局部麻醉与超声引导下竖脊肌平面阻滞对经皮椎间孔镜下髓核摘除术的镇痛比较.pdf

收稿日期:2021-03-12;修订日期:2021-06-07作者简介:阳婷婷(1987-),女,江西籍,住院医师,硕士研究方向:临床麻醉及超声引导下神经阻滞通信作者:王韶双电子邮箱:临床研究局部麻醉与超声引导下竖脊肌平面阻滞对经皮椎间孔镜下髓核摘除术的镇痛比较阳婷婷,宋珂珂,汪博,王韶双(西安交通大学第一附属医院麻醉手术部,陕西西安 710061)摘要:目的观察超声引导下竖脊肌平面阻滞(erector spinae plane block,ESPB)对经皮椎间孔镜下髓核摘除术(percutaneous endoscopic lumbar discectomy,PELD)术中镇痛的效果。方法 选择腰椎间盘突出症患者58 例,按照随机数字表法分为 ESPB 组(试验组)和对照组。ESPB 组(n=30)采用超声引导下竖脊肌平面阻滞麻醉,对照组(n=28)单纯应用关节突关节局部浸润麻醉。比较两组患者椎间孔成形期及纤维环操作期的疼痛数字评分(numerical rating scale,NRS);记录术中追加舒芬太尼患者人数、手术时间、住院时间等;比较术前及术后第 6 周 Oswestry 功能障碍指数(Oswestry disability index,ODI);比较两组患者的不良反应。结果 ESPB 组在椎间孔成形期的平均 NRS 评分及峰值 NRS 评分、纤维环操作期平均 NRS 评分均显著低于对照组(P0.05)。对照组术中追加舒芬太尼人数显著多于 ESPB 组(P0.05)。两组患者术前及术后第 6 周 ODI 无显著差异(P0.05)。两组均未出现呼吸抑制、一过性下肢感觉运动障碍情况。术中高血压、心动过速、术后恶心呕吐发生率,对照组显著高于 ESPB 组(P0.05)。结论 采用 PELD 治疗腰椎间盘突出症时,应用超声引导下竖脊肌平面阻滞麻醉可有效提高术中的镇痛效果,并降低不良反应的发生率。关键词:竖脊肌平面阻滞;经皮椎间孔镜下髓核摘除术;镇痛;腰椎间盘突出症中图分类号:R614.3 文献标识码:A 文章编号:1005-7234(2023)04-0578-04DOI:10.3969/j.issn.1005-7234.2023.04.020Comparison of analgesic efficacy of local anesthesia and ultrasound-guided erector spinae plane block in patients undergoingpercutaneous endoscopic lumbar discectomyYANG Ting-ting,SONG Ke-ke,WANG Bo,WANG Shao-shuang(Department of Anesthesia and Surgery,the First Affiliated Hospital of Xian Jiaotong University,Xian 710061,China)Abstract:ObjectiveTo observe the analgesic efficacy of ultrasound-guided erector spinae plane block(ESPB)in patientsundergoing percutaneous endoscopic lumbar discectomy(PELD).Methods Fifty eight patients,41 males and 17 females,aged 18-70 years,falling into ASA physical status -,scheduled for elective percutaneous endoscopic lumbar discectomy from september2018 to September 2020 were enrolled and randomly divided into the ESPB group(experimental group)and the control group.For theESPB group(n=30),patients receivedultrasound-guided ESPB(n=28).For the control group,patients only received localanesthesia.The numerical rating scale(NRS)for pain evaluation was recorded at the time of lumbar foraminoplasty and annulus fibrosusoperation.The number of additional sufentanil patients,operation time,hospital stay time,Oswestry disability index(ODI)at pre-operation and 6 weeks after surgery and the adverse reactions of the two groups were compared.Results During lumbar foraminoplastyphase the peak NRS and average NRS of the ESPB group were significantly lower than those of the control group(P0.05).Duringannulus fibrosus operation phase the average NRS of the ESPB group was significantly lower than that of the control group(P0.05).The number of additional sufentanil in the control group was significantly higher than that in the ESPB group(P0.05).There was no respiratory depression or transient lower limb sensorimotor disorder in the two groups(P0.05).However,the incidences of intraoperative hypertension,tachycardia,postoperative nausea and vomiting in the control groupwere significantly higher than those in the ESPB group(P4 分时,应患者要求可给予舒芬太尼5 ug/次;发生低血压(BP 降低幅度大于基础值的 20%或低于 90/60 mmHg)时,静脉注射麻黄碱6 mg/次;发生高血压(BP 升高幅度大于基础值的 20%或高于 140/90 mmHg)时,静脉注射乌拉地尔 10 mg/次;发生心动过缓(HR100 次/min)时,静脉注射艾司洛尔 10 mg/次。