腰椎術后急性牽涉痛的臨床觀察及文獻分析

張慶祥 陸錫平 沈樂

【摘要】 目的 通過總結腰椎術后急性牽涉痛的臨床特點， 探討其可能的發生機制。方法 回顧性分析8例腰椎術后急性牽涉痛患者的臨床特點、轉歸和治療方法。結果 術后急性牽涉痛常在麻醉失效后發生， 中位時間約在術后50 min出現， 平均持續時間30 min， 平均視覺模擬評分法（VAS）評分8分。主要表現為以術側為主的下肢痙攣性疼痛， 伴腹股溝、臀部、腰部和髖周彌漫性疼痛。有下肢痛覺過敏現象和肢端涼感， 無肌力減退表現， 無病理征。癥狀多在2 h以內迅速緩解， 緩解后存留肌肉酸痛， 無明顯神經損害的臨床表現， 后期無永久性神經損傷證據。結論 腰椎術后急性牽涉痛是通過交感神經傳導的牽涉痛， 有背根神經節和交感神經參與， 背根神經節缺血致敏可能性大。它的發生有獨特機制， 和脊神經傳導通路有關。

【關鍵詞】 并發癥;牽涉痛;腰椎;背根神經節

DOI：10.14163/j.cnki.11-5547/r.2020.21.017

Clinical observation and literature analysis of acute referred pain after lumbar spine surgery? ?ZHANG qing-xiang， LU Xi-ping， SHEN Le. Department of Orthopedics， The PLA No.960 Hospital Zibo Branch， Zibo 255300， China

【Abstract】 Objective? ?To summarize the clinical characteristics of acute referred pain after lumbar spine surgery， and explore the possible pathogenesis. Methods? ?The clinical characteristics and the outcome and effective treatment of 8 cases with acute referred pain after lumbar spine surgery. Results? ?Acute referred pain often occurred after anesthesia failure， with a median time of about 50 min after surgery， an average duration of 30 min， and an average visual analogue scale （VAS） score of 8 points. The main manifestations were spasmodic pain of the lower extremities mainly on the operative side， and diffuse pain in the groin， buttock， waist and around the hip. There were hyperalgesia and cold sensation of extremities， no hypomyosis and no pathological sign. Most of the symptoms were quickly relieved within 2 h but muscle soreness remained. There was no clinical manifestation of obvious nerve damage and no evidence of permanent nerve damage in the later period. Conclusion? ?Acute referred pain after lumbar surgery is a kind of implicated pain through sympathetic nerve conduction， with the involvement of dorsal root ganglia and sympathetic nerves， and the possibility of sensitization of dorsal root ganglia ischemia was high. Its occurrence had a unique mechanism and was related to the spinal nerve conduction pathway.

【Key words】 Complications; Referred pain; Lumbar spine; Dorsal root ganglion

腰椎術后的神經并發癥， 從輕微的感覺減退到嚴重的馬尾綜合征， 不同的手術方式有不同的發生率[1， 2]。

一般歸咎于神經根直接損傷、再灌注損傷、牽拉性損

傷、血腫壓迫等原因[3， 4]。除了這些常見的神經并發癥外， 在臨床上可以觀察到一種少見的術后急性牽涉痛， 發生率很低， 特點為發作時間短， 發病急， 癥狀重， 體征少， 但是緩解迅速， 常規的鎮痛治療難以奏效， 其啟動和緩解因素難以用常規機制得到完美解釋。本研究回顧性分析8例術后發生牽涉痛患者的臨床資料， 并結合文獻報道， 認為這種牽涉痛雖然發生率較低， 但代表了腰腿痛復雜的機制和解剖學基礎， 提示了背根神經節在腰腿痛的發生機制中獨特的作用。……