创伤性脊髓损伤患者的流行病学及住院费用影响因素研究

目的:分析创伤性脊髓损伤(SCI)患者的流行病学特征,评价创伤性SCI患者的住院费用,探索影响住院费用的因素。方法:收集中国康复研究中心收治的252例创伤性SCI患者流行病学相关数据,并采用描述性分析患者基本信息、损伤情况、并发症、住院时间、费用及支付方式,单因素分析和多元线性回归模型分析患者基本特征对住院费用的影响。结果:共252例患者,男女比为4.1:1,41~60岁的患者占比最大(37.3%),工人在患者中占比最大(26.2%);致伤原因中交通事故占首位(26.4%),其次为高空坠落(25.5%);颈段SCI患者占首位(47.2%),其次为胸段(43.3%);ASIA评分A级患者为主(48%),其次为D级患者(22.6%);并发症中发病率前3位分别是神经痛(44.4%)、泌尿系感染(23.8%)、痉挛(22.6%);医疗保险就医患者(34.9%),工伤保险患者(18.7%),其余为自费医疗患者(46.4%)。手术等级、并发症数量、合并症情况、损伤节段、损伤程度、伤后时间间隔的组间差距均影响康复费用;手术等级、并发症数量、受伤时间、损伤节段是康复费用的主要影响因素。结论:男性在SCI患者中的占比升高,颈段SCI患者占比增大;应注意行车和施工中的安全防护,遵守交通法规和操作流程,高龄人群应预防跌倒的发生。医疗保险制度不断完善,减轻了脊髓损伤患者的经济负担。受伤时间对日均住院费用影响最大,其次为手术等级、并发症数量和损伤节段,为合理配置医疗资源可考虑从这几方面着手。     

脊髓损伤患者康复期尿路感染的危险因素

目的:进一步明确影响脊髓损伤(SCI)患者康复期尿路感染(UTI)发生的危险因素。方法:收集我科2003年5月至2008年11月住院的脊髓损伤患者190例,筛选出140例患者进行回顾性分析,选择11个可能对患者尿路感染发生有关的因素,分别进行分组,比较各组的尿路感染率,单因素分析确定影响尿路感染发生的危险因素,多因素Logistic回归分析确定影响其发生的独立危险因素。结果:140例患者总的尿路感染率为44.29%,单因素分析表明:脊髓损伤程度、尿管留置时间、尿管冲洗频率、膀胱区理疗、康复介入时间、尿路感染前抗生素使用和使用时间,以及有无低蛋白血症是影响脊髓损伤住院患者康复期尿路感染的危险因素。多因素Logistic回归分析表明:脊髓损伤程度(P=0.001)、尿管留置时间(P0.05)是影响脊髓损伤住院患者康复期尿路感染发生的独立危险因素。结论:脊髓损伤患者尿路感染的发生与多个危险因素有关。损伤程度、尿管留置时间是影响其发生的独立危险因素。     

汶川地震脊髓损伤患者日常生活活动能力预后的相关因素分析

目的：探讨汶川地震脊髓损伤患者治疗前后影响日常生活活动（ADL）能力的相关因素。方法：选择可能对脊髓损伤患者临床预后有影响的因素,以入院康复治疗2个月后改良Barthel指数（MBI）为预后指标,进行回顾性和多因素分析。入选病例为35例地震致脊髓损伤患者。结果：经康复治疗2个月后,患者的MBI从治疗前的15.17提高到58.71。治疗后的ADL能力与年龄、康复介入时机、治疗前ADL评分不相关;与ASIA损伤等级、神经平面呈正相关;与受压时间、并发症数呈负相关。结论： ASIA损伤等级、神经平面、受压时间、并发症数都是影响地震致脊髓损伤患者ADL能力预后的主要因素。     