1.3 观察评估指标主要指标:在椎间孔成形开始及结束时、纤维环切开及成形时,采用 NRS 评分评价疼痛程度,记录平均疼痛 NRS 评分及峰值 NRS 评分。次要指标:记录术中需追加舒芬太尼患者人数、手术时间、住院时间,术前及术后第 6 周采用 Oswestry 功能障碍指数(Oswestry disability index,ODI)对临床疗效进行评估。不良反应:记录术中高血压、低血压、心动过缓、心动过速、呼吸抑制、一过性下肢感觉运动障碍、术中及术后 24 h 内恶心呕吐等不良反应发生率。1.4 统计学方法采用 SPSS 25.0 软件进行统计分析,计量资料以“xs”表示,组间比较采用两独立样本 t 检验。计数资料组间比较采用 x2检验。P0.05),见表 1。ESPB 组在椎间孔成形期的平均 NRS 评分及峰值 NRS 评分、纤维环操作期平均 NRS 评分都显著低于对照组(P0.05);见表 3。两组患者术中均未出现低血压、呼吸抑制、一过性下肢感觉运动障碍情况;术中高血压、心动过速、术后恶心呕吐发生率,对照组显著高于 ESPB 组(P0.05);对照组 1 名患者术后眩晕,观察 2 h 后自行好转,见表 4。975颈腰痛杂志 2023 年第 44 卷第 4 期 The Journal of Cervicodynia and Lumbodynia 2023,Vol.44 No.4表 1 两组患者一般情况的比较组别例数ASA 分级(/)男/女(n)年龄(岁)BMI(kg/m2)手术节段(L4-5/L5-S1)ESPB 组304/2621/951.111.823.22.212/18对照组284/2420/853.913.524.22.513/15表 2 两组患者主要指标比较(分,xs)组别例数椎间孔成形期平均 NRS 评分椎间孔成形期峰值 NRS 评分纤维环操作期平均 NRS 评分纤维环操作期峰值 NRS 评分ESPB 组301.10.6a1.70.9a1.30.5a2.70.8对照组282.10.94.61.61.91.03.11.1 注:与对照组比较,aP0.05表 3 两组患者次要指标比较(xs)组别例数术中追加舒芬太尼人数n(%)手术时间(min)住院时间(d)术前 ODI(%)术后第 6 周ODI(%)ESPB 组30073.29.02.70.752.27.413.54.5对照组2815(53.6%)75.08.42.60.653.38.414.55.5表 4 两组患者不良反应比较n(%)组别例数(n)高血压心动过缓心动过速恶心呕吐眩晕ESPB 组303(10%)a01(3.3%)a0a0对照组2811(39.3%)2(7.1%)12(42.6%)4(14.3%)1(3.6%)注:与对照组比较,aP0.05),或与局部麻醉组追加的舒芬太尼已发挥镇痛作用有关。ESPB 阻滞中局部麻醉药可沿着竖脊肌深面向头侧和尾侧广泛扩散并覆盖多个皮节感觉区域10。由于阻滞点邻近椎间孔,局部麻醉药可透过横突周围的结蹄组织渗到椎旁间隙,同时阻滞脊神经的腹侧支和背侧支。因此,ESPB 可有效缓解躯体疼痛11。此外,ESPB 具有超声下横突及肌肉间隙图像易识别、阻滞平面广、镇痛效果确切和并发症少等优点12。既往研究证实,超声引导下ESPB 可有效降低后路腰椎融合术患者的术后静息疼痛评分及自控静脉镇痛的舒芬太尼用量,优化术后镇痛效果13。与对照组相比,超声引导下 ESPB不延长手术时间及住院时间。本研究观察了患者术后第 6 周 ODI 指数,两组间无显著差异,证实了两组患者术后的临床效果具有可比性。本研究也存在一定的不足:缺乏较长的随访时间;所有患者均来自单一中心,样本量较小,望将来能够开展多中心的随机对照临床试验,延长随访时间,以获得更为客观的结论。参考文献:1 Jarebi M,Awaf A,Lefranc M,et al.A matched comparison of085颈腰痛杂志 2023 年第 44 卷第 4 期 The Journal of Cervicodynia and Lumbodynia 2023,Vol.44 No.4outcomes between percutaneous endoscopic lumbar discectomy andopen lumbar microdiscectomy for the treatment of lumbar disc herni-ation:a 2-year retrospective cohort studyJ.Spine.2021,21(1):114-121.2 Choi KC,Park CK.Percutaneous endoscopic lumbar discectomyfor L5-S1 disc herniation:Consideration of the relation between theiliac crest and L5-S1 discJ.Pain Physician,2016,19(2):E301-E308.3 Kim HS,Paudel B,Jang JS,et al.Percutaneous endoscopic lum-bar discectomy for all types of lumbar disc herniations(LDH)in-cluding severely difficult and extremely difficult LDH casesJ.Pain Physician,2018,21(4):E401-E408.4 Wu K,Zhao Y,Feng Z,et al.Stepwise local anesthesia for percu-taneous endoscopic interlaminar discectomy:Technique strategyand clinical outcomes J.World Neurosurg,2020,134:E346-E352.5 Forero M,Adhikary SD,Lopez H,et al.The erector spinae planeblock:A novel analgesic technique in thoracic neuropathic painJ.Reg Anesth Pain Med,2016,41:621-627.6 祝斌,刘晓光.经皮腰椎内窥镜下手术麻醉方案选择的前瞻性随机对照研究J.