早期化学预防与创伤性脊髓损伤后静脉血栓栓塞风险降低相关，且不会同时增加脊髓内血肿扩大的风险。
Early chemoprophylaxis is associated with decreased venous thromboembolism risk without concomitant increase in intraspinal hematoma expansion after traumatic spinal cord injury.
作者信息
Chang Ronald, Scerbo Michelle H, Schmitt Karl M, Adams Sasha D, Choi Timothy J, Wade Charles E, Holcomb John B
机构信息
From the Center for Translational Injury Research (R.C., M.H.S, S.D.A., T.J.C., C.E.W., J.B.H.), University of Texas Health Science Center, Houston, Texas; Department of Surgery, McGovern Medical School (R.C., M.H.S., S.D.A., C.E.W., J.B.H.), Houston, Texas; and Department of Neurosurgery (K.M.S.), McGovern Medical School, Houston, Texas.
出版信息
J Trauma Acute Care Surg. 2017 Dec;83(6):1088-1094. doi: 10.1097/TA.0000000000001675.
BACKGROUND
After traumatic spinal cord injury (SCI), there is increased risk of venous thromboembolism (VTE), but chemoprophylaxis (PPX) may cause expansion of intraspinal hematoma (ISH).
METHODS
Single-center retrospective study of adult trauma patients from 2012 to 2015 with SCI.
EXCLUSION CRITERIA
VTE diagnosis, death, or discharge within 48 hours. Patients were dichotomized based on early (≤48 hours) heparinoid and/or aspirin PPX. Intraspinal hematoma expansion was diagnosed intraoperatively or by follow-up radiology. We used multivariable Cox proportional hazards to estimate the effect of PPX on risk of VTE and ISH expansion controlling for age, injury severity score (ISS), complete SCI, and mechanism as static covariates and operative spine procedure as a time-varying covariate.
RESULTS
Five hundred one patients with SCI were dichotomized into early PPX (n = 260 [52%]) and no early PPX (n = 241 [48%]). Early PPX patients were less likely blunt injured (91% vs 97%) and had fewer operative spine interventions (65% vs 80%), but age (median, 43 vs 49 years), ISS (median 24 vs 21), admission ISH (47% vs 44%), and VTE (5% vs 9%) were similar. Cox analysis found that early heparinoids was associated with reduced VTE (hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.16-0.84) and reduced pulmonary embolism (PE) (HR, 0.20; 95% CI, 0.06-0.69). The estimated number needed to treat with heparinoids was 10 to prevent one VTE and 13 to prevent one PE at 30 days. Early aspirin was not associated with reduced VTE or PE. Seven patients (1%) had ISH expansion, of which four were on PPX at the time of expansion. Using heparinoid and aspirin as time-varying covariates, neither heparinoids (HR, 1.90; 95% CI, 0.32-11.41) nor aspirin (HR, 3.67; 95% CI, 0.64-20.88) was associated with ISH expansion.
CONCLUSION
Early heparinoid therapy was associated with decreased VTE and PE risk in SCI patients without concomitant increase in ISH expansion.
LEVEL OF EVIDENCE
Therapeutic, level IV.
背景
创伤性脊髓损伤（SCI）后，静脉血栓栓塞症（VTE）风险增加，但化学预防（PPX）可能导致脊髓内血肿（ISH）扩大。
方法
对2012年至2015年成年SCI创伤患者进行单中心回顾性研究。
排除标准
VTE诊断、死亡或48小时内出院。根据早期（≤48小时）使用类肝素和/或阿司匹林进行PPX将患者分为两组。脊髓内血肿扩大通过术中诊断或随访影像学检查确定。我们使用多变量Cox比例风险模型来估计PPX对VTE风险和ISH扩大的影响，将年龄、损伤严重程度评分（ISS）、完全性SCI、损伤机制作为静态协变量，脊柱手术作为时变协变量进行控制。
结果
501例SCI患者分为早期PPX组（n = 260 [52%]）和非早期PPX组（n = 241 [48%]）。早期PPX组患者钝性损伤的可能性较小（91%对97%），脊柱手术干预较少（65%对80%），但年龄（中位数，43岁对49岁）、ISS（中位数24对21）、入院时ISH（47%对44%）和VTE（5%对9%）相似。Cox分析发现，早期使用类肝素与VTE风险降低相关（风险比[HR]，0.37；95%置信区间[CI]，0.16 - 0.84）和肺栓塞（PE）风险降低相关（HR，0.20；95% CI，0.06 - 0.69）。在30天时，估计使用类肝素预防一例VTE需要治疗10例患者，预防一例PE需要治疗13例患者。早期使用阿司匹林与VTE或PE风险降低无关。7例患者（1%）发生ISH扩大，其中4例在扩大时正在接受PPX治疗。将类肝素和阿司匹林作为时变协变量，类肝素（HR，1.90；95% CI，0.32 - 11.41）和阿司匹林（HR，3.67；95% CI，0.64 - 20.88）均与ISH扩大无关。
结论
早期类肝素治疗与SCI患者VTE和PE风险降低相关，且不会伴随ISH扩大增加。
证据级别
治疗性，IV级。
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