康复治疗的起始时间对不同节段脊髓损伤治疗效果的影响

目的探讨脊髓不同节段损伤(SCI)进行脊髓损伤后康复治疗起始时间达到康复目标出现的并发症、残损分级变化、所需时间等指标变化。方法选择脊髓不同节段损伤病例120例,按损伤至入组时间的不同分组,分为术后组(n=62)、延迟组(n=58),比较术后组与延迟组不同节段脊髓损伤所需的康复时间、残损分级指标的变化,发生肺部感染、下尿路感染、下肢深静脉血栓、压疮等并发症发生情况。结果术后组的不同节段脊髓损伤所需康复时间显著短于延迟组,差异有统计学意义(P 0. 05);随着损伤平面的增高,脊髓损伤所需康复时间越长。术后组的脊髓损伤残损分级指标变化与延迟组比较,差异无统计学意义(P 0. 05);术后组发生肺部感染、下尿路感染、下肢深静脉血栓、压疮等并发症发生情况显著低于对照组,差异有统计学意义(P 0. 05)。结论随着脊髓损伤平面的增高,康复所需时间逐渐延长。早期康复干预可缩短康复时间和降低术后并发症的发生率。     

脊椎骨折合并脊髓损伤的康复护理

脊椎骨折合并脊髓损伤的主要临床表现是,脊椎节段损伤平面以下感觉与运动发生不同程度的障碍,括约肌麻痹,大小便失禁.患者恢复期的康复护理可提高疗效,防止并发症,现将康复护理体会介绍如下.……     

运动想象疗法治疗脊髓损伤神经源性膀胱患者的影响因素分析

目的：探求运用运动想象疗法治疗脊髓损伤神经源性膀胱患者的影响因素。方法将入组92例应用运动想象疗法进行膀胱功能训练的脊髓损伤神经源性膀胱患者,根据其训练效果是否明显分为两组,分别观察包括年龄、文化程度、康复介入时机、脊髓损伤类型等在内的11项可能影响训练效果的因素,使用Logistic回归分析影响疗效的因素。结果患者的文化程度、抑郁状态、神经源性膀胱类型、介入时间及坚持疗程不同会影响患者进行膀胱训练,差异有统计学意义(χ2值分别为5.851,6.903,6.901,30.597,4.211;P<0.05)。大专以下文化程度、HAMD≥17分、介入时间≥60 d、坚持疗程<8周及神经源性膀胱类型为尿失禁是应用运动想象疗法对脊髓损伤神经源性膀胱患者进行膀胱训练时的不利影响因素。结论文化程度、抑郁状态、康复介入时机、坚持疗程、神经源性膀胱类型是应用运动想象疗法对脊髓损伤神经源性膀胱患者进行膀胱训练时的影响因素,在进行运动想象疗法训练时应针对这些影响因素加强宣教指导。     

不同时机康复介入对不同程度的脊髓损伤患者神经功能恢复的影响研究

目的探讨不同时机康复介入对不同程度的脊髓损伤患者神经功能恢复的影响。方法选取2009年10月至2011年10月接受手术治疗和术后康复的不同程度的脊髓损伤患者48例,随机分为早期康复介入组和晚期康复介入组,每组24例。观察不同时机康复介入对不同程度的脊髓损伤患者神经功能恢复的影响。结果治疗后,两组患者的运动评分、触觉评分和痛觉评分均明显高于治疗前（P〈0．05）;早期介入组运动评分、触觉评分和痛觉评分均明显高于晚期介入组（P〈0．05）;早期介入组患者的康复治疗时间与晚期介入组患者之间比较无明显差异（P〉0．05）。结论旱期康复介入对不同程度的脊髓损伤患者神经功能恢复效果明显．值得推广．     

胸腰段脊柱爆裂骨折伴脊髓损伤的治疗

目的　评价不同经后路内固定方法治疗胸腰段脊柱骨折伴脊髓损伤的疗效。方法　回顾性分析 96例经后路长、短节段内固定治疗胸腰段脊柱骨折伴脊髓损伤患者术后神经功能恢复程度、骨折复位愈合效果和并发症的发生情况。结果　短节段组在神经功能恢复程度上与长节段组无显著差异 (P >0 .0 5 ) ,但短节段组的脊柱后凸术后矫正丢失角度明显 <长节段组 ,而且并发症少。结论　后路短节段内固定治疗胸腰段脊柱骨折伴脊髓损伤的效果明显优于后路长节段内固定     