中国脊柱脊髓杂志,2015,25(12):1069-1072.7 Ye XF,Wang S,Wu AM,et al.Comparison of the effects of gen-eral and local anesthesia in lumbar interlaminar endoscopic surgeryJ.Ann Palliat Med,2020,9(3):1103-1108.8 Zhu Y,Zhao Y,Fan G,et al.Comparison of the effects of localanesthesia and epidural anesthesia for percutaneous transforaminalendoscopic discectomy in elderly patients over 65 years oldJ.IntJ Surg,2017,48:260-263.9 Pascarella G,Costa F,Strumia A,et al.The multiple pathways oflocal anaesthetic during lumbar erector spinae plane block:an ul-trasound findingJ.Anaesthesia.2021,76(1):142-143.10 Ivanusic J,Konishi Y,Barrington MJ.A cadaveric study investi-gating the mechanism of action of erector spinae blockadeJ.Reg Anesth Pain Med,2018,43(6):567-571.11 Adhikary SD,Bernard S,Lopez H,et al.Erector spinae planeblock versus retrolaminar block:A magnetic resonance imagingand anatomical studyJ.Reg Anesth Pain Med,2018,43(7):756-762.12 Tsui BCH,Fonseca A,Munshey F,et al.The erector spinaeplane(ESP)block:A pooled review of 242 casesJ.ClinAnesth,2019,53:29-34.13 吴茜,薛飞,王珏,等.超声引导下双侧竖脊肌平面阻滞对后路腰椎融合术后镇痛效果的影响J.临床麻醉学杂志,2019,35(9):842-845.(上接第 577 页)8 Ba Z,Pan F,Liu Z,et al.Percutaneous endoscopical transforami-nal approach versus PLF to treat the single-level adjacent segmentdisease after PLF/PLIF:1-2 years follow-upJ.InternationalJournal of Surgery,2017,42:22.9 Wang Y T,Wu X T,Chen H,et al.Endoscopy-assisted posteriorlumbar interbody fusion in a single segmentJ.Journal of ClinicalNeuroence,2014,21(2):287-292.10 李磊本,梁秋冬.椎间孔镜下腰椎融合术治疗退变性腰椎管狭窄的疗效分析J.当代医药论丛,2020(13).11 王向前,李军,郭广铭,等.内镜下减压融合经皮椎弓根钉内固定治疗退变性腰椎、度滑脱J.中国医学工程,2019,27(12):58-60.12 王楹.全内镜下后路腰椎椎体间融合术的学习曲线评估及对比分析全内镜下与小切口后路腰椎椎体间融合术治疗腰椎退行性疾病疗效D.广州医科大学,2018.13 王轩获,郭舟桐,马宁,等.经皮椎间孔镜与减压融合手术治疗腰椎管狭窄症的效果比较J.宁夏医学杂志,2019,41(9):826-828.14 邓亦奇,孙付杰,汪明星,等.脊柱内镜与椎间融合治疗腰椎间盘突出症伴终板骨软骨炎的疗效对比J.实用骨科杂志,2018,24(8):677-681.15 马俊豪,王利民,赵亮,等.经皮椎间孔镜与后路椎间盘切除椎间融合钉棒内固定术治疗腰椎间盘突出症的疗效比较J.中国实用医刊,2017,44(14):49-51.16 Ruan W,Feng F,Liu Z,et al.Comparison of percutaneous endo-scopic lumbar discectomy versus open lumbar microdiscectomy forlumbar disc herniation:A meta-analysisJ.Int J Surg,2016,31:86-92.17 Hara M,Takahashi H,Yokoyama Y,et al.Comparison of the in-vasiveness of conventional discectomy and microendoscopic discec-tomy for lumbar disc herniation:differences in the methods of ap-proachJ.Asian J Endosc Surg,2015,8:40-47.18 GibsonJNA,SubramanianA,ScottCEH.Arandomizedcontrolled trial of transforaminal endoscopic discectomy vs micro-discectomyJ.Eur Spine J,2017,26:847-856.19 Jin Tao Q,Y u T,Mei W,et al.Comparison of MIS vs.openPLIF/TLIF with regard to clinical improvement,fusion rate,andinci-dence of major complication:a meta-analysis J.EurSpine J,2015,24:1058-1065.20 Lee K,Yue W,Yeo W,et al.Clinical and radiological outcomesof open versus minimally invasive transforaminal lumbar interbodyfusionJ.Eur Spine J,2012,21:2265-2270.21 Morgenstern C,Yue JJ,Morgenstern R.Full percutaneous trans-foraminal lumbar interbody fusion using the facet-sparing,trans-kambin approachJ.Clinical spine surgery,2020,33(1):40-45.185颈腰痛杂志 2023 年第 44 卷第 4 期 The Journal of Cervicodynia and Lumbodynia 2023,Vol.44 No.4