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Journal of Southern Medical University logoLink to Journal of Southern Medical University
. 2020 Dec 20;40(12):1804–1809. [Article in Chinese] doi: 10.12122/j.issn.1673-4254.2020.12.16

经椎间孔硬膜外阻滞术治疗腰痛伴神经根性疼痛

Lumbar transforaminal epidural block for treatment of low back pain with radicular pain

Yubao HE 1, Lei CHEN 1, Zhiyang XU 1, Jieying WANG 1, Bo LIU 2,*
PMCID: PMC7835691  PMID: 33380385

Abstract

目的

评价经椎间孔硬膜外阻滞术（LTEB）治疗腰痛伴神经根性疼痛的临床效果。

方法

回顾性分析自2017年3月~2019年4月期间北京市垂杨柳医院骨科收治的78例腰痛伴神经根性疼痛患者的临床病例资料，分为LTEB组（n=33）和对照组（n=45）。LTEB组采用LTEB治疗方案，而对照组采用牵引、按摩、针灸、理疗等综合保守治疗方法。记录两组患者的性别构成、年龄、症状、体格检查、病程、住院时间、随访时间。出院后2周、1个月、3个月预约门诊复查随访3~24月，治疗前、出院后2周、1个月及3个月采用数字评定法（NRS）评分及Oswestry功能障碍指数（ODI）评价治疗效果。

结果

LTEB手术时间25.7±7.5 min。术后5例患者出现下肢无力感，均在24~72 h内自行恢复。所有患者治疗前后腰痛、下肢痛NRS评分及ODI评分均降低（P=0.001）。尽管术后2周LTEB组治疗后腰痛比对照组明显缓解（t=2.224，P=0.034），但是总体上两组治疗后腰痛对比和NRS评分随着时间变化没有统计学差异。LTEB治疗后下肢疼痛缓解和ODI评分明显下降（P < 0.001），并随着时间变化LTEB治疗后下肢疼痛和评分明显下降（P < 0.01）。

结论

LTEB是一种有效治疗腰痛伴神经根性疼痛的微创方法，短期随访中，在疼痛缓解和功能改善方面效果满意。

Keywords: 腰痛, 脊椎穿刺, 硬膜外注射, 硬膜外镇痛, 微创性外科手术

在腰椎疾病中，腰腿痛很常见，可能是腰椎椎间盘突出或者椎管狭窄对神经根施加压力，导致下肢出现神经根支配区域疼痛、功能障碍[1]，常常需要应用阿片类药物止痛，严重影响患者生活质量[2]。随着腰腿痛发病率的增加，多种治疗方式迅速得到发展，大多数病人对保守治疗有效[3]。但当保守治疗无效后，采用微创的介入治疗越来越多。其中，腰椎经椎间孔硬膜外阻滞术（LTEB）就是一种微创介入治疗方法，治疗椎间盘病变引起的脊柱疼痛和神经根病综合征已经应用了几十年[4-6]。然而，关于LTEB的安全性、缓解疼痛和改善功能的研究结论仍然存在争议[7-10]。

本研究总结分析了近2年我院78例腰痛伴下肢根性疼痛患者LTEB治疗结果，旨在探讨LTEB治疗腰痛伴下肢根性疼痛的安全性和疗效。

1. 资料和方法

1.1. 一般资料

选取2017年3月~2019年4月期间，北京市垂杨柳医院骨科收治的78例腰痛伴下肢根性疼痛症状的患者病例及复诊资料，进行回顾性分析。根据治疗方案，分为LTEB组（n=33）和对照组（n=45）。男性32例，女性46例，年龄66.3±14.8（34~91）岁，病程66.7±63.7（1~240）月，住院11.6±8.1（4~41）d，随访7.7±5.7（3~24）月。其中单侧症状46例（59.0%），双侧症状32例（41.0%）。神经根支配区域感觉减退55例（70.5%），肌力减退11例（14.1%），直腿抬高试验阳性44例（56.4%）。两组患者一般资料比较，P > 0.05，具有可比性（表 1）。研究方案由清华大学附属垂杨柳医院伦理委员会批准，研究按照1964年赫尔辛基宣言的伦理标准进行，批准号为K2017021301。患者及家属均签署检查和治疗知情同意书。

1.

