加速康复外科路径对内镜下腰椎融合术围手术期疗效的影响

Effect of an enhanced recovery after surgery(ERAS) on perioperative outcomes of endoscopic lumbar interbody fusion

中文关键词:  加速康复外科  内镜下腰椎融合术  阿片类药物  随机对照试验

英文关键词:Enhanced recovery after surgery  Endoscopic lumbar interbody fusion  Opioids  Randomized controlled trial

中文摘要:

  【摘要】 目的：探讨加速康复外科（enhanced recovery after surgery，ERAS）路径在内镜下腰椎融合术（endoscopic lumbar interbody fusion，Endo-LIF）中对围手术期疗效的影响。方法：采用单中心、随机、单盲（结局评估者盲）对照试验设计，连续纳入我院2023年1月~2024年6月间拟行内镜下单节段腰椎融合术的患者共132例，采用区组随机法分为ERAS组66例和对照组66例，对照组实施常规围术期管理；ERAS组在麻醉与镇痛、术后早期进食与下床活动及并发症预防等17项措施中实施标准化ERAS路径。记录患者术后24h阿片类药物使用量（oral morphine equivalent，OME）、术后3d的40项恢复质量量表（Quality of Recovery-40，QoR-40）评分及住院时长（length of stay，LOS）、静脉患者自控镇痛（intravenous patient-controlled analgesia，IV-PCA）使用时长，术后2周及3个月Oswestry功能障碍指数（Oswestry disability index，ODI）、疼痛视觉模拟评分（visual analogue scale，VAS）及术后30d内并发症发生情况。结果：两组患者性别、年龄、体质指数（body mass index，BMI）、手术节段及围手术期风险分层等一般资料均无统计学差异（P＞0.05）。与对照组相比，ERAS组术后24h OME显著降低［70（45～94）mg vs 127（82～178）mg，P=0.030］，IV-PCA使用时长明显缩短（25±6h vs 36±8h，P<0.001）。ERAS组LOS为6.8±1.7d，显著短于对照组的10.3±2.6d（P<0.001）。术后第3d，ERAS组QoR-40评分高于对照组（179±14分 vs 170±16分，P<0.001）。术后2周ERAS组ODI改善幅度优于对照组（P<0.001），术后3个月两组差异无统计学意义（P=0.261）。两组术后30d内并发症发生率无统计学差异（P＞0.05），并发症主要有血肿、尿潴留及感染等，经保守治疗后均痊愈，无二次手术及非计划再入院。结论：基于17项措施的ERAS路径在Endo-LIF患者中安全可行，可显著减少围手术期阿片类药物消耗量，有效提高患者早期术后恢复质量，并显著缩短LOS。

英文摘要:

  【Abstract】 Objectives: To investigate the impact of an enhanced recovery after surgery(ERAS) on the perioperative outcomes of endoscopic lumbar interbody fusion(Endo-LIF). Methods: A single-center, randomized, single-blind(outcome assessor-blinded) controlled trial was conducted. A total of 132 consecutive patients scheduled for single-level Endo-LIF at our hospital from January 2023 to June 2024 were enrolled. Using block randomization, patients were assigned to either the ERAS group(n=66) or the control group(n=66). The control group received routine perioperative management, while the ERAS group followed a standardized ERAS pathway comprising 17 measures, including optimized anesthesia and analgesia, early oral intake, early ambulation, and complication prevention. Perioperative outcomes including postoperative 24h opioid consumption(calculated as oral morphine equivalents, OME), Quality of Recovery-40(QoR-40) scores on postoperative 3d, length of stay(LOS), duration of intravenous patient-controlled analgesia(IV-PCA) use, Oswestry disability index(ODI) at 2 weeks and 3 months postoperatively, the visual analogue scale (VAS) pain score, and postoperative complications within 30d were recorded. Results: There were no statistically significant differences in baseline characteristics such as gender, age, body mass index(BMI), surgical level, and perioperative risk stratification between the two groups(P>0.05). Compared with the control group, the ERAS group showed significantly lower postoperative 24h OME[70(45-94)mg vs 127(82-178)mg, P=0.030] and significantly shorter duration of IV-PCA use(25±6h vs 36±8h, P<0.001). The LOS in the ERAS group was significantly shorter than that in the control group(6.8±1.7d vs 10.3±2.6d, P<0.001). On postoperative 3d, the QoR-40 score in the ERAS group was higher than that in the control group(179±14 vs 170±16, P<0.001). Regarding functional recovery, the improvement in ODI at 2 weeks postoperatively was superior in the ERAS group(P<0.001), while no significant difference was observed at 3 months(P=0.261). There was no significant difference in the incidence of complications within 30d postoperatively between the two groups(P>0.05), and the main complications included hematoma, urinary retention and infection, which were cured after conservative treatment without secondary surgeries or unplanned readmissions. Conclusions: The ERAS approach based on 17 measures is safe and feasible for patients undergoing Endo-LIF. It significantly reduces perioperative opioid consumption, improves early subjective quality of recovery, and shortens LOS.