广西壮族自治区64家医院椎管内麻醉神经损伤调查分析
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摘要
椎管内麻醉(neuraxial anesthesia)包括硬膜外麻醉(epidural anesthesia,EA)、腰硬联合麻醉(combined spinal-epidural anesthesia, CSEA)及蛛网膜下腔麻醉(spinal anesthesia, SA)简称腰麻。由于具有镇痛效果确切、肌肉松弛良好、麻醉药品使用较少、术中病人意识清醒及术后良好的镇痛效果等优点,近百年来广泛用于临床麻醉。
虽然椎管内麻醉已在临床运用了很长时间,但它并非没有并发症,且各文献报道的神经损伤的发生率数值差别较大[1-4],因此其确切的发病率很难确定。在临床上,其发病率可能被低估了,导致麻醉医师忽视了神经系统并发症风险。实际发生的神经损伤并发症可能比预期的要多,因此,椎管内麻醉神经系统并发症(尤其是神经损伤)仍然是临床麻醉医生关注的问题。而且随着麻醉材料、技术及设备的不断完善,重新评估严重并发症的发病率和特点是非常有必要的。椎管内麻醉相关的神经并发症(主要是神经损伤)的流行病学数据是必不可少的,是测量和评估椎管内麻醉的安全性和质量的重要指标,国外虽然有不少报道[1-],但目前国内在椎管内麻醉神经损伤方面尚缺大样本、多中心的统计资料和数据。因此,有必要建立椎管内麻醉相关神经并发症数据库,以便进行调查统计分析。
为此,本研究对2008年1月1日至2012年12月31日五年间广西壮族自治区各级医院椎管内麻醉后出现神经系统并发症进行一项回顾性调查研究分析,旨在了解广西壮族自治区各级医院椎管内麻醉使用现状及对椎管内麻醉引起的神经损伤发病率及其严重程度、后遗症持续时间,以及椎管内麻醉引起的神经损伤相关因素进行了流行病学调查分析,以评估椎管内麻醉神经损伤相关的风险因素,并对各类神经损伤的康复时间、显效时间及其神经损伤后遗症情况进行分析。我们探讨了椎管内麻醉神经损伤的发病率、愈后情况和风险因素,并对椎管内麻醉神经损伤的相关因素的流行病学数据进行分析,为椎管内麻醉临床使用及椎管内麻醉后神经损伤流行病学数据研究积累一些临床实践经验,对临床麻醉医生有一定参考价值。
第一部分广西64家医院椎管内麻醉使用情况及椎管内麻醉后神经损伤的发病率调查分析
目的
本研究目的是了解广西壮族自治区64家医院椎管内麻醉使用现状,并对椎管内麻醉引起的神经损伤发病率及治愈率进行初步分析。为椎管内麻醉临床使用及椎管内麻醉后神经损伤流行病学数据积累一些临床实践经验。
方法
经广西壮族自治区麻醉质量控制中心批准后,对2008年1月1日至2012年12月31日五年间广西壮族自治区各级医院椎管内麻醉后出现神经系统并发症进行一项回顾性调查研究。调查方式为问卷调查。自行设计椎管内麻醉神经并发症调查表。2012年10月,以广西壮族自治区麻醉质量控制中心的名义通过信函发放和手机短信相结合方式通知广西壮族自治区各级医院的麻醉科主任,要求各级医院麻醉科主任登陆广西麻醉网下载椎管内麻醉神经并发症调查表格并认真填写。表格1调查内容包括：广西壮族自治区各级医院2008-2012年五年间椎管内麻醉的病例数、椎管内麻醉(硬膜外麻醉、腰硬联合麻醉及单纯腰麻)神经并发症的病例数及医院级别。出现并发症的患者填写神经并发症表格2,包括患者的年龄、性别、手术日期、术前诊断、既往病史、麻醉方式、麻醉时间和手术时间、手术方式和手术体位、穿刺间隙,穿刺过程中有无神经刺激征、术后有无镇痛及镇痛药物的使用情况、椎管内麻醉药物使用情况、神经损伤类型、确诊时间及开始治疗时间、治疗措施及其愈后状况、治疗的显效时间及康复时间、神经系统后遗症状等。调查表填写内容不完善的通过电话随访或E-mail追加完善调查报告。根据人口统计学和临床特征采用SPSS13.0统计软件包中的描述性分析和x2检验及Fisher确切概率检验法对数据进行统计学分析。P<0.05为差异有统计学意义。
结果
2008～2012年五年间27家三级甲等医院实施硬膜外麻醉96897例,占36.6%；腰硬联合麻醉150236例,占56.8%；单纯腰麻17573例,占6.6%；共计264706例。37家非三级甲等医院实施硬膜外麻醉106509例,占44.7%；腰硬联合麻醉128665例,占54.1%；单纯腰麻2837例,占1.2%。共计238011例,合计502717例。无论是三级甲等医院还是非三级甲等医院,都是以腰硬联合麻醉最为常用,而且是呈逐年上升的趋势。其次为硬膜外麻醉,而单纯腰麻用的最少,在非三级甲等医院尤为明显。205例患者出现椎管内麻醉神经损伤,椎管内麻醉神经损伤的总发生率为4.08/万,其中硬膜外麻醉发生神经损伤41例,发生率为2.01/万,腰硬联合麻醉发生神经损伤154例,发生率为5.52/万,单纯腰麻发生神经损伤10例,发生率为4.9/万,硬膜外麻醉神经损伤的发生率最低,而腰硬联合麻醉神经损伤的发生率最高(X2=35.821,P=0.000),差异有统计学意义(P<0.05)；对三种麻醉方式神经损伤发生率进行了两两比较发现,硬膜外麻醉神经损伤发生率与腰硬联合麻醉(X2=35.774,P=0.000)及单纯腰麻(X2=6.772,P=0.009)相比较,差异均有统计学意义(P<0.05),而腰硬联合麻醉与单纯腰麻神经损伤发生率相比较,差异没有统计学意义(P>0.05)。其中三级甲等医院椎管内麻醉发生神经损伤有134例,占5.06/万,非三级甲等医院椎管内麻醉发生神经损伤有71例,占2.98/万,三级甲等医院椎管内麻醉神经损伤发生率较非三级甲等医院高(X2=13.291,P=0.000),差异有统计学意义(P<0.05)。但两种等级医院发生神经损伤的OR值=0.589(95%CI0.442～0.786)。205例神经损伤病例中,短暂神经综合征(TNS)为最多,有171例,发生率为3.4/万；其次是脊神经根损伤(RD)有25例,发生率为0.5/万,而马尾综合征(CES)及截瘫(paraplegia)各4例,发生率均为0.08/万；硬膜外血肿(EH)1例,发生率为0.02/万。硬膜外麻醉发生TNS为30例,发生率为1.47/万；腰硬联合麻醉发生TNS为132例,发生率为4.7/万；单纯腰麻发生TNS为9例,发生率为4.41/万。硬膜外麻醉TNS的发生率最低,而腰硬联合麻醉TNS的发生率最高,X2=37.352,P=0.000,差异有统计学意义(P<0.05)。腰硬联合麻醉TNS发生率与单纯腰麻相比较,差异无统计学意义(P>0.05)。神经损伤的总治愈率为89.8%,短暂神经综合征(TNS)病人治愈率为100%,而脊神经根损伤(RD)患者只有48%病人完全康复,马尾综合征(CES)只有1例病人(25%)完全康复。硬膜外麻醉、腰硬联合麻醉、单纯腰麻神经损伤病人完全治愈率分别为82.9%、91.6%、90.0%,差异无统计学意义(P>0.05)。永久性神经损伤的发生率为0.42/万,其中硬膜外麻醉永久性神经损伤发生率为0.34/万,腰硬联合麻醉为0.47/万,单纯腰麻为0.49/万,差异无统计学意义(P>0.05)。
结论