两组腰腿痛患者一般资料比较

Comparison of general data of the two groups of patients with low back and radicular pain

Group n Gender [n(%)] Symptom [n(%)] Physical examination [n(%)] Age (year, Mean±SD) Course of disease (Month, Mean±SD) Length of stay (day, Mean±SD) Follow up time (Month, Mean±SD)
Male Female Unilateral Bilateral Hypoesthesia Muscle weakness The straight leg raising test was positive
LTEB: Lumbar transforaminal epidural block. "—" means no data.
Control 45 19 (42.2) 26 (57.8) 27 (60) 18 (40) 30 (66.7) 7 (15.6) 23 (51.1) 68.5±16.0 72.0±74.5 15.9±9.1 7.0±5.4
LTEB 33 13 (39.4) 20 (60.6) 19 (57.6) 14 (42.4) 25 (75.8) 4 (12.1) 21 (63.6) 64.0±13.6 61.5±52.8 7.3±3.5 8.4±6.2
χ2/t/U 0.063 0.046 0.757 0.185 1.215 0.836 0.447 3.404 -
P 0.802 0.830 0.384 0.667 0.270 0.410 0.659 0.003 0.567
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1.2. 纳入标准和排除标准

入选标准：腰痛伴下肢神经根支配区域疼痛；影像学检查显示腰椎退行性改变；保守治疗效果不明显。排除标准：凝血功能障碍；合并糖尿病或者胃、十二指肠溃疡；腰椎结核；腰椎肿瘤；强直性脊柱炎；既往腰椎手术病史；精神疾病；复诊资料不完全。

1.3. 手术方法

常规监测心电图、呼吸、脉搏和血氧饱和度。患者取俯卧位，头高脚低倾斜15°，根据术前症状体征及影像学资料判断责任神经根，如果双侧症状选择症状较重一侧。根据术前影像学设计术中穿刺路径，采用后外侧Kambin三角入路[11]。术前应用克氏针定位穿刺路径，标记皮肤表面入点。穿刺点周围碘伏消毒，铺无菌巾单，采用浓度为2.235 mg/mL甲磺酸罗哌卡因40 mL（国药准字H20070066；扬子江药业集团有限公司）局部麻醉，皮肤及皮下组织注射5 mL，深筋膜注射10 mL，关节突周围10 mL，其余15 mL中5 mL用于硬膜外阻滞、10 mL备用。采用22 G穿刺针穿刺，影像学术中透视见针尖终点在正位片位于患侧椎弓根下方（不能超过椎弓根内侧缘）、侧位片位于椎间孔下方，解剖学的穿刺终点位于责任神经根腋腹侧的硬膜外区域（后纵韧带后方），为责任神经根的出口位置。回抽无血液后，局部注射碘海醇造影剂（100 mL：30 g）（国药准字H20063128；辰欣药业股份有限公司）1~3 mL，询问患者是否出现与术前疼痛区域分布一致的胀痛感、麻木感、放电感或者其他异感，同时术中透视再次确认位置及药物弥散情况。再次回抽无血液后，将浓度为2.235 mg/mL甲磺酸罗哌卡因5 mL+得宝松0.5 mL（国药准字J20140160；瑞士MSD Merck Sharp & Dohme AG）混合液缓慢注入，拔除穿刺针，穿刺点再次75%酒精消毒后，无菌敷料覆盖。观察10 min，询问患者术前疼痛变化，如无其他不良反应，安返病房。术后平卧6 h即可下床活动，使用腰围固定3 d。

1.4. 保守治疗方法

对照组采用药物[12]、牵引、按摩、针灸、理疗[13]等综合保守治疗方法。

1.5. 观察指标和评价标准

疼痛强度以数字评分量表（NRS）[14]评定（表 2）。NRS是最常用测量疼痛的自我报告量表之一，因为应用容易，不需要专门的设备，而且是0~10进制，是医疗专业人员的首选。患者通常会被问到“，0表示没有疼痛，10表示最强烈或最严重的疼痛，您的疼痛有多强烈？”

2.

