术前血浆血管紧张素Ⅱ2型受体浓度与全膝关节置换术后慢性疼痛的相关性

Correlation between concentration of preoperative angiotensin Ⅱ type 2 receptor and chronic post-surgical pain after total knee arthroplasty

中文关键词: 血管紧张素Ⅱ 2型受体  全膝关节置换术  术后慢性疼痛

英文关键词: Angiotensin Ⅱ type 2 receptor  Total knee arthroplasty  Chronic post-surgical pain

中文摘要:

      
目的 探讨术前血浆血管紧张素Ⅱ2型受体（AT₂R）浓度与全膝关节置换术（TKA）术后慢性疼痛（CPSP）的相关性。
方法 选择择期全麻下行首次单侧TKA的患者120例，男46例，女74例，年龄45~70岁，BMI 18~30 kg/m²，ASA Ⅰ—Ⅲ级。所有患者麻醉方法和手术方式一致。术后3个月随访患者膝关节VAS疼痛评分，静息和（或）运动时VAS疼痛评分>3分记为CPSP阳性，≤3分记为CPSP阴性，根据CPSP将患者分为阳性组（n=41）和阴性组（n=79）。记录性别、年龄、BMI、ASA分级、膝骨关节炎（KOA）病程等一般情况。记录术前、术后1 d和术后3个月静息、运动时VAS疼痛评分。记录术前paindetect量表（PD-Q）评分、WOMAC评分、焦虑抑郁量表（HAD）评分、K-L分级、术前和术后1 d压力性痛觉阈值（PPT）、术前血浆AT₂R浓度、术中丙泊酚和瑞芬太尼用量、手术时间、止血带使用时间、出血量和术后补救镇痛情况。
结果 本研究TKA患者CPSP的发生率为34.2%。与阴性组比较，阳性组KOA病程明显延长（P<0.05），术前血浆AT₂R浓度明显升高（P<0.05），术前运动时VAS疼痛评分、PD-Q评分、WOMAC评分、术后3个月静息和运动时VAS疼痛评分均明显升高（P<0.05），术前PPT明显降低（P<0.05）。其余指标两组差异无统计学意义。多因素Logistic回归分析显示，术前血浆AT₂R浓度和PD-Q评分是CPSP发生的独立危险因素。根据ROC曲线分析，术前血浆AT₂R浓度临界值为1 067.3 pg/ml，敏感性为0.607，特异性为0.811，曲线下面积0.751（0.660~0.853）；PD-Q评分临界值为18分，敏感性为0.833，特异性为0.716，曲线下面积0.765（0.591~0.896）。
结论 术前血浆AT₂R浓度是CPSP发生的独立危险因素，术前血浆AT₂R浓度越高，CPSP发生风险越高，对于CPSP诊断有一定的价值。

英文摘要:

      
Objective To observe the correlation between concentration of preoperative angiotensin Ⅱ type 2 receptor （AT₂R） and chronic post-surgical pain (CPSP) after total knee arthroplasty (TKA).
Methods A total of 120 patients undergoing elective general anesthesia for the first unilateral TKA were selected， 46 males and 74 females， aged 45-70 years, BMI 18-30 kg/m², ASA physical status Ⅰ-Ⅲ. All patients were treated with the same anesthetic and surgical methods. The VAS scores of knee joint were followed up 3 months postoperation. The VAS score at rest or (and) during exercise more than 3 points was defined as CPSP positive, otherwise, was defined as CPSP negative. The patients were divided into two groups randomly：positive group (n = 41) and negative group (n = 79) according to CPSP. Gender, age, BMI, ASA physical status, duration of knee osteoarthritis (KOA) were recorded. VAS scores preoperation, 1 day postoperation and 3 months postoperation at rest and during exercise, preoperative paindetect questionaire scale (PD-Q) scores, preoperative western ontario and mcmaster universities arthritis index (WOMAC) scores, preoperative hospital anxiety and depression scale (HAD) scores, preoperative kellgren-lawrence (K-L) grades, pressure pain threshold (PPT) preoperation and 1 day postoperation, concentration of preoperative plasma AT₂R, intraoperative dosages of propofol and remifentanil, duration of operation, usage time of tourniquet, bleeding volume, and postoperative rescue analgesia were recorded.
Results The incidence of CPSP was 34.2% in this study. Compared with negative group, the length of duration of KOA in positive group was significantly longer (P < 0.05), the concentration of preoperative plasma AT₂R in positivve group was significantly higher (P < 0.05), preoperative VAS score during exercise， preoperative PD-Q score， preoperative WOMAC score, and VAS scores at rest and during exercise 3 months after operation of positive group were significantly higher (P < 0.05), preoperative PPT of positive group was significantly lower (P < 0.05). There were no statistically significant differences in other indicators between two groups. Multivariate binary logistic regression showed that high concentration of plasma AT₂R and preoperative PD-Q score were independent risk factors of CPSP. According to ROC curve analysis, the critical value of plasma AT₂R concentration was 1 067.3 pg/ml, sensitivity was 0.607, specificity was 0.811, and the area under the curve was 0.751 (0.660-0.853),the critical value of PD-Q score was 18， sensitivity was 0.833， specificity was 0.716， and area under curve was 0.765 (0.591-0.896).
Conclusion Concentration of preoperative plasma AT₂R was independent risk factor of CPSP. The higher concentration of preoperative plasma AT₂R is, the higher risk of CPSP occurrs. So concentration of preoperative plasma AT₂R has clinical value for the diagnosis of CPSP．