急性脊髓损伤患者自主神经功能障碍性低血压的危险因素分析

Analysis of risk factors for autonomic reflex dysfunction hypotension of acute spinal cord injury

目的探讨急性脊髓损伤患者发生自主神经功能障碍性低血压的发生情况及高危因素。方法采用回顾性病例对照研究分析2011年1月—2016年12月解放军总医院第七医学中心收治的191例急性脊髓损伤患者临床资料,其中男164例,女27例;年龄18~60岁,平均46.4岁。致伤原因:交通伤97例,高空坠落伤55例,重物砸伤30例,摔伤9例。损伤节段:颈髓损伤98例,胸髓损伤52例,腰髓损伤19例,圆锥损伤22例。美国脊髓损伤协会(ASIA)神经功能分级:A级61例,B级52例,C级38例,D级40例。将收缩压低于90 mmHg,心率低于60次/min定义为自主神经功能障碍性低血压,其中35例为低血压组,156例为非低血压组。观察自主神经功能障碍性低血压发生情况。比较两组性别、年龄、体重指数、致伤原因、骨折类型、脊髓损伤节段、ASIA分级、血压、心率、合并损伤及住院时间。应用单因素分析模型观察各因素与自主神经功能障碍性低血压发生的相关性,筛查导致低血压发生的可疑相关因素,再应用Logistic回归分析明确与自主神经功能障碍性低血压相关的高危因素。结果发生自主神经功能障碍性低血压患者均为颈髓和胸髓损伤,在98例颈髓损伤患者中,26例发生自主神经功能障碍性低血压,发生率为27%;在54例胸髓损伤患者中,9例发生自主神经功能障碍性低血压,发生率为17%,均为T5节段及以上损伤的患者。单因素分析结果显示,两组在性别、年龄、体重指数、致伤原因、骨折类型、是否有合并损伤及住院时间等方面差异均无统计学意义(P>0.05)。两组间脊髓损伤节段、ASIA分级差异有统计学意义(P<0.01)。Logistic回归分析显示,脊髓损伤节段(OR=0.185,95%CI 0.081~0.424)和ASIA分级(OR=0.108,95%CI 0.048~0.244)与自主神经功能障碍性低血压显著相关(P<0.01)。结论脊髓损伤节段与ASIA分级是发生自主神经功能障碍性低血压的独立危险因素,脊髓损伤节段越高,脊髓损伤程度越重,越容易发生自主神经功能障碍性低血压。

Objective To investigate the incidence and risk factors of autonomic reflex dysfunction hypotension in patients with acute spinal cord injury.Methods A retrospective case control study was made on the data of 191 patients with acute spinal cord injury admitted to Seventh Medical Center of PLA General Hospital from January 2011 to December 2016,including 164 males and 27 females,aged 18-60 years with an average age of 46.4 years.The injury mechanisms of injuries were traffic accidents in 97 patients,high falling injury in 55,heavy pound injury in 30 and fall injury in 9.The injured segments included 98 patients with cervical spinal cord injury,52 with thoracic spinal cord injury,19 with lumbar spinal cord injury and 22 with cone injury.According to the American Spinal Injury Association(ASIA),61 patients were classified as grade A,52 as grade B,38 as grade C and 40 as grade D.Autonomic reflex dysfunction hypotension was defined as a systolic blood pressure below 90 mmHg and heart rate below 60 beat/min.There were 35 patients in hypotension group and 156 patients in non-hypotension group.Incidence of autonomic reflex dysfunction hypotension was observed.The data of sex,age,body mass index,injury mechanism,fracture type,spinal cord injury segment,spinal cord injury grade,blood pressure,heart rate,combined injury and length of hospital stay were collected.Univariate analysis was used to observe the correlation between each factor and the occurrence of autonomic reflex dysfunction hypotension,to screen the suspected related factors,and then Logistic regression analysis was used to identify the independent correlation factors related to autonomic reflex dysfunction hypotension.Results Autonomic reflex dysfunction hypotension was found in patients with acute spinal cord injury at the cervical and thoracic regions.In 98 patients with cervical spinal cord injury,26 patients(27%)had autonomic reflex dysfunction hypotension;in 54 patients with thoracic spinal cord injury,9 patients(17%)had autonomic reflex dysfunction hypotension.All of them showed T5 segment or above injury.Univariate analysis showed significant differences in spinal cord injury segment and spinal cord injury grading between the two groups(P<0.01),but not in gender,age,body mass index,injury mechanism,fracture type,combined injury or not,and length of hospital stay(P>0.05).Logistic regression analysis showed that spinal cord injury segment(OR=0.185,95%CI 0.081-0.424)and spinal cord injury grade(OR=0.108,95%CI 0.048-0.244)were independent factors related to autonomic reflex dysfunction hypotension(P<0.01).Conclusions Spinal cord injury segment and spinal cord injury grading are independently correlated to autonomic reflex dysfunction hypotension.The higher the injury segment is and the severer the injury is,the more likely autonomic reflex dysfunction hypotension is to occur.