系统康复治疗对完全性颈6脊髓损伤患者预后的影响

目的:观察系统康复治疗对完全性颈6(C6)节段脊髓损伤患者预后的疗效.方法:完全性C6脊髓损伤患者12例,均在临床治疗基础上进行系统康复治疗,治疗前后采用功能独立性量表(FIM)、Barthel指数(BI)进行评定,并观察并发症发生情况.结果:经过平均5.4个月的治疗,12例患者BI及FIM评分均较治疗前明显提高(P＜0.01);泌尿系统感染、体位性低血压、压疮、交感神经反射亢进等并发症发生率较治疗前明显下降(P＜0.01).结论:系统康复治疗可以明显改善完全性C6节段脊髓损伤患者ADL能力,预防和治疗并发症,提高脊髓损伤患者生活质量.     

外伤致脊髓损伤患者的康复期护理

目的:探讨外伤后脊髓损伤患者康复期的护理要点。方法:通过康复治疗小组进行治疗及心理支持,对108例外伤后脊髓损伤康复期患者实施各种康复护理措施。对可能出现的各种并发症,护士及早的康复介入,循序渐进,进行防治。结果:经过康复护理的早期介入,提高了脊髓损伤患者的生活质量,调动了脊髓损伤患者的主动性,发挥其残存功能,帮助他们重归家庭和社会。结论:外伤后脊髓损伤患者的康复,要尽早开始,减少并发症,并依靠患者自身的努力,改善生活自理能力。     

Aging with spinal cord injury: changes in selected health indices and life satisfaction

OBJECTIVES: To document the impact of age, age at injury, years postinjury, and injury severity on changes over time in selected physical and psychosocial outcomes of people aging with spinal cord injury (SCI), and to identify the best predictors of these outcomes. DESIGN: Retrospective cross-sectional and longitudinal examination of people with SCI. SETTING: Follow-up of people who received initial rehabilitation in a regional Model Spinal Cord Injury System. PARTICIPANTS: People who meet the inclusion criteria for the National Spinal Cord Injury Database were studied at 5, 10, 15, 20, and 25 years postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Number of pressure ulcers, number of times rehospitalized, number of days rehospitalized, perceived health status, satisfaction with life, and pain during the most recent follow-up year. RESULTS: The number of days rehospitalized and frequency of rehospitalizations decreased and the number of pressure ulcers increased as time passed. For the variables of pressure ulcers, poor perceived health, the perception of pain and lower life satisfaction, the best predictor of each outcome was the previous existence or poor rating of that same outcome. CONCLUSIONS: Common complications of SCI often herald the recurrence of those same complications at a later point in time, highlighting the importance of early intervention to prevent future health and psychosocial difficulties.     

Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury

OBJECTIVE: To compare neurologic, medical, and functional outcomes of patients with acute spinal cord injury (SCI) undergoing early (<24 h and 24-72 h) and late (>72 h) surgical spine intervention versus those treated nonsurgically. DESIGN: Retrospective case series comparing outcomes by surgical and nonsurgical groups during acute care, rehabilitation, and at 1-year follow-up. SETTING: Multicenter National Spinal Cord Injury Database. PARTICIPANTS: Consecutive patients with acute, nonpenetrating, traumatic SCI from 1995 to 2000, admitted in the first 24 hours after injury. Surgical spinal intervention was likely secondary to nature of injury and the need for spinal stabilization. Interventions Not applicable. MAIN OUTCOME MEASURES: Changes in neurologic outcomes (motor and sensory levels, motor index score, American Spinal Injury Association [ASIA] Impairment Scale [AIS]), medical complications (pneumonia and atelectasis, deep vein thrombosis and pulmonary embolism, pressure ulcers, autonomic dysreflexia, rehospitalization), and functional outcomes (acute and rehabilitation length of stay [LOS], hospital charges, FIM instrument score, FIM motor efficiency scores). RESULTS: Subjects in the early surgery group were more likely ( P <.05) to be women, have paraplegia, and have SCI caused by motor vehicle collisions. The nonsurgical group was more likely ( P <.05) to have an older mean age and more incomplete injuries. ASIA motor index improvements (from admission to 1-y follow-up) were more likely ( P <.05) in the nonsurgical groups, as compared with the surgical groups. Those with late surgery had significantly ( P <.05) increased acute care and total LOS and hospital charges along with higher incidence of pneumonia and atelectasis. No differences between groups were found for changes in neurologic levels, AIS grade, or FIM motor efficiency. CONCLUSIONS: ASIA motor index improvements were noted in the nonsurgery group, though likely related to increased incompleteness of injuries within this group. Early versus late spinal surgery was associated with shorter LOS and reduced pulmonary complications, however, no differences in neurologic or functional improvements were noted between early or late surgical groups.     

