【摘要】：背景：近年來(lái),隨著經(jīng)濟(jì)的蓬勃發(fā)展以及人民生活水平的不斷提高,老百姓對(duì)自身健康的關(guān)注日漸增加,疼痛作為“第五生命體征”已經(jīng)日漸成為診療過(guò)程中患者越來(lái)越關(guān)注的問(wèn)題。在外科領(lǐng)域,患者術(shù)后最直接關(guān)切的則是術(shù)后疼痛帶來(lái)的痛苦與折磨。脊柱外科學(xué)是近年來(lái)的一門(mén)新興尖端學(xué)科,多數(shù)疾病需要經(jīng)歷手術(shù)治療過(guò)程。脊柱手術(shù)創(chuàng)傷大、失血多、手術(shù)持續(xù)時(shí)間長(zhǎng),術(shù)后易較早期產(chǎn)生術(shù)區(qū)疼痛,若處理不當(dāng)則往往會(huì)演變成慢性疼痛,隨之而來(lái)的而是一系列不良并發(fā)癥的產(chǎn)生,延緩患者術(shù)后康復(fù)進(jìn)程,影響總體手術(shù)預(yù)期。由此看來(lái),及時(shí)處理術(shù)后疼痛十分關(guān)鍵且必要。臨床上經(jīng)驗(yàn)性鎮(zhèn)痛方法效果差,療效欠佳,然而目前業(yè)內(nèi)尚缺乏針對(duì)性、模式化的疼痛治療方案和更加高效、有序、成熟的術(shù)后疼痛管理經(jīng)驗(yàn)。研究、探討無(wú)痛治療模式下的脊柱術(shù)后鎮(zhèn)痛療效為脊柱外科醫(yī)師提供了術(shù)后疼痛管理新選擇。 目的：運(yùn)用隨機(jī)對(duì)照的方法研究在由本科室創(chuàng)建的無(wú)痛治療模式(PTM, Pain-free Therapy Mode)管理下自行配置復(fù)合鎮(zhèn)痛方劑(羅哌卡因+嗎啡+腎上腺素)治療脊柱胸腰椎體骨折后路切開(kāi)復(fù)位釘棒系統(tǒng)內(nèi)固定術(shù)術(shù)后疼痛的臨床綜合鎮(zhèn)痛效果。 方法：隨機(jī)選擇80位病人預(yù)備行經(jīng)后路胸、腰椎切開(kāi)復(fù)位內(nèi)固定植入手術(shù)治療,胸椎27例(T11、T12),腰椎42例(L1-L4),胸腰椎復(fù)合(11例),壓縮性、爆裂性診斷為主。采用雙盲法隨機(jī)將患者分為研究組和對(duì)照組各40例,兩組患者術(shù)前VAS疼痛評(píng)分無(wú)統(tǒng)計(jì)學(xué)差異(P0.05)。研究組采用由我科創(chuàng)建的無(wú)痛治療模式鎮(zhèn)痛方案,所有病人術(shù)前均給予西樂(lè)葆口服實(shí)施預(yù)先鎮(zhèn)痛,術(shù)畢縫皮前給予自配復(fù)合鎮(zhèn)痛方劑(嗎啡+羅哌卡因+腎上腺素)稀釋于生理鹽水中注射于椎旁肌。手術(shù)結(jié)束患者麻醉清醒后給予及通安口服,痛時(shí)給藥,必要時(shí)皮下注射嗎啡補(bǔ)救鎮(zhèn)痛。對(duì)照組術(shù)前給予西樂(lè)葆口服,術(shù)畢椎旁肌肌注生理鹽水作為對(duì)照,術(shù)后同樣給予及通安口服鎮(zhèn)痛,必要時(shí)嗎啡補(bǔ)救加強(qiáng)。記錄補(bǔ)救鎮(zhèn)痛嗎啡用量、次數(shù)。記錄術(shù)后4、8、12、24、36和48h病人切口疼痛VAS評(píng)分,評(píng)分標(biāo)準(zhǔn)結(jié)合視覺(jué)模擬評(píng)分法(VAS)與NRS數(shù)字量表,與此同時(shí),記錄鎮(zhèn)靜評(píng)分和不良反應(yīng)(皮膚瘙瘁、頭暈、惡心、嘔吐、呼吸抑制)發(fā)生情況,調(diào)查患者總體手術(shù)滿意率。 結(jié)果：共有71例患者進(jìn)入最后統(tǒng)計(jì)學(xué)分析,其中研究組37例,對(duì)照組34例。研究組與對(duì)照組病人術(shù)后4、8、12、24、36小時(shí)刀口疼痛VAS評(píng)分均有所降低,鎮(zhèn)靜評(píng)分有所升高,但研究組各時(shí)點(diǎn)疼痛評(píng)分顯著低于對(duì)照組,下降趨勢(shì)更明顯,兩組間疼痛評(píng)分差異有高度統(tǒng)計(jì)學(xué)意義(P0.01)。48小時(shí)以后兩組間差異開(kāi)始減小。另外,統(tǒng)計(jì)顯示兩組病人術(shù)后有關(guān)不良副反應(yīng)沒(méi)有統(tǒng)計(jì)學(xué)差異(P0.05),并且,研究組患者整體鎮(zhèn)痛滿意度和信心指數(shù)明顯高于對(duì)照組患者(P0.05)。此外,我們還觀察到了研究組與對(duì)照組相比有著較少的術(shù)后嗎啡補(bǔ)救鎮(zhèn)痛次數(shù)、用量以及多學(xué)科會(huì)診次數(shù)。 結(jié)論：在無(wú)痛治療模式管理下羅哌卡因、腎上腺素、嗎啡組成復(fù)合鎮(zhèn)痛方劑用于脊柱后路胸腰椎壓縮、爆裂骨折開(kāi)放手術(shù)術(shù)后疼痛的控制治療取得了良好的術(shù)后鎮(zhèn)痛、鎮(zhèn)靜效果,副作用少,安全性高,有效減輕了術(shù)后疼痛給患者帶來(lái)的痛苦,使患者得到了較滿意的睡眠質(zhì)量,提高了患者的整體手術(shù)滿意度,極大促進(jìn)了患者的術(shù)后早期功能鍛煉與全面康復(fù)。無(wú)痛治療模式為脊柱外科臨床醫(yī)師提供了全新的、可靠的鎮(zhèn)痛選擇。
[Abstract]:BACKGROUND: In recent years, with the vigorous development of economy and the continuous improvement of people's living standards, people pay more and more attention to their own health. Pain as the "fifth vital sign" has increasingly become a problem of concern to patients in the process of diagnosis and treatment. In the field of surgery, postoperative pain zone is the most direct concern of patients after surgery. Spinal surgery is a new and cutting-edge subject in recent years. Most diseases need to undergo surgical treatment. Spinal surgery is characterized by severe trauma, excessive blood loss, long duration of surgery, and early postoperative pain. If not handled properly, it often evolves into chronic pain, followed by a series of adverse reactions. From this point of view, it is very important and necessary to deal with postoperative pain promptly. Clinical experience analgesia method is ineffective and ineffective. However, there is still a lack of pertinence in the industry, the model of pain treatment program and more efficient, orderly, mature postoperative pain tube. To explore the analgesic effect of painless spinal surgery provides spinal surgeons with a new choice for postoperative pain management.
