局部强化与常规麻醉下经皮椎体成形术治疗多节段急性症状性骨质疏松性胸腰椎骨折的疗效比较

Comparative efficacy of percutaneous vertebroplasty under enhanced regional and conventionalanesthesia for multisegmental acute symptomatic osteoporotic thoracolumbar fractures

目的比较局部强化与常规麻醉下经皮椎体成形术(PVP)治疗多节段急性症状性骨质疏松性胸腰椎骨折(m⁃ASOTLF)的疗效。方法采用回顾性队列研究分析2021年1月至2022年12月西安交通大学附属红会医院收治的91例m⁃ASOTLF患者的临床资料,其中男36例,女55例;年龄55~80岁[(67.4±7.3)岁]。美国麻醉医师协会(ASA)分级:Ⅰ级18例,Ⅱ级52例,Ⅲ级21例。损伤节段:T6~T1023例,T11~L247例,L3~L521例。患者均行PVP治疗。45例采用局部强化麻醉(强化麻醉组),46例采用局部常规麻醉(常规麻醉组)。比较两组手术时间、术中出血量、术中心率、术中平均动脉压(MAP)、术中透视次数、骨水泥总注射量;术前,术后1 d、1个月及末次随访时视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI);术前,术后1、6及12 h简易精神状态量表(MMSE)评分;术前及术后1 d前缘椎体高度(AVH)、中央椎体高度(MVH)、椎体后凸角(VKA);骨水泥渗漏发生率。结果患者均获随访12~20个月[(15.8±2.6)个月]。两组手术时间、术中出血量、术中心率、术中MAP、术中透视次数及骨水泥总注射量差异均无统计学意义(P>0.05)。术前及末次随访时两组VAS、ODI差异均无统计学意义(P>0.05)。强化麻醉组术后1 d、1个月VAS分别为(2.5±0.4)分、(1.8±0.3)分,均低于常规麻醉组的(3.5±0.4)分、(2.0±0.5)分(P<0.01);强化麻醉组术后1 d、1个月ODI分别39.8±3.3、26.5±5.0,均低于常规麻醉组的43.8±7.5、30.3±6.4(P<0.01)。两组术后各时间点VAS、ODI均较术前降低,且术后各时间点差异均有统计学意义(P<0.05)。两组术前,术后1、6及12 h MMSE评分差异均无统计学意义(P>0.05)。两组术后1、6 h的MMSE评分均较术前降低,且术后6 h的MMSE评分较术后1 h提高(P<0.05),术后12 h的MMSE与术前差异无统计学意义(P>0.05)。术前两组AVH、MVH及VKA差异均无统计学意义(P>0.05)。强化麻醉组术后1 d的AVH、MVH分别为(22.4±4.2)mm、(22.7±3.7)mm,均高于常规麻醉组的(19.3±3.7)mm、(20.1±6.3)mm(P<0.05或0.01);强化麻醉组术后1 d的VKA为(13.9±3.7)°,低于常规麻醉组的(15.8±4.1)°(P<0.05)。两组术后1 d的AVH、MVH、VKA均较术前改善(P<0.05)。强化麻醉组骨水泥渗漏发生率为6.7%(3/45),低于常规麻醉组的21.7%(10/46)(P<0.05)。结论与局部常规麻醉相比,局部强化麻醉下PVP治疗m⁃ASOTLF在术后早期缓解疼痛、改善脊柱功能、恢复椎体高度及减少骨水泥渗漏发生率等方面更具优势。

Objective To compare the efficacy of percutaneous vertebroplasty(PVP)under enhanced regional and conventional anesthesia for multisegmental acute symptomatic osteoporotic thoracolumbar fractures(m⁃ASOTLF).Methods A retrospective cohort study was conducted to analyze the data of 91 patients with m⁃ASOTLF who were admitted to Honghui Hospital of Xi′an Jiaotong University from January 2021 to December 2022,including 36 males and 55 females,aged 55⁃80 years[(67.4±7.3)years].According to American Society of Anesthesiologists(ASA)classification system,18 patients were classified as grade I,52 grade II,and 21 grade III.Injured segments included T6⁃T10 in 23 patients,T11⁃L2 in 47 and L3⁃L5 in 21.All the patients were treated with PVP,among whom 45 were given enhanced regional anesthesia(enhanced anesthesia group)and 46 regional conventional anesthesia(conventional anesthesia group).The following indicators were compared between the two groups:the operation time,intraoperative bleeding,intraoperative heart rate,intraoperative mean arterial pressure(MAP),number of intraoperative fluoroscopies,and total amount of bone cement injected;the visual analogue scale(VAS)and Oswestry dysfunction index(ODI)before surgery,at 1 day,1 month after surgery and at the last follow⁃up;the mini⁃mental state examination(MMSE)before surgery,at 1,6,and 12 hours after surgery;the anterior vertebrae height(AVH),middle vertebrae height(MVH),and vertebral kyphosis angle(VKA)before and at 1 day after surgery;the incidence of complications such as bone cement leakage.Results All the patients were followed up for 12⁃20 months[(15.8±2.6)months].There were no significant differences between the two groups in the operation time,intraoperative bleeding,intraoperative heart rate,intraoperative MAP,number of intraoperative fluoroscopies or total amount of bone cement injected(P>0.05).No significant differences were found between the two groups in VAS or ODI before surgery and at the last follow⁃up(P>0.05).The VAS scores in the enhanced anesthesia group were(2.5±0.4)points and(1.8±0.3)points at 1 day and 1 month postoperatively respectively,which were both lower than(3.5±0.4)points and(2.0±0.5)points in the conventional anesthesia group(P<0.01).The ODI values in the enhanced anesthesia group were 39.8±3.3 and 26.5±5.0 at 1 day and 1 month postoperatively respectively,which were both lower than 43.8±7.5 and 30.3±6.4 in the conventional anesthesia group(P<0.01).The VAS and ODI at all postoperative time points decreased in both groups compared with those before surgery,with significant differences among those at all postoperative time points(P<0.05).There was no significant difference between the two groups in the MMSE scores before,at 1,6,and 12 hours after surgery(P>0.05).The MMSE scores at 1 and 6 hours postoperatively were lower than that preoperatively in both groups(P<0.05),and it was increased at 6 hours compared with that at 1 hour postoperatively(P<0.05).There was no significant difference between the MMSE scores at 12 hours postoperatively and preoperatively in both groups(P>0.05).The differences between the two groups in AVH,MVH,or VKA preoperatively were not statistically significant(P>0.05).The AVH and MVH at 1 day postoperatively in the enhanced anesthesia group were(22.4±4.2)mm and(22.7±3.7)mm respectively,which were both higher than those in the conventional anesthesia group[(19.3±3.7)mm and(20.1±6.3)mm](P<0.05 or 0.01);the VKA at 1 day postoperatively in the enhanced anesthesia group was(13.9±3.7)°,which was lower than that in the conventional anesthesia group(15.8±4.1)°(P<0.05).The AVH,MVH,and VKA in both groups were all improved at 1 day postoperatively compared with those preoperatively(P<0.05).The incidence of bone cement leakage in the enhanced anesthesia group was 6.7%(3/45),which was lower than 21.7%(10/46)in the conventional anesthesia group(P<0.05).Conclusion Compared with conventional regional anesthesia,PVP under enhanced regional anesthesia for m⁃ASOTLF has more advantages in early postoperative pain relief,improvement of spinal function,restoration of vertebral height and reduction of bone cement leakage.