数字评分量表

Numerical Rating Scale

Sore 0 1 2 3 4 5 6 7 8 9 10
Pain intensity No pain Mild pain Moderate pain Severe pain Worst pain imaginable
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根据Oswestry功能障碍指数（ODI）[15]评价功能障碍程度（表 3）。ODI是一个自我管理的调查问卷，在10个项目的量表上测量“腰部特定功能”，每个项目有6个回答。每项得分从0~5分，分数越高功能越差，将所得分数根据百分制转换成0~100分。这十项包括疼痛强度、个人护理、举重、行走、坐姿、站立、睡眠、工作、社交生活和旅行。

3.

Oswestry功能障碍指数

Oswestry disability index

Score 0 1 2 3 4 5
Pain intensity I can tolerate the pain I have without having to use pain killers The pain is bad but I manage without taking pain killers Pain killers give complete relief from pain Pain killers give moderate relief from pain Pain killers give very little relief from pain Pain killers have no effect on the pain and I do not use them
Personal care I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but manage most of my personal care I need help every day in most aspects of self care I do not get dressed wash with difficulty and stay in bed
Lifting I can lift heavy weights without extra pain I can lift heavy weights but it gives extra pain Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned for example on a table Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned I can lift only very light weights I cannot lift or carry anything at all
Walking Pain does not prevent me walking any distance Pain prevents me walking more than 1 mile Pain prevents me walking more than 0.5 miles Pain prevents me walking more than 0.25 miles I can only walk using a stick or crutches I am in bed most of the time and have to crawl to the toilet
Sitting I can sit in any chair as long as I like I can only sit in my favourite chair as long as I like Pain prevents me sitting more than 1 hour Pain prevents me from sitting more than 0.5 hours Pain prevents me from sitting more than 10 minutes Pain prevents me from sitting at all
Standing I can stand as long as I want without extra pain I can stand as long as I want but it gives me extra pain Pain prevents me from standing for more than 1 hour Pain prevents me from standing for more than 30 minutes Pain prevents me from standing for more than 10 minutes Pain prevents me from standing at all
Sleeping Pain does not prevent me from sleeping well I can sleep well only by using tablets Even when I take tablets I have less than 6 hours sleep Even when I take tablets I have less than 4 hours sleep Even when I take tablets I have less than 2 hours of sleep Pain prevents me from sleeping at all
Sex life My sex life is normal and causes no extra pain My sex life is normal but causes some extra pain My sex life is nearly normal but is very painful My sex life is severely restricted by pain My sex life is nearly absent because of pain Pain prevents any sex life at all
Social life My social life is normal and gives me no extra pain My social life is normal but increases the degree of pain Pain has no significant effect on my social life apart from limiting my more energetic interests such as dancing Pain has restricted my social life and I do not go out as often Pain has restricted my social life to my home I have no social life because of pain
Travelling I can travel anywhere without extra pain I can travel anywhere but it gives me extra pain Pain is bad but I manage journeys over 2 hours Pain restricts me to journeys of less than 1 hour Pain restricts me to short necessary journeys under 30 minutes Pain prevents me from travelling except to the doctor or hospital
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1.6. 随访

出院后通过门诊预约复查随访。随访内容包括NRS评分、ODI评分，是否行再次腰椎注射药物、微创或者开放手术。

1.7. 统计学方法

计量资料以均数±标准差表示，组间比较采用t检验，治疗前后NRS评分及ODI评分比较采用重复测量数据方差分析。计数资料以百分率表示，组间比较采用χ2检验或者Fisher精确检验；随访时间组间比较采用Mann-Whitney秩和检验。应用统计学软件SPSS 20.0处理数据，P < 0.05为差异有统计学意义。

