腰椎术后椎管内与静脉应用类固醇激素的镇痛效果比较

Comparison of analgesic effects of epidural versus intravenous steroid hormone application after lumbar spine surgery

背景类固醇激素因其强大的抗炎作用,常被用于腰椎手术后缓解患者的急性疼痛。临床上主要有硬膜外局部施用和静脉输注两种给药方式,但两者的效果及适用人群尚有争论。目的比较腰椎微创经椎间孔椎体间融合术(minimal invasive posterior transfominal lumber interbody fusion,MIS-TLIF)后使用局部类固醇激素(倍他米松)与静脉类固醇激素(甲泼尼龙琥珀酸钠)对于术后疼痛缓解和神经根保护的有效性和安全性。方法回顾分析2019年1月-2021年6月在解放军总医院第一医学中心骨科接受MIS-TLIF手术患者的病历资料,术后局部使用类固醇激素为A组,术后静脉使用类固醇激素为B组,共纳入254例患者。通过倾向性评分共匹配(1:1)192例患者,比较两组患者术后视觉模拟评分法(visual analogue scale,VAS)评分、功能障碍指数(oswestry disability index,ODI)、术后首次下床时间、围术期血糖、骨密度变化、术后根性疼痛发生率和术后并发症发生情况。评价两种用药方式的围术期效果和适用人群。结果匹配后A组96例,男性28例,女性68例,平均年龄(53.9±8.5)岁;B组96例,男性36例,女性60例,平均年龄(53.2±7.4)岁。两组一般资料差异无统计学意义(P>0.05)。两组术后各时间点VAS差异无统计学意义(P均>0.05)。A组术后平均首次下床时间短于B组(25 h vs 27 h,P=0.034),A组术后3个月内根性疼痛发生率显著低于B组(11%vs 24%,P=0.023)。B组糖尿病患者用药后第2天和第3天血糖值明显低于A组(P均<0.05),B组中女性患者3个月后出现骨密度下降比例明显低于A组(5%vs 18%,P=0.023),两组患者术后均未发生药物相关不良反应和并发症。结论两种用药方式镇痛效果相当,局部类固醇激素表现出较好的神经根保护作用,而糖尿病及绝经期女性患者使用静脉类固醇激素获益更多。

Background Steroid hormones are often used to relieve acute pain in patients after lumbar spine surgery because of their powerful anti-inflammatory effects.The two main clinical methods of administration are epidural topical administration and intravenous infusion,but their advantages and disadvantages and the population for which they are suitable are still debated.Objective To compare the effectiveness and safety of topical steroids(betamethasone)and intravenous steroids(methylprednisolone sodium succinate)for postoperative pain relief and nerve root protection after minimal invasive posterior transforaminal lumbar interbody fusion(MIS-TLIF)of the lumbar spine.Methods From January 2019 to June 2021,a retrospective analysis was performed in the medical records of patients undergoing MIS-TLIF surgery at the Department of Orthopaedics,the First Medical Center,Chinese PLA General Hospital,patients with postoperative topical steroid hormone served as group A and patients with postoperative intravenous steroid hormone served as group B.The postoperative pain score(visual analogue scale,VAS),functional disability index(oswestry disability index,ODI),first time out of bed after surgery,perioperative blood glucose,bone density changes,postoperative radicular pain occurrence,and postoperative complications were compared between the two groups,and the perioperative effect of the two drug administration methods and the applicable population were evaluated.Results Totally 192 patients were matched(1:1)by propensity score,including 96 patients in group A(28 males and 68 females,with a mean age of[53.9±8.5]years),and 96 patients in group B(36 males,and 60 females,with a mean age of[53.2±7.4]years).There was no significant difference in basic information between the two groups after matching.The Mean VAS scores in the group A were not significantly different from the group B on each day after surgery(all P>0.05).The mean getting out-of-bed time in group A was shorter than that in group B(25 h vs 27 h,P=0.034),and the incidence of radicular pain was significantly lower than that in group B at 3 months after surgery(11%vs 24%,P=0.023).Glucose values were significantly lower in diabetic patients in group B than those in group A on day 2 and 3 after medication(P<0.05,respectively),and the proportion of female patients in group B who showed a decrease in bone mineral density after 3 months was significantly lower than that in the group A(5%vs 18%,P=0.023).No drugrelated adverse reactions or complications occurred in both groups after surgery.Conclusion The analgesic effects of the two dosing regimens are comparable,with topical steroids showing better nerve root protection,while diabetic and menopausal female patients benefit more from the use of intravenous steroids.