抑郁与腰椎间盘突出症患者术后疗效的关系

Association between depression and the postoperative effect in patients with lumbar disc protrusion

目的:探讨抑郁与腰椎间盘突出症手术预后是否相关。方法:选择2000-06/2003-12在中国医科大学附属第二医院住院行腰椎间盘突出症手术治疗的患者107例。①分别记录患者的病程、术前症状和体征总评分、术前疼痛程度评分根据视觉模拟评分记录。选用抑郁自评量表进行术前心理评估,53分为标准分。按抑郁自评量表评分将患者分为两组:<标准分为正常组,82例;≥标准分为抑郁组,25例。两组患者在性别、年龄、工作性质、文化程度及吸烟史方面无显著性差异(P>0.05)。②根据北美脊柱协会制定的60项指标结合临床实际制定出疗效评价量表共50分,内容包括4方面:症状(6分):腰或臀疼痛3分,腿痛或麻木3分;症状对功能的影响(19分):行走0～4分,站、坐、睡、抬物、剧烈活动、性生活各0～2分,排尿0～3分;体征(16分):腰部活动受限和畸形0～2分,腰部扣痛0～1分,健腿抬高试验0～2分,直腿抬高试验0～4分,肌力0～3分,感觉0～2分,反射0～2分;CT或MR同区域定位(9分):1～3区分别为3～9分。术后随访评分不包括CT或MR检查评分。③107例患者根据术后症状评分计算出症状改善率,即(术前症状评分-术后症状评分)/术前症状评分×100%。其中47例患者通过门诊复查得到术后体征评分,计算症状体症改善率,即犤(术前症状评分+术前体征评分)-(术后症状评分+术后体征评分)犦(术前症状评分+术前体征评分)×100%。同时还调查术后疼痛频率(从不痛到经常疼痛为0～2分)和术后工作能力(从恢复原来工作到未工作为0～4分)。④组间基线资料比较采用卡方检验,术前疼痛程度评分、症状改善率等行独立样本t检验。结果:按意向处理分析,107例患者均成功得到随访,随访时间2.08～3.46年,平均2.48年。①术前疼痛程度评分:抑郁组明显高于正常组犤(3.80±0.73),(3.28±0.94)分,P<0.05犦。②术后疼痛频率评分:抑郁组高于正常组犤(0.96±0.35),(0.45±0.57)分,P<0.01犦。③术后疼痛程度评分:抑郁组明显高于正常组犤(1.20±0.63),(0.58±0.65)分,P<0.01犦。④术后症状改善率:抑郁组低于正常组犤(67.87±17.86),(81.44±21.08)%,P<0.01犦。⑤术后工作能力评分:抑郁组术后工作能力较差,明显高于正常组犤(1.48±1.00),(0.78±1.04)分,P<0.01犦。⑥术后症状体征改善率:抑郁组明显低于正常组犤(69.27±16.51),(84.31±18.03)%,P<0.05犦。结论:抑郁患者术后症状改善率和症状体征改善率低,疼痛频率和疼痛程度高,术后工作能力较差。提示抑郁与腰椎间盘突出症手术的预后情况相关,是腰椎间盘突出症术后康复的不利因素,术前应对患者进行抑郁评定。

AIM： To investigate whether depression is associated with the operative prognosis of lumbar disc protrusion.METHODS： Totally 107 patients with lumbar disc protrusion, who were operated in the Second Affiliated Hospital of China Medical University from June 2000 to December 2003, were involved in this study. ① The disease course, total score of preoperative symptom and physical sign were recorded,the preoperative painful degree was recorded with the visual analog scale.The preoperative psychology was assessed with self-rating depression scale,and the score of 53 points was taken as the standard score, the patients were divided into normal group （〈 the standard score, n=83） and depression group（≥the standard score, n=25）. There were insignificant differences in gender,age, professional nature, educational background and smoking history between the two groups （P 〉 0.05）. ② According to the 60 indexes set by North American Spine Society together with the clinical practice, the curative effect assessment scale of 50 points was designed, it included 4 aspects：Symptoms （6 points）： 3 points for pain in lumbar part or hip, 3 points for leg pain or numbness; Influence of symptoms on function （19 points）： 4 points for walking, 0 to 2 points for standing, sitting, sleeping, lifting, aggravating activities and sexual life respectively, 0 to 3 points for miction; Physical sign（16 points）： 0 to 2 points for lumbar limitation of activity and deformation, 0 or 1 point for pain due to flap at lumbar part, 0 to 2 points for undamaged limb lifting test, 0 to 4 points for straight leg lifting test, 0 to 3 points for muscle force, 0 to 2 for sense, 0 to 2 points for reflection; CT or MR localization for the same region （9 points）： 3 to 9 points for 0 to 3 regions respectively, which were not included in the score of postoperative follow-up.③The ameliorative rate of symptoms in the 107 patients was calculated according to the scores of postoperative symptoms, that was, （score of preoperative symptom-score of postoperative symptom） / score of preoperative symptom×100%; 47 cases of the patients got their score of postoperative physical sign through re-examination in the clinic, and then the ameliorative rate of symptom and physical sign, that was, [（score of preoperative symptom ＋ score of preoperative physical sign） - （score of preoperative symptom ＋ score of postoperative physical sign）] / （score of preoperative symptom ＋ score of preoperative physical sign）×100%. The postoperative pain frequency （0 to 2 points for painless to often painful）and postoperative work capacity （0 to 4 points for recovery to former work to workless） were also investigated. ④ Chi-square test was used for intergroup comparison of baseline data, single sample t test was used for analysis of score of preoperative pain severity and ameliorative rate of symptom.RESULTS： According to intention-to-treat analysis, all the 107 patients were followed up successfully for 2.08 to 3.46 years with an average of 2.48 years. ① Score of preoperative pain severity： It was obviously higher in the depression group than in the normal group [（3.80±0.73）, （3.28±20.94）points, P 〈 0.05]. ② Score of postoperative pain frequency： It was higher in the depression group than in the normal group [（0.96±0.35）, （0.45±0.57）points, P 〈 0.01]. ③ Score of postoperative pain severity： It was obviously higher in the depression group than in the normal group [（1.20±0.63）,（0.58±0.65） points, P 〈 0.01]. ④ Postoperative ameliorative rate of symptom： It was lower in the depression group than in the normal group[（67.87±17.86）, （81.44±21.08）%, P 〈 0.01]. ⑤ Score of postoperative work capacity： The postoperative work capacity in the depression group was worse, the score was markedly higher than that in the normal group [（1.48±1.00）,（0.78＋1.04） points, P 〈 0.01]. ⑥ Ameliorative rate of postoperative symptom and physical sign： It was obviously lower in the depression group than in the normal group [（69.27±16.51）, （84.31±18.03）%, P 〈 0.05].CONCLUSION： The postoperative ameliorative rates of symptom and physical sign are lower in depressive patients, their pain frequency and severity are higher, and postoperative work capacity is worse; It is indicated that depression is associated with the operative prognosis for patients with lumbar disc protrusion, and it is an adverse factor for the postoperative rehabilitation of lumbar di~ protrusion, so the preoperative evaluation of depression should for given to the patients.