老年人脊柱手术后深静脉血栓的诊断与预防

doi:10.3969/j.issn.2095-4344.2017.23.015

摘要/Abstract

摘要：

文章快速阅读：

文题释义：

深静脉血栓：是指血液非正常地在深静脉内凝结，属于下肢静脉回流障碍性疾病。血栓形成大都发生于制动状态(尤其是骨科大手术)。致病因素有血流缓慢、静脉壁损伤和高凝状态三大因素。血栓形成后，除少数能自行消融或局限于发生部位外，大部分会扩散至整个肢体的深静脉主干，若不能及时诊断和处理，多数会演变为血栓形成后遗症，长时间影响患者的生活质量；还有一些患者可能并发肺栓塞，造成极为严重的后果。

纤维蛋白原：一种由肝脏合成的具有凝血功能的蛋白质。纤维蛋白是在凝血过程中，凝血酶切除血纤蛋白原中的血纤肽A和B而生成的单体蛋白质。简单地说，就是一种与凝血有关的蛋白质，即凝血因子。

摘要

背景：深静脉血栓是骨科术后常见并发症，预防和治疗下肢深静脉血栓至关重要，但是老年人脊柱手术后深静脉血栓发生率和预防研究的较少。

目的：探讨老年人脊柱手术后深静脉血栓的诊断及低分子肝素钙预防脊柱手术后深静脉血栓发生的疗效。

方法：将行脊柱手术的患者根据术后是否应用低分子肝素钙分为2组，未应用者为对照组，应用低分子肝素钙组在脊柱术后12 h皮下注射低分子肝素钙0.4 mL(4 100 IU)，次日起每天1次皮下注射至7-14 d。治疗前及治疗结束后分别检测凝血活酶时间、凝血酶时间、活化部分凝血活酶时间、血浆纤维蛋白原；记录术后切口引流量及术前术后下肢血管彩超检查结果。

结果与结论：①低分子肝素钙组治疗后血浆纤维蛋白原降低，凝血酶时间、凝血活酶时间、活化部分凝血活酶时间轻度延长，但均在正常范围内；②低分子肝素钙组深静脉血栓的发生为0，显著低于对照发生率5%(P < 0.05)；③结果说明，脊柱手术后应用低分子肝素钙明显的降低了深静脉血栓发生。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程
ORCID: 0000-0001-5874-692X(杨利勇)

关键词: 骨科植入物, 脊柱植入物, 深静脉血栓, 脊柱手术, 低分子肝素钙

Abstract:

BACKGROUND: Deep vein thrombosis is a common complication following bone surgeries, so its prevention and treatment become critical. However, there are few studies on the incidence of deep vein thrombosis after spine surgery in the elderly.

OBJECTIVE: To explore the diagnosis of deep vein thrombosis after spine surgery in the elderly and its incidence after intervention with low-molecular-weight heparin.

METHODS: All patients undergoing spine surgery were randomly divided into experimental and control groups. Patients in the experimental group were subjected to the subcutaneous injection of 0.4 mL of low-molecular-weight heparin (4 100 IU) at 12 hours postoperatively, once daily for 7-14 days from the next day. Those received no intervention served as controls. The thromboplastin time, thrombin time, activated partial thromboplastin time, and level of plasma fibrinogen were detected before and after treatment. Color Doppler ultrasound results of the lower extremity vessel before and after treatment and postoperative drainage volume were recorded.

RESULTS AND CONCLUSION: (1) In the experimental group, the lower level of plasma fibrinogen and slightly prolonged thromboplastin time, thrombin time and activated partial thromboplastin time were observed, but all were within the normal range. (2) The incidence of deep vein thrombosis in the experimental group (0%) was significantly lower than that in the control group (5%, P < 0.05). (3) To conclude, low-molecular-weight heparin therapy significantly reduced the incidence of deep vein thrombosis after spine surgery.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Spine, Venous Thrombosis, Anticoagulants, Tissue Engineering

中图分类号:

R318

杨利勇，马海港，李振，早东阳，张继. 老年人脊柱手术后深静脉血栓的诊断与预防[J]. 中国组织工程研究, 2017, 21(23): 3694-3699.

