背景:术后咽后血肿(PRH)和相关的呼吸困难是颈前路椎间盘切除术和融合术(ACDF)后罕见但危及生命的并发症,需要紧急识别和治疗。然而,ACDF后PRH的当前知识是有限的。同时,上气道的形态特征是否是PRH的危险因素尚不清楚。
目的:本研究旨在调查发病率,临床特征,和风险因素,尤其是上呼吸道的形态特征,ACDF后PRH和相关呼吸困难。
方法:巢式病例对照研究。
方法:回顾性分析2010年1月至2021年12月在一家机构连续接受ACDF的患者。
方法:结果测量包括发病率,临床特征,干预,PRH和相关呼吸困难的结局和危险因素。
方法:所有PRH患者均分为血肿组。对于每个PRH受试者,随机选择3例无PRH的对照组作为对照组。临床特征,对患者的干预措施和结局进行了描述.评估了潜在的危险因素,包括人口统计,合并症,手术特点,凝血功能,失血,术前血压,和上气道的形态特征[椎前软组织厚度(PVT)和横突肌(TAM)和会厌的位置]。采用单因素检验和多因素logistic回归分析确定PRH的危险因素。还对有和没有呼吸困难的PRH患者进行了亚组分析。
结果:在接受ACDF的10615名患者中,18家(0.17%)开发PRH。从索引手术到PRH形成的中位时间为8.5小时(25和75百分位数:4小时至24小时)。所有PRH患者最初都出现伤口肿胀。12例(0.11%)患者因PRH出现呼吸困难,其中2人接受了紧急插管,其中1人接受了紧急气管切开术。所有患者均行血肿清除术,大多数人在撤离后症状完全缓解,除了一名死于缺血性缺氧性脑病的患者。会厌与TAM(LET)之间的水平大于2,后纵韧带骨化(OPLL)和术前较高的舒张压(DBP)被发现是PRH形成的危险因素。亚组分析显示,C5处椎前软组织厚度较小与呼吸困难的发展有关。
结论:本研究是迄今为止最大规模的研究,关注ACDF后PRH和相关呼吸困难。我们的研究表明,ACDF后PRH和相关呼吸困难的发生率分别为0.17%和0.11%,分别。PRH的主要症状是伤口肿胀和急性呼吸困难。大多数PRH病例发生在术后急性期。我们证明了PRH的风险因素是(1)OPLL,(2)LET≥2和(3)术前DBP较高,主张增加对上气道形态学特征的关注,以识别ACDF后PRH的风险。紧急认识和及时干预,可以避免严重的临床结局.
BACKGROUND: Postoperative retropharyngeal hematoma (PRH) and related dyspnea are rare but life-threatening complications following anterior cervical discectomy and fusion (ACDF) that require urgent recognition and treatment. However, current knowledge of PRH after ACDF is limited. Meanwhile, whether the morphological features of upper airway are the risk factors of PRH remains unknown.
OBJECTIVE: The study aimed to investigate the incidence, clinical features, and risk factors, especially the morphological features of upper airway, of PRH and related dyspnea following ACDF.
METHODS: A nested case‒control study.
METHODS: Consecutive patients who underwent ACDF at a single institute from January 2010 to December 2021 were retrospectively reviewed.
METHODS: The outcome measures included the incidence, clinical features, intervention, outcome and risk factors for PRH and related dyspnea.
METHODS: All patients with PRH were classified into the hematoma group. For each PRH subject, three control subjects without PRH were randomly selected as the control group. The clinical features, interventions and outcomes of patients were described. Potential risk factors were evaluated, including demographics, comorbidities, surgical characteristics, coagulation function, blood loss, preoperative blood pressure, and the morphological features of upper airway [prevertebral soft tissue thickness (PVT) and location of transverse arytenoid muscle (TAM) and epiglottis]. Univariate tests and multivariable logistic regression analysis were used to determine the risk factors for PRH. Subgroup analysis was also conducted for PRH patients with and without dyspnea.
RESULTS: Among the 10615 patients who underwent ACDF, 18 (0.17%) developed PRH. The median time from the index surgery to PRH formation was 8.5 hours (25 and 75 percentile: 4 hours to 24 hours). All the PRH patients initially presented with wound swelling. Twelve (0.11%) patients presented dyspnea due to PRH, 2 of whom received urgent intubation and 1 of whom received emergent tracheotomy. All patients underwent hematoma evacuation, and most of them presented with completely relieved symptoms after evacuation, except for one patient who died from ischemic hypoxic encephalopathy. A level between the epiglottis and the TAM (LET) greater than 2, ossification of posterior longitudinal ligament (OPLL) and higher diastolic blood pressure (DBP) before surgery were found to be risk factors for PRH formation. Subgroup analysis revealed that a smaller prevertebral soft tissue thickness at C5 was associated with the development of dyspnea.
CONCLUSIONS: This study is the largest study to date focusing on the PRH and related dyspnea after ACDF. Our study showed that the incidences of PRH and related dyspnea after ACDF were 0.17% and 0.11%, respectively. The predominant symptoms of PRH were wound swelling and acute dyspnea. Most PRH cases occurred in the acute postoperative period. We demonstrated the risk factors for PRH to be (1) OPLL, (2) LET≥2 and (3) higher DBP before surgery and advocate paying increased attention to upper airway morphological features for identifying the risk of PRH after ACDF. With urgent recognition and timely intervention, severe clinical outcomes could be avoided.