X线引导下经椎间孔硬膜外注射治疗腰椎间盘突出症的疗效观察

目的 探讨X线引导下经椎间孔硬膜外注射（transforaminal epidural steroids injection, TFESI）治疗腰椎间盘突出症的临床疗效。方法 回顾性分析2014年5月至2017年5月我院收治并经X线引导下行TFESI治疗的156例腰椎间盘突出症病人的临床资料,将其纳入观察组,将同期采用牵引、推拿、卧床等保守治疗的150例腰椎间盘突出症病人纳入对照组。收集并比较两组治疗前后的疼痛视觉模拟量表（visual analogue scale, VAS）评分及MacNab治疗有效率。结果 观察组均顺利完成硬膜外注射,无严重并发症发生,8例病人术后出现下肢乏力,于术后3~6 h后恢复;2例病人术后出现头晕、头痛及恶心等症状,于卧床休息后好转。对照组和观察组治疗后的VAS评分分别为（2.21±0.41）分、（1.56±0.32）分,均显著低于同组病人治疗前水平,且观察组得分明显低于对照组,差异均具有统计学意义（P均＜0.05）。末次随访时,观察组有102例显效,26例有效,28例无效,总有效率为82.1%;对照组有68例显效,19例有效,63例无效,总有效率为58.0%,差异有统计学意义（P＜0.05）。结论 X线引导下TFESI治疗腰椎间盘突出症临床疗效好,是介于保守治疗与手术治疗之间的一种有效方法。     

经椎间孔硬脊膜激素封闭治疗腰椎间盘突出症的研究进展

近年来我国腰腿痛的发病率明显增高,而椎间盘突出又是引起腰腿痛的主要原因之一,其所致的功能障碍正日益成为一项公共健康问题[1]。大约80%~90%的患者经保守治疗后病情能得到缓解或者痊愈[2]。若保守治疗无效,方考虑手术治疗。在保守治疗中,硬膜外封闭疗法已广泛应用。硬脊膜穿刺造影技术最早运用于没有CT及MRI检查设备时观察椎管及神经根的受压情况。腰痛及下肢放射痛的原因大多数是由于神经根受机械压迫及椎间盘退变纤维环破裂后髓核组织产生的局部炎症刺激神经根所致。经椎间孔硬脊膜激素封闭（transforaminal epidural steroids injection,TFESI）应用穿刺针经椎弓根下方入路或者Kambin三角入路能直接到达神经根及椎间盘突出部位,通过注射激素控制局部炎症刺激达到缓解根性疼痛目的。应用经椎间孔硬脊膜造影封闭技术治疗由于腰椎间盘突出引起的神经根疼痛,有大量的研究报道。我们把这些研究分为观察性研究（简单描述运用干预方式观察到的结果）、对照性研究（TFESI和其他介入方式的结果进行比较）,综述如下。     

The use of lumbar epidural/transforaminal steroids for managing spinal disease

Lumbar epidural steroid injections are used to manage low back and leg pain (ie, sciatica). Utilization of the procedure is increasing, with Medicare spending for lumbar epidural procedures topping $175 million annually. Few prospective randomized controlled trials have clearly demonstrated the efficacy of epidural steroid injections; many have shown conflicting results. Several studies show favorable short-term outcomes with epidural steroid injection for radicular pain, but less conclusive results are achieved >6 months. Methodologic flaws limit interpretation of results from most scientific studies. As a tool for predicting surgical outcome, epidural spinal injection has been found to have a sensitivity between 65% and 100%, a specificity between 71% and 95%, and a positive predictive value as high as 95% for 1-year surgical outcome. Despite inconclusive evidence, when weighing the surgical alternatives and associated risk, cost, and outcomes, lumbar epidural steroid injections are a reasonable nonsurgical option in select patients.     

