雙側椎旁阻滯用于經皮椎體后凸成形術2例報告

魏 濱 張 華 徐 懋 張利萍 郭向陽 田 耘②

(北京大學第三醫院麻醉科，北京 100191)

伴隨著我國的人口老齡化，骨質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不僅導致患者劇烈的疼痛，還會引起脊柱畸形，嚴重影響患者的生活質量[3]。經皮椎體后凸成形術(percutaneous kyphoplasty，PKP)作為微創的治療手段能夠快速緩解疼痛，恢復患者活動功能，在臨床中得到廣泛的應用[4～6]。對于接受PKP的老年患者，麻醉管理具有較大的挑戰性，全身麻醉和局部浸潤麻醉是目前常用的麻醉方法[7]。全身麻醉的優勢是患者舒適度高，但容易導致術中血流動力學波動，全麻藥物的使用和氣管插管也會增加相關不良事件的發生風險[8]；局部浸潤麻醉利于早期發現手術損傷或骨水泥滲漏導致的神經損傷，劣勢是麻醉效果差，有變更麻醉方式和降低手術依從性的顧慮[9]。椎旁阻滯(paravertebral block，PVB)是將局麻藥注射到椎體兩側、出椎間孔的脊神經根附近，阻斷疼痛信號的傳導通路，從而減輕或解除患者的疼痛[10]。目前，將PVB用于PKP的報道很少，我院2015年12月對2例老年患者OVCF采用雙側PVB下行PKP，麻醉效果滿意，報道如下。

1 臨床資料

病例1：女，76歲。因摔倒傷及腰部疼痛、活動受限40 d于2015年12月入院。患者40 d前不慎摔倒，臀部著地，傷后感腰部疼痛活動受限，當時無昏迷、頭痛頭暈、胸悶憋氣、四肢麻木無力、惡心嘔吐及大小便失禁。由家人送外院診治，相關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腰部及雙側大腿疼痛，為進一步治療到我院就診。既往原發性高血壓30年，規律服用氨氯地平、厄貝沙坦治療，自訴血壓控制良好；冠心病25年，規律服用阿司匹林、阿托伐他汀，20 d前可疑心絞痛發作1次；帕金森病史多年，規律服藥治療。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疏松；心電圖示房性早搏；超聲心動圖示主動脈瓣中度狹窄，左室射血分數51%；下肢血管超聲示雙下肢肌間靜脈血栓形成。實驗室檢查：血常規Hb 98 g/L；尿常規尿蛋白1+；生化、凝血檢查大致正常；動脈血氣檢查示PaO262 mm Hg。專科查體：自主體位，蹣跚步態。胸腰部無軟組織腫脹，腰部L1棘突水平觸痛、叩擊痛陽性；功能活動受限；雙下肢活動肌力及感覺正常。術前診斷：L1椎體壓縮骨折；骨質疏松癥；冠心病；高血壓病；帕金森病；貧血；下肢肌間靜脈血栓形成。患者術前常規禁食水，完善術前檢查，評估并存疾病。入室后建立靜脈通路，監測脈搏血氧飽和度、無創血壓和心電圖。采用雙側T12～L1間隙PVB：患者俯臥于手術床，胸部下面墊胸枕，雙下肢略屈曲。使用G形臂機定位L1椎體，記號筆標記L1椎體的棘突，旁開棘突約2 cm處作為穿刺點。選擇超聲聯合神經刺激器引導下進行PVB阻滯，神經刺激器起始電流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PVB藥量為10 ml。常規消毒局部皮膚，鋪巾，無菌耗材包裹超聲探頭，同時將神經電刺激器與刺激針連接，準備穿刺。采用1%利多卡因浸潤穿刺點，操作者左手持超聲探頭，右手持穿刺針，在超聲實時引導下進針，PVB采用傳統入路，平面外穿刺技術。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，側向移動探頭，直至關節突、橫突和腰大肌的典型超聲圖像出現。在超聲探頭外側中點處進針，當針尖越過L1椎體的橫突上緣后，注意觀察肋間及腹壁肌肉是否發生顫搐，若穿刺針越過L1橫突上緣1 cm后，未引出上述靶肌肉顫搐，退針調整方向后繼續緩慢進針直至肋間及腹壁肌肉出現顫搐，然后將刺激電流減小至0.5 mA，若仍能引出靶肌肉的顫搐，且穿刺針回抽無血、腦脊液，給予0.4%羅哌卡因3 ml，觀察5 min。若患者無蛛網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10 ml。依法行對側PVB，穿刺完成后，覆蓋無菌紗布，利用針尖測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，麻醉時間為73 min，手術時間49 min，術中出血量2 ml，術中及術后均無麻醉相關并發癥。PVB完成10 min后測定麻醉平面，左側麻醉平面上界為T12，下界為L3；右側麻醉平面上界為T12，下界為L4。患者在手術通道建立、球囊擴張椎體和灌注骨水泥等關鍵手術步驟中均無疼痛不適，手術依從性好，術中未追加鎮靜鎮痛藥物。術后1 d出院。術后1年隨訪無麻醉相關并發癥。

