Deyo Richard A, Hickam David, Duckart Jonathan P, Piedra Mark
*Departments of Family Medicine, Medicine, Public Health and Preventive Medicine, and Center for Research on Occupational and Environmental Toxicology, †Department of Medicine, and ‡Department of Neurological Surgery, Oregon Health and Science University, Portland, OR; and §Portland Center for the Study of Chronic Comorbid Mental and Physical Disorders, Portland VA Medical Center, Portland, OR.
Spine (Phila Pa 1976). 2013 Sep 1;38(19):1695-702. doi: 10.1097/BRS.0b013e31829f65c1.
Secondary analysis of the prospectively collected Veterans Affairs National Surgical Quality Improvement Program database.
Determine rates of major medical complications, wound complications, and mortality among patients undergoing surgery for lumbar stenosis and examine risk factors for these complications.
Surgery for spinal stenosis is concentrated among older adults, in whom complications are more frequent than among middle-aged patients. Many studies have focused on infections or device complications, but fewer studies have focused on major cardiopulmonary complications, using prospectively collected data.
We identified patients who underwent surgery for a primary diagnosis of lumbar stenosis between 1998 and 2009 from the Veterans Affairs National Surgical Quality Improvement Program database. We created a composite of major medical complications, including acute myocardial infarction, stroke, pulmonary embolism, pneumonia, systemic sepsis, coma, and cardiac arrest.
Among 12,154 eligible patients, major medical complications occurred in 2.1%, wound complications in 3.2%, and 90-day mortality in 0.6%. Major medical complications, but not wound complications, were strongly associated with age. American Society of Anesthesiologists (ASA) class was a strong predictor of complications. Insulin use, long-term corticosteroid use, and preoperative functional status were also significant predictors. Fusion procedures were associated with higher complication rates than with decompression alone. In logistic regressions, ASA class and age were the strongest predictors of major medical complications (odds ratio for ASA class 4 vs. class 1 or 2: 2.97; 95% confidence interval, 1.68-5.25; P = 0.0002). After adjustment for comorbidity, age, and functional status, fusion procedures remained associated with higher medical complication rates than were decompressions alone (odds ratio = 2.85; 95% confidence interval, 2.14-3.78; P < 0.0001).
ASA class, age, type of surgery, insulin or corticosteroid use, and functional status were independent risk factors for major medical complications. These factors may help in selecting patients and planning procedures, improving patient safety.
对前瞻性收集的退伍军人事务部国家外科质量改进计划数据库进行二次分析。
确定腰椎管狭窄症手术患者的主要医疗并发症、伤口并发症发生率及死亡率，并探讨这些并发症的危险因素。
脊柱狭窄手术主要集中在老年人中，他们比中年患者更容易出现并发症。许多研究集中在感染或器械并发症上，但使用前瞻性收集的数据，关注主要心肺并发症的研究较少。
我们从退伍军人事务部国家外科质量改进计划数据库中识别出1998年至2009年间因腰椎管狭窄症初次诊断而接受手术的患者。我们创建了一个主要医疗并发症的综合指标，包括急性心肌梗死、中风、肺栓塞、肺炎、全身性败血症、昏迷和心脏骤停。
在12154例符合条件的患者中，主要医疗并发症发生率为2.1%，伤口并发症发生率为3.2%，90天死亡率为0.6%。主要医疗并发症与年龄密切相关，但伤口并发症与年龄无关。美国麻醉医师协会（ASA）分级是并发症的有力预测指标。胰岛素使用、长期使用皮质类固醇以及术前功能状态也是重要的预测指标。融合手术的并发症发生率高于单纯减压手术。在逻辑回归分析中，ASA分级和年龄是主要医疗并发症的最强预测指标（ASA 4级与1级或2级相比的优势比：2.97；95%置信区间，1.68 - 5.25；P = 0.0002）。在调整合并症、年龄和功能状态后，融合手术的医疗并发症发生率仍高于单纯减压手术（优势比 = 2.85；95%置信区间，2.14 - 3.78；P < 0.0001）。
ASA分级、年龄、手术类型、胰岛素或皮质类固醇使用以及功能状态是主要医疗并发症的独立危险因素。这些因素可能有助于选择患者和规划手术，提高患者安全性。
