腰椎手术中椎旁肌不同脂肪浸润程度对罗库溴铵使用剂量及效果的影响

Effect of paravertebral muscle fat infiltration on dosage and effect of rocuronium use in lumbar surgery

目的探讨在腰椎手术中,椎旁肌不同程度的脂肪浸润对罗库溴铵使用剂量及效果的影响。方法前瞻性队列研究。纳入2021年12月—2022年9月山西医科大学第二医院择期行经L_(4~5)节段椎管减压+椎体融合手术患者87例,其中男42例、女45例,年龄31~65岁。美国麻醉协会Ⅰ级22例、Ⅱ级65例。87例患者术前行MR检查,测量L_(4~5)节段手术区域的椎旁肌(包括脊肌、多裂肌)的横截面积(CSA)、功能性肌肉面积(FMA)、脂肪浸润率。按照患者的脂肪浸润率将87例患者分为3组:脂肪浸润率<30%的28例为轻度脂肪浸润组(L组),脂肪浸润率30%~50%的30例为中度脂肪浸润组(M组),脂肪浸润率>50%的29例为重度脂肪浸润组(H组)。术中采用Drager Trident肌松监测仪监测斜方肌的肌肉松弛情况;术中麻醉维持期间罗库溴铵连续泵注,根据强直刺激后计数(PTC)调整罗库溴铵泵速(维持0<PTC≤2),并根据术中肌肉松弛状态间断给予罗库溴铵5 mg。观察指标:(1)比较3组患者临床基线资料;(2)比较3组患者腰椎L_(4~5)节段椎旁肌CSA、FMA;(3)比较3组患者麻醉维持期间罗库溴铵的用药总量、泵注时间、泵速,罗库溴铵起效时间、临床时效、恢复指数,以及术中肌松满意度评分。结果(1)3组患者性别、年龄、身高、体质量、体质量指数(BMI)、去脂体质量、术前白蛋白与电解质等临床基线资料比较,差异均无统计学意义(P值均>0.05)。(2)3组患者腰椎L4~5椎旁肌CSA差异无统计学意义(P>0.05),FMA由大到小为L组(35.8±4.4)cm^(2)、M组(29.3±6.7)cm^(2)、H组(19.9±3.1)cm^(2),差异有统计学意义(F=73.22,P<0.001)。(3)麻醉维持期间罗库溴铵的用药总量由高到低为L组(42.1±5.0)mg、M组(30.5±8.1)mg、H组(25.5±5.4)mg,泵速由高到低为L组(23.7±2.8)μg·kg^(-1)·min^(-1)、M组(18.1±2.6)μg·kg^(-1)·min^(-1)、H组(16.42±2.3)μg·kg^(-1)·min^(-1),起效时间由长到短为L组(108.4±8.6)s、M组(102.8±10.2)s、H组(96.9±8.2)s,临床时效由长到短为H组(31.0±3.1)min、M组(27.0±3.2)min、L组(24.0±2.6),差异均有统计学意义(F=51.05、60.54、11.45、40.76,P值均<0.001);而3组患者罗库溴铵的泵注时间、恢复指数及术中肌松的满意度评分差异均无统计学意义(P值均>0.05)。结论在腰椎手术中,患者手术区域椎旁肌的脂肪浸润程度越低,罗库溴铵的用量越大、起效时间越长、临床时效越短;椎旁肌的脂肪浸润程度可为患者在腰椎手术中罗库溴铵的个体化用药提供参考。

Objective This study aimed to investigate the effect of different degrees of fat infiltration of paravertebral muscles on the use of rocuronium in lumbar surgery.Methods This study was a prospective cohort study.From December 2021 to September 2022,87 patients who underwent L_(4-5) spinal canal decompression combined with vertebral fusion surgery were selected in the Second Hospital of Shanxi Medical University,including 42 males and 45 females aged 31-65 years.The American Association of Anesthesiology classified 22 cases as gradeⅠand 65 cases as gradeⅡ.All patients underwent preoperative MR examination to measure the cross sectional area(CSA),functional muscle area(FMA),and fat infiltration rate of the spine muscle and multifidus muscle(collectively referred to as paravertebral muscle)in the L_(4-5) segment of the surgical area.They were divided into three groups in accordance with the fat infiltration rate,Among them,28,30,and 29 patients with fat infiltration rates<30%,≥30%-50%,and>50%were categorized into mild fat infiltration group(L group),moderate fat infiltration group(M group),and severe fat infiltration group(H group),respectively.The Drager Trident muscle relaxation monitor was used to monitor the muscle relaxation of trapezius muscle.During the maintenance of anesthesia,rocuronium was continuously pumped.The pump speed of rocuronium was adjusted in accordance with the post-tetanic stimulation count(PTC)to maintain 0<PTC≤2;5 mg of rocuronium was given intermittently on the basis of the muscle relaxation state during operation.For observational indicators,(1)the clinical baseline data of the three groups of patients were compared;(2)the CSA and FMA of lumbar paravertebral muscles at L_(4~5) of the three groups were compared;and(3)the total dosage of rocuronium,the pump time,the pump speed,the onset time of rocuronium,the clinical efficacy,the recovery index,and the satisfaction score of intraoperative muscle relaxation among the three groups were compared.Results(1)No statistically significant difference was found in the clinical baseline data of gender,age,height,body mass,body mass index,degreased body mass,preoperative albumin,and electrolyte among the three groups(all P values>0.05).(2)No statistically significant difference was observed in the CSA of lumbar L_(4−5) paravertebral muscles among the three groups(P>0.05).The FMA was,from large to small,in the following order:L group(35.8±4.4)cm^(2),M group(29.3±6.7)cm^(2),H group(19.9±3.1)cm^(2).The difference was statistically significant(F=73.22,P<0.001).(3)During the maintenance of anesthesia,the total amount of rocuronium was,from high to low,as follows:L group(42.1±5.0)mg,M group(30.5±8.1)mg,H group(25.5±5.4)mg.The pump speed was,from high to low,as follows:L group(23.7±2.8)μg·kg^(-1)·min^(-1),M group(18.1±2.6)μg·kg^(-1)·min^(-1),H group(16.42±2.3)μg·kg^(-1)·min^(-1).The onset time from long to short was as follows:L group(108.4±8.6)s,M group(102.8±10.2)s,H group(96.9±8.2)s.The clinical efficacy ranged from long to short in the following order:H group(31.0±3.1)min,M group(27.0±3.2)min,L group(24.0±2.6)min,with significant differences(F=51.05,60.54,11.45,40.76;all P values<0.001).However,no significant difference was found in the pump time,recovery index,and satisfaction score of intraoperative muscle relaxation among the three groups(all P values>0.05).Conclusion In lumbar surgery,the lower the degree of fat infiltration in the paraspinal muscles of patients in the operation area,the greater the amount of rocuronium,the longer the onset time,and the shorter the clinical efficacy.The degree of fat infiltration in the paraspinal muscles could provide a reference for the individualized use of rocuronium in lumbar surgery.