创伤性脊髓损伤患者神经功能转归的影响因素分析

Analysis on factors influencing neurological outcome in patients with traumatic spinal cord injury

目的分析不同医院间影响创伤性脊髓损伤(TSCI)住院患者神经功能转归的因素,探讨TSCI的防治方向。方法采用多阶段分层整群抽样的方法回顾性调查2018年1月1日至12月31日69家三级医院TSCI住院患者的病案信息;用Wilcoxon和Kruskal-Wallis H秩和检验分析出入院ASIA(美国脊髓损伤协会)损伤分级的差异;用两水平logistic随机截距模型分析不同医院TSCI患者ASIA损伤分级变化的影响因素。结果4404例TSCI患者中,恢复组1200例(27.25%),且出入院的分级分布差异有统计学意义(P<0.001)。ASIA损伤分级变化的总变异中,24.12%由医院层面的差异引起。多因素分析中,年龄每增长1岁,分级改善概率降低0.90%;与腰骶段相比,胸、颈段的分级改善概率分别降低28.90%、21.50%;完全性损伤者的分级改善概率较不完全者降低29.00%;伴随骨折脱位者的分级改善概率较不伴随者降低33.50%;受伤至手术时间间隔≤3日的分级改善概率较>3日增加0.353倍;康复训练者的分级改善概率增加1.069倍;与未手术者相比,减压固定术的分级改善概率增加1.565倍,减压固定融合术增加1.139倍。结论TSCI的住院治疗效果较差;不同医院水平下的年龄、损伤及救治特征差异均与TSCI的预后有关,表明亟待制定精准化的TSCI预防策略和建立区域化的"急救–治疗–康复"一体化平台。

Objective To analyze the factors affecting the neurological outcome of inpatients with traumatic spinal cord injury(TSCI)in different hospitals,and explore the future prevention and treatment of TSCI.Methods Multistage stratified cluster sampling method was used to extract the medical record information of TSCI patients hospitalized in 69 gradeⅢhospitals from January 1 to December 31,2018.Wilcoxon and Kruskal-Wallis H rank sum test was used to analyze the changes in injury grade of TSCI patients at discharge and admission according to American Spinal Injury Association(ASIA)injury classification;the two-level logistic random intercept model was used to analyze the influencing factorls of the changes in injury grade of TSCI patients according to ASIA injury classification in different hospitals.Results Among the 4404 TSCI patients,1200 were in recovery group,accounting for 27.25%,and the difference in injury grade distribution at discharge and admission was significant.In the total variation of ASIA injury grade change,24.12%was caused by hospital-level differences.In multivariate analysis,the grading improvement rate decreased by 0.90%for one-year increase of age.Compared with the lumbosacral segment.The grading improvement rates in the chest and neck segments were reduced by 28.90%and 21.50%,respectively.The grading improvement rate in patients with complete injury was 29.00%lower than that in patients with incomplete injury.The grading improvement rate in patients with fracture and dislocation was 33.50%lower than that in patients without these conditions.The grading improvement rate in patients with interval between injury and operation≤3 days was 0.353 times higher than that in patients with the interval>3 days.The grading improvement rate in patients with rehabilitation training increased by 1.069 times.Compared with patients without surgery,the grading improvement rate in patients with decompression fixation increased by 1.565 times,and the rate in those with decompression fixation and fusion increased by 1.139 times.Conclusion The effect of TSCI inpatient treatment was poor;the differences in age,injury and treatment characteristics at different hospital levels were all related to the prognosis of TSCI,indicating that it is urgent to develop precise TSCI prevention strategies and establish a regional integration of"emergency-treatment-rehabilitation"platform.