Yang Li-yong, Ma Hai-gang, Li Zhen, Zao Dong-yang, Zhang Ji. Diagnosis and prevention of deep vein thrombosis after spine surgery in the elderly [J]. Chinese Journal of Tissue Engineering Research, 2017, 21(23): 3694-3699.

图/表（结果） 3

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引言

材料方法

讨论

脊柱脊髓损伤患者长期卧床及老年人脊柱手术后卧床极易导致深静脉血栓形成的发生，但常常被临床脊柱外科医师忽视，目前，已经进入老年人社会，老年脊柱患者日益增多，老年人脊柱手术在临床手术中非常普及，老年人术后卧床时间长，同时很多老年患者伴有心血管疾病，由于老年人具有血流缓慢、血管动脉粥样硬化及血液黏稠度高的特点，老年人脊柱术后更容易发生深静脉血栓，深静脉血栓继而引发肺栓塞的风险明显增加，预防老年人脊柱术后深静脉血栓是十分重要的。

脊柱手术静脉血栓栓塞的首次描述是学者Virchow 于1856年报道，他首次描述并提出血栓形成的基本要素，即Virchow三联征：血流流速缓慢，损伤的血管壁，血液成分出现变化(血液高凝状态)。全身麻醉、身体某部位感染、年龄较高、高脂血症、有深静脉血栓病史、心房房颤及心血管疾病史是脊柱手术术后深静脉血栓形成发生的高风险危险因素^[10-14]，身体肥胖、合并内分泌疾病、凝血功能不正常、异体输血、脊柱手术术后卧床时间长等因素可导致脊柱手术术后深静脉形成的发生率明显增高^[5]。

脊柱手术后深静脉血栓形成的发生可能还与以下其他因素相关：①脊柱手术前合并下肢运动障碍；②脊柱手术中长时间俯卧位，术中体位压迫髂静脉或股静脉；③脊柱手术内固定物包括椎弓根螺钉与椎间融合器刺激周围血管；④术中导致神经损伤或术中牵拉刺激植物神经系统导致下肢静脉失去肌肉泵作用和血管舒缩反射，使血液循环系统血流缓慢、外周静脉扩张；⑤手术期间长时间卧床。

不同种脊柱疾病及不同手术方式对脊柱手术后深静脉血栓的发生率也有影响。Cheng等^[15]作者对87篇不同种脊柱疾病手术后发生深静脉血栓的相关文献进行回顾性分析，研究结果发现脊柱术后未皮下注射或口服抗凝药物的患者中，脊柱疾病畸形矫形手术术后深静脉血栓发生率为5.3%，脊柱椎体骨折外伤手术术后深静脉血栓发生率为6%，深静脉血栓的发生率要高于脊柱退行性疾病手术(2.3%)。Audibert等^[16]学者报道脊柱手术范围在2个节段以内的单纯椎板开窗椎间盘摘除或半椎板及全椎板切除术术后深静脉血栓的发生率低于1%。脊柱疾病手术值骨融合和扩大椎板切除术术后深静脉血栓的发生率分别为0.3%和2.2%，脊柱疾病导致脊髓损伤患者术后深静脉血栓栓塞的发生率明显增加，国内有许多学者研究认为，不同原因所导致的脊髓损伤可使机体的凝血系统激活，导致血液系统高凝状态，脊髓损伤的血液数小时即可处于高凝状态，能持续三四天^[17-21]。国外有学者研究发现，单纯脊柱椎体骨折和脊髓损伤发生深静脉血栓的风险明显增加，分别增加2倍和3倍^[22-³²^]。

