Dynesys系统结合PLIF在多节段腰椎退行性疾病的应用

目的:探讨Dynesys动态稳定系统联合腰椎后路椎间融合(PLIF)在腰椎多节段退变性疾病治疗中的临床疗效。方法:对2010年9月至2013年5月采用Dynesys动态稳定系统结合PLIF治疗的46例多节段腰椎退变性疾病患者进行回顾性分析,男17例,女29例;年龄38～68岁,平均(56.38±11.63)岁。手术节段:L₂-L₅ 16例(6例融合L_4,5,10例融合L_3,4、L_4,5);L₃-S₁ 30例(11例融合L₅S₁,19例融合L_4,5、L₅S₁).术后分别指术后3个月、术后1年和末次随访。分析内容包括:Oswestry功能障碍指数(ODI)、腰痛和腿痛的视觉模拟评分(VAS),并通过腰椎动力位X线观察节段活动度(ROM)、椎间隙高度(DHI)的变化情况。结果:术后随访时间16～48个月,平均(23.23±7.34)个月,术后3次随访腰痛、腿痛VAS 及ODI均较术前有明显降低 (p<0.01);融合节段椎间隙高度较术前明显增大(p<0.05),邻近非融合节段椎间隙高度与术前比较无明显变化(p>0.05);融合手术节段术后活动度均较术前显着减小(p<0.01),非融合的手术节段活动度均较术前减少(p<0.05).上邻近非融合手术节段活动度术前与术后3个月及术后1年比较差异无统计学意义(p>0.05),但与末次随访时比较时活动度增加(p<0.05).结论:Dynesys动态稳定系统结合PILF治疗腰椎多节段退行性疾病的近期疗效满意,可在融合、非融合中个体化选择。能够部分保留椎间活动度,预防邻近节段早期退变的发生,但长期临床疗效还需长时间临床观察。     

Preoperative pain sensitivity predicts postoperative pain severity and analgesics requirement in lumbar fusion surgery – a prospective observational study

BACKGROUND CONTENTThe goal of postoperative pain management is to facilitate the patient's return to normal activity and decrease the detrimental effects of acute postsurgical pain. In order to provide more tailored and successful pain treatment, it is necessary to identify individuals who are at a high risk of experiencing severe postoperative pain. The most precise way to assess pain sensitivity is by determining the pressure pain threshold and heat pain threshold by objective methods using a digital algometer and neurotouch respectively.PURPOSEThe primary aim of the study is to assess the preoperative pain threshold and its influence on postoperative pain severity and analgesics requirements in patients undergoing lumbar fusion surgeries.STUDY DESIGNProspective, observational study.PATIENT SAMPLESixty patients requiring a single-level lumbar fusion surgery.OUTCOME MEASURESPostoperative pain intensity and the amount of postoperative analgesics consumption.METHODSIn our patients, preoperative pain sensitivity was assessed by pressure pain threshold measurements with the help of a digital algometer, and heat pain threshold using a neurotouch instrument. In addition, pain sensitivity questionnaires (PSQ) were used in all our patients to determine pain sensitivity. Preoperative psychosocial and functional assessments were performed by Hospital anxiety-depression scores (HADS), and Oswestry disability index (ODI) respectively. Preoperative visual analog scale (VAS) score was determined at three instances of needle prick (phlebotomy, glucometer blood sugar, and intradermal antibiotic test dose) and during the range of movements of the lumbar spine region. Postoperative VAS score and postoperative breakthrough analgesic requirements were recorded in all of these patients from day 0 to day 3.RESULTSThe average age of the patients was 51.11±13.467 years and 70% were females. Females had lower mean algometry values (72.14±7.56) compared to males (77.34±6.33). Patients with higher HADS (p<.0016), higher PSQ (p<.001), higher ODI scores(p<.001), and female gender significantly correlated with a lower algometer average indicating high pain sensitivity. Patients with lower preoperative VAS scores and with higher neurotouch scores showed lower postoperative VAS scores at different time periods. Preoperative VAS scores, algometer average scores, neurotouch scores, and HADS scores were considered as independent variables (predictors) for postoperative VAS at 6 hours period. By the multivariate analysis, factors like preoperative VAS scores, algometer average scores, and HADS scores were statistically significant (p<.05). There was a significant correlation between algometer average scores (p<.001) with the breakthrough analgesics.CONCLUSIONPreoperative assessment of pain sensitivity can predict postoperative analgesic requirements and aid in recovery. Patients with a lower pain threshold should be counseled preoperatively and also receive a better titration of analgesics perioperatively.