高能量胸腰椎骨折围手术期下肢深静脉血栓形成的危险因素分析

目的:探讨高能量胸腰椎骨折围手术期下肢深静脉血栓形成(deep venous thrombosis,DVT)的危险因素。方法:选择429例采用手术治疗的高能量胸腰椎骨折患者,从病历系统中提取年龄、性别、体质量指数、是否合并高血压、是否合并糖尿病、是否合并冠心病、术前和术后美国脊柱损伤协会(American Spinal Injury Association,ASIA)脊髓损伤神经功能分级、骨折至手术时间、卧床时间、D-二聚体血浆含量、纤维蛋白原血浆含量、凝血酶时间(thrombin time,TT)、活化部分促凝血酶原激酶时间(activated partial thromboplastin time,APTT)、凝血酶原时间(prothrombin time,PT)、高密度脂蛋白(high density lipoprotein,HDL)血清含量、低密度脂蛋白(low density lipoprotein,LDL)血清含量、血小板计数、红细胞体积分布宽度(red cell volume distribution width,RDW)变异系数、手术时间、出血量、补液量、是否输血、引流量等信息。按照术前是否发生下肢DVT将患者分为术前下肢DVT组和术前无下肢DVT组,按照术后是否发生下肢DVT将患者分为术后下肢DVT组和术后无下肢DVT组。分别对术前下肢DVT组和术前无下肢DVT组、术后下肢DVT组和术后无下肢DVT组患者的相关信息进行单因素分析,然后对其中组间差异有统计学意义的因素分别进行多因素Logistic回归分析。结果:术前下肢DVT组62例,术前无下肢DVT组367例。2组患者的年龄、术前ASIA脊髓损伤神经功能分级、骨折至手术时间、D-二聚体血浆含量、RDW变异系数比较,组间差异均有统计学意义(t=2.960,P=0.004;χ²=12.161,P=0.007;t=9.040,P=0.000;Z=-6.771,P=0.000;Z=-7.030,P=0.000);2组患者的性别、体质量指数、是否合并高血压、是否合并糖尿病、是否合并冠心病、纤维蛋白原血浆含量、TT、APTT、PT、HDL血清含量、LDL血清含量、血小板计数比较,组间差异均无统计学意义(χ²=0.104,P=0.747;t=0.734,P=0.460;χ²=0.042,P=0.838;χ²=0.762,P=0.383;χ²=0.449,P=0.503;Z=-0.640,P=0.522;Z=-1.250,P=0.211;Z=-0.203,P=0.839;Z=-1.691,P=0.091;Z=-1.146,P=0.252;Z=-0.839,P=0.401;Z=-1.589,P=0.112)。Logistic回归分析结果显示,骨折至手术时间、术前ASIA脊髓损伤神经功能分级(A级)、D-二聚体血浆含量是高能量胸腰椎骨折术前发生下肢DVT的危险因素(β=0.137,P=0.001,OR=1.147;β=2.117,P=0.000,OR=8.308;β=0.187,P=0.000,OR=1.205)。术后下肢DVT组83例,术后无下肢DVT组346例。2组患者的年龄、术后ASIA脊髓损伤神经功能分级、卧床时间、D-二聚体血浆含量、纤维蛋白原血浆含量、手术时间、出血量、补液量、是否输血、引流量比较,组间差异均有统计学意义(t=4.780,P=0.000;χ²=15.902,P=0.001;Z=-4.422,P=0.000;Z=-7.078,P=0.000;Z=-8.486,P=0.000;Z=-4.692,P=0.000;Z=-4.346,P=0.000;Z=-2.628,P=0.009;χ²=10.298,P=0.005;Z=-2.777,P=0.005);2组患者的性别、体质量指数、是否合并高血压、是否合并糖尿病、是否合并冠心病、TT、APTT、PT比较,组间差异均无统计学意义(χ²=0.892,P=0.345;t=1.550,P=0.122;χ²=1.212,P=0.271;χ²=0.004,P=0.948;χ²=0.049,P=0.825;Z=-0.870,P=0.384;Z=-0.637,P=0.524;Z=-0.228,P=0.819)。Logistic回归分析结果显示,年龄、术后ASIA脊髓损伤神经功能分级(A级)、卧床时间、D-二聚体血浆含量、纤维蛋白原血浆含量、输血是高能量胸腰椎骨折术后发生下肢DVT的危险因素(β=0.041,P=0.006,OR=1.042;β=2.239,P=0.000,OR=10.374;β=0.159,P=0.008,OR=1.172;β=0.591,P=0.000,OR=1.805;β=0.428,P=0.000,OR=1.535;β=0.708,P=0.036,OR=2.030)。结论:骨折至手术时间、术前ASIA脊髓损伤神经功能分级(A级)、D-二聚体血浆含量是高能量胸腰椎骨折术前发生下肢DVT的危险因素;年龄、术后ASIA脊髓损伤神经功能分级(A级)、卧床时间、D-二聚体血浆含量、纤维蛋白原血浆含量、输血是术后发生下肢DVT的危险因素。

Analysis of risk factors for lower limb deep venous thrombosis in the perioperative period of high-energy thoracolumbar fractures

