Przewlekły zespół kompartmentowy wywołany wysiłkiem
Rokowania, prognozy i postęp choroby
Przewlekły zespół ciasnoty przedziałów powięziowych (CECS) kończyn dolnych charakteryzuje się bólem wysiłkowym, obrzękiem mięśni i upośledzeniem funkcji mięśniowych, najczęściej w obrębie podudzia. Leczenie chirurgiczne (fasciotomia) jest wskazane u pacjentów z nieskutecznym leczeniem zachowawczym i wykazuje skuteczność w 60-96% przypadków, z lepszymi wynikami u pacjentów z izolowanym zajęciem przedziału przedniego i/lub bocznego. Kluczowymi czynnikami prognostycznymi poprawy po fasciotomii są: pole pod krzywą (AUC) śródwysiłkowego ciśnienia wewnątrzprzedziałowego ≥ 22 000 mm Hgs² (r = 0,76; P = 0,0002), historia bólu (r = 0,61; P = 0,005) oraz czas trwania objawów (r = 0,60; P = 0,006). Wyniki leczenia są gorsze u personelu wojskowego, gdzie powrót do pełnej sprawności osiąga mniej niż 45%, a nawet 22%. Opóźnienie w skierowaniu na operację powyżej 12 miesięcy jest istotnym predyktorem niekorzystnych rezultatów.
Przewidywanie wyników leczenia przewlekłego zespołu ciasnoty przedziałów powięziowych (CECS)
Przewlekły zespół ciasnoty przedziałów powięziowych (Chronic Exertional Compartment Syndrome, CECS) to schorzenie kończyn dolnych charakteryzujące się bólem wywołanym wysiłkiem, obrzękiem mięśni i upośledzeniem funkcji mięśniowych, zwykle w obrębie podudzia. Mimo że nie jest to stan zagrażający życiu i zazwyczaj nie powoduje trwałych uszkodzeń przy odpowiednim leczeniu, ból, osłabienie lub drętwienie związane z CECS może uniemożliwić pacjentowi kontynuowanie ćwiczeń lub uprawianie sportu na tym samym poziomie intensywności.1 Przewidywanie wyników leczenia ma kluczowe znaczenie dla właściwego kierowania pacjentów na leczenie zachowawcze lub operacyjne.
Rokowanie po leczeniu chirurgicznym
Leczenie chirurgiczne przewlekłego zespołu ciasnoty przedziałów powięziowych (fasciotomia) często jest rozważane u pacjentów, u których leczenie zachowawcze nie przyniosło rezultatów. CECS kończyn dolnych zwykle dobrze reaguje na fasciotomię, jednak wyniki pooperacyjne są zróżnicowane, z dobrymi do doskonałych rezultatami raportowanymi u 60% do 96% pacjentów.2 Ta zmienność wyników podkreśla potrzebę dokładnego prognozowania skuteczności zabiegu przed jego przeprowadzeniem.
Badania wykazały korelację między zwiększonym polem pod krzywą (AUC) śródwysiłkowego ciśnienia wewnątrzprzedziałowego (ICP) a zmniejszeniem wyników bólu w skali VAS, z silną korelacją, jeśli AUC wynosiło 22 000 mm Hgs² (r = 0,76; P = 0,0002). Historia bólu (r = 0,61; P = 0,005) oraz czas trwania objawów od ich pojawienia się do ustania bólu (r = 0,60; P = 0,006) były skorelowane z poprawą bólu po fasciotomii.3
Wyniki operacji zależą również od zajętych przedziałów mięśniowych. Pacjenci z izolowanym zajęciem przedziału przedniego i/lub bocznego (ponad 80%) zgłaszają zasadniczo lepsze wyniki w porównaniu z pacjentami z zajęciem głębokiego tylnego przedziału (60%). Campano i wsp. w przeglądzie systematycznym 24 artykułów wykazali 66% skuteczności i 84% zadowolenia (przy krótko- i średnioterminowej obserwacji) po zabiegu chirurgicznym.4
Beck i wsp. w retrospektywnym badaniu 155 pacjentów pediatrycznych wykazali 79,5% wskaźnik powrotu do aktywności sportowej, przy czym 18,8% wymagało dodatkowej rewizji chirurgicznej. Rokowanie zależy również od zajętego przedziału, gdyż przedział przedni (najczęstsza lokalizacja) daje lepsze wyniki. Dodatkowo, CECS obejmujący pojedynczy przedział ma wyższy wskaźnik powodzenia chirurgicznego niż CECS obejmujący wiele przedziałów.5
Wyniki w określonych populacjach pacjentów
Szczególnie problematyczne są wyniki leczenia chirurgicznego CECS wśród personelu wojskowego. Analizy sugerują, że mniej niż 45% brytyjskiego personelu wojskowego udaje się powrócić do pełnego stanu sprawności, a najnowsze dowody pokazują, że liczba ta może wynosić zaledwie 22%.6 Te niskie wskaźniki powodzenia u żołnierzy stanowią wyzwanie w określeniu, czy operacja jest warta rozważenia w tej populacji.