2. 结果

2.1. 手术情况

患者手术时间25.7±7.5 min（15~45 min）。术后5例患者出现下肢无力感，均在24~72 h内自行恢复。术中没有发生其他轻微并发症，如恶心、呕吐、晕厥、短暂性虚弱、尿潴留，也没有发生严重的并发症，如蛛网膜脑炎、脑脊液漏、硬膜外血肿、硬膜外脓肿、神经损伤、器械折断、截瘫、脊髓栓塞、过敏反应甚至死亡等[16-17]。LTEB治疗后，随访期间2例患者因相同部位疼痛再次行腰椎注射药物治疗，2例患者行微创手术治疗，只有1例患者选择开放手术治疗。

2.2. 临床结果评价

所有患者治疗前后腰痛NRS评分均降低，差异有统计学意义F=10.269，P=0.001）。尽管术后2周LTEB组治疗后腰痛比对照组明显缓解（t=2.224，P=0.034），但是总体上两组治疗后腰痛对比并没有显著性差异（F=1.512，P=0.229），且两组患者腰痛NRS评分随着时间变化没有显著性统计学差异（F=1.743，P=0.183，表 4）。

4.

两组腰腿痛患者治疗后NRS评分的比较

Comparison of NRS scores between the two groups after treatment

Group n Low back pain NRS score (score, Mean±SD) Lower limb pain score (score, Mean±SD)
Before treatment 2 weeks after discharge 1 month after discharge 3 months after discharge Before treatment 2 weeks after discharge 1 month after discharge 3 months after discharge
LTEB: Lumbar transforaminal epidural block; NRS: Numerical rating scale; FLow back pain intra subject=10.269, P=0.001; FLow back pain inter subject=1.512, P=0.229; FLow back pain interaction=1.743, P=0.183; FLower limb pain intra subject=34.938, P=0.001; FLower limb pain inter subject=12.380, P=0.002; FLower limb pain interaction=6.307, P=0.002; aP < 0.05, comparison between LTEB and control group.
Control 45 3.5±2.1 2.4±1.6 2.1±1.4 2.2±1.1 7.9±1.2 5.2±1.3 4.7±1.7 4.9±1.6
LTEB 33 4.0±2.6 1.3±1.2a 1.2±1.1 1.4±1.2 8.7±1.1 2.4±2.1a 2.7±1.9a 2.9±2.2a
t 0.623 2.224 1.865 1.932 1.904 4.481 3.011 2.900
P 0.538 0.034 0.073 0.064 0.067 0.001 0.005 0.007
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所有患者下肢疼痛治疗后明显缓解，NRS评分存在明显统计学差异（F=34.938，P=0.001）。两组患者对比，LTEB治疗后下肢疼痛缓解更明显，有明显统计学差异（F=12.380，P=0.002），且随着时间变化LTEB治疗后下肢疼痛进一步缓解，两组比较有统计学差异（F=6.307，P=0.002，表 4）。

所有患者治疗后ODI评分明显下降，存在统计学差异（F=103.571，P=0.001)。与对照组相比，LTEB治疗后ODI评分下降更明显（F=27.153，P=0.001)，且随着时间变化LTEB治疗后ODI评分下降趋势更明显（F=14.723，P=0.001，表 5）。

5.

两组腰腿痛患者治疗后ODI评分的比较

Comparison of ODI scores between the two groups after treatment

Group n ODI score (score, Mean±SD)
Before treatment 2 weeks after discharge 1 month after discharge 3 months after discharge
LTEB: Lumbar transforaminal epidural block; ODI: Oswestry disability index; Fintra subject=103.571, P=0.001; Finter subject=27.153, P=0.001; Finteraction=14.723, P=0.001.
Control 45 73.9±9.0 44.7±12.5 41.5±12.0 48.2±10.2
LTEB
t 		33 80.0±8.5
1.919		 18.0±16.1
5.062		 14.8±12.2
6.044		 21.3±13.5
6.141
P 0.065 0.001 0.001 0.001
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3. 讨论

