双侧椎旁阻滞用于经皮椎体后凸成形术2例报告

魏 滨 张 华 徐 懋 张利萍 郭向阳 田 耘②

(北京大学第三医院麻醉科，北京 100191)

伴随着我国的人口老龄化，骨质疏松性椎体压缩骨折(osteoporosis vertebral compression fracture，OVCF)的患病率正逐年增高[1,2]。OVCF不仅导致患者剧烈的疼痛，还会引起脊柱畸形，严重影响患者的生活质量[3]。经皮椎体后凸成形术(percutaneous kyphoplasty，PKP)作为微创的治疗手段能够快速缓解疼痛，恢复患者活动功能，在临床中得到广泛的应用[4～6]。对于接受PKP的老年患者，麻醉管理具有较大的挑战性，全身麻醉和局部浸润麻醉是目前常用的麻醉方法[7]。全身麻醉的优势是患者舒适度高，但容易导致术中血流动力学波动，全麻药物的使用和气管插管也会增加相关不良事件的发生风险[8]；局部浸润麻醉利于早期发现手术损伤或骨水泥渗漏导致的神经损伤，劣势是麻醉效果差，有变更麻醉方式和降低手术依从性的顾虑[9]。椎旁阻滞(paravertebral block，PVB)是将局麻药注射到椎体两侧、出椎间孔的脊神经根附近，阻断疼痛信号的传导通路，从而减轻或解除患者的疼痛[10]。目前，将PVB用于PKP的报道很少，我院2015年12月对2例老年患者OVCF采用双侧PVB下行PKP，麻醉效果满意，报道如下。

1 临床资料

病例1：女，76岁。因摔倒伤及腰部疼痛、活动受限40 d于2015年12月入院。患者40 d前不慎摔倒，臀部着地，伤后感腰部疼痛活动受限，当时无昏迷、头痛头晕、胸闷憋气、四肢麻木无力、恶心呕吐及大小便失禁。由家人送外院诊治，相关检查后考虑腰椎压缩骨折，未住院治疗，在家卧床休息及口服止痛药(具体不详)，保守治疗后病情加重出现腰部及双侧大腿疼痛，为进一步治疗到我院就诊。既往原发性高血压30年，规律服用氨氯地平、厄贝沙坦治疗，自诉血压控制良好；冠心病25年，规律服用阿司匹林、阿托伐他汀，20 d前可疑心绞痛发作1次；帕金森病史多年，规律服药治疗。入院查体：BP 165/101 mm Hg，HR 79次/min，RR 20次/min，SpO291%，神志清楚，双上肺呼吸音粗，双下肺可闻及少量湿罗音。辅助检查：腰椎正侧位X线片示L1椎体压缩骨折；腰椎CT(平扫+重建)及MR(平扫)示L1椎体压缩骨折；胸部正位X线片示双肺纹理多；骨密度检查示重度骨质疏松；心电图示房性早搏；超声心动图示主动脉瓣中度狭窄，左室射血分数51%；下肢血管超声示双下肢肌间静脉血栓形成。实验室检查：血常规Hb 98 g/L；尿常规尿蛋白1+；生化、凝血检查大致正常；动脉血气检查示PaO262 mm Hg。专科查体：自主体位，蹒跚步态。胸腰部无软组织肿胀，腰部L1棘突水平触痛、叩击痛阳性；功能活动受限；双下肢活动肌力及感觉正常。术前诊断：L1椎体压缩骨折；骨质疏松症；冠心病；高血压病；帕金森病；贫血；下肢肌间静脉血栓形成。患者术前常规禁食水，完善术前检查，评估并存疾病。入室后建立静脉通路，监测脉搏血氧饱和度、无创血压和心电图。采用双侧T12～L1间隙PVB：患者俯卧于手术床，胸部下面垫胸枕，双下肢略屈曲。使用G形臂机定位L1椎体，记号笔标记L1椎体的棘突，旁开棘突约2 cm处作为穿刺点。选择超声联合神经刺激器引导下进行PVB阻滞，神经刺激器起始电流1 mA，频率2 Hz，脉冲宽度0.1 ms。超声定位选择M-Turbo便携式超声仪低频凸阵探头。局部麻醉药物选择0.4%罗哌卡因，单侧PVB药量为10 ml。常规消毒局部皮肤，铺巾，无菌耗材包裹超声探头，同时将神经电刺激器与刺激针连接，准备穿刺。采用1%利多卡因浸润穿刺点，操作者左手持超声探头，右手持穿刺针，在超声实时引导下进针，PVB采用传统入路，平面外穿刺技术。超声探头置于脊柱中线L1椎体水平行矢状切面扫描，找到L1椎体棘突后，侧向移动探头，直至关节突、横突和腰大肌的典型超声图像出现。在超声探头外侧中点处进针，当针尖越过L1椎体的横突上缘后，注意观察肋间及腹壁肌肉是否发生颤搐，若穿刺针越过L1横突上缘1 cm后，未引出上述靶肌肉颤搐，退针调整方向后继续缓慢进针直至肋间及腹壁肌肉出现颤搐，然后将刺激电流减小至0.5 mA，若仍能引出靶肌肉的颤搐，且穿刺针回抽无血、脑脊液，给予0.4%罗哌卡因3 ml，观察5 min。若患者无蛛网膜下腔阻滞征象和其他不适后，再给予0.4%罗哌卡因7 ml，局麻药共计10 ml。依法行对侧PVB，穿刺完成后，覆盖无菌纱布，利用针尖测定患者的麻醉阻滞范围。麻醉满意后行PKP，患者顺利完成手术，麻醉时间为73 min，手术时间49 min，术中出血量2 ml，术中及术后均无麻醉相关并发症。PVB完成10 min后测定麻醉平面，左侧麻醉平面上界为T12，下界为L3；右侧麻醉平面上界为T12，下界为L4。患者在手术通道建立、球囊扩张椎体和灌注骨水泥等关键手术步骤中均无疼痛不适，手术依从性好，术中未追加镇静镇痛药物。术后1 d出院。术后1年随访无麻醉相关并发症。

