【罂粟摘要】有无凝血功能障碍患者行腰椎穿刺术与脊髓血肿的关系
有无凝血功能障碍患者行腰椎穿刺术与脊髓血肿的关系
凝血功能障碍可能会使临床医生拒绝行腰椎穿刺。
探讨有无凝血功能障碍患者接受腰椎穿刺术后发生脊髓血肿的危险性。
丹麦全国范围内的基于人群的队列研究，使用医疗注册登记来确定接受腰椎穿刺术和接受脑脊液分析的人（2008年1月1日至2018年12月31日；随访至2019年10月30日）。凝血功能障碍定义为血小板<150×109/L，国际标准化比率（INR）>1.4，或活化部分凝血活酶时间（APTT）>39s。
腰椎穿刺时出现凝血功能障碍。
操作后30天内发生脊髓血肿的风险。风险以数字和百分比的形式提供，CI为95%。次要观察指标包括创伤性腰椎穿刺的风险（排除被诊断为蛛网膜下腔出血的患者）。校正后的危险率比（HR）采用Cox回归模型计算。
在64730例（女性占51%，中位年龄43岁[四分位数范围22~62岁]）研究对象中，共进行腰椎穿刺操作83711例次。这些病例中，血小板减少7875例（9%），INR升高1393例（2%），APTT延长2604例（3%）。99%以上的研究参与者完成了随访。总体而言，无凝血功能障碍的49526例患者中有99例（0.20%；95%CI，0.16%-0.24%）在操作后30天内发生脊髓血肿，而有凝血功能障碍的10371例患者中有24例（0.23%；95%CI，0.15%-0.34%）。脊髓血肿的独立危险因素为男性（校正后危险比为1.72；95%CI为1.15~2.56）、41~60岁人群（校正后HR为1.96；95%CI为1.01~3.81）和61~80岁人群（校正后HR为2.20；95%CI为1.12~4.33）（见表1、图1）。根据凝血功能障碍的总体严重程度，在按儿科专科或医学适应症（感染、神经状况和血液系统恶性肿瘤）对凝血功能障碍严重程度进行的亚组分析中，风险没有显著增加，也没有根据操作的累积次数 显著增加。INR在1.5~2.0（36.8%；95%CI，33.3%~40.4%）、2.1~2.5（43.7%；95%CI，35.8%~51.8%）、2.6~3.0（41.9%，95%CI 30.5~53.9）的患者创伤性腰椎穿刺率高于INR正常者（28.2%；95%CI，27.7%~28.75%）。APTT在40~60s的患者（26.3%；95%CI，24.2%~28.5%）与APTT正常者（21.3%；95%CI，20.6%~21.9%）相比更易发生创伤性脊椎抽液，风险差异为5.1%（95%CI，2.9%~7.2%）。
本项在丹麦进行的队列研究中，腰椎穿刺术后发生脊髓血肿的风险在无凝血功能障碍的患者中为0.20%，在有凝血功能障碍的患者中为0.23%。虽然这些结果可能会在进行腰椎穿刺术的决策时提供参考信息，但研究中观察到的比率可能在一定程度上存在由于医师选择相对低风险的患者进行腰椎穿刺术而对结果的真实性产生偏倚。
Association of Lumbar Puncture With Spinal Hematoma in Patients With and Without Coagulopathy.
Importance: Coagulopathy may deter physicians from performing a lumbar puncture.
Objective: To determine the risk of spinal hematoma after lumbar puncture in patients with and
without coagulopathy.
Design, Setting, and Participants: Danish nationwide, population-based cohort study using medical registries to identify persons who underwent lumbar puncture and had cerebrospinal fluid analysis (January 1, 2008-December 31, 2018; followed up through October 30, 2019). Coagulopathy was defined as platelets lower than 150 × 109/L, international normalized ratio (INR) greater than 1.4, or activated partial thromboplastin time (APTT) longer than 39 seconds.
Exposures:Coagulopathy at the time of lumbar puncture.
Main Outcomes and Measures:Thirty-day risk of spinal hematoma. Risks were provided as numbers and percentages with 95% CIs. Secondary analyses included risks of traumatic lumbar puncture (>300 × 106 erythrocytes/L after excluding patients diagnosed with subarachnoid hemorrhage). Adjusted hazard rate ratios (HRs) were computed using Cox regression models.
Results:A total of 83 711 individual lumbar punctures were identified among 64 730 persons (51% female; median age, 43 years [interquartile range, 22-62 years]) at the time of the procedure. Thrombocytopenia was present in 7875 patients (9%), high INR levels in 1393 (2%), and prolonged APTT in 2604 (3%). Follow-up was complete for more than 99% of the study participants. Overall, spinal hematoma occurred within 30 days for 99 of 49 526 patients (0.20%; 95% CI, 0.16% - 0.24%) without coagulopathy vs 24 of 10 371 patients (0.23%; 95% CI, 0.15%-0.34%) with coagulopathy. Independent risk factors for spinal hematoma were male sex (adjusted hazard ratio [HR], 1.72; 95% CI, 1.15-2.56), those aged 41 through 60 years (adjusted HR, 1.96; 95% CI, 1.01-3.81) and those aged 61 through 80 years (adjusted HR, 2.20; 95% CI, 1.12-4.33). Risks did not increase significantly according to overall severity of coagulopathy, in subgroup analyses of severity of coagulopathy by pediatric specialty or medical indication (infection, neurological condition, and hematological malignancy), nor by cumulative number of procedures. Traumatic lumbar punctures occurred more frequently among patients with INR levels of 1.5 to 2.0 (36.8%; 95% CI, 33.3%-40.4%), 2.1 to 2.5 (43.7%; 95% CI, 35.8%-51.8%), and 2.6 to 3.0 (41.9% 95% CI 30.5-53.9) vs those with normal INR (28.2%; 95% CI, 27.7%-28.75%). Traumatic spinal tap occurred more often in patients with an APTT of 40 to 60 seconds (26.3%; 95% CI, 24.2%-28.5%) vs those with normal APTT (21.3%; 95% CI, 20.6%-21.9%) yielding a risk difference of 5.1% (95% CI, 2.9%-7.2%).
Conclusions and Relevance:In this Danish cohort study, risk of spinal hematoma following lumbar puncture was 0.20% among patients without coagulopathy and 0.23% among those with coagulopathy. Although these findings may inform decision-making about lumbar puncture by describing rates in this sample, the observed rates may reflect bias due to physicians selecting relatively low-risk patients for lumbar puncture.
贵州医科大学 高鸿教授课题组
翻译：唐剑 佟睿 编辑：佟睿 审校：曹莹
您的每个点赞、在看，都是对我们莫大的支持！