糖皮质激素在退变性颈脊髓病围手术期应用进展
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摘要
退变性颈脊髓病是导致成人脊髓功能障碍的最常见原因,现阶段减压手术已成为其缓解症状的主要方法。不论是前路,还是后路,减压手术的疗效已被证实。但在关注手术疗效的同时,其并发症也越来越受关注。糖皮质激素围手术期应用是否能够降低退变性颈脊髓病减压手术并发症的发生率一直是个争议的话题。在基础研究领域已证实,减压术后出现神经功能下降与缺血-再灌注损伤和免疫系统激活有关,并且甲泼尼龙可以促进长期受压的脊髓运动功能恢复,降低减压手术围手术期神经并发症,并在不破坏循环免疫细胞组成的情况下保护神经元细胞,进而建议在退变性颈脊髓病减压手术围手术期应用甲泼尼龙。但是在临床研究中,尚缺乏高等级证据。我国多名专家共同完成了《肾上腺糖皮质激素围手术期应用专家共识(2017版)》,为我国医师在围手术期应用糖皮质激素提供规范和指导。但是该共识主要是针对于一般共性手术的围手术期用药,对于退变性颈脊髓病的围术期应用并未详述。本文结合糖皮质激素在退变性颈脊髓病围手术期应用的相关文献,对其在术后吞咽困难、辅助镇痛、C_5神经根麻痹等方面的作用进行综述。
Degenerative cervical myelopathy is the most common cause of spinal cord dysfunction in adults. The efficacy of decompression surgery has been demonstrated in both anterior and posterior approaches. While paying attention to the curative effect of surgery, its complications are also getting more and more concern. Whether perioperative glucocorticoid use can reduce the incidence of decompression complications in degenerative cervical myelopathy has been a controversial topic. In the field of basic research, neurological decline after decompression has been confirmed to be related to ischemia-reperfusion injury and immune system activation. In addition, methylprednisolone reduces perioperative neurological complications following decompressive surgery for degenerative cervical myelopathy by protecting neurons from inflammation, without compromising the composition of circulating immune cells. However, in clinical studies, there is still a lack of high-level evidence. Experts in China jointly completed the expert consensus on perioperative application of adrenal glucocorticoids(2017 version), which provides norms and guidance for Chinese physicians in the application of perioperative glucocorticoids. However, this consensus mainly aims at general surgery, and the perioperative application of degenerative cervical myelopathy is not detailed. In this review, the author summarized the advances of glucocorticoids in dysphagia, auxiliary analgesia and C_5 nerve root palsy, in perioperative period of Degenerative cervical myelopathy, combined with relevant literature.
Degenerative cervical myelopathy is the most common cause of spinal cord dysfunction in adults. The efficacy of decompression surgery has been demonstrated in both anterior and posterior approaches. While paying attention to the curative effect of surgery, its complications are also getting more and more concern. Whether perioperative glucocorticoid use can reduce the incidence of decompression complications in degenerative cervical myelopathy has been a controversial topic. In the field of basic research, neurological decline after decompression has been confirmed to be related to ischemia-reperfusion injury and immune system activation. In addition, methylprednisolone reduces perioperative neurological complications following decompressive surgery for degenerative cervical myelopathy by protecting neurons from inflammation, without compromising the composition of circulating immune cells. However, in clinical studies, there is still a lack of high-level evidence. Experts in China jointly completed the expert consensus on perioperative application of adrenal glucocorticoids(2017 version), which provides norms and guidance for Chinese physicians in the application of perioperative glucocorticoids. However, this consensus mainly aims at general surgery, and the perioperative application of degenerative cervical myelopathy is not detailed. In this review, the author summarized the advances of glucocorticoids in dysphagia, auxiliary analgesia and C_5 nerve root palsy, in perioperative period of Degenerative cervical myelopathy, combined with relevant literature.
引文
[1] BAKHSHESHIAN J,MEHTA V A,LIU J C.Current diagnosis and management of cervical spondylotic myelopathy[J].Global Spine J,2017,7(6):572-586.
