Thomas Piers A W, Mitchell Paul S, Marshman Laurence A G
Department of Neurosurgery, The Townsville Hospital, Douglas, Townsville, Queensland, Australia; School of Medicine and Dentistry, James Cook University, Douglas, Townsville, Queensland, Australia.
Department of Neurosurgery, The Townsville Hospital, Douglas, Townsville, Queensland, Australia.
World Neurosurg. 2019 Apr;124:e489-e497. doi: 10.1016/j.wneu.2018.12.119. Epub 2019 Jan 3.
Although chronic subdural hematoma (CSDH) is generally benign, long-term survival (LTS) after CSDH is poor in a significant subgroup. This dichotomy has been compared to fractured neck of femur. However, although early postoperative mortality (within 30 days of CSDH) is well recorded with CSDH and similar to fractured neck of femur (4%-8%), scant accurate data exist regarding early postoperative morbidity (POMB). POMB, which prolongs length of stay (LOS) after major nonneurosurgery, is associated with decreased LTS. One recent CSDH study suggested a POMB standard of 10% i.e., notably less than with fractured neck of femur (45%).
POMB was recorded in a novel prospective single-center cohort after CSDH. The POSSUM (Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity), American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) score, and American Society of Anesthesiologists (ASA) grade were assessed as tools for potentially predicting POMB. Receiver operating characteristic (ROC) curves were calculated.
Early postoperative mortality (within 30 days of CSDH) occurred in 3 of 114 patients (3%). Seventy-one POMB events occurred in 54 of 114 patients (47%), with 27 of 54 (50%) having a Clavien-Dindo grade ≥2. Most POMB was neurologic (n = 47/71, 66%). Age (P = 0.01), Glasgow Coma Scale (GCS) score (P = 0.001), Markwalder grade (P = 0.01), hypertension (P = 0.047), and/or ≥1 preexistent comorbidity (P = 0.041) were predictive. LOS (P = 0.01) and discharge modified Rankin Scale score (P < 0.001) were significantly associated. Predicted and observed POMB with POSSUM were significantly disparate (χ = 15.23; P = 0.001): POSSUM area under ROC (AUROC = 0.611) was also nondiscriminatory. ACS-NSQIP (χ = 18.51; P < 0.001; AUROC = 0.629) and ASA grades (P = 0.25) were also nonpredictive.
POMB was frequently disabling, mostly neurologic, and as frequent and diverse as with fractured neck of femur. POMB was significantly correlated with LOS and discharge modified Rankin Scale score. Surprisingly, POSSUM, ACS-NSQIP, and ASA grades were not predictive and would not aid consent. Simple parameters (age, Glasgow Coma Scale, Markwalder grade, hypertension, and/or ≥1 other comorbidity) were instead predictive. Longitudinal follow-up will determine whether POMB affects LTS. CSDH, like fractured neck of femur, is distinct.
尽管慢性硬膜下血肿（CSDH）通常是良性的，但在相当一部分亚组患者中，CSDH后的长期生存率（LTS）较低。这种二分法已与股骨颈骨折相比较。然而，尽管CSDH术后早期死亡率（CSDH后30天内）记录良好，且与股骨颈骨折相似（4%-8%），但关于术后早期发病率（POMB）的准确数据却很少。POMB会延长重大非神经外科手术后的住院时间（LOS），并与LTS降低相关。最近一项关于CSDH的研究提出POMB标准为10%，即明显低于股骨颈骨折（45%）。
在一项新型前瞻性单中心队列研究中记录CSDH后的POMB。评估POSSUM（生理和手术严重程度评分以计算死亡率和发病率）、美国外科医师学会国家外科质量改进计划（ACS-NSQIP）评分以及美国麻醉医师协会（ASA）分级，作为潜在预测POMB的工具。计算受试者工作特征（ROC）曲线。
114例患者中有3例（3%）发生术后早期死亡（CSDH后30天内）。114例患者中有54例（47%）发生71次POMB事件，其中54例中的27例（50%）Clavien-Dindo分级≥2。大多数POMB为神经系统相关（n = 47/71，66%）。年龄（P = 0.01）、格拉斯哥昏迷量表（GCS）评分（P = 0.001）、Markwalder分级（P = 0.01）、高血压（P = 0.047）和/或≥1种既往合并症（P = 0.041）具有预测性。LOS（P = 0.01）和出院时改良Rankin量表评分（P < 0.001）显著相关。POSSUM预测的POMB与观察到的POMB显著不同（χ = 15.23；P = 0.001）：POSSUM的ROC曲线下面积（AUROC = 0.611）也无鉴别力。ACS-NSQIP（χ = 18.51；P < 0.001；AUROC = 0.629）和ASA分级（P = 0.25）也无预测性。
POMB常常导致功能障碍，主要为神经系统方面，且与股骨颈骨折一样频繁和多样。POMB与LOS和出院时改良Rankin量表评分显著相关。令人惊讶的是，POSSUM、ACS-NSQIP和ASA分级无预测性，无助于知情同意。相反，简单参数（年龄、格拉斯哥昏迷量表、Markwalder分级、高血压和/或≥1种其他合并症）具有预测性。纵向随访将确定POMB是否影响LTS。CSDH与股骨颈骨折一样，具有独特性。
