魏 濱 張 華 徐 懋 張利萍 郭向陽(yáng) 田 耘②

(北京大學(xué)第三醫(yī)院麻醉科，北京 100191)

伴隨著我國(guó)的人口老齡化，骨質(zhì)疏松性椎體壓縮骨折(osteoporosis vertebral compression fracture，OVCF)的患病率正逐年增高[1,2]。OVCF不僅導(dǎo)致患者劇烈的疼痛，還會(huì)引起脊柱畸形，嚴(yán)重影響患者的生活質(zhì)量[3]。經(jīng)皮椎體后凸成形術(shù)(percutaneous kyphoplasty，PKP)作為微創(chuàng)的治療手段能夠快速緩解疼痛，恢復(fù)患者活動(dòng)功能，在臨床中得到廣泛的應(yīng)用[4～6]。對(duì)于接受PKP的老年患者，麻醉管理具有較大的挑戰(zhàn)性，全身麻醉和局部浸潤(rùn)麻醉是目前常用的麻醉方法[7]。全身麻醉的優(yōu)勢(shì)是患者舒適度高，但容易導(dǎo)致術(shù)中血流動(dòng)力學(xué)波動(dòng)，全麻藥物的使用和氣管插管也會(huì)增加相關(guān)不良事件的發(fā)生風(fēng)險(xiǎn)[8]；局部浸潤(rùn)麻醉利于早期發(fā)現(xiàn)手術(shù)損傷或骨水泥滲漏導(dǎo)致的神經(jīng)損傷，劣勢(shì)是麻醉效果差，有變更麻醉方式和降低手術(shù)依從性的顧慮[9]。椎旁阻滯(paravertebral block，PVB)是將局麻藥注射到椎體兩側(cè)、出椎間孔的脊神經(jīng)根附近，阻斷疼痛信號(hào)的傳導(dǎo)通路，從而減輕或解除患者的疼痛[10]。目前，將PVB用于PKP的報(bào)道很少，我院2015年12月對(duì)2例老年患者OVCF采用雙側(cè)PVB下行PKP，麻醉效果滿意，報(bào)道如下。

