Послеоперационная реабилитация нейрохирургических пациентов, перенесших операцию на спинном мозге
Послеоперационная реабилитация нейрохирургических пациентов, перенесших операцию на спинном мозге
Фанталис Д., Бордовский С.П., Преображенская И.С. Послеоперационная реабилитация нейрохирургических пациентов, перенесших операцию на спинном мозге. Consilium Medicum. 2022;24(2):110–117. DOI: 10.26442/20751753.2022.2.201409
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Fantalis D, Bordovsky SP, Preobrazhenskaya IS. Postoperative rehabilitation of neurosurgical patients after spinal cord surgery – results of our own study. Consilium Medicum. 2022;24(2):110–117.
DOI: 10.26442/20751753.2022.2.201409
Послеоперационная реабилитация нейрохирургических пациентов, перенесших операцию на спинном мозге
Фанталис Д., Бордовский С.П., Преображенская И.С. Послеоперационная реабилитация нейрохирургических пациентов, перенесших операцию на спинном мозге. Consilium Medicum. 2022;24(2):110–117. DOI: 10.26442/20751753.2022.2.201409
________________________________________________
Fantalis D, Bordovsky SP, Preobrazhenskaya IS. Postoperative rehabilitation of neurosurgical patients after spinal cord surgery – results of our own study. Consilium Medicum. 2022;24(2):110–117.
DOI: 10.26442/20751753.2022.2.201409
Цель. Оценить, в какой степени когнитивные и эмоциональные нарушения у пациентов, которым предстоит операция на спинном мозге, оказывают влияние на качество реабилитации, и определить эффективность когнитивно-моторного тренинга. Материалы и методы. В исследование включены 60 пациентов (30 мужчин и 30 женщин), которые имели показание для операции на спинном мозге. Всем пациентам выполнены оценка соматического и неврологического статуса, а также количественное нейропсихологическое тестирование. Оценивалось влияние когнитивных и эмоциональных расстройств до и после операции на выраженность болевого синдрома и двигательных нарушений. При включении в исследование пациенты рандомизированы в основную (30 человек) и контрольную (30 человек) группы. Пациенты основной группы проходили когнитивно-моторный тренинг, который выполнялся с помощью оригинального методического пособия. Когнитивные, эмоциональные, двигательные нарушения, выраженность болевого синдрома, а также качество жизни и приверженность пациентов когнитивно-моторному тренингу оценивались через 3 и 6 мес после выполненного оперативного вмешательства. Выраженность когнитивных и эмоциональных нарушений у пациентов основной и контрольной групп до операции не различалась. Результаты. После операции выраженность когнитивных нарушений достоверно больше у пациентов контрольной группы (p=0,03). Пациенты контрольной группы достоверно хуже, чем пациенты основной группы, выполняли задания на память (p=0,00), у них также достоверно ниже скорость психических процессов (p=0,00). Указанные различия сохранялись через 3 мес после операции (p=0,00). Через неделю после выполненного оперативного вмешательства выраженность тревоги и депрессии достоверно выше у пациентов контрольной группы (p=0,01). Положительный эффект операции в виде уменьшения боли достигнут у всех пациентов, но в контрольной группе отмечено нарастание выраженности болевого синдрома через 6 меc наблюдения по сравнению с таковым через 3 мес. Нарастание выраженности болевого синдрома взаимосвязано с увеличением депрессии, тревоги и когнитивных расстройств. Пациенты основной группы с высокой приверженностью когнитивному тренингу показали достоверно большую положительную динамику как в отношении когнитивных функций, так и в отношении тревоги и депрессии (р<0,05). Опрос пациентов после включения в исследование с предоставлением им предполагаемых рекомендаций оказания клинической помощи показал следующее: 58 (96,7%) пациентов отметили, что предлагаемые рекомендации клинической помощи, с их точки зрения, существенно улучшили бы их послеоперационные прогнозы. Важные моменты, которые должны быть отражены в клинических рекомендациях по ведению пациентов с операциями на спинном мозге, с точки зрения пациентов: обсуждение с врачом картины своей болезни, длительности госпитализации, предполагаемого исхода, прогноза (60 пациентов, 100%), обучение медицинского персонала навыкам реабилитации (51 пациент, 85% пациентов), общение с пациентами, которые уже перенесли подобную операцию ранее в этом хирургическом отделении (49 пациентов, 81,7%), обеспечение преемственности и обсуждение всего маршрута реабилитации до операции (60 пациентов, 100%). Заключение. Когнитивные и эмоционально-эффективные нарушения определяют качество жизни и реабилитации пациентов, перенесших оперативное вмешательство на спинном мозге. Целесообразно включение когнитивно-моторного тренинга в программу реабилитации пациентов после спинальных нейрохирургических операций.
