脊柱内固定术后感染危险因素与临床诊治
脊柱内固定术后感染的危险因素分析及对策脊柱内固定术后感染:危险因素与临床诊治 朱军、殷翔、范伟力、柳峰、刘鹏、赵建华(第三军医大学第三附属医院脊柱外科,400042,重庆)摘 要:目的探讨脊柱内固定术后感染的危险因素、临床特点及治疗方法及对策。方法回顾性分析2012年1月至12月我科472例行脊柱内固定手术患者的病例资料,分析术后伤口感染相关危险因素、临床特点及对策。结果472例患者术后感染共9例,发生率1.91(9/4720)。,其中男性6例,女性3例,平均年龄50.6岁(3878岁)。,发生术后感染患者均为脊柱后路手术,包括颈椎1例、胸椎1例、腰椎7例。平均手术时间170mins(100325mins);平均术中失血量556ml( 2001500ml);平均术后总引流量425ml( 651350ml),大多比同期同类手术明显增加;。伤口感染初始征象出现时间为术后10d(616d)。白细胞总数、血沉及CRP在术后47d明显升高,且维持在高位水平14d以上。细菌培养显示致病菌主要为常见皮肤菌群。本组感染患者 9例患者均接受伤口清创引流手术,未取出内固定及植骨,术后使用敏感抗生素,随访819个月(平均11个月),除1例复发(再次使用敏感抗生素治愈)外,其余无临床感染复发征象。结论脊柱术后伤口感染主要发生于后路开放性手术,均为深部感染;术中、术后出血总量大、手术时间长是造成围手术期营养状况差及感染的危险因素;。其临床特征是伤口渗液和局部深压痛,发热及切口表面红肿相对少见;及时清创引流、一期缝合伤口及应用敏感抗生素,可取得良好效果;清创手术不必常规取出内固定物及植骨。关键词:脊柱手术; 感染;清创Risk factors and treatment for wound infections after spinal internal fixationZhu Jun,Yin Xiang,Fan Weili,Liu Feng,Liu Peng,Zhao Jianhua(Department of Spinal Surgery, Third Affiliated Hospital, Third Military Medical University, Chongqing 400042,China)Abstract Objective To investigate the risk factors and treatment for infections after spinal internal fixation surgery. Methods The clinical data of 472 patients who underwent spinal internal fixation surgery from Jan. to Dec. 2012 was analyzed retrospectively. Risk factors and treatment for infections were summarized and discussed. Rresults Of 472 patients, postoperative infections occurred in 9 cases with the infection rate of 1.91%, and an average age of 50.6 years (38 78 years). All cases were underwent posterior procedures. The average operation time, intraoperative blood and postoperative drainage was 170mins (100 325mins), 556ml (200 1500ml) and 425ml (65 1350ml), which were greater than the similar surgeries of same period. The initial signs of wound infection was observed at 10days (6 16 d) after surgery. CRP, ESR and WBC were significantly increased in 4 7d after surgery, and maintained at high level at least for 14 days. Bacterial culture results showed infection bacteria were mainly common skin flora. All patients received emergency operation of wound debridement, drainage and sensitive antibiotic treatment. The mean follow-up time was 11 months (819 months). One infection recurred during followed-up and subsequent treatment was successful.