Badanie dotyczące leczenia zachowawczego wśród wojskowych wykazało, że spośród badanych pacjentów 25 miało pomyślny wynik po rehabilitacji, podczas gdy 20 miało wynik niepomyślny. Jednakże, to badanie nie zidentyfikowało żadnych znaczących czynników prognostycznych, które przewidywałyby wynik programu rehabilitacyjnego dla CECS, co wskazuje na potrzebę większych prób badawczych.7
Czynniki prognostyczne i modele predykcyjne
W celu lepszego przewidywania wyników leczenia opracowano systemy punktacji i modele prognostyczne. Analiza regresji liniowej systemu punktacji CoSy (R² = 0,61) sugerowała dobry element predykcyjny dla wysokiego wyniku i lepszego zmniejszenia bólu po fasciotomii. Dane korelacyjne sugerowały również, że punktacja graniczna dla pozytywnego wyniku wynosi prawdopodobnie 4.8
Zastosowanie uczenia maszynowego w medycynie ortopedycznej jest rosnącym obszarem, pokazującym obiecujące wyniki w przewidywaniu wyników leczenia. W jednym z badań optymalny model rozwinięty przy użyciu zaproponowanych ram był SVM (Support Vector Machine), osiągający wynik dokładności 0,80 ± 0,07 i AUC 0,85 ± 0,08.9
Zidentyfikowano również kluczowe cechy pacjenta, które powinny być brane pod uwagę przy kierowaniu pacjenta na fasciotomię z powodu CECS. Powolna szybkość skierowania na operację została zidentyfikowana jako kluczowa modyfikowalna cecha, która była użyteczna w rozróżnianiu między dobrymi i złymi wynikami chirurgicznymi.10 Istnieją również dowody na to, że opóźnienie 12 miesięcy od diagnozy jest predyktorem złych wyników po operacji.11
Czynniki prognostyczne dla leczenia zachowawczego
Badania nad czynnikami prognostycznymi dla wyników leczenia zachowawczego CECS nie dały jednoznacznych rezultatów. W jednozmiennej analizie regresji logistycznej czynniki wykazujące iloraz szans ≥1 dla niepomyślnego wyniku obejmowały palenie tytoniu, spożywanie alkoholu, ciśnienie wewnątrzmięśniowe, czas trwania dolegliwości ≥6 miesięcy oraz wymagania fizyczne służby wojskowej. Mimo że wyniki mają potencjalne znaczenie kliniczne, nie zaobserwowano istotności statystycznej.1213
Przewlekły zespół ciasnoty przedziałów powięziowych może reagować na leczenie zachowawcze i modyfikację aktywności. Jeśli leczenie niezabiegowe nie pomaga, lekarz może zalecić operację. Operacja jest skuteczna dla wielu osób i może umożliwić powrót do sportu.14
Kierunki przyszłych badań
Pomimo rosnącej liczby badań nad czynnikami prognostycznymi w CECS, nadal istnieje potrzeba większych badań prospektywnych w celu potwierdzenia skuteczności systemów przewidywania wyników. Badacze proponują dalsze testowanie systemów punktacji, aby pomóc klinicystom w ich zarządzaniu takimi pacjentami.15
Większa próba z identycznym projektem badania może dostarczyć dalszych dowodów dotyczących czynników prognostycznych, co ułatwiłoby opracowanie modelu, który przewiduje wyniki programu rehabilitacyjnego dla CECS.1617 Badania z większą kohortą pacjentów mogłyby prowadzić do identyfikacji czynników prognostycznych, które są istotnie związane z wynikami leczenia zachowawczego.18
Zastosowanie zaawansowanych technik, takich jak uczenie maszynowe, otwiera nowe możliwości w dokładniejszym przewidywaniu wyników leczenia CECS, co potencjalnie może poprawić podejmowanie decyzji klinicznych i rezultaty leczenia pacjentów.19
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Materiały źródłowe
- #1 Chronic exertional compartment syndrome – Symptoms & causes – Mayo Clinichttps://www.mayoclinic.org/diseases-conditions/chronic-exertional-compartment-syndrome/symptoms-causes/syc-20350830
Chronic exertional compartment syndrome may respond to nonsurgical treatment and activity modification. If nonsurgical treatment doesn’t help, your doctor might recommend surgery. Surgery is successful for many people and might allow you to return to your sport. […] Chronic exertional compartment syndrome isn’t a life-threatening condition and usually doesn’t cause lasting damage if you get appropriate treatment. However, pain, weakness or numbness associated with chronic exertional compartment syndrome may prevent you from continuing to exercise or practice your sport at the same level of intensity.