我们的研究中LTEB采用了经椎间孔入路，结果显示，术后5例患者出现下肢无力感，均在24~72 h内自行恢复。术中没有发生脑脊液漏、神经损伤等并发症。尽管LTEB可以采用经椎板间后正中入路[18]、经椎旁入路[19]或经椎间孔入路[20]，但是，椎间孔入路更具特异性，可选择特定的神经根，损伤硬膜囊导致脑脊液漏风险最小[21]。另外，我们的研究中LTEB治疗后下肢疼痛缓解更明显，且随着时间变化LTEB治疗后下肢疼痛进一步缓解。说明经椎间孔入路可以在硬膜腹侧疼痛源附近注射大量的药物，药物扩散范围广泛，因此经椎间孔入路在减轻患者疼痛和改善功能障碍方面更为有效[22-23]。

本研究中我们采用C型臂透视术中实时监控穿刺过程，既安全又快速，手术时间短，仅仅需要20~30 min。初期LTEB是在没有影像学引导的情况下进行的，医生主要凭借感觉进行穿刺定位，这样疼痛缓解的成功率较低。由于患者的疗效取决于注射药物的准确位置，因此透视引导下进行LTEB是很重要的[24]，术中透视定位技术的广泛应用，使精确操作成为可能。

我们的研究选择Kambin三角入路，没有发生静脉栓塞、神经水肿和硬膜外出血等术中并发症。这和Kambin三角的解剖特点密切相关，众所周知，Kambin三角是由走行神经根、下椎体上缘、上椎弓根内缘形成[25]。该三角内没有重要的神经、血管组织，为解剖学的安全区域，因此Kambin三角入路很少刺激神经根和周围组织损伤轻，能够减少静脉栓塞、神经水肿和硬膜外出血的风险。

我们研究中采用的是得宝松[26]，属于长效激素，临床效果肯定。也有学者采用地塞米松和甲基强的松龙，取得了满意的疼痛缓解效果[27]。但是我们考虑到甲基强的松龙属于中效激素，而且得宝松钠水潴留副作用比地塞米松轻，而抗炎作用强。

NRS评分是临床中最常用的疼痛评分之一，具有灵敏度高，通俗易懂等优势，因此在临床中应用广泛[28]。但是仅仅评价患者疼痛改善情况并不能有效的评估患者生活质量，因此，我们的研究中，增加了ODI评分，作为评估功能状态和生活质量的重要指标。

我们的研究对象为腰痛伴神经根性疼痛患者，短期疗效肯定，尽管3个月时NRS及ODI评分出现上升趋势，但是并没有统计学差异。因此，通过LTEB可以在短期内有效地治疗腰椎间盘突出症[29]。

在我们研究中，麻醉药选用10 mL甲磺酸罗哌卡因（8.94 mg/mL）加30 mL生理盐水进行稀释。因为罗哌卡因亲脂性低，不容易穿透大的有髓鞘的运动纤维，感觉和运动神经阻滞分离明显，尤其是低浓度罗哌卡因的运动感觉分离更明显[30]。我们发现LTEB治疗后患者腰痛也得到一定程度缓解，尤其是出院后2周患者腰痛缓解更明显。分析原因为LTEB过程中药物会弥散到关节突周围，同时神经根阻滞的同时，背根神经节和脊神经背支同样受到阻滞，因此，腰痛亦会得到缓解。

我们的研究也有一些局限性：首先本研究是在一个科室进行的回顾性研究，患者例数相对较少，需要进一步的前瞻性多中心随机试验，采用更大的样本来确定是否有显著的临床应用结果。

综上所述，LTEB是一种有效治疗腰痛伴神经根性疼痛的微创方法，短期随访中，在疼痛缓解和功能改善方面效果满意。

Biography

何玉宝，博士，副主任医师，E-mail: hyb_7@sina.com

Contributor Information

何 玉宝 (Yubao HE), Email: hyb_7@sina.com.

刘 波 (Bo LIU), Email: drliubo@sina.cn.

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