[2] TETREAULT L A,KARADIMAS S,WILSON J R,et al.The natural history of degenerative cervical myelopathy and the rate of hospitalization following spinal cord Injury:an updated systematic review[J].Global Spine J,2017,7(3 Suppl):28S-34S.
[3] FEHLINGS M G,IBRAHIM A,TETREAULT L,et al.A global perspective on the outcomes of surgical decompression in patients with cervical spondylotic myelopathy:results from the prospective multicenter AOSpine international study on 479 patients[J].Spine,2015,40(17):1322-1328.
[4] TETREAULT L,IBRAHIM A,C?Té P,et al.A systematic review of clinical and surgical predictors of complications following surgery for degenerative cervical myelopathy[J].J Neurosurg Spine,2016,24(1):77-99.
[5] WILSON J R,RADCLIFF K,SCHROEDER G,et al.Frequency and acceptability of adverse events after anterior cervical discectomy and fusion:a survey study from the cervical spine research society[J].Clin Spine Surg,2018,31(5):E270-E277.
[6] VIDAL P M,KARADIMAS S K,ULNDREAJ A,et al.Delayed decompression exacerbates ischemia-reperfusion injury in cervical compressive myelopathy[J].JCI Insight,2017,2(11):S51-S51.
[7] KARADIMAS S K,LALIBERTE A M,TETREAULT L,et al.Riluzole blocks perioperative ischemia-reperfusion injury and enhances postdecompression outcomes in cervical spondylotic myelopathy[J].Sci Transl Med,2015,7(316):316ra194.
[8] VIDAL P M,ULNDREAJ A,BADNER A,et al.Methylprednisolone treatment enhances early recovery following surgical decompression for degenerative cervical myelopathy without compromise to the systemic immune system[J].J Neuroinflammation,2018,15(1):222-234.
[9] 徐建国,唐会,姚尚龙,等.肾上腺糖皮质激素围手术期应用专家共识(2017版)[J].临床麻醉学杂志,2017,33(7):712-716.
[10] LIU J,HAI Y,KANG N,et al.Risk factors and preventative measures of early and persistent dysphagia after anterior cervical spine surgery:a systematic review[J].Eur Spine J,2018,27(6):1209-1218.
[11] LIU J M,TONG W L,CHEN X Y,et al.The incidences and risk factors related to early dysphagia after anterior cervical spine surgery:a prospective study[J].PLoS One,2017,12(3):e0173364.
[12] ZADEGAN S A,JAZAYERI S B,ABEDI A,et al.Corticosteroid administration to prevent complications of anterior cervical spine fusion:a systematic review[J].Global spine J,2018,8(3):286-302.
[13] HAWS B E,KHECHEN B,NARAIN A S,et al.Impact of local steroid application on dysphagia following an anterior cervical discectomy and fusion:results of a prospective,randomized single-blind trial[J].J Neurosurg Spine,2018,29(1):10-17.
[14] JENKINS T J,NAIR R,BHATT S,et al.The effect of local versus intravenous corticosteroids on the likelihood of dysphagia and dysphonia following anterior cervical discectomy and fusion:a single-blinded,prospective,randomized controlled trial[J].J Bone Joint Surg Am,2018,100(17):1461-1472.
[15] JAIN N,BROCK J L,PHILLIPS F M,et al.Chronic preoperative opioid use is a risk factor for increased complications,resource use,and costs after cervical fusion[J].Spine J,2018,23(13):S1592-S1610.
[16] KWON S K,YANG I H,BAI S J,et al.Periarticular injection with corticosteroid has an additional pain management effect in total knee arthroplasty[J].Yonsei Med J,2014,55(2):493-498.
[17] FEHLINGS M G,FALLAH A.Perioperative steroids in spine surgery[J].J Neurosurg Spine,2010,13(6):743-744.
[18] JAMJOOM B A,JAMJOOM A B.Efficacy of intraoperative epidural steroids in lumbar discectomy:a systematic review[J].BMC Musculoskelet Disord,2014,15(7):146-151.