第一作者简介:朱军,男(1980-),大学本科,研究方向:脊柱外科 电话:(023)68757930, E-mail:cqdpyyzj163.com通讯作者:刘鹏 Email:liupengd163.com 赵建华 E-mail:zhaojianhua1964yahoo.comConclusion Wound infection after internal fixation mainly occurred in the posterior procedure of spine, which were deep infection. The main clinical manifestation was the wound exudate and local deep tenderness, fever and wound surface swelling were relatively rare. Increased intraoperative bleeding, postoperative drainage volume, operation time were the risk factors, which lead to perioperative malnutrition and subsequent infections. Debridement, drainage, and intravenously sensitive antibiotics could obtain an ideal outcome for most cases. It was not necessary to remove the internal fixation instrument and bone grafting.随着社会老龄化、建筑业迅速发展以及汽车保有量增加,脊柱退变性疾病、肿瘤与创伤等需要行脊柱手术治疗的患者数量呈激增趋势。术后感染是常见脊柱手术并发症之一。由于感染部位较深,且局部有内固定装置,感染常常难以控制,一旦波及蛛网膜下腔,可能引起脑膜炎、败血症,甚至导致患者死亡等严重后果。因此,分析脊柱内固定术后感染的危险因素并探讨相应对策,及临床特点对脊柱术后感染的预防和、早期诊断术后感染及治疗有重要意义,同时本文也对术后感染的治疗进行了探讨。本研究通过回顾性分析2012年1月1日至2012年12月31日我科类切口脊柱手术中发生感染的病例资料,探讨分析了脊柱内固定术后感染的危险因素、临床特点,同时总结出一定诊治经验及处理方法。现将结果报道如下。1 临床资料1.1一般资料 检索我科2012年1月1日至2012年12月31日脊柱手术病例资料。纳入标准:类切口;传统开放内置物植入手术。排除标准: 术前诊断明确为脊柱结核、化脓性脊柱炎、化脓性椎间盘炎;因外院手术后切口感染转入我院者;经皮穿刺微创手术。根据上述纳入和排除标准,共获得470472例患者资料,年龄2378岁,平均42岁,男性302例、女性168例。疾病种类和手术部位、类型如下:退行性疾病323例(颈椎前路手术71例,颈椎后路手术12例;胸椎后路手术4例;腰椎后路手术236例,腰椎前路手术2例);脊柱骨折123例(颈椎前路手术12例,颈椎后路手术6例,颈椎前后路联合手术3例;胸椎后路27例;腰椎后路手术75例);脊柱肿瘤7例(一期后路全脊椎切除术7例);脊柱侧弯17例(后路矫形植骨融合内固定术17例)。1.2临床表现 本研究470472例患者中9例出现术后伤口感染,发生率1.91%(9/470472),其中男性6例,女性3例。患者一般资料及细菌学实验结果见表1。9例均在术后616天(平均10天)确诊为伤口感染;其中7例(77.8%)首先表现为切口渗液和局部深压痛,而无发热症状;2例(22.2%)首先表现为头痛、发热及全身肌肉酸痛,体温波动在38°41.2°之间,继而出现伤口渗液。伤口感染初始征象出现时间为术后10d(616d)。表1 9例术后感染患者一般资料及细菌学实验结果病例性别年龄(岁)诊断手术方式手术时间(mins)术中出血(ml)引流量(ml)培养细菌敏感抗生素1女52腰4椎体滑脱症PLF1901500600无2男38腰2椎体爆裂性骨折ORIF120200250少动鞘氨醇单胞菌硫酸阿米卡星3男55胸12椎体骨折ORIF100600370阴沟肠杆菌硫酸阿米卡星4女59枢椎骨折ORIF21030065阴沟肠杆菌硫酸阿米卡星5男40腰椎间盘突出症PLF120400160无6男58腰椎管狭窄症PLF210400270无7女38腰椎间盘突出症PLF+#150400150无8男78腰4椎体滑脱症PLF3258001350金黄色葡萄球菌头孢曲松钠9男38腰椎间盘突出症PLF110400240无注: ORIF(open reduction and internal fixation):切开复位内固定术PLF(posterior lumbar fusion):后路植骨融合内固定术#:同种异体骨作为植骨材料1.3治疗方法确诊感染后立即使用广谱、高效、足量抗生素治疗,并急诊实施切口清创引流术。术中所见9例患者均为伤口深部感染,切口深部有不等量的脓性分泌物及软组织坏死后的絮状物,于切口深部取分泌物进行细菌培养及药敏实验。彻底清除坏死组织及被脓性分泌物附着的植骨材料,使用大量生理盐水(3000ml5000ml)反复冲洗切口,留置18号“T”管3-5根,保留内固定装置,一期闭合伤口。药敏结果得出后换用敏感抗生素治疗2周。待伤口引流液低于10ml,逐一拔出引流管。从确诊感染开始,至少每周复查血常规、血沉和CRP。 1.4 数据汇总及分析采用回顾性调查方法对 9 例术后伤口感染的脊柱手术患者的一般情况、手术情况、术后恢复情况、细菌学实验结果及血液实验室检查结果等相关指标进行汇总分析