1.无论是三级甲等医院还是非三级甲等医院,都以腰硬联合麻醉最为常用,且呈逐年上升的趋势,其次为硬膜外麻醉,单纯腰麻使用得最少。三级甲等医院椎管内麻醉神经损伤发生率较非三级甲等医院高,但三级甲等医院椎管内麻醉发生神经损伤的风险并不比非三级甲等医院的高。
2.与椎管内麻醉相关神经损伤的发生率是很低的(4.08/万),硬膜外麻醉的神经损伤发生率最低(P<0.05),腰硬联合麻醉和腰麻的神经损伤发生率没有统计学差异。椎管内麻醉永久性神经损伤发生率为0.42/万,但三种麻醉方式的永久性神经损伤发生率无统计学差异(P>0.05)。
3.神经损伤类型以短暂神经综合征(TNS)为最多见,发生率为3.4/万。硬膜外麻醉TNS的发生率最低(1.47/万),而腰硬联合麻醉TNS的发生率最高(4.7/万),差异有统计学意义(P<0.05)。大多数的神经损伤是可以完全治愈的,神经损伤的总治愈率为89.8%。TNS病人的治愈率为100%(P<0.05),三种麻醉方式神经损伤的治愈率也无统计学差异。
第二部分广西64家医院椎管内麻醉神经损伤相关因素调查分析
目的
本研究的目的是对广西壮族自治区64家医院椎管内麻醉神经损伤严重程度、自限能力及后遗症持续时间以及椎管内麻醉引起的神经损伤相关因素进行调查分析,并对各类神经损伤的康复时间、显效时间及其神经损伤后遗症情况进行分析,以评估麻醉相关神经并发症的风险因素。为椎管内麻醉后神经损伤流行病学研究积累一些临床实践经验,对临床麻醉医生有一定参考价值。
方法
经广西壮族自治区麻醉质量控制中心批准后,对2008年1月1日至2012年12月31日五年间广西壮族自治区各级医院椎管内麻醉后出现神经系统并发症进行一项回顾性调查研究。调查方式为问卷式调查。自行设计椎管内麻醉神经并发症调查表。2012年10月,以广西壮族自治区麻醉质量控制中心的名义通过信函发放和手机短信相结合方式通知广西壮族自治区各级医院的麻醉科主任,要求各级医院麻醉科主任登陆广西麻醉网下载椎管内麻醉神经并发症调查表并认真填写。表格1调查内容包括：广西壮族自治区各级医院2008～2012年五年间椎管内麻醉的病例数、椎管内麻醉(硬膜外麻醉、腰硬联合麻醉及单纯腰麻)神经并发症的例数及医院级别。出现并发症的患者填写神经并发症表格2,包括患者的年龄、性别、手术日期、术前诊断、既往病史、麻醉方式、麻醉时间和手术时间、手术方式和术中体位、穿刺间隙,穿刺过程中有无神经刺激征、术后有无镇痛及镇痛药物的使用情况、椎管内麻醉药物使用情况、神经损伤类型、确诊时间及开始治疗时间、治疗措施及其愈后状况、治疗的显效时间及康复时间、神经系统后遗症状等。调查表填写内容不完善的通过电话随访或E-mail追加完善调查报告。其中不需要药物治疗的神经损伤病例有142例,归为自限组(I组),而需要药物治疗的神经损伤病例有63例,归为治疗组(II组)。治疗组中63例患者中对药物治疗有效的、完全治愈的有42例,归为完全治愈组；对药物治疗效果不佳的、未完全治愈的有21例,归为未完全治愈组。其中定义神经损伤引起的伤残或残障持续3个月或3个月以上的为严重性神经损伤[5],则未完全治愈病人又分为轻度后遗症(Mild sequelae, MS)和严重后遗症(severe sequelae, SS)。定义神经损伤症状持续12个月或12个月以上的为永久性神经损伤[6]0神经损伤分为三类：短暂神经综合征(Transient neurological syndrome)=TNS,脊神经根损伤(Radicular damage)=RD,截瘫(包括马尾综合征和硬膜外血肿)[7=Paraplegia。采用SPSS13.0统计软件包对数据进行分析,计数资料比较采用x2检验及Fisher的精确检验法,多因素分析采用Logistic回归分析,变量包括麻醉方式、穿刺间隙、性别、年龄、手术方式、手术体位、穿刺中有无不适、腰麻药物、硬膜外药物、镇痛、镇痛药物、神经损伤类型。康复时间和显效时间的相关因素分析采用生存分析中的Kaplan-Meier和Cox回归分析方法。P<0.05为差异有统计学意义。
结果
Logistic回归分析显示,麻醉方式和神经损伤类型与神经损伤病人自限率有相关性(P<0.05)。205例神经损伤的病人不需要药物处理的病例为142例,自限率为69.3%,其中单纯腰麻的自限率最高,自限率为90%,而硬膜外麻醉的自限率最低,仅为41.5%,差异有统计学意义(P<0.05)。无需药物治疗以短暂神经综合征(TNS)病人为最多,142例,自限率为83.0%,脊神经根损伤(RD)和截瘫类(Paraplegia)病人的自限率均为0.0%,X2=91.872,P=0.000.Logistic回归分析显示,神经损伤类型、穿刺间隙与神经损伤病人愈后及严重后遗症发生率有相关性(P<0.05)；L3-4穿刺点病人的康复率显著的高于其他两个穿刺点,严重后遗症发生率显著的低于其他两个穿刺(P<0.05)。L3-4穿刺间隙病人的康复率为95.3%,为最高,其神经损伤病人严重后遗症发生率仅为1.9%,为最低；而穿刺间隙为L1-2及以上病人的康复率仅为70%,为最低,神经损伤病人严重后遗症发生率却高达20%,为最高,差异有统计学意义(P<0.05)。短暂神经综合征(TNS)、脊神经根损伤(RD)、截瘫类(Paraplegia)病人完全康复率分别为100%、48%、11.1%,X2=127.5,P=0.000。神经损伤严重后遗症总发生率为0.26/万,短暂神经综合征(TNS)无神经后遗症出现,脊神经根损伤严重后遗症发生率为20%。截瘫类病人严重后遗症发生率高达88.9%,X2=105.2,P=0.000。Cox回归分析显示麻醉方式、穿刺间隙和神经损伤类型与神经损伤病人康复时间有很大的相关性(P<0.05)；腰硬联合麻醉后神经损伤病人的所需康复时间最长,平均估计值和中位数估计值分别为71.8天和3天；硬膜外麻醉神经损伤病人所需康复时间平均估计值和中位数估计值分别为58.3天和4天；而单纯腰麻后神经损伤病人所需康复时间最短,平均估计值和中位数估计值分别为15.2天和1天,X2=10.602,P=0.005。短暂神经综合征(TNS)的康复时间最短,平均估计值和中位数估计值分别为2.9天和2天；脊神经根损伤(RD)平均估计值和中位数估计值分别为78.7天和75天；而截瘫类病人的康复时间最长,平均估计值和中位数估计值分别为255.6天和180天,X2=119.034,P=0.000。穿刺间隙L2-3、L3-4及≥L1-2神经损伤病人康复时间的平均估计值分别为60.9天、29.2天和41.3天,中位数估计值分别为3天、2天和2天,X2=9.411,P=0.009。短暂神经综合征(TNS)的治疗的显效时间最短,显效时间的平均估计值和中位数估计值分别为3.9天和2天；脊神经根损伤(RD)显效时间的平均估计值和中位数估计值分别为8.8天和5天；而截瘫类神经损伤病人的显效时间最长,显效时间的平均估计值和中位数估计值分别为67.6天和40天,X2=30.293,P=0.000。
结论
1.单纯腰麻的自限率最高,而硬膜外麻醉的自限率最低,腰硬联合麻醉神经损伤的自限率与单纯腰麻相似。短暂性神经综合征(TNS)病人的自限率最高,而脊神经根损伤和截瘫类病人的自限率为零,均需要药物干预。
