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Article

Применение мультимодальных схем анальгезии при хирургическом лечении пациентов с поясничной грыжей межпозвонкового диска: предварительная оценка эффективности

Нейрохирургия. 2017. № 1. С. 45-53.
Генов П., Тимербаев В., Гринь А., Реброва О. Ю.

Objective: to determine the influence of perioperative analgesia methods on the incidence of « failed back surgery syndrome» after intervertebral discal hernia removal. Material and methods: This prospective study was conducted from 2010 till 2013 and included 129 patients who underwent lumbar discectomy regarding intervertebral discal hernia. Patients of group GA+R (n=20) were operated on under general anesthesia (GA) and received «analgesia at request» (R) in postoperative period. Group SA+PMA included patients (n=23) who were operated under spinal anesthesia (SA) with the following usage of preventive multimodal analgesia (PMA) based on ketoprofen, paracetamol and nalbuphine. General anesthesia and PMA was used in GA+PMA (n=21) group; the additional wound infiltration by bupivacaine solution (I) was used in GA+PMA+I (n=21) group; application of corticosteroids (A) in the area of damaged spinal root - in GA+PMA+A (n=20) group; combination of wound infiltration by bupivacaine solution and application of corticosteroids - in GA+PMA+IA (n=24) group. The intensity of acute postoperative pain was assessed within 7 postoperative days. The phone interview was conducted in 6 months after operation with examination of long-term outcomes of surgical treatment. Results: The analgesia was inadequate in all patients of GA+R group within 4 postoperative days comparing with adequate analgesia in patients of GA+PMA group during whole period of observation. The pain syndrome within first 4 postoperative days had significantly lower intensity among patients of GA+PMA group comparing with GA+R group. Patients of SA+PMA group reported that pain intensity was significantly lower only during first 2 hours after operation comparing with GA+PMA group. Patients of GA+PMA+I and GA+PMA+IA groups had lower intensity pain within 2 postoperative days comparing with GA+PMA group. Studying the long-term outcomes of surgical treatment it was revealed that 60% of patients had back and/or lower extremity pain, among them 30% - lower extremity pain in 6 months after operation. The mean pain intensity was assessed as 2,85 (2; 3) according to numeric rating scale, 24% of patients suffered from chronic pain reported about sleep disturbances, 23% - significant reduction in the life quality, 25% of patients were были unable to work. There were no statistically significant differences between examined groups concerning incidence of chronic back and/or lower extremity pain as well as lower extremity pain (p=0,459 и p=0,903 consequently, x2test) and mean pain intensity (p=0,112, Kruskal-Wallis test ANOVA) in 6 months after operation. Conclusion: The usage of preventive multimodal analgesic schemes provides the adequate pain control within 7 postoperative days while the usage of analgesia at request does not allow solving this challenge within first 4 postoperative days after intervertebral discal hernia removal. The spontaneous release of pain intensity is seen after 4th postoperative day. The SA usage in patients with discal hernia provides the pain release only during first several hours after operations (within time of residual subarachnoid block) comparing with patients underwent surgery under GA. The usage of wound infiltration by bupivacaine solution allows achieving the lowering of pain intensity during first 2 postoperative days comparing with patie nts without wound infiltration. The 60% of patients suffered from back and/or lower extremity pain and 30% of patients - from lower extremity pain in 6 months after operation/ More over the chronic severe pain syndrome is observed in 23-25% of patients, accompanied by sleep disturbances, inability to work and significant reduction in the life quality The incidence of failed back surgery syndrome occurrence after intervertebral discal hernia removal is independent of perioperative analgesia schemes.