超声引导下腰方肌阻滞改善肝肿瘤消融术后疼痛的应用价值

李亮; 冯新嫄; 殷俊; 周仲松; 张超学

doi:10.16766/j.cnki.issn.1674-4152.003124

超声引导下腰方肌阻滞改善肝肿瘤消融术后疼痛的应用价值

doi: 10.16766/j.cnki.issn.1674-4152.003124

安徽医科大学第一附属医院超声科，安徽合肥 230022

基金项目:

安徽省重点研究与开发计划项目 202004j07020031

详细信息

通讯作者:
张超学, E-mail: zcxay@163.com

中图分类号: R445.1 R614.4 R735.7
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出版历程
- 收稿日期: 2023-03-11
- 网络出版日期: 2023-09-13

The application of preoperative ultrasound-guided quadratus lumborum block for the analgesia after hepatic microwave ablation

Department of Ultrasound, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, China

摘要

摘要: 目的探讨术前超声引导下腰方肌阻滞对肝肿瘤微波消融术后的镇痛效果。方法采用回顾性队列研究，收集2017年1月—2020年12月于安徽医科大学第一附属医院行超声引导下肝脏肿瘤微波消融术的患者190例，其中40例术前行超声引导下腰方肌阻滞术联合全身麻醉(研究组)，余150例术前仅行全身麻醉(对照组)。通过倾向性评分分析法，比较2组患者与术后疼痛相关的基线数据进行评分并1∶ 1匹配，产生研究组及对照组，比较2组患者术后VAS疼痛评分，40项恢复质量评分量表(QoR40)术后恢复评分及术后疼痛治疗情况。结果通过倾向性评分匹配分析，共40名患者完成匹配进入对照组。匹配后实验组与对照组之间基线数据差异无统计学意义。单因素回归分析筛选与术后疼痛相关的因素后纳入多因素回归分析，腰方肌阻滞与术后疼痛呈负相关关系。2组QoR40术后恢复评分比较[(171.85±10.14)分vs.(167.45±10.59)分]，差异无统计学意义(t=-1.884，P=0.065)。匹配对照组术后需治疗疼痛例数较研究组增多，但2组差异无统计学意义(P=0.057)。结论相比单纯全身麻醉，术前腰方肌阻滞联合全身麻醉可有效缓解肝脏微波消融术后疼痛。
- 腰方肌阻滞 /
- 微波消融术 /
- 镇痛
Abstract: Objective To investigate the postoperative analgesic effect of ultrasound-guided quadratus lumborum block(QLB) for microwave ablation of liver tumor. Methods A retrospective cohort study was conducted to collect 190 patients who underwent ultrasound-guided microwave ablation (MWA) of liver tumors at the First Affiliated Hospital of Anhui Medical University from January 2017 to December 2020, 40 patients of whom underwent ultrasound-guided QLB (research group) and the remaining 150 patients underwent general anesthesia only (control group). Baseline data related to postoperative pain were scored and matched 1∶ 1 by propensity score analysis to produce a study group and a control group, then the postoperative visual analogue scale (VAS) score, the quality of recovery-40 questionnaire (QoR40) score and the treatment for postoperative pain after operation were compared between the two groups. Results After propensity score matching, there was no statistical difference for the baseline data between the research group (40 patients included) and the control group (40 patients included) after matching. There was no statistical difference in the baseline data between the two groups (all P>0.05). The factors related to the postoperative pain were selected by single factor regression and then included in multi-factor regression. Multi-factor regression analysis showed that OLB was negatively correlated with postoperative pain (P < 0.05). There was no significant difference in the QoR40 scores [(171.85±10.14) points vs. (167.45±10.59) points]between the two groups (t=-1.884, P=0.065). The number of cases requiring treatment was reduced in the experimental group compared with the control group, however, the difference was not statistically significant (P=0.057). Conclusion Compared with the general anesthesia, the combination of preoperative QLB and general anesthesia can reduce the preoperative pain for the patients underwent hepatic MWA.
- Quadratus lumborum block /
- Hepatic microwave ablation /
- Analgesia

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图 1 腰方肌阻滞穿刺路径超声解剖

注：俯卧位显示腰方肌、腰大肌、竖脊肌及第三腰椎横突(黄色箭头)；显示腰方肌及腰大肌之间的胸腰筋膜(红色箭头)。

Figure 1. Ultrasound anatomy of quadrate musculi lumbosus block puncture path

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图 2 超声引导下腰方肌阻滞

注：穿刺针(箭头)到达腰方肌与腰大肌之间，注入麻醉药物，腰大肌与腰方肌分离。

Figure 2. Ultrasound guided lower back quadrate block

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表 1 倾向性评分匹配后2组基线数据对比

Table 1. The baseline data of the two groups were compared after matching the propensity score