Effects of lumbar epidural anesthesia on brainstem auditory response

Auditory brainstem responses (ABR) are used increasingly to monitor the integrity of neural pathways in anesthetized patients. To evaluate the effect of epidural anesthesia on the central nervous system, we studied the effects of lumbar epidural anesthesia with lidocaine on the ABR in 10 patients. The seven peak latencies (waves I-VII) and amplitudes (waves I-VII) of the ABR were recorded before and 15 min after epidural anesthesia. Peak latencies of waves III, IV, V, VI, VII increased after epidural anesthesia compared with control values. Amplitude of waves II only decreased significantly following epidural anesthesia compared with control values. We further compared the interpeak latencies to investigate the brainstem transmission. Interpeak latencies (I-II, II-III, III-IV, IV-V, V-VI, VI-VII) were unchanged from the control values except waves VI-VII interval. Interpeak latencies of every second peak (II-IV, IV-VI, V-VII), of every third peak (II-V, III-VI, IV-VII), of every forth peak (I-VI, II-VII), of every fifth peak (I-VII) increased after epidural anesthesia compared with control values. The data obtained in the study demonstrated that lumbar epidural anesthesia with lidocaine prolonged the interpeak latencies of ABR. Considering that the waves of ABR are related to anatomically distinct sites in the auditory pathway (I; Acoustic nerve, II; Cochlear nucleus, III; Superior olivary complex, IV; Lateral lemniscus, V; Inferior colliculus, VI: Medial geniculate body, VII; Auditory radiation), the delay in the latencies of ABR seems to be present in the time intervals which involve more than two or three synaptic transmissions.     

A retrospective study of epidural and intravenous steroids after percutaneous endoscopic lumbar discectomy for large lumbar disc herniation

Objective: To assess the early curative effect of epidural or intravenous administration of steroids during a percutaneous endoscopic lumbar discectomy (PELD).Methods: 28 consecutive patients who underwent PELD due to large lumbar disc herniation betweenNovember 2014 and January 2016 were followed up for 6 months. These patients were divided into twogroups according to the treatment they received after PELD. 14 patients (Group A) were treated by PELD and epidural steroids, while the other 14 patients (Group B) were treated by PELD and intravenous steroids. We evaluated the effectiveness by the preoperative and postoperative visual analogue scale (VAS) scores for back and leg pain, and the postoperative Oswestry disability index (ODI) at 3 weeks after surgery via the clinical charts and telephone interview. Postoperative hospital stay and time return to work were investigated as well.Results: There is a significant decrease in VAS (back, leg), ODI, and time return to work (p < 0.05). For VAS (back), Group A showed a significant decrease compared with Group B at 1 day and 1 week after surgery (p=0.011, p=0.017). As for VAS (leg), Group A showed a significant decrease compared with Group B at 1 day, 1 week, 3 weeks, and 3 months follow-up examinations (p=0.002, p=0.006, p < 0.001, p < 0.001). For ODI, Group A showed a notable decrease compared with Group B (p < 0.001). Thepostoperative hospital stay in two groups was not statistically different (p=0.636). But the time return to work in Group A was significantly shorter than that in Group B (p=0.023).Conclusion: Patients who underwent PELD with epidural steroid administration for large lumbar discherniation showed favorable curative effect compared with those who underwent PELD with intravenous steroid administration.     

Paraesthesia with lumbar epidural catheters.

The epidural space was located in 32 obstetric patients using loss of resistance to air, while in a further 35 saline was used. The incidence of paraesthesia was 56% in the air group and 57% in the saline group. There was no significant difference between the groups in terms of other complications or in the quality of analgesia provided.     

不同硬膜外阻滞对患者异丙酚镇静效应的影响

目的 评价不同硬膜外阻滞对患者异丙酚镇静效应的影响.方法 择期行肠癌根治术患者30例和胃癌根治术患者15例,年龄20～64岁,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将肠癌根治术患者随机分为2组(n=15):生理盐水对照组(Ⅰ组)和腰段硬膜外阻滞组(Ⅱ组);胃癌根治术患者为胸段硬膜外阻滞组(Ⅲ组).Ⅰ组和Ⅱ组于L2.3间隙行硬膜外穿刺置管,Ⅲ组于L9.10间隙行硬膜外穿刺置管,Ⅱ组和Ⅲ组硬膜外注射1.5％利多卡因15 ml(包括试验量3 ml);Ⅰ组给予等容量生理盐水.于硬膜外给药后12 min时TCI异丙酚,血浆靶浓度4μg/ml.于输注异丙酚前记录硬膜外阻滞范围(阻滞脊神经数);分别于输注异丙酚2、3、4、5min时采集动脉血样,测定血浆异丙酚浓度,同时记录各时间点TCI泵计算的异丙酚血浆浓度和BIS值.结果 与Ⅰ组比较,Ⅱ组和Ⅲ组BIS值降低(P＜0.05),血浆异丙酚浓度和异丙酚血浆计算浓度差异无统计学意义(P＞0.05);与Ⅱ组比较,Ⅲ组BIS值降低,硬膜外阻滞范围较广(P＜0.05),血浆异丙酚浓度和异丙酚血浆计算浓度差异无统计学意义(P＞0.05).结论 胸段硬膜外阻滞强化患者异丙酚镇静效应的程度高于腰段硬膜外阻滞.     

