胸腰骶椎结核术后早期并发症的Clavien-Dindo分级评估及其危险因素分析

Clavien-Dindo classification and risk factors for early postoperative complications in thoracic-lumbarsacral spinal tuberculosis patients

目的 :应用Clavien-Dindo(C-D)并发症分类系统对胸腰骶椎结核术后早期并发症进行评估,并分析其危险因素。方法:回顾性分析2000年1月~2015年12月在我院因脊柱结核行一期病灶清除、椎间植骨内固定术治疗的187例患者临床资料。男112例,女75例;年龄18~85岁,平均45.7±16.0岁。74例有神经功能损害,术前存在合并症29例。病变部位依次为胸椎40例(21.4%)、胸腰段51例(27.3%)、腰椎74例(39.6%)和腰骶椎22例(11.8%)。采用前路手术55例、后路手术98例及前后联合入路手术34例。使用C-D分类系统对患者术后住院期间(≤30d)并发症进行分级评估,先行单因素Logistic回归分析,观察年龄、性别、吸烟史、术前ASIA分级、术前合并症、术前抗结核治疗时间、病变部位、病变范围、术前血红蛋白、术前白蛋白、术前血沉、手术入路、手术时间及术中出血量与并发症的相关性,并对P<0.2的变量行多因素Logistic回归分析术后并发症的危险因素。结果:总体并发症发生率为37.4%(70/187),按照C-D并发症分类,Ⅰ级、Ⅱ级、Ⅲ级、Ⅳ级和Ⅴ级并发症发生率分别为24.1%、8.0%、2.7%、2.1%和0.5%。单因素Logistic回归分析显示术前合并症、病变范围、术前血红蛋白和术前白蛋白与总体并发症相关,年龄、术前合并症、术前抗结核时间、术前白蛋白和手术时间与Ⅱ级或以上级别并发症相关。多因素Logistic回归分析表明术前白蛋白低为总体并发症的独立危险因素(P=0.034),而术前合并症和手术时间长为Ⅱ级或以上级别并发症的独立危险因素(P=0.024和P=0.015)。结论 :CD并发症分类系统简单、可以提示并发症严重程度,是评估术后并发症的有效方法。术前白蛋白低是胸腰骶椎结核术后早期总体并发症发生的危险因素;术前合并症和手术时间长是脊柱结核术后早期发生C-D分级Ⅱ级或以上级别并发症的危险因素。

Objectives： To assess the early postoperative complications of thoracic-lumbar-sacral spinal tuberculosis by using the Clavien-Dindo（C-D） classification system, and to identify the risk factors related with them. Methods： All 187 cases of thoracic-lumbar-sacral spinal tuberculosis who were treated by one-stage debridement, interbody fusion and instrumentation between January 2000 and December 2015 were retrospectively analyzed. There were 112 males and 75 females, with an average age of 45.7±16.0 years（range, 18-85 years）. 74 cases were suffered from neurological dysfunction and 29 cases were complicated with comorbidities. There were 40 cases（21.4%） with thoracic tuberculosis, 51 cases（27.3%） with thoracolumbar tuberculosis, 74 cases（39.6%） with lumbar tuberculosis, and 22 cases（11.8%） with lumbosacral tuberculosis. 55 cases were treated by anterior approach, 98 cases were treated by posterior approach, and anterior approach combined posterior approach surgery was performed in 34 cases. Postoperative complications during hospitalization period（≤30d） were collected and evaluated by C-D classification. Univariate logistic regression analysis was used to evaluate possible relationships between early postoperative complications and the factors including： age, sex, history of smoking, preoperative ASIA grade, preoperative comorbidities, duration of preoperative anti-TB treatment, location of spinal lesion, extent of disease, preoperative hemoglobin, preoperative albumin, preoperative erythrocyte sedimentation rate, surgical approach, operation time, and intraoperative blood loss. Variables with P〈0.2 in the univariate analysis were considered in a multivariate logistic analysis that identified significant independent risk factors. Results： The overall complication rate was 37.4%（70/187）. According to the C-D classification, the incidence of complications of grade Ⅰ, grade Ⅱ, grade Ⅲ, grade Ⅳ and grade Ⅴ was 24.1%, 8.0%, 2.7%, 2.1% and 0.5%, respectively. Univariate logistic regression analysis showed that preoperative comorbidities, extent of disease, preoperative hemoglobin and preoperative albumin were associated with overall complications. Age, preoperative comorbidities, duration of preoperative anti-TB treatment, preoperative albumin and operation time were associated with grade Ⅱ or above complications. Multivariate logistic regression analysis identified low level of preoperative albumin（P=0.034） was an independent risk factor for overall complications. Preoperative comorbidities（P=0.024） and prolonged operation time（P=0.015） as the independent risk factors for grade Ⅱ or above complications. Conclusions： C-D system is simple and can suggest the severity of complications. It is an effective method for assessing postoperative complications. Low level of preoperative albumin is a risk factor for overall complications after surgery. Preoperative comorbidities and prolonged operation time are risk factors for grade Ⅱ or above of postoperative complications.