【作者】 张彬；

【导师】 王运涛；

【作者基本信息】 东南大学 ， 临床医学（专业学位）， 2020， 硕士

【摘要】 背景经椎间孔腰椎椎体间融合术(TLIF)作为改良的后路腰椎椎体间融合术(PLIF),不仅具备PLIF的所有优点,同时避免了PLIF的危险性和局限性,目前已经成为各种腰椎退行性疾病(LDD)的主要术式。但是,TLIF同样也面临一些问题,术后发热是此类手术后常见现象,术后发热不仅增加患者和家属的心理负担、延长住院周期、增加住院费用,而且对患者的围手术期管理造成众多不便。目前,关于TLIF后发热危险因素研究尚少,哪些因素值得关注尚无定论。目的探讨经椎间孔腰椎椎体间融合术后发热特点和危险因素,以及评估发热诊断检查的临床价值。方法收集东南大学附属中大医院2018年1～12月接受TLIF患者的临床资料,统计患者术前1d至术后7d每日的最高体温,将术后发热定义为体温超过38℃,根据是否发热分为发热组和未发热组,同时收集患者的年龄、性别、体重指数(BMI)、糖尿病、手术时间、手术节段、术中自体血液回输、术中出血量、术后血红蛋白丢失值、异体输血及感染等因素,对上述因素进行单因素分析和多因素Logistic回归分析,确定影响术后发热的危险因素。结果共有390例患者接受TLIF,其中175例患者出现术后发热,发热发生率为44.9%(175/390);其中男66例,女109例,年龄23～84岁(61.67±10.55岁)。在发热病例中,第1次发热症状以术后第1日最常见(83例,占所有发热病例数的47.4%),术后第3日(42例,24%)和术后第2日(40例,22.9%)次之;住院期间患者平均最高体温为术后第2日37.91±0.57℃;术后发热发生率最高见于术后第2日(90例,23.1%),术后第1日(84例,21.5%)和术后第3日(83例,21.3%)次之。在90项发热诊断检查中,共有8项结果呈阳性(8.9%),其中包括5例尿液分析阳性(12.5%),2例尿液培养阳性(12.5%),1例伤口培养阳性(50.0%)。与非持续发热者相比,术后持续至少3日发热者,其感染事件的发生率明显升高,差异有统计学意义(P<0.05);与体温未超过39.0℃患者相比,体温超过39.0℃的高热患者,其感染事件的发生率明显升高,差异有统计学意义(P<0.05)。单因素分析显示:手术时间、术中自体血液回输、术中出血量、术后血红蛋白丢失值、异体输血有统计学差异(P<0.1),年龄、性别、BMI、糖尿病、手术节段、感染无统计学差异(P>0.1)。多因素Logistic回归分析提示:异体输血和手术时间为术后发热的独立危险因素(P<0.05),术中自体血液回输为术后发热的保护性因素(OR=0.10,P<0.05)。结论TLIF后发热较常见,且多在术后前3日,异体输血和手术时间延长会增加TLIF后发热的发生风险,而术中自体血液回输可以降低术后发热的发生风险。虽然TLIF后发热与感染无显著相关性,但是对于持续发热或者高热患者,还是应该引起外科医生的重视。由于阳性检测率低和相应产生的高昂费用,应避免常规使用血液培养评估TLIF后发热患者。更多还原

【Abstract】 BackgroundTransforaminal lumbar interbody fusion(TLIF),as a modified posterior lumbar interbody fusion(PLIF),not only has all the advantages of PLIF,but also avoids the risks and limitations of PLIF,which has become the main surgical method for various lumbar degenerative diseases(LDD).However,TLIF also faces some problems.Postoperative fever is a common phenomenon after such operations.Postoperative fever not only increases the psychological burden of patients and their families,prolongs the hospitalization period,and increases the hospitalization cost,but also causes a lot of inconvenience to the perioperative management of patients.At present,there are few studies on the risk factors of fever after TLIF,and it is no conclusion on which factors should be concerned.ObjectiveTo investigate the characteristics and risk factors of fever after transforaminal lumbar interbody fusion,and to evaluate the clinical value of diagnostic examination of fever.MethodsThe clinical data of patients who received TLIF in Zhongda Hospital affiliated to Southeast University from January to December 2018 were collected,and the maximum body temperature of the patients was calculated from 1 day before operation to 7 days after operation.Postoperative fever was defined as body temperature exceeding 38℃.The patients were divided into fever group and non-fever group according to whether they had fever or not.At the same time,age,gender,BMI,diabetes,duration of surgery,number of operative levels,intraoperative autotransfusion,blood loss,hemoglobin loss,allogeneic transfusion,infection were collected.Univariate analysis and multivariate logistic regression analysis were conducted to determine the risk factors affecting postoperative fever.ResultsA total of 390 patients with TLIF were reviewed,of which 175 patients had fever,the incidence of fever was 44.9%(175/390).There were 66 males and 109 females,aged from 23 to 84years(61.67±10.55 years).Among the fever cases,the first fever symptom was the most common on the first day after surgery(83 cases,accounting for 47.4% of all fever cases),followed by the third day after surgery(42 cases,24%)and the second day after surgery(40 cases,22.9%).The mean maximum body temperature of the patients during hospitalization was 37.91 ± 0.57 ℃.The highest incidence of postoperative fever was found on the second day after surgery(90 cases,23.1%),followed by the first day after surgery(84 cases,21.5%)and the third day after surgery(83cases,21.3%).There were a total of 8 positive tests out of 90 performed fever workup tests(8.9%).These included five positive urine analysis(12.5%),two positive urine cultures(12.5%),one positive wound culture(50.0%).Compared with non-continuous fever patients,the incidence of infection events was significantly higher in patients with fever lasting at least 3 days after operation,the difference was statistically significant(P < 0.05);compared with patients whose body temperature did not exceed 39.0 C,the incidence of infection events was significantly higher in patients whose body temperature exceeded 39.0 C,the difference was statistically significant(P <0.05).Univariate analysis found that there was a statistical difference in duration of surgery,intraoperative autotransfusion,blood loss,hemoglobin loss,allogeneic transfusion(P<0.1),and no statistical difference in age,gender,BMI,diabetes,number of operative levels,infection(P>0.1).Multifactor Logistic regression showed that allogeneic transfusion and duration of surgery were independent risk factors for fever after TLIF(P<0.05),while intraoperative autotransfusion was a protective factor(OR= 0.10,P>0.05).ConclusionFever after TLIF is more common,and mostly in the first 3 days after surgery,allogeneic transfusion and prolonged operation time increase the risk of fever after TLIF,while intraoperative autologous blood transfusion can reduce the risk of fever after TLIF.Although fever after TLIF is not significantly associated with infection,surgeons should pay attention to patients with persistent fever or high fever.The routine use of blood cultures for the assessment of postoperative fever in such population should be avoided due to the low rate of positive tests and the associated high cost.更多还原