1 臨床資料

病例1：女，76歲。因摔倒傷及腰部疼痛、活動(dòng)受限40 d于2015年12月入院?；颊?0 d前不慎摔倒，臀部著地，傷后感腰部疼痛活動(dòng)受限，當(dāng)時(shí)無(wú)昏迷、頭痛頭暈、胸悶憋氣、四肢麻木無(wú)力、惡心嘔吐及大小便失禁。由家人送外院診治，相關(guān)檢查后考慮腰椎壓縮骨折，未住院治療，在家臥床休息及口服止痛藥(具體不詳)，保守治療后病情加重出現(xiàn)腰部及雙側(cè)大腿疼痛，為進(jìn)一步治療到我院就診。既往原發(fā)性高血壓30年，規(guī)律服用氨氯地平、厄貝沙坦治療，自訴血壓控制良好；冠心病25年，規(guī)律服用阿司匹林、阿托伐他汀，20 d前可疑心絞痛發(fā)作1次；帕金森病史多年，規(guī)律服藥治療。入院查體：BP 165/101 mm Hg，HR 79次/min，RR 20次/min，SpO291%，神志清楚，雙上肺呼吸音粗，雙下肺可聞及少量濕羅音。輔助檢查：腰椎正側(cè)位X線片示L1椎體壓縮骨折；腰椎CT(平掃+重建)及MR(平掃)示L1椎體壓縮骨折；胸部正位X線片示雙肺紋理多；骨密度檢查示重度骨質(zhì)疏松；心電圖示房性早搏；超聲心動(dòng)圖示主動(dòng)脈瓣中度狹窄，左室射血分?jǐn)?shù)51%；下肢血管超聲示雙下肢肌間靜脈血栓形成。實(shí)驗(yàn)室檢查：血常規(guī)Hb 98 g/L；尿常規(guī)尿蛋白1+；生化、凝血檢查大致正常；動(dòng)脈血?dú)鈾z查示PaO262 mm Hg。專科查體：自主體位，蹣跚步態(tài)。胸腰部無(wú)軟組織腫脹，腰部L1棘突水平觸痛、叩擊痛陽(yáng)性；功能活動(dòng)受限；雙下肢活動(dòng)肌力及感覺正常。術(shù)前診斷：L1椎體壓縮骨折；骨質(zhì)疏松癥；冠心?。桓哐獕翰?；帕金森病；貧血；下肢肌間靜脈血栓形成。患者術(shù)前常規(guī)禁食水，完善術(shù)前檢查，評(píng)估并存疾病。入室后建立靜脈通路，監(jiān)測(cè)脈搏血氧飽和度、無(wú)創(chuàng)血壓和心電圖。采用雙側(cè)T12～L1間隙PVB：患者俯臥于手術(shù)床，胸部下面墊胸枕，雙下肢略屈曲。使用G形臂機(jī)定位L1椎體，記號(hào)筆標(biāo)記L1椎體的棘突，旁開棘突約2 cm處作為穿刺點(diǎn)。選擇超聲聯(lián)合神經(jīng)刺激器引導(dǎo)下進(jìn)行PVB阻滯，神經(jīng)刺激器起始電流1 mA，頻率2 Hz，脈沖寬度0.1 ms。超聲定位選擇M-Turbo便攜式超聲儀低頻凸陣探頭。局部麻醉藥物選擇0.4%羅哌卡因，單側(cè)PVB藥量為10 ml。常規(guī)消毒局部皮膚，鋪巾，無(wú)菌耗材包裹超聲探頭，同時(shí)將神經(jīng)電刺激器與刺激針連接，準(zhǔn)備穿刺。采用1%利多卡因浸潤(rùn)穿刺點(diǎn)，操作者左手持超聲探頭，右手持穿刺針，在超聲實(shí)時(shí)引導(dǎo)下進(jìn)針，PVB采用傳統(tǒng)入路，平面外穿刺技術(shù)。超聲探頭置于脊柱中線L1椎體水平行矢狀切面掃描，找到L1椎體棘突后，側(cè)向移動(dòng)探頭，直至關(guān)節(jié)突、橫突和腰大肌的典型超聲圖像出現(xiàn)。在超聲探頭外側(cè)中點(diǎn)處進(jìn)針，當(dāng)針尖越過(guò)L1椎體的橫突上緣后，注意觀察肋間及腹壁肌肉是否發(fā)生顫搐，若穿刺針越過(guò)L1橫突上緣1 cm后，未引出上述靶肌肉顫搐，退針調(diào)整方向后繼續(xù)緩慢進(jìn)針直至肋間及腹壁肌肉出現(xiàn)顫搐，然后將刺激電流減小至0.5 mA，若仍能引出靶肌肉的顫搐，且穿刺針回抽無(wú)血、腦脊液，給予0.4%羅哌卡因3 ml，觀察5 min。若患者無(wú)蛛網(wǎng)膜下腔阻滯征象和其他不適后，再給予0.4%羅哌卡因7 ml，局麻藥共計(jì)10 ml。依法行對(duì)側(cè)PVB，穿刺完成后，覆蓋無(wú)菌紗布，利用針尖測(cè)定患者的麻醉阻滯范圍。麻醉滿意后行PKP，患者順利完成手術(shù)，麻醉時(shí)間為73 min，手術(shù)時(shí)間49 min，術(shù)中出血量2 ml，術(shù)中及術(shù)后均無(wú)麻醉相關(guān)并發(fā)癥。PVB完成10 min后測(cè)定麻醉平面，左側(cè)麻醉平面上界為T12，下界為L(zhǎng)3；右側(cè)麻醉平面上界為T12，下界為L(zhǎng)4。患者在手術(shù)通道建立、球囊擴(kuò)張椎體和灌注骨水泥等關(guān)鍵手術(shù)步驟中均無(wú)疼痛不適，手術(shù)依從性好，術(shù)中未追加鎮(zhèn)靜鎮(zhèn)痛藥物。術(shù)后1 d出院。術(shù)后1年隨訪無(wú)麻醉相關(guān)并發(fā)癥。

2 討論

OVCF是老年人常見的骨折類型[11]，保守治療效果常不理想，長(zhǎng)期臥床會(huì)帶來(lái)肺部感染、尿路感染、下肢深靜脈血栓形成等一系列嚴(yán)重并發(fā)癥，危及患者生命安全[12,13]。手術(shù)治療可以迅速緩解OVCF引起的疼痛，但老年患者麻醉手術(shù)風(fēng)險(xiǎn)高，目前臨床上尚缺乏公認(rèn)的OVCF患者手術(shù)的最優(yōu)麻醉方案。