Aim. To assess the extent to which cognitive and emotional disorders in patients undergoing spinal cord surgery affect the quality of rehabilitation and, based on the data obtained, to suggest optimization of rehabilitation measures. Materials and methods. The study included 60 patients (30 men and 30 women) whose condition required spinal cord surgery. All patients underwent assessment of somatic and neurological status, as well as quantitative neuropsychological testing. The influence of cognitive and emotional disorders before and after surgery on the severity of pain syndrome and movement disorders was assessed. When included in the study, patients were randomized into the main (30 people) and control (30 people) group. The patients of the main group received cognitive-motor training, which was carried out using the methodological manual “Cognitive Training for Patients with Moderate Cognitive Impairment”, developed by the staff of the Department of Nervous Diseases and Neurosurgery of the Sechenov First Moscow State Medical University (Sechenov University). Cognitive, emotional, motor disorders, severity of pain syndrome, as well as the quality of life and adherence of patients to cognitive-motor training were assessed 3 and 6 months after the surgical intervention.The severity of cognitive and emotional disorders in patients of the main and control groups did not differ before the operation. Results. After the operation, the severity of cognitive impairments was significantly higher in patients of the control group (p=0.03). Patients in the control group were significantly worse than patients in the main group in performing memory tasks (p=0.00), they also had a significantly lower rate of mental processes (p=0.00). These differences persisted 3 months after surgery (p=0.00). A week after the surgical intervention, the severity of anxiety and depression was significantly higher in patients in the control group (p=0.01). The positive effect of the operation in the form of pain reduction was achieved in all patients, but in the control group there was an increase in the severity of the pain syndrome after six months of observation compared with that after three months. An increase in the severity of the pain syndrome was associated with an increase in depression, anxiety, and cognitive impairment. The analysis showed that patients of the main group with high adherence to cognitive training showed significantly greater positive dynamics both in terms of cognitive functions and in terms of anxiety and depression (p<0.05). A survey of patients after inclusion in the study with the provision of prospective recommendations for clinical care showed the following: 58 patients (96.7% of patients) noted that the proposed recommendations for clinical care, from their point of view, would significantly improve their postoperative prognosis. Important points that should be reflected in the clinical guidelines for the management of patients with spinal cord surgery, from the point of view of patients, were: discussion with the doctor of the picture of their illness, duration of hospitalization, expected outcome, prognosis (60 patients, 100%), medical education rehabilitation skills (51 patients, 85% of patients), communicating with patients who have already undergone a similar operation earlier in this surgical department (49 patients, 81.7%), ensuring continuity and discussing the entire rehabilitation route before surgery (60 patients, 100%). Conclusion. Cognitive and emotionally disorders determine the quality of life and rehabilitation of patients who have undergone surgery on the spinal cord. Our results allow us to recommend the inclusion of cognitive-motor training in the rehabilitation program for patients after spinal neurosurgical operations.
Keywords: postoperative cognitive dysfunction, cognitive impairment, emotional disorders, cognitive-motor training, treatment, rehabilitation, postoperative pain syndrome, movement disorders, spinal surgery
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1. Wei P, Yang F, Zheng Q, et al. The potential role of the NLRP3 Inflammasome activation as a link between mitochondria ROS generation and Neuroinflammation in postoperative cognitive dysfunction. Front Cell Neurosci. 2019;13:73.
2. Moller JT, Cluitmans P, Rasmussen LS, et al. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet. 1998;351(9117):1742.
3. Moller JT, Cluitmans P, Rasmussen LS, et al. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International study of post-operative cognitive dysfunction Lancet. 1998;351:857-61.
4. VanDijk D, Jansen E.W, Hijman R, et al. Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial. JAMA. 2002;287:1405-12.
5. Fodale V, Santamaria LB, Schifilliti D, Mandal PK. Anaesthetics and postoperative cognitive dysfunction: a pathological mechanism mimicking Alzheimer's disease. Anaesthesia. 2010;65:388-95.
6. Steinmetz J, Christensen KB, Lund T, et al. Long-term consequences of postoperative cognitive dysfunction. Anesthesiology. 2009;110:548-55.
7. Захаров В.В., Яхно Н.Н. Когнитивные расстройства в пожилом и старческом возрасте: методическое руководство для врачей. М. 2005 [Zakharov VV, Iakhno NN. Kognitivnye rasstroistva v pozhilom i starcheskom vozraste: metodicheskoe rukovodstvo dlia vrachei. Moscow. 2005 (in Russian)].
8. Le Y, Liu S, Peng M, et al. Aging differentially affects the loss of neuronal dendritic spine, neuroinflammation and memory impairment at rats after surgery. PLoS One. 2014;9:e106837.
9. Monk TG, Weldon BC, Garvan CW, et al. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology. 2008;108:18-30.
10. Ayyadhah Alanazi A. Reducing anxiety in preoperative patients: a systematic review. Br J Nurs. 2014;23(7):387-93.
11. Stamenkovic DM, Rancic NK, Latas MB, et al. Preoperative anxiety and implications on postoperative recovery: what can we do to change our history. Minerva Anestesiol. 2018;84:1307-17.
12. Wilson CJ, Mitchelson AJ, Tzeng TH, et al. Caring for the surgically anxious patient: a review of the interventions and a guide to optimizing surgical outcomes. Am J Surg. 2016;212:151-9.