[19] WILSON-SMITH A,CHANG N,LU V M,et al.Epidural steroids at closure after microdiscectomy/laminectomy for reduction of postoperative analgesia:systematic review and meta-analysis[J].World Neurosurg,2018,110(3):e212-e221.
[20] HU A,GU X,GUAN X,et al.Epidural versus intravenous steroids application following percutaneous endoscopic lumbar discectomy[J].Medicine,2018,97(18):e0654-e0660.
[21] SCHNEIDER B J,MAYBIN S,STUROS E.Safety and complications of cervical epidural steroid injections[J].Phys Med Rehabil Clin N Am,2018,29(1):155-169.
[22] EPSTEIN N E.Major risks and complications of cervical epidural steroid injections:an updated review[J].Surg Neurol Int,2018,9(5):86-96.
[23] MANCHIKANTI L,MALLA Y,CASH K A,et al.Comparison of effectiveness for fluoroscopic cervical interlaminar epidural injections with or without steroid in cervical post-surgery syndrome[J].Korean J Pain,2018,31(4):277-288.
[24] OKUBADEJO G O,TALCOTT M R,SCHMIDT R E,et al.Perils of intravascular methylprednisolone injection into the vertebral artery.An animal study[J].J Bone Joint Surg Am,2008,90(9):1932-1938.
[25] LEE J W,PARK K W,CHUNG S K,et al.Cervical transforaminal epidural steroid injection for the management of cervical radiculopathy:a comparative study of particulate versus non-particulate steroids[J].Skeletal Radiol,2009,38(11):1077-1082.
[26] EL-YAHCHOUCHI C,GESKE J R,CARTER R E,et al.The noninferiority of the nonparticulate steroid dexamethasone vs the particulate steroids betamethasone and triamcinolone in lumbar transforaminal epidural steroid injections[J].Pain Med,2013,14(11):1650-1657.
[27] KENNEDY D J,PLASTARAS C,CASEY E,et al.Comparative effectiveness of lumbar transforaminal epidural steroid injections with particulate versus nonparticulate corticosteroids for lumbar radicular pain due to intervertebral disc herniation:a prospective,randomized,double-blind trial[J].Pain Med,2014,15(4):548-555.
[28] PARIVASH S N,KRANZ P G,GRAY L,et al.CT fluoroscopy-guided interlaminar epidural steroid injections in the cervical spine:rate of nontarget injection into the retrodural space of okada[J].AJR Am J Roentgenol,2018,211(2):426-431.
[29] SCHREIBER A L,MCDONALD B P,KIA F,et al.Cervical epidural steroid injections and spinal cord injuries[J].Spine J,2016,16(10):1163-1166.
[30] WANG T,WANG H,LIU S,et al.Incidence of C5 nerve root palsy after cervical surgery:A meta-analysis for last decade[J].Medicine,2017,96(45):e8560-e8573.
[31] SHOU F,LI Z,WANG H,et al.Prevalence of C5 nerve root palsy after cervical decompressive surgery:a meta-analysis[J].Eur Spine J,2015,24(12):2724-2734.
[32] GUZMAN J Z,BAIRD E O,FIELDS A C,et al.C5 nerve root palsy following decompression of the cervical spine:a systematic evaluation of the literature[J].Bone Joint J,2014,96-B(7):950-955.
[33] TAKENAKA S,HOSONO N,MUKAI Y,et al.Significant reduction in the incidence of C5 palsy after cervical laminoplasty using chilled irrigation water[J].Bone Joint J,2016,98-B(1):117-124.
[34] DOMBROWSKI M E,MORALES-RESTREPO A,FOURMAN M S,et al.Prophylactic perioperative dexamethasone decreases the incidence of postoperative C5 palsies after a posterior cervical laminectomy and fusion[J].Spine J,2018,19(5):31-44.
[35] BLUME C,WIEDERHOLD H,GEIGER M,et al.Lacking benefit of intraoperative high-dose dexamethasone in instrumented surgery for cervical spondylotic myelopathy[J].J Neurol Surg A Cent Eur Neurosurg,2018,79(2):116-122.