不同脊柱疾病手术患者围手术期深静脉血栓的预防目前最常用的措施是术后化学抗凝。化学抗凝最长用、最安全的药物是低分子肝素钙。低分子肝素钙化学成分是肝素类，是低分子量肝素，机体生物利用度大约是98%，低分子肝素钙注射后，它的半衰期为8-10 h，可重复注射，低分子肝素钙不仅具有高比例的抗凝血因子Xa活性，同时也具有较低的抗凝血因子a或抗凝血酶活性。低分子肝素钙不仅能促使血管内皮细胞释放纤维蛋白溶解酶原激活剂，同时能使优球蛋白溶解时间缩短，抗栓作用能力明显增加，低分子肝素钙能内皮细胞抗血栓作用增强，但是不干扰血管内皮细胞其他功能^[^33-43^]，低分子肝素钙不仅应用于预防血管血栓栓塞性疾病，同时还具有血液稀释作用。低分子肝素钙与普通肝素相比，低分子肝素钙的抗凝、抗栓作用明显增强，但是低分子肝素钙无明显的出血副作用，它的半衰期长，可皮下注射易于操作等优点。

结果发现，发现低分子肝素钙组治疗24 h后凝血活酶时间、凝血酶时间、活化部分凝血活酶时间轻度延长，纤维蛋白原浓度降低，与治疗前比较差异有显著性意义 (P < 0.05)，但均在正常范围内；两组切口引流量相比差异无统计学意义；低分子肝素钙组术后无下肢肢体肿胀，彩色多普勒超声检测未发现下肢有明显深静脉血栓；对照组未皮下注射低分子肝素钙组患者，4(4.9%)例出现下肢肿胀，并在术后第1周行彩色多普勒超声检查发现有静脉血栓，深静脉血栓发生的部位2例在小腿腓静脉，2例是在腘静脉，这4例患者中，均是老年患者，是静脉血栓形成的高风险患者，平均年龄为71.7年，两组深静脉血栓发生例数相比差异有显著性意义(P < 0.05)。

临床检测深静脉血栓最常见的是彩色多普勒超声。超声于1982年第一次被用于深静脉血栓的诊断，以后渐渐被发展成为诊断深静血栓的的标准。彩色多普勒超声可评价静脉血管内的血流。也可以评价血栓后静脉是否通畅，彩色多普勒超声检测范围包括腹股沟韧带末端髂外静脉、股总静脉及小腿肌间静脉。彩色多普勒超声用于下肢静脉血栓的诊断，同时又可评估临床治疗的效果，是诊断下肢静脉血栓简单有效的方法^[10]，因此本临床研究常规行下肢血管彩色多普勒超声检查。

脊柱疾病手术后应用抗凝药物治疗在临床上仍存在争议，抗凝药物可引起椎管内出血，出血渗血形成血肿，血肿压迫脊髓及神经导致下肢的瘫痪。Green等^[^44-54^]学者报道，对于脊柱疾病术后皮下注射低分子量肝素钙速碧林可有效预防脊柱疾病术后下肢深静脉血栓形成，术后患者无血栓形成，也未发现椎管血肿形成。Deep等^[^55-65^]学者报道了130 例不同种疾病导致脊髓损伤后连续皮下注射低分子量肝素钙速碧林的患者，只有2例表现有临床症状的深静脉血栓，致命的肺栓塞和椎管内出血并发症并没有出现。本研究发现，脊柱疾病术后皮下注射低分子肝素钙组无并发出现黑便、咯血、椎管内出血、鼻出血及牙龈出血等并发症。

不同种脊柱脊柱疾病术后深静脉血栓形成具有隐匿性，同时脊柱疾病患者中有很多是老年患者，具有容易发生深静脉血栓形成的危险因素，临床医师应该高度重视，脊柱疾病手术后应该应用弹力袜，熟手应用下肢加压充气装置，术前有静脉血栓患者应该术前置入下腔静脉滤器，术后物理抗凝与化学药物抗凝均是有效安全预防脊柱疾病术后深静脉血栓形成的有效措施。目前临床的预防措施皮下注射低分子肝素钙在脊柱疾病手术术后具有较好的有效性和安全性。

研究结果提示，低分子肝素钙可有效地降低深静脉血栓形成的风险。因此，对于具有深静脉高危因素的患者，在脊柱术后主张采用低分子量肝素钙(速碧林)进行预防性治疗。至于是否作为临床常规治疗方法有待进一步研究。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程