- #2https://pmc.ncbi.nlm.nih.gov/articles/PMC9201312/
Chronic exertional compartment syndrome (CECS) of the lower limb usually responds well to fasciotomy in patients with failed nonoperative treatment. […] We identified diagnostic criteria in the history and examination of patients with CECS that can be used to help predict positive outcomes after fasciotomy. […] We propose a scoring system to aid clinicians in their management of such patients. […] We recommend taking these results forward in prospective trials to test the efficacy of predictive scoring. […] There is, however, a variability in published outcomes after this procedure, with good to excellent outcomes reported in 60% to 96% of patients. […] The correlation data also suggested that the cutoff score for a positive outcome is likely 4. […] Linear regression analysis of the CoSy score (R 2 = 0.61) suggested a good predictive element for a high score and better pain reduction after fasciotomy.
- #3https://pmc.ncbi.nlm.nih.gov/articles/PMC9201312/
We found a significant correlation between an increased AUC of the intraexercise ICP and a reduction in VAS pain scores, with a strong correlation if the AUC was 22,000 mm Hgs2 (r = 0.76; P = .0002). […] A history of pain (r = 0.61; P = .005) and the duration of symptoms from onset to the cessation of pain (r = 0.60; P = .006) were both correlated with an improvement in pain after fasciotomy. […] We found no correlation with other reported ICP measurements such as pre-exercise pressure or 5-minute postexercise pressure. […] The data around sex and outcomes are relatively settled. […] There is also evidence to support a delay of 12 months from the diagnosis as a predictor of poor outcomes after surgery.
- #4 Exertional Compartment Syndrome | Treatment & Management | Point of Carehttps://www.statpearls.com/point-of-care/64490
Chronic exertional compartment syndrome (CECS) occurs in the setting of recurrent, reversible ischemic episodes following the cessation of activity resulting in the predictable decrease in fascial compartment pressures. […] Although benign, the refractory nature of CECS often results in a substantial portion of patients ultimately electing to proceed with fasciotomies. […] In general, patients with isolated anterior and/or lateral compartment (over 80%) involvement generally report superior outcomes compared to their deep posterior compartment counterparts (60%). […] Campano et al. in their systematic review of 24 articles showed a 66% success rate and an 84% satisfaction rate (short and mid-term follow-up) after surgical repair. […] Beck et al. in their retrospective study of 155 pediatric patients showed a 79.5% return to sports rate with 18.8% requiring additional surgical revision. […] Prognosis also depends on the involved compartment as the anterior compartment (the most common location) has better outcomes. Additionally, a single compartment CECS has a better surgical success rate than CECS involving multiple compartments.
