腰丛联合坐骨神经阻滞在高龄患者髋关节置换中的应用

目的探讨腰丛联合坐骨神经阻滞对高龄髋关节置换术患者术后疼痛的缓解作用及对认知功能的保护机制。 方法选取2016年6月至2018年5月于海南省万宁市人民医院行单次全髋关节置换术的高龄患者120例，年龄80~100岁，纳入标准：年龄范围为80~100岁，美国麻醉医师协会(ASA)分级Ⅱ~Ⅲ级；符合全髋关节置换术相关手术指征；认知功能正常。排除标准：合并严重原发疾病者；合并精神病或神经系统疾病者；依从性较差者；对本研究麻醉方案过敏者。所有患者采用随机数字表法分为两组：全身麻醉组(GA组)，腰丛-坐骨神经阻滞组(PCSNB组)，每组各60例。比较两组术中情况(麻醉操作时间、手术时间、术中出血量、术中补液量)，手术前后血清碱性成纤维细胞生长因子(bFGF)水平。采用视觉模拟量表(VAS)评估两组患者术后疼痛程度，采用简易精神状态量表(MMSE)及蒙特利尔认知评估量表(MoCA)评估两组患者认知功能。正态分布的计量资料采用t检验，同一指标在3个以上不同时间点上比较，采用重复测量方差分析。 结果PCSNB组麻醉操作时间显著高于GA组(t＝17.74，P<0.001)，术中出血量及术中补液量均显著低于GA组(t＝7.56、14.59、7.60，均为P<0.001)。术后1 d两组血清bFGF水平均有所下降(t＝13.14、6.82，均为P<0.001)，但PCSNB组血清bFGF水平显著高于GA组(t＝7.43，P <0.001)。PCSNB组术后2、12及24 h的VAS评分显著低于对照组(F＝8.03、6.56，均为P <0.001)。术后1 d，PCSNB组MMSE评分及MoCA评分均显著低于对照组(t＝3.89、4.58，均为P <0.001)。 结论腰丛联合坐骨神经阻滞可减轻高龄髋关节置换术患者术后疼痛，对患者认知功能具有保护作用，可能与bFGF水平有关。

Application of lumbar plexus combined with sciatic nerve block in total hip arthroplasty of elderly patients

ObjectiveTo investigate the preventive effect of lumbar plexus combined with sciatic nerve block on postoperative pain in elderly patients undergoing hip arthroplasty and the protective mechanism of cognitive function. MethodsA total of 120 patients, aged from 80 to 100 years, who underwent a single total hip arthroplasty in Wanning People′s Hospital from June 2016 to May 2018 were selected. Inclusion criteria: the American Society of Anesthesiologists (ASA) class II to III; the patients met the relevant surgical indications for total hip arthroplasty; the cognitive function was normal. Exclusion criteria: the patients with severe primary diseases; psychiatric or neurological diseases; poor compliance; those who were allergic to the anesthesia protocol of this study. All the patients were divided into two groups by random number table method: general anesthesia group (GA group), lumbar plexus-sciatic nerve block group (PCSNB group), 60 cases in each group. The intraoperative conditions (anesthesia operation time, operation time, intraoperative blood loss, intraoperative fluid volume), and serum basic fibroblast growth factor (bFGF) levels before and after the operation were compared between the two groups. The visual analog scale (VAS) score was used to evaluate the postoperative pain, and the mini mental state scale (MMSE) and the Montreal cognitive assessment (MoCA) were used to evaluate the cognitive function. Measurement data of normal distribution were analyzed by t test; the same index which was different at more than three time points were compared by repeated measures analysis of variance. ResultsThe anesthesia operation time in PCSNB group was significantly higher than that in GA group (t=17.74, P<0.001), and the intraoperative blood loss and intraoperative fluid replacement volume were significantly lower than those in GA group (t=7.56, 14.59, 7.60, all P<0.001). On the first day after the operation, the serum bFGF levels of the two groups were decreased (t=13.14, 6.82, both P<0.001), but the serum bFGF levels in the PCSNB group were significantly higher than those in the GA group (t=7.43, P<0.001). The VAS scores of the PCSNB group at two, 12 and 24 h after the operation were significantly lower than those of the control group (F=8.03, 6.56, both P < 0.001). One day after the operation, the MMSE score and MoCA score of the PCSNB group were significantly lower than those of the control group (t=3.89, 4.58, both P < 0.001). ConclusionLumbar plexus combined with sciatica block can relieve postoperative pain in elderly patients undergoing hip arthroplasty and has protective effect on cognitive function, which may be related to the level of bFGF.