加速康复外科理念下腰椎单节段开放手术不放置引流管的临床探索研究

Clinical exploration study of single-segment lumbar open surgery without postoperative drainage following enhanced recovery after surgery

背景传统腰椎后路手术术后会放置引流管以预防术后硬膜外血肿、切口延迟愈合等并发症。加速康复外科(enhanced recovery after surgery,ERAS)理念认为,应采取一系列措施减少应激以促进外科患者康复,包括避免不必要的放置引流管。目的评价ERAS理念指导下的腰椎单节段开放手术术后不放置切口引流管的安全性和有效性。方法收集解放军总医院第七医学中心脊柱外科2020年12月—2021年4月需进行腰椎单节段开放手术的患者。术中进行充分止血,关闭术野前用0.9%氯化钠注射液浸泡切口并观察,若0.9%氯化钠注射液澄清可看见术野底部则纳入“不放置引流管组”,否则纳入“放置引流管组”。比较两组围术期的术后并发症,红细胞计数(red blood count,RBC)、血红蛋白(hemoglobin,Hb)的术前术后差值,不同时间点的腰腿痛视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍评分(Oswestry’s disability index,ODI),术前及术后7 d时匹兹堡睡眠质量指数(Pittsburgh sleep quality index,PSQI)、焦虑自评量表评分(self-rating anxiety scale score,SAS),术后下地时间、舒适满意度等。结果最终纳入63例患者,其中“不放置引流管组”30例,“放置引流管组”33例。两组在性别、年龄构成、手术类型构成、手术出血量、手术时长方面差异无统计学意义(P>0.05)。“不放置引流管组”未出现术后并发症;“放置引流管组”共出现3例术后并发症,包括1例术后腰痛加重伴下肢功能障碍且需要二次手术,1例术后引流管意外脱出,1例泌尿道感染。实验室指标方面,术前基线水平一致情况下,两组病例的术后白细胞计数、粒细胞计数、RBC、Hb、C反应蛋白差异均无统计学意义(P>0.05);两组血沉(erythrocyte sedimentation rate,ESR)变化差异有统计学意义,“放置引流管组”围术期ESR升高更显著(P<0.05)。两组腰腿痛VAS、ODI、PSQI、SAS差异均无统计学意义(P>0.05)。“不放置引流管组”的术后下地时间早于“放置引流管组”[M(IQR):3(2~4)d vs 4(3~5)d,P=0.011],舒适满意度得分高于“放置引流管组”(6.90±1.86 vs 5.30±2.27,P=0.004)。结论腰椎后路单节段切开、内固定相关的手术不放置引流管,在充分止血、排除相关术后并发症风险前提下是安全可行的,是脊柱外科加速康复中一种可选择的措施,可促进患者术后早期下地活动,并提高患者舒适满意度。

Background Drainage tube should be used after posterior lumbar surgery to prevent complications such as postoperative epidural hematoma,neurological dysfunction,and delayed incision healing by traditional view.Enhanced recovery after surgery(ERAS)suggests that a series of measures should be adopted to reduce stress to promote recovery of surgical patients,including avoiding unnecessary drainage placement.Objective To investigate the application value and conditions of non-drainage after single-level lumbar open surgery under the guidance of ERAS.Methods Patients who needed single-segment open lumbar surgery from December 2020 to April 2021 in the Department of Spine Surgery,the Seventh Medical Center of Chinese PLA General Hospital were selected.Adequate hemostasis was performed during the operation.The incision was observed,which was soaked in 0.9%sodium chloride injection(normal saline,NS)before suture.If the bottom of the surgical field could be seen through the clear NS,the patient was included in the non-drainage group,otherwise she/he was included in the drainage group.The perioperative complications,the difference of red blood cell count(RBC),hemoglobin(Hb)before and 3 days after operation,Pittsburgh sleep quality index score(PSQI)and self-rating anxiety scale score(SAS)before and 7 days after operation were compared between the two groups.Visual analogue score(VAS)of lumbocrural pain,Oswestry’s dysfunction score(ODI)at different time points were evaluated.Time-to-ambulation and the score of comfort satisfaction and other indexes were also analyzed.Results Totally 63 patients were included,of whom 30 cases were in the non-drainage group and 33 cases in the drainage group.There was no statistical difference in gender,age composition,operation type composition,operation blood loss and operation duration between the two groups.No postoperative complication occurred in the non-drainage group,however,3 cases had postoperative complications in the drainage group,including 1 case of postoperative lumbocrural pain aggravated with lower limbs dysfunction and requiring a second operation,1 case of postoperative drainage tube inadvertent removal,1 case of postoperative urinary tract infection.In terms of laboratory indicators,with consistent preoperative baseline levels,there were no statistically significant differences in postoperative WBC,GC,RBC,Hb,and CRP between the two groups(P>0.05).However,there was a statistically significant difference in erythrocyte sedimentation rate(ESR)changes between the two groups(P<0.05),indicating a more pronounced increase in ESR during the perioperative period in the drain placement group.The perioperative blood loss was more in the drainage group.There were no significant differences in VAS,ODI,PSQI and SAS between the two groups(P>0.05).The time-to-ambulation in the non-drainage group was earlier than that in the drainage group(M[IQR]:3[2-4]d vs 4[3-5]d,P=0.011).The score of comfort satisfaction in the non-drainage group was significantly higher than that in the drainage group(6.90±1.86 vs 5.30±2.27,P=0.004).Conclusion The operation related to posterior lumbar single segment,open approach and internal fixation with no drainage is safe and feasible under the premise of sufficient hemostasis and exclusion of related postoperative complications,which can be adopted to accelerate the rehabilitation of spinal surgery patients,promote the early postoperative movement of patients,and improve patients’score of comfort satisfaction.