OVCF患者常具有高齡、合并疾病眾多和病情危重的特點(diǎn)，準(zhǔn)確的術(shù)前風(fēng)險(xiǎn)評(píng)估和選擇合適的麻醉方法對(duì)降低OVCF患者術(shù)后并發(fā)癥和改善其轉(zhuǎn)歸有很大幫助。目前，PKP的麻醉方法主要有全身麻醉和局部浸潤(rùn)麻醉2種，全身麻醉更為常用[7]。全身麻醉舒適度高，機(jī)械通氣便于呼吸的管理，對(duì)于骨水泥栓塞或過(guò)敏等危急狀況也利于迅速實(shí)施搶救[14]；但全麻藥物的大量使用會(huì)增加術(shù)后麻醉相關(guān)不良事件的發(fā)生風(fēng)險(xiǎn)，這種風(fēng)險(xiǎn)對(duì)于老年患者尤甚[15,16]。老年人隨著年齡的增加，重要的器官功能日漸衰退，全身麻醉對(duì)于老年人脆弱的心、腦、肺、肝、腎功能的影響是巨大的，結(jié)局也可能是災(zāi)難性的[17]。相比之下，局部浸潤(rùn)麻醉可避免全身用藥、氣管內(nèi)插管及機(jī)械通氣，保證患者處于清醒狀態(tài)，有利于早期發(fā)現(xiàn)手術(shù)損傷或骨水泥滲漏導(dǎo)致的不良反應(yīng)。但局部浸潤(rùn)麻醉的劣勢(shì)也是不容忽視的，麻醉阻滯效果不完善可能帶給病人巨大的痛苦，部分病人甚至因此而不能耐受手術(shù)，降低患者的手術(shù)依從性，增加手術(shù)風(fēng)險(xiǎn)。Lee等[18]報(bào)道采用小劑量的鎮(zhèn)靜鎮(zhèn)痛藥物可以緩解OVCF患者因局部浸潤(rùn)麻醉阻滯不全帶來(lái)的疼痛不適，并取得了不錯(cuò)的療效。清醒鎮(zhèn)靜實(shí)施短小手術(shù)在臨床中有廣泛的應(yīng)用[19,20]，但對(duì)于俯臥位下接受PKP的高齡、合并疾病眾多及病情危重的OVCF患者而言，應(yīng)謹(jǐn)慎的使用鎮(zhèn)靜藥物，避免因氣道丟失而造成災(zāi)難性后果。Hannallah等[21]報(bào)道將椎管內(nèi)麻醉應(yīng)用于PKP，麻醉后血流動(dòng)力學(xué)波動(dòng)、老年人脊椎退行性變及OVCF致脊柱畸形導(dǎo)致的穿刺困難和損傷是臨床中不容忽視的問題。

PVB應(yīng)用于臨床已有近百年的歷史[22]，伴隨著麻醉可視化技術(shù)的不斷進(jìn)步與成熟，PVB的應(yīng)用日益廣泛。Murata等[23]報(bào)道胸椎PVB可以有效緩解多發(fā)肋骨骨折造成的急性疼痛，相較于靜脈自控鎮(zhèn)痛，PVB可以改善患者的呼吸功能且相關(guān)副作用更少。Ohtori等[24]報(bào)道PVB可以有效緩解OVCF造成的急性疼痛。帶狀皰疹后遺神經(jīng)痛是一種頑固的神經(jīng)病理性疼痛，嚴(yán)重影響患者的生活和工作[25,26]。Makharita等[27]報(bào)道胸椎PVB可以有效降低帶狀皰疹后遺神經(jīng)痛的發(fā)生風(fēng)險(xiǎn)。Zaporowska-Stachowiak等[28]報(bào)道PVB可以有效管理晚期癌痛。全身麻醉復(fù)合PVB可以降低開胸手術(shù)患者的應(yīng)激反應(yīng)，提供完善的術(shù)后鎮(zhèn)痛和更低的麻醉相關(guān)副反應(yīng)[29，30]。Kashiwagi等[31]報(bào)道胸椎PVB用于胸腔鏡手術(shù)可以改善患者術(shù)后的呼吸功能。Sun等[32]報(bào)道雙側(cè)胸椎PVB在冠狀動(dòng)脈旁路移植患者中的鎮(zhèn)痛效果明顯優(yōu)于靜脈自控輸注嗎啡，同時(shí)還可以降低術(shù)后心血管并發(fā)癥的發(fā)生風(fēng)險(xiǎn)。另外，PVB在乳腺[33]和腹部[34]等手術(shù)中都得到成功的應(yīng)用。

超聲技術(shù)的引入和神經(jīng)刺激器的使用令PVB操作簡(jiǎn)便，阻滯成功率提高，并發(fā)癥發(fā)生風(fēng)險(xiǎn)降低[27]。PVB可以有效阻滯脊神經(jīng)的各分支，對(duì)呼吸循環(huán)功能影響小，術(shù)后麻醉并發(fā)癥少，可以為PKP提供完善的麻醉。PVB還可以根據(jù)不同患者和病情的需要提供急、慢性疼痛治療，癌痛治療，復(fù)合麻醉和術(shù)后鎮(zhèn)痛，在臨床工作中發(fā)揮巨大的作用，是重要的輔助治療手段[30,33,35]。

綜上所述，PVB臨床操作簡(jiǎn)便，麻醉效果確切，對(duì)老年患者脆弱的心、腦、肺等重要臟器功能干擾輕微，只要應(yīng)用恰當(dāng)，PVB可作為老年患者接受PKP的麻醉方法。

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