经腰入路枕大池吗啡输注治疗头颈部难治性癌痛的安全性及有效性评价

Evaluation of the safety and efficacy of morphine infusion into cisterna magna via lumbar approach in the treatment of intractable cancer pain in head and neck

摘要:

目的：评价经腰椎入路枕大池吗啡输注治疗头颈部难治性晚期癌痛的安全性及有效性。方法：回顾性分析湘雅二医院疼痛病房从2019 年4 月至2021年10 月行腰椎穿刺逆行枕大池置管吗啡持续输注镇痛的13例头颈部晚期难治性癌痛患者的临床资料，收集所有患者临床资料及相关并发症情况：采用疼痛数字评分法 (numerical rating scale, NRS)进行的术前和术后疼痛评分、手术时间、术后阿片类药物辅助镇痛情况、术后日均爆发痛次数、生活质量评分（Short Form-36）、术后住院日、术中及术后相关并发症如脊髓神经损伤、蛛网膜下腔感染、脑脊液漏头痛、尿潴留、瘙痒、嗜睡、呼吸抑制、谵妄、恶心呕吐和便秘等的发生情况。结果：所有13例枕大池鞘内置管手术在46~78（66.4±22.5）min 内完成；导管一次到位率100%；没有一例患者发生腰椎穿刺和枕大池置管操作相关的脊髓损伤和蛛网膜下腔感染等不良事件；术前NRS疼痛评分7.5±1.2/10，术后1周为1.4±1.2/10，术后1 个月为1.2±0. 9/10，术后3个月为0.8±0.7/10；术前口服吗啡剂148.1±46.2毫克，术后1周为0.2±0.046毫克，术后1 个月为0.7±0.12毫克，术后3个月为1.0±0.64毫克，术前术后术前术后有明显的统计学意义(P ＜0.05)；所有患者术后日均爆发痛发生次数明显减少，1例患者需要口服吗啡辅助镇痛；枕大池镇痛优良率达到100%; 术后住院5~11(7.8±2.5) d；枕大池吗啡输注术后相关不良反应情况：脑脊液漏头痛2例、尿潴留8例，瘙痒2 例，便秘3例，谵妄1例，均经过保守治疗处理，无一例患者发生呼吸抑制和导管移位；术前SF-36生活质量评分31.8±6.5，术后1周为42.8±7.3；术后1个月为46.1±8.8，术后3个月为55.2±10.8，术前术后有明显的统计学意义(P ＜0.05)。结论：经腰椎穿刺枕大池置管行吗啡镇痛治疗头颈部晚期难治性癌痛具有手术时间短，镇痛效果佳，并发症少，生活质量明显提高的优势，是一项安全、有效的中枢镇痛技术。

Abstract:

Objective: To evaluate the safety and efficacy of morphine infusion into cisterna magna via lumbar approach in the treatment of intractable cancer pain in head and neck. Methods: The clinical data of 13 patients with advanced intractable cancer pain in head and neck who underwent lumbar puncture and continuous infusion of morphine in cisterna magna for analgesia in the pain ward of the Second Xiangya Hospital from April 2019 to October 2021 were analyzed retrospectively. Clinical data and related complications of all patients were collected: preoperative and postoperative pain score evaluated by numerical rating scale (numerical rating scale, NRS) , operation time, postoperative opioid-assisted analgesia, daily average incidence of postoperative pain outbreaks, quality of life score (Short Form-36), postoperative hospital stay, intraoperative and postoperative complications such as spinal cord injury, subarachnoid infection, cerebrospinal fluid leakage headache, urinary retention, itching, drowsiness, respiratory depression, delirium, nausea, vomiting and constipation. Results: All 13 cases of intrathecal catheterization of cisterna magna were performed within 46~78 (66.4 ±22.5) min. The one-time arrival rate of catheter was 100%. There was no adverse events such as spinal cord injury and subarachnoid infection related to lumbar puncture and cisterna magna catheterization. The NRS pain score was 7.5 ±1.2/10 before operation, 1.4 ±1.2/10 one week after operation, 1.2 ± 0.9/10 one month after operation and 0.8 ± 0.7/10 three months after operation. The average oral daily morphine dose was 148.1±46.2 mg before operation, the average intrathecal daily morphine dose was 0.2±0.046 mg one week after operation, 0.7±0.12 mg one month after operation and 1.0±0.64 mg three months after operation. There was significant statistical significance before and after operation (P < 0.05). The daily average incidence of postoperative pain outbreaks was significantly reduced in all patients and one patient needed oral morphine for analgesia. The excellent rate of analgesia in cisterna magna reached 100%. Postoperative hos pital stay was 5~11 days (7.8 ±2.5d). Adverse reactions after morphine infusion in the cisterna magna: 2 cases of cerebrospinal fluid leakage headache, 8 cases of urinary retention, 2 cases of itching, 3 cases of constipation, 1 cases of delirium. All patients were treated conservatively, and none of them had respiratory depression and catheter displacement.The SF-36 quality of life score was 31.8 ± 6.5 before operation, 42.8 ± 7.3 one week after operation, 46.1 ± 8.8 one month after operation, and 55.2 ± 10.8 three months after operation. There was significant statistical significance before and after operation (P < 0.05). Conclusion: Morphine analgesia infusion into Cisterna Magna via lumbar approach is a safe and effective central analgesia technique for the treatment of advanced intractable cancer pain in head and neck with the advantages of short operation time, significant analgesic effect, few complications and obvious improvement of quality of life.