急性创伤性颈髓损伤后早期发生呼吸系统并发症的危险因素研究

Risk Factors for Early Respiratory Complications after Acute Traumatic Cervical Spinal Cord Injury

背景急性创伤性颈髓损伤(TCSCI)会导致患者膈肌麻痹,影响呼吸运动,因而患者需要通过手术治疗来降低呼吸系统并发症的发生率并改善预后。但目前关于影响急性TCSCI后发生呼吸系统并发症相关因素的研究较少。目的评估急性TCSCI患者1周内发生呼吸系统并发症的危险因素。方法回顾性分析2016年11月-2018年7月在新疆医科大学附属中医医院脊柱外科治疗并随访3个月的74例急性TCSCI患者的病例资料,根据患者受伤1周内是否发生呼吸系统并发症分为疾病组(n=43)和对照组(n=31)。收集患者入院后的病例资料,包括:性别、年龄、体质指数(BMI)、吸烟史、合并症(高血压、糖尿病)、创伤原因、美国脊髓损伤协会(ASIA)损伤程度分级、ASIA运动评分(AMS)、有无相关创伤、损伤平面、创伤严重程度评分(ISS)、临床肺部感染评分(CPIS)、治疗方案、手术方式、手术时间、住院时间、删失率。采用多因素Logistic回归分析探讨急性TCSCI患者发生呼吸系统并发症的影响因素。结果74例急性TCSCI患者中,合并呼吸系统并发症43例(58.1%),其中肺炎5例、肺水肿1例、行机械通气37例。37例行机械通气的患者中有31例在术前完成操作,其中21例为气管插管状态,10例为气管切开状态。疾病组ASIA损伤程度分级完全损伤患者多于对照组,AMS低于对照组,有相关创伤的患者多于对照组,ISS、CPIS高于对照组,采用后路手术方式的患者所占比例多于对照组,住院时间长于对照组(P<0.05)。多因素Logistic回归分析结果显示,ASIA损伤程度分级〔OR=3.290,95%CI(1.214,6.862)〕、AMS〔OR=2.430,95%CI(1.103,5.436)〕、CPIS〔OR=1.235,95%CI(1.036,3.264)〕、手术方式〔OR=1.225,95%CI(1.033,3.106)〕是急性TCSCI患者发生呼吸系统并发症的影响因素(P<0.05)。结论ASIA损伤程度分级、AMS、CPIS和手术方式是预测急性TCSCI患者出现呼吸系统并发症的独立危险因素,对于完全损伤、AMS或CPIS较高、行后路手术的患者,需早期加强呼吸管理,积极给予机械通气。

Background Acute traumatic cervical spinal cord injury(TCSCI)can lead to diaphragmatic paralysis,impairing the breathing exercises.Such patients need surgical treatment to reduce the incidence of respiratory complications and improve prognosis.However,the risk factors for respiratory complications within 1 week after acute TCSCI have been rarely studied.Objective To assess the risk factors for respiratory complications occurred within 1 week after acute TCSCI.Methods Participants were 74 cases of acute TCSCI who received treatment in the Affiliated Hospital of Traditional Chinese Medicine of Xinjiang Medical University during November 2016 to July 2018 and a 3-month follow-up,including 43 with respiratory complications within 1 week after acute TCSCI(disease group),and 31 without(control group).A retrospective analysis was performed on their data about sex,age,BMI,history of smoking,comorbidities(hypertension,diabetes),pathogeny,level of spinal cord injury and ASIA motor score evaluated by the ASIA Impairment Scale,prevalence of injury,anatomic level of injury,Injury Severity Score(ISS),Clinical Pulmonary Infection Score(CPIS),treatment regimen,surgical approach and duration,length of stay,and prevalence of dropout.Multivariate Logistic regression model was used to analyze the variables possibly associated with respiratory complications after acute TCSCI.Results Of the 43 cases(58.1%)with respiratory complications,5 had pneumonia,1 had pulmonary edema,and 37 had mechanical ventilation.Mechanical ventilation was performed preoperatively in 31 cases(21 cases via endotracheal tube,and 10 via tracheotomy).The disease group had higher prevalence of complete spinal cord injury,higher prevalence of coexisted injuries,lower mean ASIA motor score,higher mean ISS and CPIS,and higher rate of having surgery using a posterior approach,as well as longer mean length of stay compared with the control group(P<0.05).Multivariate Logistic regression analysis the level of spinal cord injury〔OR=3.290,95%CI(1.214,6.862)〕,AMS score〔OR=2.430,95%CI(1.103,5.436)〕,CPIS〔OR=1.235,95%CI(1.036,3.264)〕,and surgical approach〔OR=1.225,95%CI(1.033,3.106)〕were independent factors associated with for respiratory complications within 1 week after acute TCSCI(P<0.05).Conclusion The level of spinal cord injury and ASIA motor score evaluated by the ASIA Impairment Scale,CPIS and surgical approach are independent factors predicting respiratory complications after acute TCSCI.Early enhanced respiratory management and active mechanical ventilation should be given to those with complete spinal cord injury,higher AMS or CPIS,and having the surgery via a posterior approach.