Maxwell Robert A, Chavarria-Aguilar Marco, Cockerham William T, Lewis Patricia L, Barker Donald E, Durham Rodney M, Ciraulo David L, Richart Charles M
Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Tennessee 37403, USA.
J Trauma. 2002 May;52(5):902-6. doi: 10.1097/00005373-200205000-00013.
Acute spinal cord injury (SCI) is a devastating problem, with over 10,000 new cases annually. Pulmonary embolism (PE) is a well-recognized risk in SCI patients, although no clear recommendations for prophylaxis exist. We therefore evaluated whether routine placement of prophylactic inferior vena cava filters is indicated in SCI patients.
The trauma registry of a regional trauma center was used to identify patients sustaining acute SCI resulting in tetraplegia or paraplegia after blunt or penetrating trauma for a 5-year period beginning in January 1995. Patients were analyzed for demographics, mechanism of injury, Injury Severity Score, associated long bone or pelvic fracture, severe closed-head injury, type of deep venous thrombosis (DVT) prophylaxis, level of SCI, and incidence of DVT and PE. DVT prophylaxis was performed in all patients with sequential compression devices (SCDs) when extremity fracture status permitted. Data are expressed as mean +/- SD and analyzed using Fisher's exact test.
There were 8,269 admissions during the study period, with an overall incidence of DVT and PE of 11.8% and 0.9%, respectively. There were 111 (1.3%) patients who sustained SCI, with an incidence of DVT and PE of 9.0% and 1.8%, respectively, and no deaths. Of these 111 patients, 41.4% were paraplegics and 58.6% were tetraplegics, and 17.1% of patients had severe closed-head injury. Mean hospital length of stay was 23 +/- 20 days for SCI patients. Surveillance duplex ultrasound was performed an average of 2.3 +/- 2.1 times during each hospitalization. Mean Injury Severity Score was 30.0 +/- 12.2. The incidence of DVT and PE in those patients with SCDs alone was 7.1% and 2.3%; for SCDs plus subcutaneous heparin, the incidence was 11.1% and 2.8%; and for SCDs plus low-molecular-weight heparin, the incidence was 7.4% and 0%, respectively, with no statistical difference between groups. The incidence of DVT in SCI patients with long bone fractures was 37.5%, which was significantly greater than the total SCI population (p < 0.02).
The incidence of DVT and PE in SCI patients was similar to that of the overall trauma population when appropriate DVT prophylaxis was used. Subgroup analysis demonstrated that SCI associated with long bone fracture significantly increases the incidence of DVT. On the basis of the low incidence of PE in the present study, routine placement of prophylactic caval filters does not appear warranted in all SCI patients. However, SCI patients with long bone fractures, patients with DVT formation despite prophylactic anticoagulation, or patients with contraindications to anticoagulation may be appropriate candidates for prophylactic caval filtration.
急性脊髓损伤（SCI）是一个严重的问题，每年有超过10000例新发病例。肺栓塞（PE）是SCI患者中公认的风险，尽管目前尚无明确的预防建议。因此，我们评估了SCI患者是否需要常规放置预防性下腔静脉滤器。
利用某地区创伤中心的创伤登记系统，确定1995年1月开始的5年期间因钝性或穿透性创伤导致急性SCI并伴有四肢瘫或截瘫的患者。分析患者的人口统计学资料、损伤机制、损伤严重程度评分、合并的长骨或骨盆骨折、严重闭合性颅脑损伤、深静脉血栓形成（DVT）预防类型、SCI水平以及DVT和PE的发生率。当肢体骨折情况允许时，所有患者均使用序贯加压装置（SCD）进行DVT预防。数据以均数±标准差表示，并采用Fisher精确检验进行分析。
研究期间共收治8269例患者，DVT和PE的总体发生率分别为11.8%和0.9%。有111例（1.3%）患者发生SCI，DVT和PE的发生率分别为9.0%和1.8%，无死亡病例。在这111例患者中，41.4%为截瘫患者，58.6%为四肢瘫患者，17.1%的患者有严重闭合性颅脑损伤。SCI患者的平均住院时间为23±20天。每次住院期间平均进行2.3±2.1次双功超声监测。平均损伤严重程度评分为30.0±12.2。仅使用SCD的患者中DVT和PE的发生率分别为7.1%和2.3%；SCD加皮下肝素的患者中，发生率分别为11.1%和2.8%；SCD加低分子肝素的患者中，发生率分别为7.4%和0%，各组之间无统计学差异。合并长骨骨折的SCI患者中DVT的发生率为37.5%，显著高于总体SCI人群（p<0.02）。
当采用适当的DVT预防措施时，SCI患者中DVT和PE的发生率与总体创伤人群相似。亚组分析表明，合并长骨骨折的SCI显著增加DVT的发生率。基于本研究中PE的低发生率，似乎并非所有SCI患者都有必要常规放置预防性腔静脉滤器。然而，合并长骨骨折的SCI患者、尽管进行了预防性抗凝仍发生DVT的患者或有抗凝禁忌证的患者可能是预防性腔静脉滤过的合适人选。