- #5 Exertional Compartment Syndrome | Treatment & Management | Point of Carehttps://www.statpearls.com/point-of-care/64490
Chronic exertional compartment syndrome (CECS) occurs in the setting of recurrent, reversible ischemic episodes following the cessation of activity resulting in the predictable decrease in fascial compartment pressures. […] Although benign, the refractory nature of CECS often results in a substantial portion of patients ultimately electing to proceed with fasciotomies. […] In general, patients with isolated anterior and/or lateral compartment (over 80%) involvement generally report superior outcomes compared to their deep posterior compartment counterparts (60%). […] Campano et al. in their systematic review of 24 articles showed a 66% success rate and an 84% satisfaction rate (short and mid-term follow-up) after surgical repair. […] Beck et al. in their retrospective study of 155 pediatric patients showed a 79.5% return to sports rate with 18.8% requiring additional surgical revision. […] Prognosis also depends on the involved compartment as the anterior compartment (the most common location) has better outcomes. Additionally, a single compartment CECS has a better surgical success rate than CECS involving multiple compartments.
- #6 Predicting surgical outcomes for chronic exertional compartment syndrome using a machine learning framework with embedded trust by interrogation strategies | Scientific Reportshttps://www.nature.com/articles/s41598-021-03825-4
Chronic exertional compartment syndrome (CECS) is a condition occurring most frequently in the lower limbs and often requires corrective surgery to alleviate symptoms. Amongst military personnel, the success rates of this surgery can be as low as 20%, presenting a challenge in determining whether surgery is worthwhile. […] Audits suggest that less than 45% of UK military personnel manage to return to a fully-fit state, with most recent evidence showing this number to be as low as 22%. […] Despite the problem of poor outcomes in military populations, only one study, to date, has sought to identify reasons as to why patients fail to have good surgical outcomes. […] The application of machine learning within orthopaedic medicine is a growing area, showing promise in treatment outcome prediction.
- #7 Identifying prognostic factors for conservative treatment outcomes in servicemen with chronic exertional compartment syndrome treated at a rehabilitation centerhttps://pmc.ncbi.nlm.nih.gov/articles/PMC5704557/
Ultimately, there were 25 patients with a successful outcome after rehabilitation and 20 patients with an unsuccessful outcome. […] A univariate logistic regression analysis was performed to evaluate the magnitude of the association between prognostic factors and an unsuccessful outcome. Factors exhibiting an odds ratio1 for an unsuccessful outcome included smoking, alcohol use, intramuscular pressure, complaint duration 6 months, and the physical demands of service. Although the results have potential clinical relevance, significance was not observed. […] Our study confirms modest short-term results for conservative treatment of CECS, as demonstrated in previous studies. However, we were unable to identify significant prognostic factors predicting the outcome of a rehabilitation treatment program for CECS. Since this study is predominantly limited by the relatively small sample size, a larger cohort using the same design might lead to identification of prognostic factors that are significantly related to conservative treatment outcomes.
- #8https://pmc.ncbi.nlm.nih.gov/articles/PMC9201312/
Chronic exertional compartment syndrome (CECS) of the lower limb usually responds well to fasciotomy in patients with failed nonoperative treatment. […] We identified diagnostic criteria in the history and examination of patients with CECS that can be used to help predict positive outcomes after fasciotomy. […] We propose a scoring system to aid clinicians in their management of such patients. […] We recommend taking these results forward in prospective trials to test the efficacy of predictive scoring. […] There is, however, a variability in published outcomes after this procedure, with good to excellent outcomes reported in 60% to 96% of patients. […] The correlation data also suggested that the cutoff score for a positive outcome is likely 4. […] Linear regression analysis of the CoSy score (R 2 = 0.61) suggested a good predictive element for a high score and better pain reduction after fasciotomy.
- #9 Predicting surgical outcomes for chronic exertional compartment syndrome using a machine learning framework with embedded trust by interrogation strategies | Scientific Reportshttps://www.nature.com/articles/s41598-021-03825-4
The optimal model, developed using the proposed framework was the SVM, achieving an accuracy score of 0.80 0.07 and AUC of 0.85 0.08. […] The findings of the model interrogation demonstrate the misclassifications that occur are most often the result of class overlap, given that KDN and CLD were the two measures shown to be most associated with instance hardness. […] This study provided an interrogation of a real-world medical dataset, comprised of military CECS patients undergoing surgical intervention. The contributions of this study are both clinical and computational. Clinically, results highlight key patient characteristics that should be considered when referring a patient for a fasciotomy for CECS. […] The slow referral speed for surgery was identified as a key modifiable feature that was useful in discriminating between good and poor surgical outcomes, and should be a focus for care improvement.
