舞蹈致儿童无骨折脱位型脊髓损伤神经学预后的影响因素及预测模型

doi:10.3969/j.issn.1006-9771.2023.05.014

《中国康复理论与实践》 ›› 2023, Vol. 29 ›› Issue (5): 582-589.doi: 10.3969/j.issn.1006-9771.2023.05.014

舞蹈致儿童无骨折脱位型脊髓损伤神经学预后的影响因素及预测模型

郭霜¹^,², 谢咏祺¹^,², 张良¹^,², 张春佳¹^,², 彭润¹^,², 杨德刚¹^,², 杨明亮¹^,²^,³^,⁴()

1.首都医科大学康复医学院，北京市 100068
2.中国康复研究中心北京博爱医院脊柱脊髓神经功能重建科，北京市 100068
3.北京脑重大疾病研究院神经损伤与修复研究所，北京市 100068
4.北京市神经损伤与康复重点实验室，北京市 100068

收稿日期:2023-02-19 修回日期:2023-03-22 出版日期:2023-05-25 发布日期:2023-06-19
通讯作者: 杨明亮(1967-)，男，汉族，湖南汨罗市人，教授，主任医师，博士研究生导师，主要研究方向：脊柱脊髓损伤后并发症治疗。E-mail：chinayml3@163.com
作者简介:郭霜(1998-)，女，汉族，江西吉安市人，硕士研究生，主要研究方向：脊柱脊髓损伤后并发症治疗。
基金资助:
1.首都卫生发展科研专项项目(No. 首发2020-2-6012(2020-2-6012);2.中国康复研究中心基础科研基金项目(2021ZX-08)

Related factors and prediction model for neurological outcome of dance-associated pediatric spinal cord injury without radiographic abnormality

GUO Shuang¹^,², XIE Yongqi¹^,², ZHANG Liang¹^,², ZHANG Chunjia¹^,², PENG Run¹^,², YANG Degang¹^,², YANG Mingliang¹^,²^,³^,⁴()

1. Capital Medical University School of Rehabilitation Medicine, Beijing 100068, China
2. Department of Spinal and Neural Function Reconstruction, Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing 100068, China
3. Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing 100068, China
4. Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing 100068, China

Received:2023-02-19 Revised:2023-03-22 Published:2023-05-25 Online:2023-06-19
Contact: YANG Mingliang, E-mail: chinayml3@163.com
Supported by:
Capital's Funds for Health Improvement and Research(2020-2-6012);China Rehabilitation Research Center Research Project(2021ZX-08)

摘要/Abstract

摘要：

目的调查舞蹈致儿童无骨折脱位型脊髓损伤(SCIWORA)的临床神经学预后特点，并探究此类脊髓损伤神经功能预后的影响因素及预测模型。

方法 2012年7月至2022年1月北京博爱医院住院的舞蹈致SCIWORA患儿75例，按照受伤后1年美国脊柱损伤协会残损分级(AIS)分为改善组(n = 14)和未改善组(n = 61)，比较两组相关数据。

结果纳入患儿均为女童，年龄4~10岁，以完全性脊髓损伤为主(52/75，69%)。受伤至康复时间与AIS分级改善呈负相关(OR = 0.926, P = 0.046, 95%CI 0.858~0.999)，而腱反射存在(OR = 46.915, P = 0.012, 95%CI 2.333~943.616)和肌张力存在(OR = 8.932, P = 0.044，95%CI 1.063~75.067)呈正相关。联合受伤至康复时间、腱反射和肌张力对于AIS分级的改善具有显著预测价值(AUC = 0.953，P < 0.001, 95%CI 0.878~0.989)，敏感性为100%，特异性为83.61%。

结论舞蹈致儿童SCIWORA的神经功能预后较差。尽早进行康复训练有利于患者的神经恢复。入院时腱反射和肌张力存在与神经学预后改善相关，可作为预测其临床神经学预后的潜在指标。

关键词: 无骨折脱位型脊髓损伤, 儿童, 预后, 影响因素

Abstract:

Objective To investigate the neurological outcome of children with dance-associated spinal cord injury without radiographic abnormality (SCIWORA) and explore its related factors and predictive model.