13. Gomes ET, Melo RL, Vasconcelos EMR, Alencar EN. Use of nursing diagnoses anxiety and fear in the medical and surgical clinics of a university hospital. Revista de Pesquisa : Cuidado é Fundamental Online. 2012;4(2):2419-26.
14. Costa VASF, Silva SCR, Lima VCP. The pre-surgery anxiety of the patient: the alliance between the nurse and psychologist. Rev SBPH. 2010;13(2):282-98.
15. Camponogara S, Soares SGA, Silveira M, et al. Percepção de pacientes sobre o período pré-operatório de cirurgia cardíaca. Rev Min Enferm. 2012;16(3):382-90.
16. Berth H, Petrowski K, Balck F. The Amsterdam Preoperative Anxiety and Information Scale (APAIS) – the first trial of a German version. Psychosoc Med. 2007;4:Doc01.
17. McCleane GJ, Cooper R. The nature of pre-operative anxiety. Anaesthesia. 1990;45:153-5.
18. Christian LM, Graham JE, Padgett DA, et al. Stress and wound healing. Neuroimmunomodulation. 2006;13(5-6):337-46.
19. Pritchard MJ. Identifying and assessing anxiety in pre-operative patients. Nurs Stand. 2009;23:35-40.
20. Pritchard MJ. Managing anxiety in the elective surgical patient. Br J Nurs. 2009;18(7):416-9.
21. Perks A, Chakravarti S, Manninen P. Preoperative anxiety in neurosurgical patients. J Neurosurg Anesthesiol. 2009;21:127-30.
22. Scott A. Managing anxiety in ICU patients: the role of pre-operative information provision. Nurs Crit Care. 2004;9(2):72-9.
23. Преображенская И.С., Яхно Н.Н. Сосудистые когнитивные расстройства – клинические проявления, диагностика, лечение. Неврологический журнал. 2007;12(5):45-51 [Preobrazhenskaya IS, Yakhno NN. Vascular cognitive impairment – clinical manifestations, diagnostic approaches and treatment. Nevrologicheskii zhurnal. 2007;12(5):45-51 (in Russian)].
24. Pearse RM, Holt PJE, Grocott MPW. Managing perioperative risk in patients undergoing elective non-cardiac surgery. BMJ. 2011;343:d5759.
25. Melzack R. Psychological aspects of pain. Implications for neural blockade. In: Eds MJ Cousins, PO Bridenbaugh. Neural Blockade in Clinical Anesthesia and Management of Pain. Philadelphia: Lippincott-Raven, 1998.
26. Gureje O. Treating chronic pain in the context of comorbid depression. Pain. 2008;134(1-2):3-4.
27. Ortiz-Cardona J, Bendo A. Perioperative Pain Management in the Neurosurgical Patient. Anesthesiology Clin. 2007;25:655-74.
28. Klimek M, Ubben J, Ammann J, et al. Pain in neurosurgically treated patients: a prospective observational study. J Neurosurg. 2006;104:350-9.
29. Jaffe RA, Samuels SI. Anesthesiologist’s manual of surgical procedures. 3rd ed. Lippincott Williams & Wilkins, Philadelphia, USA, 2004.
30. Gerbershagen HJ, Aduckathil S, van Wijck AJ, et al. Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology. 2013;118:934-44.
31. Joshi GP, Kehlet H. Procedure-specific pain management. The road to improve postsurgical pain management? (editorial). Anesthesiology. 2013;118:780-2.
32. Taenzer P, Melzack R, Jeans ME. Influence of psychological factors on postoperative pain, mood and analgesic requirements. Pain. 1986;24:331-42.
33. De Cosmo G, Congedo E, Lai C, et al. Preoperative psychologic and demographic predictors of pain perception and tramadol consumption using intravenous patient-controlled analgesia. Clin J Pain. 2008;24:399-405.
34. McGregor AH, Dicken B, Jamrozik K. National audit of post-operative management in spinal surgery. BMC Musculoskeletal Disord. 2006;7:47.
35. Ostelo RW, Costa LO, Maher CG, et al. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev. 2008;8(4):CD003007.
36. Преображенская И.С., Фанталис Д., Абдышова С.А., Киндарова А.А. Нелекарственные методы терапии когнитивных нарушений. Неврология, нейропсихиатрия, психосоматика. 2019;11(3S):68-77 [Preobrazhenskaya IS, Fantalis D, Abdyshova SA, Kindarova AA. Non-drug therapies for cognitive impairment. Neurology, Neuropsychiatry, Psychosomatics. 2019;11(3S):68-77 (in Russian)]. DOI:10.14412/2074-2711-2019-3S-68-77
37. La Morte W. Prospective and Retrospective Cohort Studies. Boston University College of Public Health, 2013.
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Авторы
Д. Фанталис*, С.П. Бордовский, И.С. Преображенская
ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия
*doctor.fant@gmail.com
________________________________________________
David Fantalis*, Sergey P. Bordovsky, Irina S. Preobrazhenskaya
Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
*doctor.fant@gmail.com