骨质疏松症的治疗对老年腰椎结核患者术后快速康复的影响

doi:10.3969/j.issn.1000-6621.2021.05.004

摘要/Abstract

摘要：

目的探讨围手术期骨质疏松症的治疗对老年腰椎结核患者术后快速康复的影响。方法回顾性分析2017年2月至2020年1月首都医科大学附属北京胸科医院收治的接受手术治疗的92例老年(年龄≥60岁)腰椎结核患者。入组患者均存在腰椎骨质疏松,所有患者均接受加速康复外科(enhanced recovery after surgery,ERAS)模式管理。将其中接受抗骨质疏松症治疗的患者作为观察组,共计48例;未接受抗骨质疏松症治疗的患者作为对照组,共计44例。通过比较两组患者的手术治疗时间、术中出血量、术后疼痛视觉模拟评分(visual analogue scale,VAS)变化情况、术后卧床时间、术后植骨融合时间、术后椎弓根螺钉松动情况、术后并发症发生率之间的差异,明确围手术期骨质疏松的治疗对老年腰椎结核患者术后快速康复的影响。结果 92例患者腰椎结核均获得治愈。经抗骨质疏松症治疗后,观察组患者术后卧床时间[(3.17±0.83)周]、术后植骨融合时间[(3.73±1.73)个月]、术后椎弓根螺钉松动发生率(6.2%,3/48)均低于对照组[分别为(3.91±0.86)周、(4.39±1.37)个月、15.9%(7/44)],差异均有统计学意义(t=-4.208,P<0.001;t=-2.333,P=0.022;χ²=4.310,P=0.038)。观察组和对照组患者在手术治疗时间[(182.71±52.16)min和(173.75±37.83)min]、术中出血量[(365.83±109.21)ml和(409.32±127.34)ml]、术后VAS评分改善情况[(5.29±1.24)分和(5.07±1.06)分]、术后并发症发生率[27.1%(13/48)和25.0%(11/44)]之间差异均无统计学意义(t=0.936,P=0.352;t=-1.762,P=0.088;t=1.033,P=0.304;χ²=0.231,P=0.631)。结论围手术期抗骨质疏松症治疗能够缩短患者术后卧床时间,维持椎弓根螺钉位置,加速植骨融合,可以作为老年腰椎结核并发骨质疏松患者ERAS措施中的组成部分。

关键词: 结核,脊柱, 腰椎, 骨质疏松, 康复

Abstract:

Objective To investigate the effect of perioperative osteoporosis treatment on enhanced recovery after surgery (ERAS) among elderly patients with lumbar tuberculosis. Methods Retrospective analysis was performed on 92 elderly patients (age ≥60 years) with lumbar tuberculosis who received surgical treatment in Beijing Chest Hospital of Capital Medical University from February 2017 to January 2020. All patients enrolled in the study had comorbidity of lumbar osteoporosis, and all patients received ERAS mode management. The patients were divided into the experimental group (48 cases) receiving anti-osteoporosis treatment and the control group (44 cases) not receiving anti-osteoporosis treatment. The effects of perioperative osteoporosis treatment on ERAS among elderly patients with lumbar tuberculosis were determined by comparing the differences of operative time, intraoperative blood loss, postoperative VAS score changes, postoperative bed time, postoperative bone graft fusion time, postoperative pedicle screw loosening, and postoperative complication rate. Results Lumbar tuberculosis was cured in all enrolled patients. After anti-osteoporosis treatment, postoperative bed rest time ((3.17±0.83) weeks), postoperative bone graft fusion time ((3.73±1.73) months) and postoperative incidence of pedicle screw loosening (6.2%, 3/48) in the experiemental group were lower than those ((3.91±0.86) weeks, (4.39±1.37) months, 15.9% (7/44)) in the control group, the differences were statistically significant (t=-4.208, P<0.001; t=-2.333, P=0.022; χ ²=4.310, P=0.038). There were no significant differences in operative time ((182.71±52.16) min, (173.75±37.83) min), intraoperative blood loss ((365.83±109.21) ml, (409.32±127.34) ml), postoperative VAS score improvement (5.29±1.24, 5.07±1.06) and postoperative complication rate (27.1% (13/48), 25.0% (11/44)) between the two groups (t=0.936, P=0.352; t=-1.762, P=0.088; t=1.033, P=0.304; χ ²=0.231, P=0.631). Conclusion Perioperative anti-osteoporosis therapy is an important part of ERAS measures for elderly lumbar tuberculosis patients complicated with osteoporosis, which can shorten postoperative bed time, maintain pedicle screw position, and accelerate bone graft fusion.