Methods From July, 2012 to January, 2022, 75 children with dance-associated SCIWORA hospitalized in Beijing Bo'ai Hospital were divided into improved group (n = 14) and non-improved group (n = 61) according to the American Spinal Injury Association Impairment Scale (AIS) grade a year later, and the related factors were analyzed.

Results All patients were girls aged four to ten years. Most of them were complete spinal cord injuries (52/75, 69%). The time of injury to rehabilitation (OR = 0.926, P = 0.046, 95%CI 0.858 to 0.999), the existing tendon reflex (OR = 46.915，P = 0.012, 95%CI 2.333 to 943.616) and muscle tension (OR = 8.932，P= 0.044，95%CI 1.063~75.067) were correlated with the AIS grade improvement. The combination of time of injury to rehabilitation, tendon reflex and muscle tone existing may predict the improvement of AIS (AUC = 0.953, P < 0.001，95%CI 0.878 to 0.989), the sensitivity and specificity were 100% and 83.61%, respectively.

Conclusion The neurological outcome of children with dance-associated SCIWORA is poor. Rehabilitation training as soon as possible is beneficial to the neurological recovery. Tendon reflexe and muscle tone existing at admission are closely related to improvement of neurological outcome, which could be used as potential indicators.

Key words: spinal cord injury without radiographic abnormality, children, prognosis, influencing factor

中图分类号:

R651.2

郭霜, 谢咏祺, 张良, 张春佳, 彭润, 杨德刚, 杨明亮. 舞蹈致儿童无骨折脱位型脊髓损伤神经学预后的影响因素及预测模型[J]. 《中国康复理论与实践》, 2023, 29(5): 582-589.

GUO Shuang, XIE Yongqi, ZHANG Liang, ZHANG Chunjia, PENG Run, YANG Degang, YANG Mingliang. Related factors and prediction model for neurological outcome of dance-associated pediatric spinal cord injury without radiographic abnormality[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2023, 29(5): 582-589.

图/表 5

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参考文献 36

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项目		入院	伤后1年随访	χ²/Z值	P值
肌张力/n	存在	17	24	38.981	< 0.001
肌张力/n	消失	58	51	38.981	< 0.001
腱反射/n	存在	20	22	-1.414	0.317
腱反射/n	消失	55	53	-1.414	0.317
Babinski征/n	引出	14	13	-0.577	0.157
Babinski征/n	未引出	61	62	-0.577	0.157
神经损伤平面/n	T_1-6	17	14	-0.447	0.655
	T_7-12	51	55
	L₁~S₅	7	6
感觉评分	M(P₂₅，P₇₅)	136(112, 160)	136(116, 168)	-2.173	0.030
感觉评分	范围	68~224	68~224	-2.173	0.030
针刺觉	M(P₂₅，P₇₅)	68(56, 80)	68(58, 86)	-1.697	0.090
针刺觉	范围	34~112	34~112	-1.697	0.090
轻触觉	M(P₂₅，P₇₅)	68(58, 84)	69(61, 84)	-1.894	0.058
轻触觉	范围	34~112	34~112	-1.894	0.058
双下肢运动评分	M(P₂₅，P₇₅)	0(0, 0)	0(0, 3)	-3.756	< 0.001
双下肢运动评分	范围	0~40	0~50	-3.756	< 0.001
AIS分级/n	A	52	52	-3.557	< 0.001
	B	11	3
	C	6	8
	D	6	10
	E	0	2

因素类别	因素赋值	赋值结果
年龄	< 8岁(0)， ≥ 8岁(1)	0 = 58，1 = 17
有无异常(受伤前两周)	无(0)，有(1)	0 = 59，1 = 16
是否摔倒	否(0)，是(1)	0 = 33，1 = 42
潜伏期	< 4 h (0)，≥ 4 h (1)	0 = 66，1 = 9
是否活动(潜伏期)	否(0)，是(1)	0 = 53，1 = 22
8h内是否使用激素	否(0)，是(1)	0 = 51，1 = 24
是否佩戴腰围	否(0)，是(1)	0 = 47，1 = 28
是否佩戴双下肢支具	否(0)，是(1)	0 = 36，1 = 39
脊髓内长T₂信号	否(0)，是(1)	0 = 7，1 = 68
肌张力是否存在	否(0)，是(1)	0 = 58，1 = 17
腱反射是否存在	否(0)，是(1)	0 = 55，1 = 20
Babinski征是否引出	否(0)，是(1)	0 = 61，1 = 14
神经损伤平面	T_1-6(1)，T_7-12(2)，L₁~S₅(3)	1 = 17，2 = 51，3 = 7

