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脊柱侧凸术中"唤醒后矫形"预防脊髓损伤的临床研究

The "wake-up correction" for preventing spinal cord injury in scoliosis surgery

摘要:

目的 研究"唤醒后矫形"在脊柱侧凸矫形中预防脊髓损伤的有效性.方法 2008年1月至2009年4月,完成21例脊柱侧凸矫形术.其中男性12例,女性9例;年龄14~31岁,平均17.7岁;主弯冠状面Cobb角92°~145°.术前对患者进行唤醒训练.术中维持丙泊酚血药浓度为3~4 mg.L,泵注雷米芬太尼0.15μg.(kg·min),吸入50%N_2O和50%O_2的气流2 L.min.首次唤醒前30 min停用肌肉松弛药,丙泊酚靶浓度渐降至1~2 mg.L,雷米芬太尼减至0.05~0.10μg.(kg·min),将预弯矫形棒与顶椎近侧椎弓根钉相连.唤醒前15 min停用丙泊酚和吸入麻醉药,维持雷米芬太尼用量不变;呼吸恢复后唤醒患者,嘱其按指令活动双侧足趾.然后吸入6%七氟醚、50%N_2O与50%O_2的新鲜气流6 L.min.监测麻醉药最低肺泡有效浓度(MAC)达1.3~1.5时停用吸入麻醉药,用2~3 min完成三维矫正,再次唤醒.记录唤醒所需时间及指令动作恢复时间,术后随访患者对唤醒过程有无记忆.结果 唤醒结果满意.矫形前、后唤醒时间分别为(10.3±4.5)和(4.3±2.3)min.术后Cobb角22°~38°,平均29°,平均矫正率74%.2例患者矫形时轻微躁动.所有患者无脊髓神经损伤,术后对唤醒试验无记忆,无痛苦和恐惧等心理体验.结论 "唤醒后矫形"能较早观察到矫形后脊髓功能,是保证脊柱侧凸矫形手术安全的有效方法之一.

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abstracts:

Objective To observe the effects of "wake-up correction" technique for preventing iatrogenic spinal cord injury in scoliosis surgery. Methods Twenty-one patients who had scoliosis with Cobb's angle 92°-145° received operation of pedicle screw insertion in all or important vertebral bodies, release of stiff segments, decompression and osteotomy. All the patients were trained how to wake up before anesthesia. Maintenance of anesthesia was achieved with infusion of propofol at target-controlled concentration 3-4 mg/L and remifentanil at 0. 15 μg/( kg·Min). Fresh gas 2 L/min of N_2O:O_2 1: 1 was inhaled during mechanical ventilation. Wake-up methods:the muscle relaxant was stopped injection 30 min before wake-up, decreasing propofol's target-controlled concentration to 1-2 mg/L and remifentanil to 0. 05-0. 10 μg/(kg·min). Once the spontaneous respiration returned, waked up the patients and asked them move both toes following our orders (the first wake-up). Then patients inhaled 6% sevoflurane in fresh gas 6 L/min (N_2O: O_2 1: 1). When the end-tidal anesthetic gas concentration was arrived 1. 3-1. 5 MAC, all of the anesthetics were stopped. The correction operation was completed and the patient was waked up again (the second wake-up). Recorded data included time used to wake up, directive action returning time, whether the patient had memory of wake-up during operation when following up. Results All patients waked up with satisfaction. The time taken the first wake-up was ( 10. 3 ±4. 5) min, and for the second was (4. 3 ±2. 3) min. There were two patients who had slightly agitation during correction. There was no one who had neurological injury. There was no memory of wake-up and no pain in all patients during operation. Cobb' angle was corrected to 22°-38° (average 29°), and the correction rate was 74%. Conclusion The "wake-up correction" is effective and satisfactory by detecting the cord function in time.

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