2.短暂性神经综合征(TNS)康复率为100%,无神经后遗症出现；其次为脊神经根损伤病人,康复率为48%,严重后遗症发生率为20%；而截瘫类(包括马尾综合征和硬膜外血肿)的康复率最低,仅为11.1%,严重后遗症发生率高达88.9%。
3.L3-4穿刺间隙病人的康复率为95.3%,其神经损伤病人严重后遗症发生率仅为1.9%；而穿刺间隙为L1-2及以上的病人的康复率仅为70%,神经损伤病人严重后遗症发生率却高达20%。
4.腰硬联合麻醉后神经损伤病人的所需康复时间最长,其次为硬膜外麻醉后神经损伤的病人,而单纯腰麻后神经损伤病人所需康复时间最短。其中短暂神经综合征(TNS)的所需康复时间及治疗显效时间最短,其次为脊神经根损伤患者,而截瘫类(包括马尾综合征和硬膜外血肿)病人所需的康复时间及治疗显效时间最长。L2-3穿刺间隙神经损伤病人的所需康复时间最长,L3-4穿刺间隙神经损伤病人的所需康复时间最短
neuraxial anesthesia, including epidural anesthesia (EA), spinal anesthesia (SA) and combined spinal-epidural anesthesia (CSEA). It is often used in clinical anesthesia, to keep the patient awake, anesthesia stable, postoperative analgesia easy, and also save medical costs. So neuraxial anesthesia is used for more than100years in clinical medicine.
Although neuraxial anesthesia has been proven to be very safe, but it has still complications. Neurological complications might be due to the inferior anesthetic techniques, or by the inherent risks of the anesthesia procedure, such as drugs and operations. Complications include both simple injection pain and permanent nerve damage, and even death. Neurological complications of neuraxial anesthesia are rare, so the exact incidence is difficult to determine. Neuraxial anesthesia is improved in technology and the adoption of new technology in recent years, it is very necessary to reevaluate the incidence of neurological complication. Few neurological complications of neuraxial anesthesia were reported, so the incidence may be underestimated, leading anesthesiologists underestimate the risk of neurological complications. Therefore, it is necessary to establish neurological complications of neuraxial anesthesia database to statistical analysis. Epidemiological data of neurological complications of neuraxial anesthesia is essential, it is an important indicator of the safety and quality of the measurement and assessment of neuraxial anesthesia.
Therefore, from January1,2008to December31,2012, a retrospective analysis of neurological complications of neuraxial anesthesia were carried out in64hospitals in Guangxi. To Investigate and analysis the about usage of neuraxial anesthesia at all levels of hospital and calculate the incidence, severity, duration, and related factors of neurological complications, and analysis rehabilitation time, effective time and its sequelae of neurological complications. To accumulate more experience of the clinical use for neuraxial anesthesia and epidemiology data of neurological complications, in order to increase clinical guide of anesthesiologist.
PART ONE A PRELIMINARY ANALYSIS ON THE USAGE OF NEURAXIAL ANESTHESIA AND IT'S NEUROLOGICAL COMPLICATIONS IN64HOSPITALS IN GUANGXI
Objective
The preliminary analysis on the usage of neuraxial anesthesia and the incidence and rehabilitation rates of neurological complications after neuraxial anesthesia in64hospitals in Guangxi. To accumulate the clinical experience of neuraxial anesthesia and epidemiology data of neurological complications after neuraxial anesthesia.