[2] TETREAULT L A,KARADIMAS S,WILSON J R,et al.The natural history of degenerative cervical myelopathy and the rate of hospitalization following spinal cord Injury:an updated systematic review[J].Global Spine J,2017,7(3 Suppl):28S-34S.
[3] FEHLINGS M G,IBRAHIM A,TETREAULT L,et al.A global perspective on the outcomes of surgical decompression in patients with cervical spondylotic myelopathy:results from the prospective multicenter AOSpine international study on 479 patients[J].Spine,2015,40(17):1322-1328.
[4] TETREAULT L,IBRAHIM A,C?Té P,et al.A systematic review of clinical and surgical predictors of complications following surgery for degenerative cervical myelopathy[J].J Neurosurg Spine,2016,24(1):77-99.
[5] WILSON J R,RADCLIFF K,SCHROEDER G,et al.Frequency and acceptability of adverse events after anterior cervical discectomy and fusion:a survey study from the cervical spine research society[J].Clin Spine Surg,2018,31(5):E270-E277.
[6] VIDAL P M,KARADIMAS S K,ULNDREAJ A,et al.Delayed decompression exacerbates ischemia-reperfusion injury in cervical compressive myelopathy[J].JCI Insight,2017,2(11):S51-S51.
[7] KARADIMAS S K,LALIBERTE A M,TETREAULT L,et al.Riluzole blocks perioperative ischemia-reperfusion injury and enhances postdecompression outcomes in cervical spondylotic myelopathy[J].Sci Transl Med,2015,7(316):316ra194.
[8] VIDAL P M,ULNDREAJ A,BADNER A,et al.Methylprednisolone treatment enhances early recovery following surgical decompression for degenerative cervical myelopathy without compromise to the systemic immune system[J].J Neuroinflammation,2018,15(1):222-234.
[9] 徐建国,唐会,姚尚龙,等.肾上腺糖皮质激素围手术期应用专家共识(2017版)[J].临床麻醉学杂志,2017,33(7):712-716.
[10] LIU J,HAI Y,KANG N,et al.Risk factors and preventative measures of early and persistent dysphagia after anterior cervical spine surgery:a systematic review[J].Eur Spine J,2018,27(6):1209-1218.
[11] LIU J M,TONG W L,CHEN X Y,et al.The incidences and risk factors related to early dysphagia after anterior cervical spine surgery:a prospective study[J].PLoS One,2017,12(3):e0173364.
[12] ZADEGAN S A,JAZAYERI S B,ABEDI A,et al.Corticosteroid administration to prevent complications of anterior cervical spine fusion:a systematic review[J].Global spine J,2018,8(3):286-302.
[13] HAWS B E,KHECHEN B,NARAIN A S,et al.Impact of local steroid application on dysphagia following an anterior cervical discectomy and fusion:results of a prospective,randomized single-blind trial[J].J Neurosurg Spine,2018,29(1):10-17.
[14] JENKINS T J,NAIR R,BHATT S,et al.The effect of local versus intravenous corticosteroids on the likelihood of dysphagia and dysphonia following anterior cervical discectomy and fusion:a single-blinded,prospective,randomized controlled trial[J].J Bone Joint Surg Am,2018,100(17):1461-1472.
[15] JAIN N,BROCK J L,PHILLIPS F M,et al.Chronic preoperative opioid use is a risk factor for increased complications,resource use,and costs after cervical fusion[J].Spine J,2018,23(13):S1592-S1610.
[16] KWON S K,YANG I H,BAI S J,et al.Periarticular injection with corticosteroid has an additional pain management effect in total knee arthroplasty[J].Yonsei Med J,2014,55(2):493-498.
[17] FEHLINGS M G,FALLAH A.Perioperative steroids in spine surgery[J].J Neurosurg Spine,2010,13(6):743-744.
[18] JAMJOOM B A,JAMJOOM A B.Efficacy of intraoperative epidural steroids in lumbar discectomy:a systematic review[J].BMC Musculoskelet Disord,2014,15(7):146-151.