- #10 Predicting surgical outcomes for chronic exertional compartment syndrome using a machine learning framework with embedded trust by interrogation strategies | Scientific Reportshttps://www.nature.com/articles/s41598-021-03825-4
The optimal model, developed using the proposed framework was the SVM, achieving an accuracy score of 0.80 0.07 and AUC of 0.85 0.08. […] The findings of the model interrogation demonstrate the misclassifications that occur are most often the result of class overlap, given that KDN and CLD were the two measures shown to be most associated with instance hardness. […] This study provided an interrogation of a real-world medical dataset, comprised of military CECS patients undergoing surgical intervention. The contributions of this study are both clinical and computational. Clinically, results highlight key patient characteristics that should be considered when referring a patient for a fasciotomy for CECS. […] The slow referral speed for surgery was identified as a key modifiable feature that was useful in discriminating between good and poor surgical outcomes, and should be a focus for care improvement.
- #11https://pmc.ncbi.nlm.nih.gov/articles/PMC9201312/
We found a significant correlation between an increased AUC of the intraexercise ICP and a reduction in VAS pain scores, with a strong correlation if the AUC was 22,000 mm Hgs2 (r = 0.76; P = .0002). […] A history of pain (r = 0.61; P = .005) and the duration of symptoms from onset to the cessation of pain (r = 0.60; P = .006) were both correlated with an improvement in pain after fasciotomy. […] We found no correlation with other reported ICP measurements such as pre-exercise pressure or 5-minute postexercise pressure. […] The data around sex and outcomes are relatively settled. […] There is also evidence to support a delay of 12 months from the diagnosis as a predictor of poor outcomes after surgery.
- #12 Identifying prognostic factors for conservative treatment outcomes in servicemen with chronic exertional compartment syndrome treated at a rehabilitation centerhttps://pmc.ncbi.nlm.nih.gov/articles/PMC5704557/
Ultimately, there were 25 patients with a successful outcome after rehabilitation and 20 patients with an unsuccessful outcome. […] A univariate logistic regression analysis was performed to evaluate the magnitude of the association between prognostic factors and an unsuccessful outcome. Factors exhibiting an odds ratio1 for an unsuccessful outcome included smoking, alcohol use, intramuscular pressure, complaint duration 6 months, and the physical demands of service. Although the results have potential clinical relevance, significance was not observed. […] Our study confirms modest short-term results for conservative treatment of CECS, as demonstrated in previous studies. However, we were unable to identify significant prognostic factors predicting the outcome of a rehabilitation treatment program for CECS. Since this study is predominantly limited by the relatively small sample size, a larger cohort using the same design might lead to identification of prognostic factors that are significantly related to conservative treatment outcomes.
- #13 Identifying prognostic factors for conservative treatment outcomes in servicemen with chronic exertional compartment syndrome treated at a rehabilitation center | Military Medical Research | Full Texthttps://mmrjournal.biomedcentral.com/articles/10.1186/s40779-017-0145-2
A univariate logistic regression analysis was performed to evaluate the magnitude of the association between prognostic factors and an unsuccessful outcome. […] Factors exhibiting an odds ratio1 for an unsuccessful outcome included smoking, alcohol use, intramuscular pressure, complaint duration 6 months, and the physical demands of service. […] Since this study is predominantly limited by the relatively small sample size, a larger cohort using the same design might lead to identification of prognostic factors that are significantly related to conservative treatment outcomes.
- #14 Chronic exertional compartment syndrome – Symptoms & causes – Mayo Clinichttps://www.mayoclinic.org/diseases-conditions/chronic-exertional-compartment-syndrome/symptoms-causes/syc-20350830
Chronic exertional compartment syndrome may respond to nonsurgical treatment and activity modification. If nonsurgical treatment doesn’t help, your doctor might recommend surgery. Surgery is successful for many people and might allow you to return to your sport. […] Chronic exertional compartment syndrome isn’t a life-threatening condition and usually doesn’t cause lasting damage if you get appropriate treatment. However, pain, weakness or numbness associated with chronic exertional compartment syndrome may prevent you from continuing to exercise or practice your sport at the same level of intensity.
