麻醉高风险高龄退变性腰椎管狭窄症患者经皮脊柱内镜下椎管减压术治疗效果研究

doi:10.12114/j.issn.1007-9572.2019.00.817

摘要/Abstract

摘要： 背景　随着人类平均寿命的延长，高龄退变性腰椎管狭窄症发病率不断增高，退变性腰椎管狭窄症多需手术减压治疗。因为高龄患者多合并多种内科疾病，术前麻醉评估风险较高，全身麻醉（简称全麻）下的椎管减压术风险很高。许多患者因为无法耐受全麻的开放手术，使日常生活功能受到明显的影响。随着脊柱内镜下椎管减压术的不断发展和成熟，局部麻醉（简称局麻）下的微创椎管减压术有望对此类患者提供安全有效的治疗方法。目的　探讨术前评估麻醉高风险的高龄退变性腰椎管狭窄症患者应用局麻下经皮脊柱内镜治疗的临床疗效。方法　选取2016年12月—2017年4月河北省人民医院骨科收治的高龄退变性腰椎管狭窄症接受经皮脊柱内镜下椎管减压术治疗的患者18例，均为术前麻醉风险评估为美国麻醉医师协会（ASA）分级标准P3及以上，手术方式采用经椎间孔入路16例，经椎板间入路2例。分别于术前、术后6周、6个月、1年进行腰和下肢疼痛视觉模拟评分（VAS）和Oswestry功能障碍指数（ODI）以评定临床疗效。结果　手术时间30~81 min，平均（49.5±17.0）min；1例患者术中出现颈项痛，中止手术后症状消失，无术后感染及椎管内血肿、腰椎不稳定等并发症，围术期合并疾病病情稳定。术后6个月、1年腰VAS低于术后6周（P<0.05）；术后6周、6个月、1年下肢VAS、ODI低于术前（P<0.001），术后1年ODI低于术后6周（P<0.001）。结论　对于麻醉高风险高龄退变性腰椎管狭窄症患者应用局麻下经皮脊柱内镜技术疗效确切，可降低疼痛程度，缓解功能障碍。

关键词: 椎管狭窄, 椎间盘退行性变, 老年人, 外科手术, 微创性, 麻醉

Abstract: Background　With the increase of life expectancy，the incidence of degenerative lumbar spinal stenosis（DLSS） in the elderly is increasing.DLSS generally requires surgical decompression.However，elderly patients are often complicated with many medical diseases，and the preoperative anesthesia assessment of spinal decompression for them is usually high risk.Many patients are unable to undergo open surgery under general anesthesia，and their daily life is obviously limited because of the disease.With the development and maturity of endoscopic decompression of spine，percutaneous endoscopic spinal decompression under local anesthesia may be a safe and effective treatment.Objective　To investigate the clinical efficacy of percutaneous spinal endoscopy under local anesthesia for elderly DLSS patients with preoperatively assessed high risk for general anesthesia.Methods　From December 2016 to April 2017，18 elderly patients with DLSS and treated with percutaneous endoscopic spinal decompression from Department of Orthopaedics，Hebei General Hospital were included.All were preoperatively assessed as having a high risk of general anesthesia（ASA P3-P4）.16 cases were operated via a transforaminal approach，and other 2 cases were operated using a translaminar approach.Outcomes were evaluated by follow-up interviews at 6 weeks，6 months，1 year after the surgery.Low back pain and leg pain were measured by Visual Analog Scale（VAS） score.Functional outcomes were assessed by Oswestry Disability Index（ODI）.Results　The operation time was 30-81 minutes〔averaged（49.5±17.0） minutes〕.One patient had neck pain during the operation，but the symptom disappeared after discontinuation of the operation.There were no complications such as postoperative infection，intraspinal hematoma，lumbar instability，and so on.The coexisting medical diseases were stable during the perioperative period.VAS score of low back pain at 6 months and 1 year after operation was significantly lower than that of 6 weeks after operation（P<0.05）.The VAS score of leg pain and ODI at 6 weeks，6 months and 1 year after operation were lower than those before operation（P<0.001）.The ODI at 1 year after operation were lower than that of 6 weeks after operation（P<0.001）.Conclusion　 By relieving the physical pain and improving the functions for daily life，percutaneous spinal endoscopic decompression under local anesthesia has been proved to be effective for elderly DLSS patients at high risk for general anesthesia.

Key words: Spinal stenosis；Intervertebral disc degeneration；Aged；Surgical procedures, minimally invasive；Anesthesia

高尚聚,李文毅,张隆,等. 麻醉高风险高龄退变性腰椎管狭窄症患者经皮脊柱内镜下椎管减压术治疗效果研究[J]. 中国全科医学, 2020, 23(27): 3433-3439. DOI: 10.12114/j.issn.1007-9572.2019.00.817.
GAO Shangju,LI Wenyi,ZHANG Long, et al. Percutaneous Endoscopic Spinal Surgery for Degenerative Lumbar Spinal Stenosis in Elderly Patients at High Risk for General Anesthesia　[J]. Chinese General Practice, 2020, 23(27): 3433-3439. DOI: 10.12114/j.issn.1007-9572.2019.00.817.

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