Key words: Tuberculosis, spinal, Lumbar vertebrae, Osteoporosis, Rehabilitation

李元, 秦世炳, 董伟杰, 范俊, 兰汀隆, 唐恺, 严广璇, 王恒. 骨质疏松症的治疗对老年腰椎结核患者术后快速康复的影响[J]. 中国防痨杂志, 2021, 43(5): 432-436. doi: 10.3969/j.issn.1000-6621.2021.05.004

LI Yuan, QIN Shi-bing, DONG Wei-jie, FAN Jun, LAN Ting-long, TANG Kai, YAN Guang-xuan, WANG Heng. Effect of osteoporosis therapy on enhanced recovery after surgery among elderly patients with lumbar tuberculosis[J]. Chinese Journal of Antituberculosis, 2021, 43(5): 432-436. doi: 10.3969/j.issn.1000-6621.2021.05.004

图/表 3

表1

围手术期ERAS管理措施

时期	围手术期ERAS管理措施
术前
术前宣教	(1)常规住院相关注意事项;(2)疾病发生机制及发展过程;(3)手术治疗的目的、手术方式、手术风险、可能出现的围手术期并发症;(4)围手术期可能出现的症状波动、并发症、预防及干预措施;(5)ERAS干预模式的具体流程;(6)指导并监督患者术前戒烟
骨质疏松管理	门诊行骨密度检查(所有入组患者),根据骨质疏松程度制定相应的抗骨质疏松治疗(只限于观察组中的患者)
术前血栓预防	(1)入院后穿戴抗血栓弹力袜;(2)四肢训练、双下肢静力性收缩,踝泵训练等;(3)根据Caprini评分,必要时采用低分子肝素钠 5000U皮下注射
术前营养	(1)评估患者全身营养状态,增加蛋白质摄入,营养风险筛查评分表(nutrition risk screening,NRS)>3分时需要进行营养科会诊;(2)高血压患者采用低盐低脂饮食,糖尿病患者采用糖尿病饮食
睡眠改善	予以艾司唑仑等药物辅助睡眠,消除紧张焦虑情绪,保证睡眠充足
术前镇痛	(1)根据疼痛视觉模拟评分决定是否给予镇痛药物;(2)所有患者术前1d给予氟比洛芬酯注射液超前镇痛
术前禁食	术前6h禁食固态食物,术前2h予以200ml碳水化合物口服
术前抗生素	选择二代广谱头孢类抗生素于术前30min内静脉滴注预防感染
术中
麻醉方式	全身麻醉
血压管理	术中收缩压控制在80~90mm Hg(1mm Hg=0.133kPa),舒张压控制在50~65mm Hg,减少术中出血;血压控制应根据患者血压情况,制定个体化方案
给氧管理	80%高浓度吸氧
体温管理	术中使用保温毯、暖风机等维持体温不低于36℃
手术操作	手术完毕缝合切口前以罗哌卡因局部皮下注射,缓解术后切口疼痛
术后
镇痛	术后2d内予以氟比洛芬酯注射液静脉滴注(50mg/次,2次/d),术后3~14d口服止痛药物
体液管理	适量补液,且限制静脉液体输入量,患者进食后减少静脉液体输入量
饮食管理	麻醉清醒后请患者安全返回病房,待无恶心呕吐等不适症状后由流质饮食过度到正常饮食
尿管管理	术后第2日拔除尿管
睡眠管理	术后继续应用睡眠辅助药物改善患者睡眠
早期活动	术后在腰椎支具的保护下行走活动
功能锻炼	术后第2日由脊柱外科医师或康复科医师进行功能锻炼宣教
随访	术后1、2、3、6、9、12个月进行门诊随访,不舒服就随时来医院就诊、看病,以及指导后期功能锻炼

表1

表2

不同临床特征在两组患者中的分布情况

临床特征	观察组(48例)	对照组(44例)	统计检验值	P值
年龄(岁, $x ˉ$ ±s)	69.30±6.97	67.20±5.74	t=0.412	0.681
性别[例(构成比,%)]			χ²=0.033	0.856
男	26(54.2)	23(52.3)
女	22(45.8)	21(47.7)
术前腰椎骨质疏松情况
T值( $x ˉ$ ±s)	-(3.20±0.47)	-(3.30±0.44)	t=-1.708	0.091

表2

表3

各术中及术后观察指标在两组患者间的比较

观察指标	观察组(48例)	对照组(44例)	统计检验值	P值
手术时间(min, $x ˉ$ ±s)	182.71±52.16	173.75±37.83	t=0.936	0.352
术中出血量(ml, $x ˉ$ ±s)	365.83±109.21	409.32±127.34	t=-1.762	0.088
术后VAS评分改善情况(分, $x ˉ$ ±s)	5.29±1.24	5.07±1.06	t=1.033	0.304
术后卧床时间(周, $x ˉ$ ±s)	3.17±0.83	3.91±0.86	t=-4.208	<0.001
术后植骨融合时间(月, $x ˉ$ ±s)	3.73±1.73	4.39±1.37	t=-2.333	0.022
术后并发症^a	27.1(13/48)	25.0(11/44)	χ²=0.231	0.631
术后椎弓根螺钉松动^a	6.2(3/48)	15.9(7/44)	χ²=4.310	0.038

表3

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