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，長期臥床會帶來肺部感染、尿路感染、下肢深靜脈血栓形成等一系列嚴重并發癥，危及患者生命安全[12,13]。手術治療可以迅速緩解OVCF引起的疼痛，但老年患者麻醉手術風險高，目前臨床上尚缺乏公認的OVCF患者手術的最優麻醉方案。

OVCF患者常具有高齡、合并疾病眾多和病情危重的特點，準確的術前風險評估和選擇合適的麻醉方法對降低OVCF患者術后并發癥和改善其轉歸有很大幫助。目前，PKP的麻醉方法主要有全身麻醉和局部浸潤麻醉2種，全身麻醉更為常用[7]。全身麻醉舒適度高，機械通氣便于呼吸的管理，對于骨水泥栓塞或過敏等危急狀況也利于迅速實施搶救[14]；但全麻藥物的大量使用會增加術后麻醉相關不良事件的發生風險，這種風險對于老年患者尤甚[15,16]。老年人隨著年齡的增加，重要的器官功能日漸衰退，全身麻醉對于老年人脆弱的心、腦、肺、肝、腎功能的影響是巨大的，結局也可能是災難性的[17]。相比之下，局部浸潤麻醉可避免全身用藥、氣管內插管及機械通氣，保證患者處于清醒狀態，有利于早期發現手術損傷或骨水泥滲漏導致的不良反應。但局部浸潤麻醉的劣勢也是不容忽視的，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，降低患者的手術依從性，增加手術風險。Lee等[18]報道采用小劑量的鎮靜鎮痛藥物可以緩解OVCF患者因局部浸潤麻醉阻滯不全帶來的疼痛不適，并取得了不錯的療效。清醒鎮靜實施短小手術在臨床中有廣泛的應用[19,20]，但對于俯臥位下接受PKP的高齡、合并疾病眾多及病情危重的OVCF患者而言，應謹慎的使用鎮靜藥物，避免因氣道丟失而造成災難性后果。Hannallah等[21]報道將椎管內麻醉應用于PKP，麻醉后血流動力學波動、老年人脊椎退行性變及OVCF致脊柱畸形導致的穿刺困難和損傷是臨床中不容忽視的問題。

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

超聲技術的引入和神經刺激器的使用令PVB操作簡便，阻滯成功率提高，并發癥發生風險降低[27]。PVB可以有效阻滯脊神經的各分支，對呼吸循環功能影響小，術后麻醉并發癥少，可以為PKP提供完善的麻醉。PVB還可以根據不同患者和病情的需要提供急、慢性疼痛治療，癌痛治療，復合麻醉和術后鎮痛，在臨床工作中發揮巨大的作用，是重要的輔助治療手段[30,33,35]。

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

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