- #15https://pmc.ncbi.nlm.nih.gov/articles/PMC9201312/
Chronic exertional compartment syndrome (CECS) of the lower limb usually responds well to fasciotomy in patients with failed nonoperative treatment. […] We identified diagnostic criteria in the history and examination of patients with CECS that can be used to help predict positive outcomes after fasciotomy. […] We propose a scoring system to aid clinicians in their management of such patients. […] We recommend taking these results forward in prospective trials to test the efficacy of predictive scoring. […] There is, however, a variability in published outcomes after this procedure, with good to excellent outcomes reported in 60% to 96% of patients. […] The correlation data also suggested that the cutoff score for a positive outcome is likely 4. […] Linear regression analysis of the CoSy score (R 2 = 0.61) suggested a good predictive element for a high score and better pain reduction after fasciotomy.
- #16 Identifying prognostic factors for conservative treatment outcomes in servicemen with chronic exertional compartment syndrome treated at a rehabilitation centerhttps://pmc.ncbi.nlm.nih.gov/articles/PMC5704557/
Chronic exertional compartment syndrome (CECS) is a condition of pain induced by exercise, and it is characterized by muscle swelling and impaired muscle function in the lower leg. Given the diversity in the diagnosis and treatment of CECS, it is desirable to determine variables pertaining to prognosis and recovery. The purpose of this study is to identify prognostic factors for conservative treatment outcomes in servicemen with CECS who were treated at a Military Rehabilitation Center. […] This study did not identify any prognostic factors that predict the outcome of a rehabilitation program for CECS. A larger sample using an identical design might provide further evidence regarding prognostic factors, which would facilitate development of a model that predicts the outcomes of a rehabilitation program for CECS.
- #17 Identifying prognostic factors for conservative treatment outcomes in servicemen with chronic exertional compartment syndrome treated at a rehabilitation center | Military Medical Research | Full Texthttps://mmrjournal.biomedcentral.com/articles/10.1186/s40779-017-0145-2
Chronic exertional compartment syndrome (CECS) is a condition of pain induced by exercise, and it is characterized by muscle swelling and impaired muscle function in the lower leg. […] This study did not identify any prognostic factors that predict the outcome of a rehabilitation program for CECS. […] A larger sample using an identical design might provide further evidence regarding prognostic factors, which would facilitate development of a model that predicts the outcomes of a rehabilitation program for CECS. […] This study aimed to identify prognostic factors for an unsuccessful treatment outcome in servicemen with CECS who were treated with a rehabilitation program at a military rehabilitation center. […] However, we were unable to identify significant prognostic factors predicting the outcome of a rehabilitation treatment program for CECS.
- #18 Identifying prognostic factors for conservative treatment outcomes in servicemen with chronic exertional compartment syndrome treated at a rehabilitation center | Military Medical Research | Full Texthttps://mmrjournal.biomedcentral.com/articles/10.1186/s40779-017-0145-2
A univariate logistic regression analysis was performed to evaluate the magnitude of the association between prognostic factors and an unsuccessful outcome. […] Factors exhibiting an odds ratio1 for an unsuccessful outcome included smoking, alcohol use, intramuscular pressure, complaint duration 6 months, and the physical demands of service. […] Since this study is predominantly limited by the relatively small sample size, a larger cohort using the same design might lead to identification of prognostic factors that are significantly related to conservative treatment outcomes.
- #19 Predicting surgical outcomes for chronic exertional compartment syndrome using a machine learning framework with embedded trust by interrogation strategies | Scientific Reportshttps://www.nature.com/articles/s41598-021-03825-4
Chronic exertional compartment syndrome (CECS) is a condition occurring most frequently in the lower limbs and often requires corrective surgery to alleviate symptoms. Amongst military personnel, the success rates of this surgery can be as low as 20%, presenting a challenge in determining whether surgery is worthwhile. […] Audits suggest that less than 45% of UK military personnel manage to return to a fully-fit state, with most recent evidence showing this number to be as low as 22%. […] Despite the problem of poor outcomes in military populations, only one study, to date, has sought to identify reasons as to why patients fail to have good surgical outcomes. […] The application of machine learning within orthopaedic medicine is a growing area, showing promise in treatment outcome prediction.