Methods
After the approval of anesthesia quality control center in Guangxi, a retrospective study analysis was carried out from January1,2008to December 31,2012, to aim at neurological complications of neuraxial anesthesia in64hospitals. Self-designed questionnaire of neurological complications of neuraxial anesthesia. From October2012, informed directors of anesthesiology department at all levels of the hospital's by both letter and phone message on behalf of anesthesia quality control center in Guangxi Zhuang Autonomous Region to download survey forms on neurological complications of neuraxial anesthesia by internet and finish form1and form2, included age, sex, date of operation, preoperative diagnosis, past medical history, anesthesia techniques, time of anesthesia and operative, surgical technique, anesthesia puncture site and parethesia, usage of postoperative analgesic and anesthetic,record the course of neurological complications, cure and neurological sequelae, and so on To supplement forms by phone or E-mail if it weren't complete. With SPSS13.0statistical package, Descriptive analysis and x2test and Fisher's exact test method was used, based on the demographic and clinical characteristics to calculate the incidence and recovery rates of neurological complications. P<0.05considered statistically significant.
Results
From2008to2012, there is the most commonly used in CSEA, but also showed an increasing trend. Followed by EA, EA showed a downward trend. SA is used the least. The incidence of neurological complications after neuraxial anesthesia was0.0408%, the incidence of neurological complications of EA, CSEA and SA were0.0201%,0.0552%,0.049%, respectively (P＜0.05). The incidence of three anesthesia neurological complication were compared, the difference was statistically significant (P=0.000), the incidence of neurological complication after EA was the least, CSEA was the most. There are statistically significant difference between the incidence of neurological complication of the two kinds grade hospital (P＜0.05), the incidence of neurological complications in large and comprehensive hospital was more than that of non-large and comprehensive hospital, the odds ratio(OR) was0.589(95%CI:0.442-0.786). The incidence of TNS was the most,0.0340%, followed by radicular damage (0.005%), the other three types of complications were relatively rare,0.0008%,0.0008%,0.0002%, respectively (P＜0.05). The incident of TNS was the least in EA (0.0147%), the incident of TNS was the most in CSEA (0.047%)(P＜0.05). The total cure rate of neurological complications was89.8%, the cute rate of three kinds of anesthesia were87.80%,90.26%,90.0%, respectively, the difference was not statistically significant (P＞0.05). All TNS patients were fully recovered (100%),48%in radicular damage,25%in cauda equina syndrome, the other two types complication of patients developed permanent damage. The total incidence of permanent neurological complication was0.0042%. The incidence of permanent complications of EA, CSEA and SA were0.0034%,0.0047%and0.0049%(P>0.05)
Conclusion
1. There is the most commonly used in CSEA, but also showed an increasing trend. Followed by EA, EA showed a downward trend, SA is used the least. The incidence of neurological complications in the large and comprehensive hospital was more than that of the non-large and comprehensive hospital.
2. The incidence of neuraxial anesthesia-related complications is very low, the neurological complications of EA was the least. The incidence of permanent complications of EA was the least, that of S A was the most.
3. Transient neurological syndrome (TNS) is the most common. The incident of TNS was the least in EA (0.0147%), the incident of TNS was the most in CSEA (0.047%)(P＜0.05). Most of the neurological complications could be completely cured.
PART TWO A ANALYSIS RELATED FACTORS ON NEUROLOGICAL COMPLICATIONS OF NEURAXIAL ANESTHESIA IN64HOSPITALS IN GUANGXI
Objective
The investigation and analysis on the severity and duration of neurological complications after neuraxial anesthesia and related factor with neurological complications. To accumulate the clinical experience of neuraxial anesthesia and epidemiology data of neurological complications after neuraxial anesthesia.
Methods
After the approval of anesthesia quality control center in Guangxi, a retrospective study analysis was carried out from January1,2008to December31,2012, to aim at neurological complications of neuraxial anesthesia in64hospitals. Self-designed questionnaire of neurological complications of neuraxial anesthesia. From October2012, informed directors of anesthesiology department at all levels of the hospital's by both letter and phone message on behalf of anesthesia quality control center in Guangxi Zhuang Autonomous Region to download survey forms on neurological complications of neuraxial anesthesia by internet and finish form1and form2, included age, sex, date of operation, preoperative diagnosis, past medical history, anesthesia techniques, time of anesthesia and operative, surgical technique, anesthesia puncture site and parethesia, usage of postoperative analgesic and anesthetic, record the course of neurological complications, cure and neurological sequelae, and so on. To supplement forms by phone or E-mail if it weren't complete. The patients without medication belong to Group I, the patients with medication belong to Group Ⅱ. Only patients with incapacitating neurologic complications lasting for3month or more were defined severe and long-lasting complications. With SPSS13.0statistical package, x2test and Fisher's exact test method, Wilcoxon test was used, multivariate analysis using logistic regression, rehabilitation time and effective time were analyzed using the Kaplan-Meier analysis and Cox regression. P＜0.05considered statistically significant.
Results
Logistic regression analysis showed that anesthesia and the type of neurologic complications had great correlation with self-limiting rate. The difference was statistically significant (P＜0.05). Self-limiting of SA was the highest,90%, that of EA was the lowest, only41.5%(P＜0.05). Self-limiting of TNS was the highest,83%, self-limiting of TNS was significantly higher than the latter two,(P＜0.05). The type of neurologic complications and puncture interspace had great correlation with rehabilitation and severe sequelae (P<0.05). The incidence of rehabilitation of L3-4was the highest,95.3%, that of L1-2was the lowest, only70%; The incidence of severe sequelae of L3_4was the lowest, only1.9%, that of L1-2was the highest,20%. The total incidence of severe sequelae was0.0026%, severe sequelae were the most in Paraplegia, no severe sequelae were developed in TNS. COX regression analysis showed that anesthesia, puncture interspace and the type of neurologic complications had great correlation with rehabilitation time. Rehabilitation mean and median time of EA were longer than those of CSEA and SA, the second were CSEA, the shortest one were SA,(P＜0.05). Rehabilitation mean and median time of Paraplegia were longer than those of radicular damage and TNS, the second were radicular damage, the shortest one were TNS,(P＜0.05). Rehabilitation mean and median time of L2.3were longer than those of L3-4and≥L1-2, the second were≥L1-2, the shortest one were L3-4(P＜0.05). Effective mean and median time of Paraplegia were longer than those of radicular damage and TNS, the second were radicular damage, the shortest one were TNS (P＜0.05).
Conclusion
1. Self-limiting of SA was the highest, that of EA was the lowest (P＜0.05). Self-limiting of TNS was the highest, self-limiting of TNS was significantly higher than the latter two(P＜0.05).
2. Recovery rate of TNS was100%, no severe sequelae were developed in TNS. That of RD was the second. Recovery rate of Paraplegia was the least, only11.1%, severe sequelae were the most in Paraplegia.
3. The incidence of rehabilitation of L3-4was95.3%, that of L1-2was70%; The incidence of severe sequelae of L3-4was1.9%, that of L1-2was20%.