[19] WILSON-SMITH A,CHANG N,LU V M,et al.Epidural steroids at closure after microdiscectomy/laminectomy for reduction of postoperative analgesia:systematic review and meta-analysis[J].World Neurosurg,2018,110(3):e212-e221.
[20] HU A,GU X,GUAN X,et al.Epidural versus intravenous steroids application following percutaneous endoscopic lumbar discectomy[J].Medicine,2018,97(18):e0654-e0660.
[21] SCHNEIDER B J,MAYBIN S,STUROS E.Safety and complications of cervical epidural steroid injections[J].Phys Med Rehabil Clin N Am,2018,29(1):155-169.
[22] EPSTEIN N E.Major risks and complications of cervical epidural steroid injections:an updated review[J].Surg Neurol Int,2018,9(5):86-96.
[23] MANCHIKANTI L,MALLA Y,CASH K A,et al.Comparison of effectiveness for fluoroscopic cervical interlaminar epidural injections with or without steroid in cervical post-surgery syndrome[J].Korean J Pain,2018,31(4):277-288.
[24] OKUBADEJO G O,TALCOTT M R,SCHMIDT R E,et al.Perils of intravascular methylprednisolone injection into the vertebral artery.An animal study[J].J Bone Joint Surg Am,2008,90(9):1932-1938.
[25] LEE J W,PARK K W,CHUNG S K,et al.Cervical transforaminal epidural steroid injection for the management of cervical radiculopathy:a comparative study of particulate versus non-particulate steroids[J].Skeletal Radiol,2009,38(11):1077-1082.
[26] EL-YAHCHOUCHI C,GESKE J R,CARTER R E,et al.The noninferiority of the nonparticulate steroid dexamethasone vs the particulate steroids betamethasone and triamcinolone in lumbar transforaminal epidural steroid injections[J].Pain Med,2013,14(11):1650-1657.
[27] KENNEDY D J,PLASTARAS C,CASEY E,et al.Comparative effectiveness of lumbar transforaminal epidural steroid injections with particulate versus nonparticulate corticosteroids for lumbar radicular pain due to intervertebral disc herniation:a prospective,randomized,double-blind trial[J].Pain Med,2014,15(4):548-555.
[28] PARIVASH S N,KRANZ P G,GRAY L,et al.CT fluoroscopy-guided interlaminar epidural steroid injections in the cervical spine:rate of nontarget injection into the retrodural space of okada[J].AJR Am J Roentgenol,2018,211(2):426-431.
[29] SCHREIBER A L,MCDONALD B P,KIA F,et al.Cervical epidural steroid injections and spinal cord injuries[J].Spine J,2016,16(10):1163-1166.
[30] WANG T,WANG H,LIU S,et al.Incidence of C5 nerve root palsy after cervical surgery:A meta-analysis for last decade[J].Medicine,2017,96(45):e8560-e8573.
[31] SHOU F,LI Z,WANG H,et al.Prevalence of C5 nerve root palsy after cervical decompressive surgery:a meta-analysis[J].Eur Spine J,2015,24(12):2724-2734.
[32] GUZMAN J Z,BAIRD E O,FIELDS A C,et al.C5 nerve root palsy following decompression of the cervical spine:a systematic evaluation of the literature[J].Bone Joint J,2014,96-B(7):950-955.
[33] TAKENAKA S,HOSONO N,MUKAI Y,et al.Significant reduction in the incidence of C5 palsy after cervical laminoplasty using chilled irrigation water[J].Bone Joint J,2016,98-B(1):117-124.
[34] DOMBROWSKI M E,MORALES-RESTREPO A,FOURMAN M S,et al.Prophylactic perioperative dexamethasone decreases the incidence of postoperative C5 palsies after a posterior cervical laminectomy and fusion[J].Spine J,2018,19(5):31-44.
[35] BLUME C,WIEDERHOLD H,GEIGER M,et al.Lacking benefit of intraoperative high-dose dexamethasone in instrumented surgery for cervical spondylotic myelopathy[J].J Neurol Surg A Cent Eur Neurosurg,2018,79(2):116-122.