The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study

Seventy-three patients with lumbar radicular pain syndromes were treated in a prospective, randomized, double-blind fashion with either seven milliliters of methylprednisolone acetate and procaine or seven milliliters of physiological saline solution and procaine. All patients had radiographic confirmation of lumbar nerve-root compression, consistent with the clinical diagnosis of either an acute herniated nucleus pulposus or spinal stenosis. No statistically significant difference was observed between the control and experimental patients with either acute disc herniation or spinal stenosis. Long-term follow-up, averaging twenty months, failed to demonstrate the efficacy of a second injection of epidural steroids administered to the patients whose pain did not respond within twenty-four hours to an injection of either eighty milligrams of methylprednisolone acetate combined with five milliliters of 1 per cent procaine or two milliliters of sterile saline combined with five milliliters of 1 per cent procaine. Therefore, a decision to use epidural steroids must be made with the realization that we failed to demonstrate its clinical efficacy in this study and that reports of serious complications of this procedure have been published.     

Some vagaries of neonatal lumbar epidural anaesthesia.

Regional anaesthesia and analgesia offer unique advantages of reduction in general anaesthesia requirements and the demands on NICU resources while improving the general outcome. We assessed the feasibility of continuous lumbar epidural analgesia in 20 neonates for various major surgical procedures lasting from 60-260 min. The babies were aged 18 h to 34 days. They were born at a gestational age of 31-40 weeks. We had difficulty in passing the epidural catheter from the lumbar route in two patients, so we had to resort to the caudal route. The problems associated with the placement of the catheter from the lumbar route are discussed. The analgesia was provided for up to 72 h. Nineteen of the babies could be extubated in the operating theatre. They were awake but comfortable at the time of extubation. There were no complications due to the technique. Subsequent to this study, epidural analgesia either by lumbar or caudal route has become the routine in our hospital for all major thoraco-abdominal surgical procedures in neonates.     

Effects of lumbar or thoracic epidural anesthesia on median nerve somatosensory evoked potentials

Somatosensory evoked potentials (SSEP) are used increasingly to monitor the integrity of neural pathways in anesthetized patients. To evaluate the influence of epidural anesthesia on the central nervous system, we studied the effects of lumbar or thoracic epidural anesthesia with lidocaine on the median nerve SSEP in 9 patients. The peak latencies (N1, P2, N2) and amplitudes (N1-P2, P2-N2) of the SSEP response over the sensory cortex were recorded before and 15 min after epidural anesthesia. The peak latencies of control and post epidural anesthesia of N1, P1, N2 were 19.2 +/- 1.7 msec, 19.6 +/- 1.6 msec (N1), 24.7 +/- 2.3 msec, 25.7 +/- 2.0 msec (P2), 32.8 +/- 2.8 msec and 34.6 +/- 2.5 msec (N2), respectively. The amplitude of control and post epidural anesthesia of N1-P2, P2-N2 were 4.5 +/- 2.9 microV, 5.9 +/- 6.6 microV (N1-P2), 4.4 +/- 3.2 microV and 5.6 +/- 5.2 microV (P2-N2), respectively. Peak latencies of all components (L1, P2, N2) increased after epidural anesthesia compared with control values. Amplitude of N1-P2 increased significantly following epidural anesthesia compared with control values. The data obtained in this study were contrary to the previous concept that anesthetic agents generally increase the latency of SSEP and decrease their amplitude.     

Coiling of lumbar epidural catheters

BACKGROUND: The difficulties in threading an epidural catheter to vertebral levels remote to the puncture level have been well documented. This study was undertaken to determine the length that a single orifice epidural catheter can be threaded into the lumbar space without coiling (coiling length), and whether this is affected by the direction of the epidural needle bevel. METHODS: Forty-five young male patients scheduled for surgery under epidural analgesia were enrolled. The epidural space was identified using a midline approach at the L(2-3) or L(3-4) interspace with the loss of resistance to air technique. A 19-G single-orifice epidural catheter (Flextip Plus, Arrow International, Inc, Reading, PA, USA) was inserted through a Tuohy needle oriented either cephalad (n=20) or caudad (n=25). During insertion, the path and the position of the catheter tip was determined by fluoroscopy using iohexol dye. RESULTS: The median coiling length was 2.8 cm, ranging from 1.0 to 8.0 cm. Only 13% of epidural catheters could be threaded 4 cm beyond the tip of the needle without coiling. No significant difference was found in coiling length between the cephalad group (2.9 cm) and the caudad group (2.5 cm). CONCLUSION: This study demonstrates that coiling length is independent of whether the bevel of the Tuohy needle is directed cephalad or caudad. We recommend that an optimal insertion depth of an end-hole single orifice catheter is 3 cm.     