自变量		AIS分级改善		OR值(95%CI)	P值
自变量		改善组(n = 14)	未改善组(n = 61)	OR值(95%CI)	P值
年龄/岁	< 8	12	46	1	0.413
年龄/岁	≥ 8	2	15	0.511(0.103~2.548)	0.413
受伤至康复时间/d		15(13.5, 21)	29(18, 61)	0.950(0.904~0.998)	0.040
病程/d		132.5(66, 278.5)	131(75.5, 228.5)	1.001(0.997~1.005)	0.712
有无异常 (受伤前两周)	有	3	13	1	0.992
有无异常 (受伤前两周)	无	11	48	1.007(0.244~4.150)	0.992
是否摔倒	是	8	34	1	0.924
是否摔倒	否	6	27	1.059(0.328~3.421)	0.924
潜伏期/h	<4	13	53	1	0.542
潜伏期/h	≥4	1	8	0.510(0.058~4.444)	0.542
潜伏期是否活动	是	3	19	1	0.474
潜伏期是否活动	否	11	42	0.603(0.151~2.413)	0.474
8 h内是否使用激素	是	7	17	1	0.117
8 h内是否使用激素	否	7	44	2.588(0.789~0.489)	0.117
是否佩戴腰围	是	5	23	1	0.890
是否佩戴腰围	否	9	38	0.918(0.274~3.077)	0.890
是否佩戴双下肢支具	是	5	34	1	0.183
是否佩戴双下肢支具	否	9	27	0.441(0.132~1.471)	0.183
脊髓内长T₂信号	是	13	55	1	0.756
脊髓内长T₂信号	否	1	6	1.418(0.157~12.820)	0.756
损伤节段长度		7.25±3.44	6.64±3.87	1.044(0.883~1.234)	0.612
肌张力是否存在	是	8	9	1	0.002
肌张力是否存在	否	6	52	7.704(2.156~27.521)	0.002
腱反射是否存在	是	11	9	1	< 0.001
腱反射是否存在	否	3	52	21.185(4.922~91.185)	< 0.001
Babinski征是否引出	是	7	7	1	0.002
Babinski征是否引出	否	7	54	7.714(2.08~28.606)	0.002
神经损伤平面	T_1-6	1	16	1	0.034
	T_7-12	9	42	3.429(0.401~29.279)	0.260
	L₁~S₅	4	3	21.333(1.726~263.673)	0.017

项目	回归系数B	标准误	Wald值	P值	OR值	95%CI
受伤至康复时间	-0.077	0.039	3.979	0.046	0.926	0.858~0.999
肌张力是否存在	2.190	1.086	4.065	0.044	8.932	1.063~75.067
腱反射是否存在	3.848	1.531	6.315	0.012	46.915	2.333~943.616
Babinski征是否引出	-1.676	1.554	1.163	0.281	0.187	0.009~3.934
神经损伤平面
T_1-6	1.708	0.426
T_7-12	1.616	1.447	1.246	0.264	5.032	0.295~85.876
L₁~S₅	2.530	2.012	1.580	0.209	12.551	0.243~648.004

因素类别	AUC	95%CI	敏感性	特异性	P值
受伤至康复时间	0.758	0.645~0.849	85.7%	67.2%	< 0.001
腱反射	0.819	0.713~0.898	78.6%	85.3%	< 0.001
肌张力	0.712	0.596~0.811	57.1%	85.3%	0.003
合并	0.953	0.878~0.989	100%	83.6%	< 0.001

舞蹈致儿童无骨折脱位型脊髓损伤神经学预后的影响因素及预测模型

Related factors and prediction model for neurological outcome of dance-associated pediatric spinal cord injury without radiographic abnormality

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