4. Mean and median of rehabilitation time of EA was longer than those of CSEA and SA, CSEA was the second, the shortest one was SA(P＜0.05). Mean and median of rehabilitation time and onset time of Paraplegia was longer than those of RD and TNS, RD were the second, the shortest one was TNS(P＜0.05).
虽然椎管内麻醉已在临床运用了很长时间,但它并非没有并发症,且各文献报道的神经损伤的发生率数值差别较大[1-4],因此其确切的发病率很难确定。在临床上,其发病率可能被低估了,导致麻醉医师忽视了神经系统并发症风险。实际发生的神经损伤并发症可能比预期的要多,因此,椎管内麻醉神经系统并发症(尤其是神经损伤)仍然是临床麻醉医生关注的问题。而且随着麻醉材料、技术及设备的不断完善,重新评估严重并发症的发病率和特点是非常有必要的。椎管内麻醉相关的神经并发症(主要是神经损伤)的流行病学数据是必不可少的,是测量和评估椎管内麻醉的安全性和质量的重要指标,国外虽然有不少报道[1-],但目前国内在椎管内麻醉神经损伤方面尚缺大样本、多中心的统计资料和数据。因此,有必要建立椎管内麻醉相关神经并发症数据库,以便进行调查统计分析。
为此,本研究对2008年1月1日至2012年12月31日五年间广西壮族自治区各级医院椎管内麻醉后出现神经系统并发症进行一项回顾性调查研究分析,旨在了解广西壮族自治区各级医院椎管内麻醉使用现状及对椎管内麻醉引起的神经损伤发病率及其严重程度、后遗症持续时间,以及椎管内麻醉引起的神经损伤相关因素进行了流行病学调查分析,以评估椎管内麻醉神经损伤相关的风险因素,并对各类神经损伤的康复时间、显效时间及其神经损伤后遗症情况进行分析。我们探讨了椎管内麻醉神经损伤的发病率、愈后情况和风险因素,并对椎管内麻醉神经损伤的相关因素的流行病学数据进行分析,为椎管内麻醉临床使用及椎管内麻醉后神经损伤流行病学数据研究积累一些临床实践经验,对临床麻醉医生有一定参考价值。
第一部分广西64家医院椎管内麻醉使用情况及椎管内麻醉后神经损伤的发病率调查分析
目的
本研究目的是了解广西壮族自治区64家医院椎管内麻醉使用现状,并对椎管内麻醉引起的神经损伤发病率及治愈率进行初步分析。为椎管内麻醉临床使用及椎管内麻醉后神经损伤流行病学数据积累一些临床实践经验。
方法
经广西壮族自治区麻醉质量控制中心批准后,对2008年1月1日至2012年12月31日五年间广西壮族自治区各级医院椎管内麻醉后出现神经系统并发症进行一项回顾性调查研究。调查方式为问卷调查。自行设计椎管内麻醉神经并发症调查表。2012年10月,以广西壮族自治区麻醉质量控制中心的名义通过信函发放和手机短信相结合方式通知广西壮族自治区各级医院的麻醉科主任,要求各级医院麻醉科主任登陆广西麻醉网下载椎管内麻醉神经并发症调查表格并认真填写。表格1调查内容包括：广西壮族自治区各级医院2008-2012年五年间椎管内麻醉的病例数、椎管内麻醉(硬膜外麻醉、腰硬联合麻醉及单纯腰麻)神经并发症的病例数及医院级别。出现并发症的患者填写神经并发症表格2,包括患者的年龄、性别、手术日期、术前诊断、既往病史、麻醉方式、麻醉时间和手术时间、手术方式和手术体位、穿刺间隙,穿刺过程中有无神经刺激征、术后有无镇痛及镇痛药物的使用情况、椎管内麻醉药物使用情况、神经损伤类型、确诊时间及开始治疗时间、治疗措施及其愈后状况、治疗的显效时间及康复时间、神经系统后遗症状等。调查表填写内容不完善的通过电话随访或E-mail追加完善调查报告。根据人口统计学和临床特征采用SPSS13.0统计软件包中的描述性分析和x2检验及Fisher确切概率检验法对数据进行统计学分析。P<0.05为差异有统计学意义。
结果
2008～2012年五年间27家三级甲等医院实施硬膜外麻醉96897例,占36.6%；腰硬联合麻醉150236例,占56.8%；单纯腰麻17573例,占6.6%；共计264706例。37家非三级甲等医院实施硬膜外麻醉106509例,占44.7%；腰硬联合麻醉128665例,占54.1%；单纯腰麻2837例,占1.2%。共计238011例,合计502717例。无论是三级甲等医院还是非三级甲等医院,都是以腰硬联合麻醉最为常用,而且是呈逐年上升的趋势。其次为硬膜外麻醉,而单纯腰麻用的最少,在非三级甲等医院尤为明显。205例患者出现椎管内麻醉神经损伤,椎管内麻醉神经损伤的总发生率为4.08/万,其中硬膜外麻醉发生神经损伤41例,发生率为2.01/万,腰硬联合麻醉发生神经损伤154例,发生率为5.52/万,单纯腰麻发生神经损伤10例,发生率为4.9/万,硬膜外麻醉神经损伤的发生率最低,而腰硬联合麻醉神经损伤的发生率最高(X2=35.821,P=0.000),差异有统计学意义(P<0.05)；对三种麻醉方式神经损伤发生率进行了两两比较发现,硬膜外麻醉神经损伤发生率与腰硬联合麻醉(X2=35.774,P=0.000)及单纯腰麻(X2=6.772,P=0.009)相比较,差异均有统计学意义(P<0.05),而腰硬联合麻醉与单纯腰麻神经损伤发生率相比较,差异没有统计学意义(P>0.05)。其中三级甲等医院椎管内麻醉发生神经损伤有134例,占5.06/万,非三级甲等医院椎管内麻醉发生神经损伤有71例,占2.98/万,三级甲等医院椎管内麻醉神经损伤发生率较非三级甲等医院高(X2=13.291,P=0.000),差异有统计学意义(P<0.05)。但两种等级医院发生神经损伤的OR值=0.589(95%CI0.442～0.786)。205例神经损伤病例中,短暂神经综合征(TNS)为最多,有171例,发生率为3.4/万；其次是脊神经根损伤(RD)有25例,发生率为0.5/万,而马尾综合征(CES)及截瘫(paraplegia)各4例,发生率均为0.08/万；硬膜外血肿(EH)1例,发生率为0.02/万。硬膜外麻醉发生TNS为30例,发生率为1.47/万；腰硬联合麻醉发生TNS为132例,发生率为4.7/万；单纯腰麻发生TNS为9例,发生率为4.41/万。硬膜外麻醉TNS的发生率最低,而腰硬联合麻醉TNS的发生率最高,X2=37.352,P=0.000,差异有统计学意义(P<0.05)。腰硬联合麻醉TNS发生率与单纯腰麻相比较,差异无统计学意义(P>0.05)。神经损伤的总治愈率为89.8%,短暂神经综合征(TNS)病人治愈率为100%,而脊神经根损伤(RD)患者只有48%病人完全康复,马尾综合征(CES)只有1例病人(25%)完全康复。硬膜外麻醉、腰硬联合麻醉、单纯腰麻神经损伤病人完全治愈率分别为82.9%、91.6%、90.0%,差异无统计学意义(P>0.05)。永久性神经损伤的发生率为0.42/万,其中硬膜外麻醉永久性神经损伤发生率为0.34/万,腰硬联合麻醉为0.47/万,单纯腰麻为0.49/万,差异无统计学意义(P>0.05)。
结论
1.无论是三级甲等医院还是非三级甲等医院,都以腰硬联合麻醉最为常用,且呈逐年上升的趋势,其次为硬膜外麻醉,单纯腰麻使用得最少。三级甲等医院椎管内麻醉神经损伤发生率较非三级甲等医院高,但三级甲等医院椎管内麻醉发生神经损伤的风险并不比非三级甲等医院的高。
2.与椎管内麻醉相关神经损伤的发生率是很低的(4.08/万),硬膜外麻醉的神经损伤发生率最低(P<0.05),腰硬联合麻醉和腰麻的神经损伤发生率没有统计学差异。椎管内麻醉永久性神经损伤发生率为0.42/万,但三种麻醉方式的永久性神经损伤发生率无统计学差异(P>0.05)。
3.神经损伤类型以短暂神经综合征(TNS)为最多见,发生率为3.4/万。硬膜外麻醉TNS的发生率最低(1.47/万),而腰硬联合麻醉TNS的发生率最高(4.7/万),差异有统计学意义(P<0.05)。大多数的神经损伤是可以完全治愈的,神经损伤的总治愈率为89.8%。TNS病人的治愈率为100%(P<0.05),三种麻醉方式神经损伤的治愈率也无统计学差异。