Early versus delayed inpatient spinal cord injury rehabilitation: an Italian study

OBJECTIVE: To examine what effect the injury-to-rehabilitation interval has on the outcome of spinal cord injury (SCI) rehabilitation. DESIGN: Retrospective study. SETTING: Spinal unit of a large rehabilitation hospital. PARTICIPANTS: Consecutive admissions were divided into groups according to age, sex, and American Spinal Injury Association impairment grade and neurologic level of injury. The patients were matched for these variables and divided into groups according to the interval from injury to admission into acute rehabilitation. This approach resulted in 150 patients with SCI grouped into 50 comparison subgroupings. Interventions Three comparison groups-short (<30 d), medium (31-60 d), and long (>60 d) time to admission (TTA)-were evaluated for rehabilitation outcomes. MAIN OUTCOME MEASURES: Barthel Index, Rivermead Mobility Index, Walking Index for Spinal Cord Injury, and motor scores at admission and discharge were examined. The changes and efficiencies were evaluated. RESULTS: The 3 groups were comparable for all medical and demographic characteristics as well as neurologic recovery. The 3 subgroups differed significantly in activity of daily living outcomes, with the short TTA group exhibiting higher Barthel Index raw discharge scores, score increases, and score efficiencies. CONCLUSIONS: Early rehabilitation seems to be a relevant prognostic factor of functional outcome. Rehabilitation intervention in patients with SCI should begin as soon as possible, in a specialized setting, because delay may adversely affect functional recovery.     

Effect of co-morbid traumatic brain injury on functional outcome of persons with spinal cord injuries

OBJECTIVE: This study was undertaken to determine if persons who sustain a spinal cord injury (SCI) and co-morbid brain injury (dual diagnosis [DDS]) evidence smaller functional gains and experience significantly longer rehabilitation lengths of stay than persons with only an SCI. DESIGN: This retrospective comparison study was performed at a 100-bed rehabilitation hospital specializing in acute SCI and traumatic brain injury rehabilitation. Summary scale outcome data of persons who sustained an SCI were compared with outcome data of a group of persons with a DDS. Comparisons were established by matching groups principally on level of SCI and admission Motor FIM trade mark score and secondarily on education, sex, and age. Outcome measures included admission Motor and Cognitive FIM score, discharge Motor and Cognitive FIM score, Motor and Cognitive FIM change, length of stay, and rehabilitation charges. RESULTS: Persons with a DDS evidenced a significantly more impaired Cognitive FIM score at admission and discharge from rehabilitation. Persons with a DDS also achieved a significantly lower Motor FIM change than persons with SCI. There were no significant differences between DDS and SCI groups regarding Cognitive FIM change, length of stay, or rehabilitation charges. Injury severity as defined by the Glasgow Coma Scale or intracranial lesions did not predict response to treatment in the DDS group. CONCLUSION: Persons with a DDS achieved smaller functional gains during rehabilitation than peers with SCI. Brain injuries seem to limit functional gains, although the relationship between brain injury severity and functional change is not linear. Prospective studies are needed to identify factors limiting functional gains in rehabilitation and assist in developing specific treatment programs for persons with SCI and brain injury.     

