. The neurological function recovery rate in 〈12 hgroupwas （79.8±26.1）% and higher than 12-24 hgroup （53.9±13.9%） and 〉24 h group （ 20.0±21.3 % ） （ both P 〈 0.05 ）. Conclusions For patients graded as ASIA scale A, B, C or those with progressive decline in ASIA scale, early surgical treatment should be recommended. For patients of ASIA scale D, E or those with tendency for neurological function recovery within a short term, conservative treatment might be considered. Patients undergoing operations with higher initial ASIA scale and shorter preoperative interval tend to demonstrate better outcomes. Patients undergoing conservative treatment with higher initial ASIA scale seem more likely to achieve good outcomes.