第二部分广西64家医院椎管内麻醉神经损伤相关因素调查分析
目的
本研究的目的是对广西壮族自治区64家医院椎管内麻醉神经损伤严重程度、自限能力及后遗症持续时间以及椎管内麻醉引起的神经损伤相关因素进行调查分析,并对各类神经损伤的康复时间、显效时间及其神经损伤后遗症情况进行分析,以评估麻醉相关神经并发症的风险因素。为椎管内麻醉后神经损伤流行病学研究积累一些临床实践经验,对临床麻醉医生有一定参考价值。
方法
经广西壮族自治区麻醉质量控制中心批准后,对2008年1月1日至2012年12月31日五年间广西壮族自治区各级医院椎管内麻醉后出现神经系统并发症进行一项回顾性调查研究。调查方式为问卷式调查。自行设计椎管内麻醉神经并发症调查表。2012年10月,以广西壮族自治区麻醉质量控制中心的名义通过信函发放和手机短信相结合方式通知广西壮族自治区各级医院的麻醉科主任,要求各级医院麻醉科主任登陆广西麻醉网下载椎管内麻醉神经并发症调查表并认真填写。表格1调查内容包括：广西壮族自治区各级医院2008～2012年五年间椎管内麻醉的病例数、椎管内麻醉(硬膜外麻醉、腰硬联合麻醉及单纯腰麻)神经并发症的例数及医院级别。出现并发症的患者填写神经并发症表格2,包括患者的年龄、性别、手术日期、术前诊断、既往病史、麻醉方式、麻醉时间和手术时间、手术方式和术中体位、穿刺间隙,穿刺过程中有无神经刺激征、术后有无镇痛及镇痛药物的使用情况、椎管内麻醉药物使用情况、神经损伤类型、确诊时间及开始治疗时间、治疗措施及其愈后状况、治疗的显效时间及康复时间、神经系统后遗症状等。调查表填写内容不完善的通过电话随访或E-mail追加完善调查报告。其中不需要药物治疗的神经损伤病例有142例,归为自限组(I组),而需要药物治疗的神经损伤病例有63例,归为治疗组(II组)。治疗组中63例患者中对药物治疗有效的、完全治愈的有42例,归为完全治愈组；对药物治疗效果不佳的、未完全治愈的有21例,归为未完全治愈组。其中定义神经损伤引起的伤残或残障持续3个月或3个月以上的为严重性神经损伤[5],则未完全治愈病人又分为轻度后遗症(Mild sequelae, MS)和严重后遗症(severe sequelae, SS)。定义神经损伤症状持续12个月或12个月以上的为永久性神经损伤[6]0神经损伤分为三类：短暂神经综合征(Transient neurological syndrome)=TNS,脊神经根损伤(Radicular damage)=RD,截瘫(包括马尾综合征和硬膜外血肿)[7=Paraplegia。采用SPSS13.0统计软件包对数据进行分析,计数资料比较采用x2检验及Fisher的精确检验法,多因素分析采用Logistic回归分析,变量包括麻醉方式、穿刺间隙、性别、年龄、手术方式、手术体位、穿刺中有无不适、腰麻药物、硬膜外药物、镇痛、镇痛药物、神经损伤类型。康复时间和显效时间的相关因素分析采用生存分析中的Kaplan-Meier和Cox回归分析方法。P<0.05为差异有统计学意义。
结果
Logistic回归分析显示,麻醉方式和神经损伤类型与神经损伤病人自限率有相关性(P<0.05)。205例神经损伤的病人不需要药物处理的病例为142例,自限率为69.3%,其中单纯腰麻的自限率最高,自限率为90%,而硬膜外麻醉的自限率最低,仅为41.5%,差异有统计学意义(P<0.05)。无需药物治疗以短暂神经综合征(TNS)病人为最多,142例,自限率为83.0%,脊神经根损伤(RD)和截瘫类(Paraplegia)病人的自限率均为0.0%,X2=91.872,P=0.000.Logistic回归分析显示,神经损伤类型、穿刺间隙与神经损伤病人愈后及严重后遗症发生率有相关性(P<0.05)；L3-4穿刺点病人的康复率显著的高于其他两个穿刺点,严重后遗症发生率显著的低于其他两个穿刺(P<0.05)。L3-4穿刺间隙病人的康复率为95.3%,为最高,其神经损伤病人严重后遗症发生率仅为1.9%,为最低；而穿刺间隙为L1-2及以上病人的康复率仅为70%,为最低,神经损伤病人严重后遗症发生率却高达20%,为最高,差异有统计学意义(P<0.05)。短暂神经综合征(TNS)、脊神经根损伤(RD)、截瘫类(Paraplegia)病人完全康复率分别为100%、48%、11.1%,X2=127.5,P=0.000。神经损伤严重后遗症总发生率为0.26/万,短暂神经综合征(TNS)无神经后遗症出现,脊神经根损伤严重后遗症发生率为20%。截瘫类病人严重后遗症发生率高达88.9%,X2=105.2,P=0.000。Cox回归分析显示麻醉方式、穿刺间隙和神经损伤类型与神经损伤病人康复时间有很大的相关性(P<0.05)；腰硬联合麻醉后神经损伤病人的所需康复时间最长,平均估计值和中位数估计值分别为71.8天和3天；硬膜外麻醉神经损伤病人所需康复时间平均估计值和中位数估计值分别为58.3天和4天；而单纯腰麻后神经损伤病人所需康复时间最短,平均估计值和中位数估计值分别为15.2天和1天,X2=10.602,P=0.005。短暂神经综合征(TNS)的康复时间最短,平均估计值和中位数估计值分别为2.9天和2天；脊神经根损伤(RD)平均估计值和中位数估计值分别为78.7天和75天；而截瘫类病人的康复时间最长,平均估计值和中位数估计值分别为255.6天和180天,X2=119.034,P=0.000。穿刺间隙L2-3、L3-4及≥L1-2神经损伤病人康复时间的平均估计值分别为60.9天、29.2天和41.3天,中位数估计值分别为3天、2天和2天,X2=9.411,P=0.009。短暂神经综合征(TNS)的治疗的显效时间最短,显效时间的平均估计值和中位数估计值分别为3.9天和2天；脊神经根损伤(RD)显效时间的平均估计值和中位数估计值分别为8.8天和5天；而截瘫类神经损伤病人的显效时间最长,显效时间的平均估计值和中位数估计值分别为67.6天和40天,X2=30.293,P=0.000。
结论
1.单纯腰麻的自限率最高,而硬膜外麻醉的自限率最低,腰硬联合麻醉神经损伤的自限率与单纯腰麻相似。短暂性神经综合征(TNS)病人的自限率最高,而脊神经根损伤和截瘫类病人的自限率为零,均需要药物干预。
2.短暂性神经综合征(TNS)康复率为100%,无神经后遗症出现；其次为脊神经根损伤病人,康复率为48%,严重后遗症发生率为20%；而截瘫类(包括马尾综合征和硬膜外血肿)的康复率最低,仅为11.1%,严重后遗症发生率高达88.9%。
3.L3-4穿刺间隙病人的康复率为95.3%,其神经损伤病人严重后遗症发生率仅为1.9%；而穿刺间隙为L1-2及以上的病人的康复率仅为70%,神经损伤病人严重后遗症发生率却高达20%。
4.腰硬联合麻醉后神经损伤病人的所需康复时间最长,其次为硬膜外麻醉后神经损伤的病人,而单纯腰麻后神经损伤病人所需康复时间最短。其中短暂神经综合征(TNS)的所需康复时间及治疗显效时间最短,其次为脊神经根损伤患者,而截瘫类(包括马尾综合征和硬膜外血肿)病人所需的康复时间及治疗显效时间最长。L2-3穿刺间隙神经损伤病人的所需康复时间最长,L3-4穿刺间隙神经损伤病人的所需康复时间最短
neuraxial anesthesia, including epidural anesthesia (EA), spinal anesthesia (SA) and combined spinal-epidural anesthesia (CSEA). It is often used in clinical anesthesia, to keep the patient awake, anesthesia stable, postoperative analgesia easy, and also save medical costs. So neuraxial anesthesia is used for more than100years in clinical medicine.