2 讨论

OVCF是老年人常见的骨折类型[11]，保守治疗效果常不理想，长期卧床会带来肺部感染、尿路感染、下肢深静脉血栓形成等一系列严重并发症，危及患者生命安全[12,13]。手术治疗可以迅速缓解OVCF引起的疼痛，但老年患者麻醉手术风险高，目前临床上尚缺乏公认的OVCF患者手术的最优麻醉方案。

OVCF患者常具有高龄、合并疾病众多和病情危重的特点，准确的术前风险评估和选择合适的麻醉方法对降低OVCF患者术后并发症和改善其转归有很大帮助。目前，PKP的麻醉方法主要有全身麻醉和局部浸润麻醉2种，全身麻醉更为常用[7]。全身麻醉舒适度高，机械通气便于呼吸的管理，对于骨水泥栓塞或过敏等危急状况也利于迅速实施抢救[14]；但全麻药物的大量使用会增加术后麻醉相关不良事件的发生风险，这种风险对于老年患者尤甚[15,16]。老年人随着年龄的增加，重要的器官功能日渐衰退，全身麻醉对于老年人脆弱的心、脑、肺、肝、肾功能的影响是巨大的，结局也可能是灾难性的[17]。相比之下，局部浸润麻醉可避免全身用药、气管内插管及机械通气，保证患者处于清醒状态，有利于早期发现手术损伤或骨水泥渗漏导致的不良反应。但局部浸润麻醉的劣势也是不容忽视的，麻醉阻滞效果不完善可能带给病人巨大的痛苦，部分病人甚至因此而不能耐受手术，降低患者的手术依从性，增加手术风险。Lee等[18]报道采用小剂量的镇静镇痛药物可以缓解OVCF患者因局部浸润麻醉阻滞不全带来的疼痛不适，并取得了不错的疗效。清醒镇静实施短小手术在临床中有广泛的应用[19,20]，但对于俯卧位下接受PKP的高龄、合并疾病众多及病情危重的OVCF患者而言，应谨慎的使用镇静药物，避免因气道丢失而造成灾难性后果。Hannallah等[21]报道将椎管内麻醉应用于PKP，麻醉后血流动力学波动、老年人脊椎退行性变及OVCF致脊柱畸形导致的穿刺困难和损伤是临床中不容忽视的问题。

PVB应用于临床已有近百年的历史[22]，伴随着麻醉可视化技术的不断进步与成熟，PVB的应用日益广泛。Murata等[23]报道胸椎PVB可以有效缓解多发肋骨骨折造成的急性疼痛，相较于静脉自控镇痛，PVB可以改善患者的呼吸功能且相关副作用更少。Ohtori等[24]报道PVB可以有效缓解OVCF造成的急性疼痛。带状疱疹后遗神经痛是一种顽固的神经病理性疼痛，严重影响患者的生活和工作[25,26]。Makharita等[27]报道胸椎PVB可以有效降低带状疱疹后遗神经痛的发生风险。Zaporowska-Stachowiak等[28]报道PVB可以有效管理晚期癌痛。全身麻醉复合PVB可以降低开胸手术患者的应激反应，提供完善的术后镇痛和更低的麻醉相关副反应[29，30]。Kashiwagi等[31]报道胸椎PVB用于胸腔镜手术可以改善患者术后的呼吸功能。Sun等[32]报道双侧胸椎PVB在冠状动脉旁路移植患者中的镇痛效果明显优于静脉自控输注吗啡，同时还可以降低术后心血管并发症的发生风险。另外，PVB在乳腺[33]和腹部[34]等手术中都得到成功的应用。

超声技术的引入和神经刺激器的使用令PVB操作简便，阻滞成功率提高，并发症发生风险降低[27]。PVB可以有效阻滞脊神经的各分支，对呼吸循环功能影响小，术后麻醉并发症少，可以为PKP提供完善的麻醉。PVB还可以根据不同患者和病情的需要提供急、慢性疼痛治疗，癌痛治疗，复合麻醉和术后镇痛，在临床工作中发挥巨大的作用，是重要的辅助治疗手段[30,33,35]。

综上所述，PVB临床操作简便，麻醉效果确切，对老年患者脆弱的心、脑、肺等重要脏器功能干扰轻微，只要应用恰当，PVB可作为老年患者接受PKP的麻醉方法。

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