项目	实验组	对照组	统计量	P值	项目	实验组	对照组	P值
年龄(x±s，岁)	55.85±1.64	57.80±1.34	-0.920^a	0.360	人工胸水[例(%)]	37(92.5)	37(92.5)	0.622^d
性别[例(%)]				0.083^d	人工腹水[例(%)]	34(85.0)	34(85.0)	0.622^d
男性	36(90.0)	29(72.5)			病灶位置[例(%)]			0.159^d
女性	4(10.0)	11(27.5)			S1	1(2.5)	1(2.5)
有手术史[例(%)]	17(42.5)	16(40.0)	0.052^b	0.820	S2	2(5.0)	3(7.5)
分期[例(%)]				0.171^d	S3	0	6(15.0)
ⅠA	29(72.5)	24(60.0)			S4	4(10.0)	6(15.0)
ⅠB	7(17.5)	14(35.0)			S5	9(22.5)	12(30.0)
ⅡA	2(5.0)	0			S6	15(37.5)	8(20.0)
ⅡB	2(5.0)	2(5.0)			S7	15(37.5)	18(45.0)
病灶大小[例(%)]				0.853^d	S8	10(25.0)	6(15.0)
< 3 cm	25(62.5)	28(70.0)			膈下	2(5.0)	7(17.5)
3~5 cm	13(32.5)	10(25.0)			包膜下	9(22.5)	6(15.0)
>5 cm	2(5.0)	2(5.0)			大血管旁	3(7.5)	3(7.5)
消融持续时间[M(P₂₅, P₇₅)，s]	18.85(10.0，22.8)	21.4(15.0，25.0)	-1.553^c	0.121	病灶数量[例(%)]			0.834^d
消融启动次数[例(%)]				0.742^d	1	31(77.5)	27(67.5)
1	7(17.5)	8(20.0)			2	3(7.5)	10(25.0)
2	15(37.5)	10(25.0)			3	2(5.0)	2(5.0)
3	7(17.5)	10(25.0)			4	2(5.0)	1(2.5)
4	2(5.0)	5(12.5)			5	2(5.0)	0
5	5(12.5)	3(7.5)
6	1(2.5)	1(2.5)
7	2(5.0)	3(7.5)
9	1(2.5)	0
注：^a为t值，^b为χ²值，^c为Z值，^d为采用Fisher精确检验；S1~8为肝脏分段标识。

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表 2 2组患者术后疼痛参数比较

Table 2. Comparison of postoperative pain parameters between 2 groups

组别	例数	2 h静息痛 [M(P₂₅, P₇₅)，分]	24 h静息痛 [M(P₂₅, P₇₅)，分]	24 h运动痛 [M(P₂₅, P₇₅)，分]	QoR40 (x±s，分)	需要治疗的疼痛[例(%)]
实验组	40	0(0，1)	0(0，1)	0(0，1)	171.85±10.14	1(2.5)
对照组	40	1(0，1)	0(0，0)	0(0，1)	167.45±10.59	7(17.5)
统计量		11.181^a	2.687^a	8.171^a	-1.884^b
P值		0.004	0.480	0.017	0.065	0.057^c
注：^a为Z值，^b为t值，^c为采用Fisher精确检验。

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表 3 变量赋值方法

Table 3. Variable assignment method

变量	赋值方法
因变量
VAS 2 h静息痛	0分=0；1分=1；2分=2
VAS 6 h静息痛	无痛=1；轻度疼痛=2；中度疼痛=3
VAS 6 h运动痛	无痛=1；轻度疼痛=2；中度疼痛=3
VAS 12 h静息痛	无痛=1；轻度疼痛=2；中度疼痛=3
VAS 12 h运动痛	无痛=1；轻度疼痛=2
VAS 24 h静息痛	0分=0；1分=1；2分=2
VAS 24 h运动痛	0分=0；1分=1；2分=2
疼痛需要治疗	否=0；是=1
自变量
组别	实验组=0；对照组=1
性别	男性=0；女性=1
手术史	有=0；无=1
分期	CNLCIa=1；CNLCIb=2；CNLCIIa=3；CNLCIIb=4
病灶长径	< 3 cm=1；3~5 cm=2；>5 cm=3
病灶数量	1枚=1；2枚=2；3枚=3；4枚=4；5枚=5
消融次数	1次=1；2次=2；3次=3；4次=4；5次=5；6次=6；7次=7；9次=9
人工胸水	是=0；否=1
人工腹水	是=0；否=1
病灶位置	S1=(0，0，0，0，0，0，0，0，0，0)；S2=(1，0，0，0，0，0，0，0，0，0)；S3=(0，1，0，0，0，0，0，0，0，0)；S4=(0，0，1，0，0，0，0，0，0，0)；S5=(0，0，0，1，0，0，0，0，0，0)；S6=(0，0，0，0，1，0，0，0，0，0)；S7=(0，0，0，0，0，1，0，0，0，0)；S8=(0，0，0，0，0，0，1，0，0，0)；膈下=(0，0，0，0，0，0，0，1，0，0)；包膜下=(0，0，0，0，0，0，0，0，1，0)；大血管旁=(0，0，0，0，0，0，0，0，0，1)

