关节置换术后精神及意识异常与不完全型脑型脂肪栓塞

摘要

目的:探讨关节置换术后患者轻度意识与精神异常与不完全型脑型脂肪栓塞的关系.方法:回顾性分析12例关节置换术后发生不完全型脑型脂肪栓塞患者的临床资料,其中男5例,女7例；年龄36～82岁,平均56.8岁.股骨颈骨折4例,股骨头坏死3例,类风湿性关节炎3例,强制性脊柱炎髋强直1例,膝关节骨性关节炎1例.在进行人工关节置换(股骨头置换3例,全髋关节置换7例,膝关节表面置换2例)手术后发生精神及行为异常、生命体征变化、颅脑磁共振检查的异常,对患者的精神及行为、生命体征、颅脑磁共振表现进行连续监测.结果:12例术后出现精神及意识轻度障碍,NIHSS评分平均1.92±3.78,在排除其他因素后确诊与关节置换术后不完全型脑型脂肪栓塞有关.在经过扩容,脱水剂及神经保护药物,改善呼吸、循环功能,激素保护及抗生素治疗后均在24～72 h后意识逐渐恢复正常.出院后随访10～36个月,平均随访18个月,患者神经系统功能正常,随访NIHSS评分均为0分,无后遗症.结论:关节置换术后不完全型脑型脂肪栓塞是造成患者轻度意识及精神状态的改变的重要原因之一,由于该病临床表现的不典型性,经常被临床医师误诊或忽视.%Objective:To investigate the relationship between mild consciousness and mental disorders after arthroplasty and incomplete cerebral fat embolism. Methods:A retrospective analysis of 12 patients with incomplete cerebral fat embolism after arthroplasty was performed from June 2004 to December 2011. There were 5 males and 7 females, ranging in age from 36 to 82 years old, averaged 56.8 years old. Four patients had femoral neck fractures; 3 patients had avascular necrosis of the femoral head; 3 patients had rheumatoid arthritis; 1 patient had ankylosed hip and 1 patient had knee osteoarthritis. The patients had consciousness and mental disorders after arthroplasty (femoral head replacement in 3 cases,total hip replacement in 7 cases,and knee joint surface replacement in 2 cases),changes of vital sign and abnormal brain MR1 examination. Results: Twelve patients had mild consciousness and mental disorders,and the NIHSS score was 1.92±3.78,which was correlated with incomplete cerebral fat embolism after arthroplasty. The patients recovered conscious within 24 to 72 hours after treatment with expansion of blood volume, dehydrating agent and neuroprotective drugs, improving respiratory and circulatory function, hormone protection and antibiotic application. The patients were followed up with a mean period of 18 months (ranging from 10 to 36 months). The patients had neurological function recovering to normal without sequelae,and the NIHSS score decreased to 0. Conclusion: Incomplete cerebral fat embolism after arthroplasty is the main reason causing mild awareness and mental disorders, which is often to be misdiagnosed or ignored because of not typical clinical manifestations.