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3.3. 斯皮尔曼相关分析
为了确定颅缺损术后潜在的相关特征是否对干预期有重要影响，我们进一步进行相关分析。Spearman的相关系数显示，干预时间与性别(ρ = 0.431, p = 0.001)、KPS评分(ρ = ?0.449, p = 0.001)、ZPS评分(ρ = ?0.449, p = 0.001)、心理功能评分(ρ = ?0.423, p = 0.001)、生活质量评分(ρ = ?0.287, p = 0.032)显著相关。然而，年龄和干预时间之间没有进一步的关联(见表2)。
Table 2. The relationship between characteristics of patients and intervention period 表2. 患者特征与干预时间的关系
Characteristics
Sex Age KPS score ZPS score
Psychological function score
Life quality score
Spearman correlation test was used. *p < 0.05.
Intervention period
ρ 0.431 ?0.190 ?0.449 ?0.449 ?0.423 ?0.278
p 0.001* 0.147 0.001* 0.001* 0.001* 0.032*
3.4. 单因素Logistic回归分析
我们的研究使用单变量逻辑回归，通过优势比(ORs)和95%置信区间(95% CIs)来确定相关参数和干预期间之间的关系,为了进一步确定相关因素和高危人群的干预。表3描述了在单变量级别使用单变量逻辑回归来描述研究对象的ORs和95%可信区间和性别(OR = 6.697, 95% CI: 2.084~21.525, p = 0.001)、KPS评分(OR = 0.106, 95% CI: 0.027~0423, p = 0.001)、ZPS评分(OR = 0.106, 95%CI: 0.027~0.423, p = 0.001)、心理功能评分(OR = 0.149, 95% CI: 0.045~0.492, p = 0.002)、生活质量评分(OR = 0.280, 95% CI: 0.085~0.921, p = 0.036)与患者是否超早期治疗有明显相关性。然而，年龄(OR = 0.433, 95% CI: 0.140~1.340, p = 0.146)和干预期之间不存在不利因素(见表3)。
Table 3. Intervention period on postoperation characteristics of patients with skull defect by logistic regression analysis 表3. Logistic回归分析干预时间对颅骨缺损患者术后特征的影响
Characteristics Sex Age KPS score
OR 95% CI p OR 95% CI p OR 95% CI p
1
0.001*
1
0.146
0.106 0.027~0.423
Intervention period
Regular group
1
0.001*
0.433 0.140~1.340 Super early group
6.697 2.084~21.525
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Continued
ZPS score
Psychological function score
Life quality score
OR, odds ratio; 95% CI, 95% confidence interval. *p < 0.05.
OR 95% CI p OR 95% CI p OR 95% CI p
1
0.001*
1
0.002*
1
0.036*
0.106 0.027~0.423
0.149 0.045~0.492
0.280 0.085~0.921
4. 讨论
我们的研究通过皮尔逊卡方、spearman相关分析及单因素log回归分析得出结果显示：超早期组术后KPS、ZPS评分及预后生活质量较常规组升高明显，且术后超早期组并发症发生率明显低于常规组。超早期颅骨修补可有效减少颅脑损伤术后颅骨缺损患者并发症及KPS、ZPS评分及预后生活质量，促进机体功能恢复，具有临床推广应用价值。选择恰当的颅骨修补时机对于颅骨缺损患者至关重要。手术时机的改变不仅要考虑到可能带来的益处，更要考虑到是否可能对患者带来的不利，术后并发症(感染、伤口问题等)及患者术后生活质量就是其中不容回避的问题，而国外在并发症方面的研究结论并不一致[12]。针对早期颅骨缺损修补术(CP)，有文献阐明其可缩短手术时间，减少术中失血量，改善神经功能及预后等[14]。相反，也有文献表明早期 CP 与高并发症发生率显著相关[15]，结论仍具有争议。Malcolm [16] [17]等的最新Meta分析结果也阐明早期(<90天) CP可显著提高CP术后神经功能预后。Bender [17]等分别对 79例早期和68例晚期CP行回顾性研究发现，早期(<86天) CP患者神经功能预后显著优于晚期(>85天)。
CP相关文献报道显示[18] [19]若术后出现较大的颅骨缺损，往往会影响到脑实质。有学者指出：1)若出现颅骨缺损情况，皮瓣会比较松弛，颅内容物会随着体位的改变而发生经常性位移；2) 大气压经皮瓣能够在其下方的脑皮层其作用，如果颅骨缺损位置接近于静脉窦，还会对窦内压力产生影响，因而会引发各种临床神经症状，严重者会对神经功能的恢复造成影响[20]。伤后1~3个月内是恢复神经功能的最佳时期，因此，在此阶段对患者实行颅骨修补术，对患者神经功能恢复、生活质量提高有着十分积极的作用[18] [21]。常规颅骨修补术施行时间主要为术后3~6个月后进行，可避免感染率的提高，预防患者受到二次损伤，但颅骨缺损时间过长会致使脑组织受到外力影响，造成颅内感染、头皮坏死、头皮血肿、四肢痉挛、意识丧失以及硬膜下积液和脑膨出等并发症，且不利于神经功能恢复；而修补术尽早施行后可促使患者颅内压及时趋于稳定，并改善脑脊液循环，脑血流速度加快，促进脑细胞代谢，有效改善患者脑神经生理功能，继而使患者认知功能得到较大程度提高[3]；并且超早期修补术后可有效降低舒张期血管收缩，使脑微小血管舒张能力增加，有效降低小血管阻力，以增加脑血流量，继而改善患者脑血管反应性。因此，超早期组术后在改善患者认知功能、脑血管反应性及生活质量方面较常规组有明显优势[9] [22] [23]。
5. 结论
综上所述，早期颅骨修补可提升患者的术后KPS、ZPS评分及生活质量评分。选择恰当的颅骨修补时机对颅骨缺损患者降低术后并发症，减少颅骨缺损面积意义重大，更可以有效改善患者神经缺损状态，
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提升患者生活能力及运动能力，值得推广。
致 谢
感谢韩丙坤在投稿过程中对本论文的帮助。
参考文献
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超早期颅骨修复改善颅脑损伤患者生活质量的临床研究