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表 4 术后疼痛显著相关因素单因素logistic回归分析

Table 4. Logistic regression analysis of significant correlation factors for postoperative pain

变量	B	SE	Wald χ²	P值	OR值	95% CI
术后6 h静息痛
腰方肌阻滞	-2.491	0.670	13.830	< 0.001	0.083	0.022~0.309
ⅠA期	-1.745	0.535	10.644	0.001	0.175	0.061~0.497
ⅠB期	1.745	0.551	10.017	0.002	5.728	1.951~16.814
1枚病灶	-1.362	0.533	6.532	0.011	0.256	0.091~0.724
2枚病灶	1.532	0.627	5.972	0.015	4.625	1.364~15.678
消融持续时间	0.115	0.030	14.338	< 0.001	1.122	1.057~1.192
消融启动次数	0.486	0.148	10.766	< 0.001	1.626	1.213~2.178
S3段1枚病灶	1.922	0.908	4.480	0.034	6.836	1.162~40.206
术后6 h运动痛
腰方肌阻滞	-1.781	0.566	9.917	0.002	0.168	0.056~0.509
ⅠA期	-1.396	0.520	7.193	0.007	0.248	0.089~0.692
ⅠB期	1.324	0.539	6.032	0.014	3.758	1.281~11.029
2枚病灶	1.417	0.552	6.590	0.038	4.125	1.994~12.854
3枚病灶	1.274	0.620	4.226	0.040	3.575	1.070~12.055
膈肌下病灶	1.675	0.728	5.296	0.021	5.341	1.297~21.993
术后12 h静息痛
腰方肌阻滞	-1.273	0.535	5.656	0.017	0.280	0.098~0.800
男性	1.570	0.626	6.292	0.012	4.806	1.393~16.581
ⅠA期	-2.913	0.804	13.134	< 0.001	0.054	0.011~0.263
ⅠB期	2.248	0.662	11.539	< 0.001	9.464	2.576~34.777
1枚病灶	-2.187	0.655	11.150	< 0.001	0.112	0.031~0.047
2枚病灶	1.669	0.670	6.211	0.013	5.306	1.405~20.041
4枚病灶	2.069	1.046	3.912	0.048	7.920	1.043~60.162
消融持续时间	0.133	0.032	17.484	< 0.001	1.142	1.073~1.215
消融启动次数	0.779	0.181	18.447	< 0.001	2.180	1.525~3.114
包膜下病灶	1.423	0.640	4.943	0.026	4.150	1.209~14.244
术后12 h运动痛
腰方肌阻滞	1.130	0.465	5.895	0.015	3.095	1.243~7.706
消融启动次数	0.326	0.144	5.136	0.023	1.386	1.045~1.837
包膜下病灶	1.603	0.692	5.362	0.021	4.966	1.790~5.002

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表 5 术后疼痛显著相关因素多因素logistic回归分析

Table 5. Multivariate logistic regression analysis of significant correlation factors for postoperative pain

变量	B	SE	Waldχ²	P值	OR值	95% CI
术后6 h静息痛
腰方肌阻滞	-3.550	1.174	9.140	0.003	0.029	0.003~0.290
人工腹水	-2.838	1.073	6.995	0.008	0.059	0.007~0.486
术后6 h运动痛
腰方肌阻滞	-1.464	0.610	5.764	0.016	0.231	0.069~0.772
ⅠA期	-2.192	1.067	4.217	0.040	0.112	0.014~0.874
术后12 h静息痛
腰方肌阻滞	-3.605	1.191	9.153	0.002	0.704	0.587~0.844
男性	4.135	1.269	10.612	0.001	1.588	1.287~1.960
4枚病灶	7.670	3.284	5.454	0.020	1.782	1.041~3.053
消融启动次数	1.918	0.685	7.839	0.005	1.227	1.067~1.410
术后12 h运动痛
腰方肌阻滞	1.400	0.543	6.640	0.010	1.305	1.075~1.586
消融启动次数	0.406	0.163	6.207	0.013	1.076	1.020~1.136
注：本表仅列出P < 0.05的变量。

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