Objective: To study the clinical analgesic effect of ropivacaine + morphine + epinephrine self-administered compound analgesic prescription (Ropivacaine + morphine + epinephrine) in the treatment of pain after posterior open reduction and screw rod system internal fixation for thoracolumbar spine fractures by randomized controlled study.
Methods: 80 patients were randomly selected for posterior thoracotomy, lumbar open reduction and internal fixation, including 27 cases of thoracic vertebrae (T11, T12), 42 cases of lumbar vertebrae (L1-L4), thoracolumbar vertebrae complex (11 cases), compression and burst diagnosis. All patients were given Celebrex orally before operation for preemptive analgesia, and self-made compound analgesic prescription (morphine + ropivacaine + adrenaline) was given to dilute paravertebral muscle in normal saline before operation. The control group was given Celebrex orally before operation, paravertebral muscles were injected with normal saline as control, and the same was given Hetong'an orally after operation. Morphine remedy was strengthened when necessary. The amount and times of morphine remedial analgesia were recorded. Visual analogue scale (VAS) and NRS digital scale were used to evaluate the VAS score of incision pain in H patients. Meanwhile, sedation score and adverse reactions (skin distemper, dizziness, nausea, vomiting, respiratory depression) were recorded to investigate the overall satisfaction rate of the patients.
Results: A total of 71 patients entered the final statistical analysis, including 37 cases in the study group and 34 cases in the control group. The VAS scores of knife-edge pain in the study group and the control group were decreased at 4,8,12,24,36 hours after operation, and the sedation scores were increased, but the pain scores in the study group were significantly lower than those in the control group at each time point, and the downward trend was more obvious. The difference between the two groups was statistically significant (P 0.01). After 48 hours, the difference between the two groups began to decrease. In addition, statistics showed that there was no statistical difference in postoperative adverse reactions between the two groups (P 0.05), and the overall satisfaction and confidence index of the study group were significantly higher than those of the control group (P 0.05). Compared with the control group, there were fewer times of postoperative morphine remedial analgesia, dosage and multidisciplinary consultation.
Conclusion: Ropivacaine, epinephrine and morphine combined analgesic prescriptions under painless management can be used to control the pain after open surgery for burst fractures and thoracolumbar vertebral compression through posterior approach. The painless treatment mode provides a new and reliable analgesic option for spinal surgery clinicians.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R687.3

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