Although neuraxial anesthesia has been proven to be very safe, but it has still complications. Neurological complications might be due to the inferior anesthetic techniques, or by the inherent risks of the anesthesia procedure, such as drugs and operations. Complications include both simple injection pain and permanent nerve damage, and even death. Neurological complications of neuraxial anesthesia are rare, so the exact incidence is difficult to determine. Neuraxial anesthesia is improved in technology and the adoption of new technology in recent years, it is very necessary to reevaluate the incidence of neurological complication. Few neurological complications of neuraxial anesthesia were reported, so the incidence may be underestimated, leading anesthesiologists underestimate the risk of neurological complications. Therefore, it is necessary to establish neurological complications of neuraxial anesthesia database to statistical analysis. Epidemiological data of neurological complications of neuraxial anesthesia is essential, it is an important indicator of the safety and quality of the measurement and assessment of neuraxial anesthesia.
Therefore, from January1,2008to December31,2012, a retrospective analysis of neurological complications of neuraxial anesthesia were carried out in64hospitals in Guangxi. To Investigate and analysis the about usage of neuraxial anesthesia at all levels of hospital and calculate the incidence, severity, duration, and related factors of neurological complications, and analysis rehabilitation time, effective time and its sequelae of neurological complications. To accumulate more experience of the clinical use for neuraxial anesthesia and epidemiology data of neurological complications, in order to increase clinical guide of anesthesiologist.
PART ONE A PRELIMINARY ANALYSIS ON THE USAGE OF NEURAXIAL ANESTHESIA AND IT'S NEUROLOGICAL COMPLICATIONS IN64HOSPITALS IN GUANGXI
Objective
The preliminary analysis on the usage of neuraxial anesthesia and the incidence and rehabilitation rates of neurological complications after neuraxial anesthesia in64hospitals in Guangxi. To accumulate the clinical experience of neuraxial anesthesia and epidemiology data of neurological complications after neuraxial anesthesia.
Methods
After the approval of anesthesia quality control center in Guangxi, a retrospective study analysis was carried out from January1,2008to December 31,2012, to aim at neurological complications of neuraxial anesthesia in64hospitals. Self-designed questionnaire of neurological complications of neuraxial anesthesia. From October2012, informed directors of anesthesiology department at all levels of the hospital's by both letter and phone message on behalf of anesthesia quality control center in Guangxi Zhuang Autonomous Region to download survey forms on neurological complications of neuraxial anesthesia by internet and finish form1and form2, included age, sex, date of operation, preoperative diagnosis, past medical history, anesthesia techniques, time of anesthesia and operative, surgical technique, anesthesia puncture site and parethesia, usage of postoperative analgesic and anesthetic,record the course of neurological complications, cure and neurological sequelae, and so on To supplement forms by phone or E-mail if it weren't complete. With SPSS13.0statistical package, Descriptive analysis and x2test and Fisher's exact test method was used, based on the demographic and clinical characteristics to calculate the incidence and recovery rates of neurological complications. P<0.05considered statistically significant.
