摘要目的 评价不同入路胸腰筋膜间平面(TLIP)阻滞对腰椎融合患者术后镇痛效果的影响.方法 择期全麻下行后正中入路腰椎融合术患者75例,ASA分级Ⅰ或Ⅱ级,性别不限,年龄40～ 70岁,BMI≤40 kg/m2,采用随机数字表法分为3组(n=25):PCIA组(P组)、内侧入路TLIP阻滞联合PCIA组(MP组)和外侧入路TLIP阻滞联合PCIA组(LP组).MP组由外侧向内侧平面内进针,在两侧多裂肌和最长肌的筋膜间隙各注射0.5％罗哌卡因20 ml;LP组由内侧向外侧平面内进针,在两侧最长肌和髂肋肌的筋膜间隙注射各0.5％罗哌卡因20ml.记录MP组和LP组阻滞前超声图像中多裂肌和髂肋肌的辨识率和辨识度评分.术毕行PCIA至术后48 h,镇痛泵配方均为舒芬太尼100 μg+托烷司琼10 mg,用0.9％生理盐水稀释至100ml,背景剂量1ml/h,PCA剂量2ml,锁定时间15 min.术后静态VAS评分＞4分时,静脉注射帕瑞昔布40 mg补救镇痛.记录术后48 h内恶心、呕吐等不良反应的发生情况.结果 与多裂肌比较,髂肋肌的辨识率和辨识度评分升高(P＜0.05).与P组比较,MP组和LP组术中丙泊酚和瑞芬太尼用量降低,术后48 h内镇痛泵按压次数、镇痛泵药物用量和帕瑞昔布用量降低(P＜0.05),术后恶心和呕吐发生率比较差异无统计学意义(P＞0.05);MP组和LP组间上述各指标比较差异无统计学意义(P＞0.05).结论 内侧入路和外侧入路TLIP阻滞用于腰椎融合术患者,有助于实现低阿片类药物麻醉模式,更有利于增强术后PCIA的效果.

abstractsObjective To evaluate the effect of different approaches to thoracolumbar interfascial plane (TLIP) block on the analgesic efficacy after lumbar spinal fusion.Methods Seventy-five patients of both sexes,of American Society of Anesthesiologists physical status Ⅰ or Ⅱ,aged 40-70 yr,with body mass index ≤40 kg/m2,undergoing posterior median approach to lumbar spinal fusion,were divided into 3 groups (n =25 each) using a random number table method:patient-controlled intravenous analgesia (PCIA) group (group P),medial approach to TLIP combined with PCIA group (group MP) and lateral approach to TLIP combined with PCIA group (group LP).TLIP block was performed by advancing the block needle in a lateral to medial direction and injecting 0.5％ ropivacaine 20 ml locally between the bilateral multifidus and longissimus muscles in group MP.TLIP block was performed by advancing the block needle in a medial to lateral direction and injecting 0.5％ ropivacaine 20 ml locally between the bilateral longissimus and iliocostalis muscles in group LP.The identification rate and distinction score between multifidus and iliocostalis muscles obtained from ultrasonic images were recorded before block in MP and LP groups.All the patients received PCIA until 48 h after surgery.PCIA solution contained sufentanil 100 μg and tropisetron 10 mg diluted to 100 ml with 0.9％ normal saline.The PCA pump was set up with a 2 ml bolus dose,a 15-min lockout interval and background infusion at a rate of 1 ml/h.When visual analogue scale score at rest ＞4 after surgery,parecoxib 40 mg was intravenously injected for rescue analgesia.The development of adverse reactions such as nausea and vomiting was recorded within 48 h after surgery.Results The identification rate and distinction score of the iliocostalis was significantly higher than that of the multifidus (P＜0.05).Compared with group P,the intraoperative consumption of propofol and remifentanil was significantly decreased,the pressing times of PCA,amount of drugs consumed in PCA and consumption of parecoxib were decreased within 48 h after surgery (P＜0.05),and no significant change was found in the incidence of nausea or vomiting in MP and LP groups (P＞0.05).There was no significant difference in the parameters mentioned above between group MP and group LP (P＞0.05).Conclusion Ultrasound-guided medial and lateral approaches to TLIP block is helpful in achieving low-dose opioid anesthesia mode and more helpful in enhancing the efficacy of PCIA when used for lumbar spinal fusion.