Effects of material properties of femoral hip components on bone remodeling.

Bone loss around femoral hip stems is one of the problems threatening the long-term fixation of uncemented stems. Many believe that this phenomenon is caused by reduced stresses in the bone (stress shielding). In the present study the mechanical consequences of different femoral stem materials were investigated using adaptive bone remodeling theory in combination with the finite element method. Bone-remodeling in the femur around the implant and interface stresses between bone and implant were investigated for fully bonded femoral stems. Cemented stems (cobalt-chrome or titanium alloy) caused less bone resorption and lower interface stresses than uncemented stems made from the same materials. The range of the bone resorption predicted in the simulation models was from 23% in the proximal medial cortex surrounding the cemented titanium alloy stem to 76% in the proximal medial cortex around the uncemented cobalt-chrome stem. Very little bone resorption was predicted around a flexible, uncemented "iso-elastic" stem, but the proximal interface stresses increased drastically relative to the stiffer uncemented stems composed of cobalt-chrome or titanium alloy. However, the proximal interface stress peak was reduced and shifted during the adaptive remodeling process. The latter was found particularly in the stiffer uncemented cobalt-chrome-molybdenum implant and less for the flexible iso-elastic implant.     

Clinical use of spinal or epidural steroids

Steroids, drugs with potent antiinflammatory properties on the damaged nervous roots, have been especially used as adjuvants of local anesthetics, by spinal route, in the treatments of low-back pain. Spinal route was chosen to obtain a higher local concentration of drug, with few systemic side effects and to improve drug's action mechanism. Steroids seem to interact with GABA receptors and thus control neural excitability through a stabilising effect on membranes, modification of nervous conduction and membrane hyperpolarization, in supraspinal and spinal site. Epidural steroids are especially used in the treatment of low back pain due to irritation of nervous roots. They have been administered alone or in association with local anesthetics and/or saline solution. Slow release formulations have been generally used (methylprednisolone acetate, and triamcinolone diacetate). Other indications of epidural steroids are: postoperative hemilaminectomy pain, prevention of post herpetic neuralgia, degenerative ostheoartrithis. Intra-thecal steroids have been frequently used in the treatment of lumbar radiculopathy due to discopathy, as an alternative treatment when epidural administration is ineffective. Positive results have been obtained with methylprednisolone acetate, alone or in association with local anesthetics. Complications related to intraspinal steroids injections are due to execution of the block and side effects of drugs. Complications associated with intrathecal steroids are more frequent and severe than epidural injections and include: adhesive arachnoiditis, aseptic meningitis, cauda equina syndrome. Steroidal toxicity seems to be related to the polyethylenic glycole vehicle. Anyway, slow release formulations contain less concentrated polyethylenic glycole. The epidural administration, a correct dilution of steroid with local anesthetics solution and/or saline solution, and a limited number of injections (no more than three) allows a significant reduction of steroid neurotoxicity.     

Effects of thoracic vs. lumbar epidural anaesthesia on systemic haemodynamics and coronary circulation in sevoflurane anaesthetized dogs

Background : Although many investigators reported changes in coronary circulation during thoracic epidural anaesthesia (TEA), no previous studies have attempted to compare it with lumbar epidural anaesthesia (LEA) concerning coronary circulation. Our aim was to compare effects of TEA on systemic haemodynamics and coronary circulation with those of LEA in anaesthetized dogs. Methods : In dogs receiving 1.5% sevoflurane, 2% lidocaine (0.1 ml kg^?1)was injected into the epidural space via an epidural catheter inserted at either the T7-T8 (TEA group, n=8) or L5-L6 (LEA group, n=8) interspace, and the same dose was repeated again 30 min later. Results : Heart rate and maximum left ventricular dP/dt decreased in the TEA group but were unchanged in the LEA group. Decreases in mean arterial pressure were found for both groups, and they were more substantial in the TEA than in the LEA group. Decreases in left ventricular minute work index were found for both groups, and they tended to be more substantial in the TEA than in the LEA group. Coronary perfusion pressure and blood flow decreased in both groups. Calculated coronary vascular resistance increased in the TEA group but was unchanged in the LEA group. Conclusion : The most significant difference between TEA and LEA concerning coronary circulation was characterized by an increase in coronary vascular resistance in the TEA group, which was not present in the LEA group. The increase in coronary vascular resistance caused by TEA may be explained by a coronary vasoconstriction caused by a lower myocardial oxygen demand.