Results
From2008to2012, there is the most commonly used in CSEA, but also showed an increasing trend. Followed by EA, EA showed a downward trend. SA is used the least. The incidence of neurological complications after neuraxial anesthesia was0.0408%, the incidence of neurological complications of EA, CSEA and SA were0.0201%,0.0552%,0.049%, respectively (P＜0.05). The incidence of three anesthesia neurological complication were compared, the difference was statistically significant (P=0.000), the incidence of neurological complication after EA was the least, CSEA was the most. There are statistically significant difference between the incidence of neurological complication of the two kinds grade hospital (P＜0.05), the incidence of neurological complications in large and comprehensive hospital was more than that of non-large and comprehensive hospital, the odds ratio(OR) was0.589(95%CI:0.442-0.786). The incidence of TNS was the most,0.0340%, followed by radicular damage (0.005%), the other three types of complications were relatively rare,0.0008%,0.0008%,0.0002%, respectively (P＜0.05). The incident of TNS was the least in EA (0.0147%), the incident of TNS was the most in CSEA (0.047%)(P＜0.05). The total cure rate of neurological complications was89.8%, the cute rate of three kinds of anesthesia were87.80%,90.26%,90.0%, respectively, the difference was not statistically significant (P＞0.05). All TNS patients were fully recovered (100%),48%in radicular damage,25%in cauda equina syndrome, the other two types complication of patients developed permanent damage. The total incidence of permanent neurological complication was0.0042%. The incidence of permanent complications of EA, CSEA and SA were0.0034%,0.0047%and0.0049%(P>0.05)
Conclusion
1. There is the most commonly used in CSEA, but also showed an increasing trend. Followed by EA, EA showed a downward trend, SA is used the least. The incidence of neurological complications in the large and comprehensive hospital was more than that of the non-large and comprehensive hospital.
2. The incidence of neuraxial anesthesia-related complications is very low, the neurological complications of EA was the least. The incidence of permanent complications of EA was the least, that of S A was the most.
3. Transient neurological syndrome (TNS) is the most common. The incident of TNS was the least in EA (0.0147%), the incident of TNS was the most in CSEA (0.047%)(P＜0.05). Most of the neurological complications could be completely cured.
PART TWO A ANALYSIS RELATED FACTORS ON NEUROLOGICAL COMPLICATIONS OF NEURAXIAL ANESTHESIA IN64HOSPITALS IN GUANGXI
Objective
The investigation and analysis on the severity and duration of neurological complications after neuraxial anesthesia and related factor with neurological complications. To accumulate the clinical experience of neuraxial anesthesia and epidemiology data of neurological complications after neuraxial anesthesia.
Methods
After the approval of anesthesia quality control center in Guangxi, a retrospective study analysis was carried out from January1,2008to December31,2012, to aim at neurological complications of neuraxial anesthesia in64hospitals. Self-designed questionnaire of neurological complications of neuraxial anesthesia. From October2012, informed directors of anesthesiology department at all levels of the hospital's by both letter and phone message on behalf of anesthesia quality control center in Guangxi Zhuang Autonomous Region to download survey forms on neurological complications of neuraxial anesthesia by internet and finish form1and form2, included age, sex, date of operation, preoperative diagnosis, past medical history, anesthesia techniques, time of anesthesia and operative, surgical technique, anesthesia puncture site and parethesia, usage of postoperative analgesic and anesthetic, record the course of neurological complications, cure and neurological sequelae, and so on. To supplement forms by phone or E-mail if it weren't complete. The patients without medication belong to Group I, the patients with medication belong to Group Ⅱ. Only patients with incapacitating neurologic complications lasting for3month or more were defined severe and long-lasting complications. With SPSS13.0statistical package, x2test and Fisher's exact test method, Wilcoxon test was used, multivariate analysis using logistic regression, rehabilitation time and effective time were analyzed using the Kaplan-Meier analysis and Cox regression. P＜0.05considered statistically significant.
Results
Logistic regression analysis showed that anesthesia and the type of neurologic complications had great correlation with self-limiting rate. The difference was statistically significant (P＜0.05). Self-limiting of SA was the highest,90%, that of EA was the lowest, only41.5%(P＜0.05). Self-limiting of TNS was the highest,83%, self-limiting of TNS was significantly higher than the latter two,(P＜0.05). The type of neurologic complications and puncture interspace had great correlation with rehabilitation and severe sequelae (P<0.05). The incidence of rehabilitation of L3-4was the highest,95.3%, that of L1-2was the lowest, only70%; The incidence of severe sequelae of L3_4was the lowest, only1.9%, that of L1-2was the highest,20%. The total incidence of severe sequelae was0.0026%, severe sequelae were the most in Paraplegia, no severe sequelae were developed in TNS. COX regression analysis showed that anesthesia, puncture interspace and the type of neurologic complications had great correlation with rehabilitation time. Rehabilitation mean and median time of EA were longer than those of CSEA and SA, the second were CSEA, the shortest one were SA,(P＜0.05). Rehabilitation mean and median time of Paraplegia were longer than those of radicular damage and TNS, the second were radicular damage, the shortest one were TNS,(P＜0.05). Rehabilitation mean and median time of L2.3were longer than those of L3-4and≥L1-2, the second were≥L1-2, the shortest one were L3-4(P＜0.05). Effective mean and median time of Paraplegia were longer than those of radicular damage and TNS, the second were radicular damage, the shortest one were TNS (P＜0.05).
Conclusion
1. Self-limiting of SA was the highest, that of EA was the lowest (P＜0.05). Self-limiting of TNS was the highest, self-limiting of TNS was significantly higher than the latter two(P＜0.05).
2. Recovery rate of TNS was100%, no severe sequelae were developed in TNS. That of RD was the second. Recovery rate of Paraplegia was the least, only11.1%, severe sequelae were the most in Paraplegia.
3. The incidence of rehabilitation of L3-4was95.3%, that of L1-2was70%; The incidence of severe sequelae of L3-4was1.9%, that of L1-2was20%.
4. Mean and median of rehabilitation time of EA was longer than those of CSEA and SA, CSEA was the second, the shortest one was SA(P＜0.05). Mean and median of rehabilitation time and onset time of Paraplegia was longer than those of RD and TNS, RD were the second, the shortest one was TNS(P＜0.05).
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