An Italian survey of traumatic spinal cord injury. The Gruppo Italiano Studio Epidemiologico Mielolesioni study

OBJECTIVE: To describe the etiology, clinical presentation, complications, outcome indicators, and links between emergency and acute intervention and rehabilitation of patients with traumatic spinal cord injury (SCI). DESIGN: Multicenter prospective study involving patients with SCI discharged, after rehabilitative care, between February 1, 1997, and January 31, 1999. SETTING: Thirty-two Italian hospitals involved in SCI rehabilitation. PARTICIPANTS: Six hundred eighty-four patients with traumatic SCI on their first admission to a rehabilitation center. INTERVENTIONS: Not applicable. Main Outcome Measures: Neurologic improvement (NI), bladder autonomy, feelings of dependency, and destination were evaluated on discharge. Pressure ulcers on admission, time from injury to admission, and length of stay (LOS) were considered as indirect measures of the effectiveness of the health system. RESULTS: Traumatic etiology had a male-to-female ratio of 4:1 (548:136). Collision on the road was the main cause of traumatic injury (53.8%). Mean time from injury to admission was 36.8 days; 126 patients (18%) were admitted within the first week after injury. Mean LOS was 135.5 days. In 184 patients (26.9%), a pressure ulcer was present on admission. On discharge, NI was recorded in 179 patients (26.2%), whereas 446 (65%) and 418 (61%) had bladder and bowel autonomy, respectively, and 560 (81.9%) returned home. In the multivariate analysis, independent variables predicting poor outcome (NI, feelings of dependency, sphincter autonomy, discharge to home, LOS) were related both to the lesion (completeness, cervical involvement) and to the indicators of health service organization (time from injury to admission, complications on admission and during stay). CONCLUSIONS: Our focus on the etiology of traumatic SCI showed that efforts should be made to prevent collisions on the road. Our study also highlights problems in the comprehensive management of patients with SCI in Italy. Better organization could help reduce the time from injury to admission, the number of complications on admission, and LOS, and it could help improve rehabilitation outcome.     

影响脊髓损伤患者出院时日常生活活动能力的相关因素分析

目的 探讨影响脊髓损伤(SCI)患者出院时日常生活活动(ADL)能力的相关因素.方法 对105例SCI患者进行分析,入选时收集每位患者病史,记录一般情况如性别、年龄、病因、损伤水平、损伤分级、受伤(发病)时间、手术时间、入院和出院时间等,并记录出院和入院时的改良Barthel指数(MBI)评分、美国脊髓损伤协会(ASIA)SCI积分,对影响患者出院时ADL能力的因素进行线性回归分析.结果 出院时,SCI患者ASIA运动评分、ASIA针刺觉评分、ASIA轻触觉评分和MBI评分均有改善,与入院时比较,差异有统计学意义(P＜0.01);多因素分析显示,SCI分级、入院时ASIA运动评分、入院时ASIA针刺觉评分等3个因素与出院时MBI评分密切相关,康复介入时间、康复疗程、入院时ASIA运动评分等3个因素与出入院MBI差值密切相关.结论 通过康复训练,各年龄阶段、不同损伤平面、不同损伤程度的SCI患者的ADL能力都可得到改善.入院时运动能力较好、康复疗程足够长、康复介入时间早的患者改善幅度也相对较大.     

影响脊髓损伤患者出院时日常生活活动能力的相关因素分析

目的 探讨影响脊髓损伤(SCI)患者出院时日常生活活动(ADL)能力的相关因素.方法 对105例SCI患者进行分析,入选时收集每位患者病史,记录一般情况如性别、年龄、病因、损伤水平、损伤分级、受伤(发病)时间、手术时间、入院和出院时间等,并记录出院和入院时的改良Barthel指数(MBI)评分、美国脊髓损伤协会(ASIA)SCI积分,对影响患者出院时ADL能力的因素进行线性回归分析.结果 出院时,SCI患者ASIA运动评分、ASIA针刺觉评分、ASIA轻触觉评分和MBI评分均有改善,与入院时比较,差异有统计学意义(P＜0.01);多因素分析显示,SCI分级、入院时ASIA运动评分、入院时ASIA针刺觉评分等3个因素与出院时MBI评分密切相关,康复介入时间、康复疗程、入院时ASIA运动评分等3个因素与出入院MBI差值密切相关.结论 通过康复训练,各年龄阶段、不同损伤平面、不同损伤程度的SCI患者的ADL能力都可得到改善.入院时运动能力较好、康复疗程足够长、康复介入时间早的患者改善幅度也相对较大.