老年患者术后认知功能障碍和术后谵妄的发生率较高，危害较大，增加社会和患者及家属的负担，针对其发病诱因、易感人群、发病机制及防治策略等国内外科研人员和医务工作者展开了大量的研究，希望能攻克这一医学难题，这篇最新发表在JMIR Res Protoc.杂志上的临床文章也针对术后谵妄和认知功能障碍的危险因素及可能机制进行了有益的探索，介绍了其研究方案，我们先睹为快吧！也期待最终的研究结果。

择期老年患者脊柱手术后谵妄和认知功能障碍的机制评估(CONFESS)：前瞻性观察试验

【背景】老年人脊柱手术后发生术后(POD)的风险特别高，这与住院时间较长、费用较高、延迟并发症的风险、长期护理依赖性和认知功能障碍(POCD)有关。在这些重大、择期手术后，哪些机制和危险因素导致POD和POCD的发生还不够清楚。

【目的】本研究旨在确定脊柱手术中可调节的危险因素。更好地了解这一点将有助于调整医疗管理和手术策略，以控制患者风险。

【方法】这是一项由德国一家三级医院神经外科、神经科和麻醉科联合进行的单中心观察性研究。所有到神经外科门诊或病房进行择期脊柱手术的60岁及以上的患者都要进行资格筛查。排除标准包括是否有神经退行性变或精神病史，以及有服用中枢神经系统活动的药物(如抗抑郁药、抗精神病药、镇静剂)。手术和麻醉过程，包括作为本研究主要终点的手术持续时间，都有详细的记录。所有患者的术前认知能力进一步通过一系列测试进行评估，其中包括建立阿尔茨海默氏症等级制度协会制定的测试量表（Consortium to Establish a Registry for Alzheimer's Disease Plus testbattery）。使用患者报告结局信息系统（Patient-Reported Outcome Measurement Information System Profile 29）和医院焦虑和抑郁量表（Hospital Anxiety andDepression Scale）评估身体、心理和社会健康和幸福感。患者还会在手术前接受脑血管超声、结构和功能脑成像。术后即刻使用护理谵妄筛查量表（Nursing Delirium Screening Scale）筛查POD，并通过《精神疾病诊断和统计手册》第5版的标准（Diagnosticand Statistical Manual of Mental Disorders, 5th Edition, criteria）进行验证。我们进一步研究了炎症的标记物(如白细胞介素、C反应蛋白、肿瘤坏死因子α)。术后3个月重复术前检查，以探讨POCD的存在及其机制。对比谵妄和非谵妄患者，统计分析即刻POD和迟发性POCD的预测因子。

【结果】这是第一项前瞻性评估脊柱外科POD和POCD危险因素的研究。招募工作正在进行中，预计到2020年年中将完成数据收集，纳入200名患者。

【结论】识别POD和POCD的可能共同的潜在机制，将是在术后早期或者甚至之前确定有效干预策略的重要一步，包括使手术策略适应个体风险特征。

原文摘要

Evaluating Mechanisms of Postoperative Delirium andCognitive Dysfunction Following Elective Spine Surgery in Elderly Patients(CONFESS): Protocol for a Prospective Observational Trial.

MüllerJ(1), Fleischmann R(2), Nowak S(1), Vogelgesang A(2), von Sarnowski B(2),Rathmann E(3), Schmidt S(4), Rehberg S(5), Usichenko T(6), Kertscho H(6),Hahnenkamp K(6), Flöel A(2)(7), Schroeder HW(1), Müller JU(1).

BACKGROUND: Elderly people are at particular high risk forpostoperative delirium (POD) following spine surgery, which is associated withlonger hospital stays, higher costs, risk for delayed complications, long-termcare dependency, and cognitive dysfunction (POCD). It is insufficientlyunderstood which mechanisms and risk factors contribute to the development ofPOD and POCD following these major but plannable surgeries.

OBJECTIVE: This study aims to identify modifiable risk factorsin spine surgery. A better understanding thereof would help adapt medicalmanagement and surgical strategies to individual risk profiles.

METHODS: This is a single-centerobservational study jointly conducted by the departments of neurosurgery,neurology, and anesthesiology at a tertiary care hospital in Germany. Allpatients aged 60 years and older presenting to the neurosurgery outpatientclinic or ward for elective spine surgery are screened for eligibility.Exclusion criteria include presence of neurodegenerative or history ofpsychiatric disease and medication with significant central nervous systemactivity (eg, antidepressants, antipsychotics, sedatives). Surgical andanesthetic procedures including duration of surgery as primary end point ofthis study are thoroughly documented. All patients are furthermore evaluatedfor their preoperative cognitive abilities by a number of tests, including theConsortium to Establish a Registry for Alzheimer's Disease Plus test battery.Physical, mental, and social health and well-being are assessed using thePatient-Reported Outcome Measurement Information System Profile 29 and HospitalAnxiety and Depression Scale. Patients additionally receive preoperativecerebrovascular ultrasound and structural and functional brain imaging. Theimmediate postoperative period includes screening for POD using the NursingDelirium Screening Scale and validation through Diagnostic and StatisticalManual of Mental Disorders, 5th Edition, criteria. We furthermore investigatemarkers of (neuro)inflammation (eg, interleukins, C-reactive protein, tumornecrosis factor alpha). Preoperative examinations are repeated 3 monthspostoperatively to investigate the presence of POCD and its mechanisms.Statistical analyses will compare delirious and nondelirious patients forpredictors of immediate (POD) and delayed (POCD) cognitive dysfunction.

RESULTS: This is the first study toprospectively evaluate risk factors for POD and POCD in spine surgery.Recruitment is ongoing, and data collection is estimated to be finished withthe inclusion of 200 patients by mid-2020.

CONCLUSIONS: The identification ofmechanisms, possibly common, underlying POD and POCD would be a major steptoward defining effective interventional strategies early in or even before thepostoperative period, including the adaptation of surgical strategies toindividual risk profiles.

TRIAL REGISTRATION: ClinicalTrials.govNCT03486288;

https://clinicaltrials.gov/ct2/show/NCT03486288.

INTERNATIONAL REGISTERED REPORT IDENTIFIER(IRRID): DERR1-10.2196/15488.

DOI: 10.2196/15488

PMID: 32053113