Objective:To explore the risk factors for lower limb deep venous thrombosis(LDVT)in the perioperative period of high-energy thoracolumbar fractures.Methods:Four hundred and twenty-nine patients who underwent surgery for treatment of high-energy thoracolumbar fractures were selected,and the information including age,gender,body mass index(BMI),whether combined with hypertension,whether combined with diabetes,whether combined with coronary heart disease(CHD),preoperative and postoperative American Spinal Injury Association(ASIA)neurological classification of spinal cord injury,duration from fracture to surgery,bed rest time,plasma D-dimer level,plasma fbrinogen level,thrombin time(TT),activated partial thromboplastin time(APTT),prothrombin time(PT),serum high density lipoprotein(HDL)level,serum low density lipoprotein(LDL)level,platelet count,coefficient of variation of red cell volume distribution width(RDW-CV),operative time,blood loss,volume of intravenous fluid infusion,blood transfusion or not and drainage volume was extracted from the Electronic Medical Record System(EMRS).The patients were divided into preoperative LDVT group(62 cases)and preoperative non-LDVT group(367 cases)according to whether LDVT was found before the surgery,and the patients were divided into postoperative LDVT group(83 cases)and postoperative non-LDVT group(346 cases)according to whether LDVT was found after the surgery.Single-factor analysis was performed on the information of patients in preoperative LDVT group and preoperative non-LDVT group,and those in.postoperative LDVT group and postoperative non-LDVT group respectively,followed by multi-factor logistic regression analysis on the factors with significant differences between groups.Results:The differences were statistically significant between preoperative LDVT group and preoperative non-LDVT group in age,preoperative ASIA neurological classification of spinal cord injury,duration from fracture to surgery,plasma D-dimer level and RDW-CV(t=2.960,P=0.004;χ²=12.161,P=0.007;t=9.040,P=0.000;Z=-6.771,P=0.000;Z=-7.030,P=0.000).There was no statistical difference in gender,BMI,whether combined with hypertension,whether combined with diabetes,whether combined with CHD,plasma fibrinogen level,TT,APTT,PT,serum level of HDL,serum level of LDL and platelet count between preoperative LDVT group and preoperative non-LDVT group(χ²=0.104,P=0.747;t=0.734,P=0.460;χ²=0.042,P=0.838;χ²=0.762,P=0.383;χ²=0.449,P=0.503;Z=-0.640,P=0.522;Z=-1.250,P=0.211;Z=-0.203,P=0.839;Z=-1.691,P=0.091;Z=-1.146,P=0.252;Z=-0.839,P=0.401;Z=-1.589,P=0.112).The results of logistic regression analysis revealed that the duration from fracture to surgery,preoperative ASIA neurological classification of spinal cord injury(Grade A)and plasma D-dimer level were the risk factors for LDVT in patients with high-energy thoracolumbar fractures before the surgery(β=0.137,P=0.001,OR=1.147;β=2.117,P=0.000,OR=8.308;β=0.187,P=0.000,OR=1.205).The differences were statistically significant between post-operative LDVT group and postoperative non-LDVT group in age,postoperative ASIA neurological classification of spinal cord injury,bed rest time,plasma D-dimer level,plasma fibrinogen level,operative time,blood loss,volume of intravenous fluid infusion,blood transfusion or not and drainage volume(t=4.780,P=0.000;χ²=15.902,P=0.001;Z=-4.422,P=0.000;Z=-7.078,P=0.000;Z=-8.486,P=0.000;Z=-4.692,P=0.000;Z=-4.346,P=0.000;Z=-2.628,P=0.009;χ²=10.298,P=0.005;Z=-2.777,P=0.005).There was no statistical difference in gender,BMI,whether combined with hypertension,whether combined with diabetes,whether combined with CHD,TT,APTT and PT between postoperative LDVT group and postoperative non-LDVT group(χ²=0.892,P=0.345;t=1.550,P=0.122;χ²=1.212,P=0.271;χ²=0.004,P=0.948;χ²=0.049,P=0.825;Z=-0.870,P=0.384;Z=-0.637,P=0.524;Z=-0.228,P=0.819).The results of logistic regression analysis revealed that the age,postoperative ASIA neurological classifi-cation of spinal cord injury(Grade A),bed rest time,plasma D-dimer level,plasma fibrinogen level and blood transfusion were the risk factors for LDVT in patients with high-energy thoracolumbar fractures after the surgery(β=0.041,P=0.006,OR=1.042;β=2.239,P=0.000,OR=10.374;β=0.159,P=0.008,OR=1.172;β=0.591,P=0.000,OR=1.805;β=0.428,P=0.000,OR=1.535;β=0.708,P=0.036,OR=2.030).Conclusion:For patients with high-energy thoracolumbar fractures,the duration from fracture to surgery,preoperative ASIA neurological classification of spinal cord injury(Grade A)and plasma D-dimer level are the risk factors for LDVT before the surgery;while the age,postoperative ASIA neurological classification of spinal cord injury(Grade A),bed rest time,plasma D-dimer level,plasma fbrinogen level and blood transfusion are the risk factors for LDVT after the surgery.