氢吗啡酮在脊柱微创手术后镇痛中的应用前景：基于现有证据的系统性分析与对UBE手术的启示

Prospects of Hydromorphone in Postoperative Analgesia for Minimally Invasive Spine Surgery: A Systematic Analysis Based on Current Evidence and Implications for UBE Surgery

摘要: 单侧双通道内镜技术(UBE)已逐渐成为治疗腰椎退行性疾病的重要微创术式，术后疼痛控制质量直接影响患者的早期康复与远期预后。氢吗啡酮作为一种强效μ阿片受体激动剂，在围手术期镇痛领域日益受到关注。然而，必须正视的是，目前尚无直接针对UBE术式的高级别临床研究发表。为此，本文基于来自其他类型脊柱手术及不同手术人群的间接证据，进行一项外推性系统分析，旨在评估氢吗啡酮在脊柱微创手术镇痛中的疗效与安全性，并探讨其对UBE术后镇痛管理的启示。通过检索PubMed、Embase、Cochrane Library、Web of Science、中国知网和万方数据库，纳入相关系统评价及随机对照试验。现有证据显示：氢吗啡酮静脉自控镇痛与吗啡在术后各时间点的疼痛评分上无统计学差异，但其瘙痒发生率显著低于吗啡；椎管内给药虽可产生一定镇痛效应，却伴随瘙痒风险升高，临床净获益有限；在恶心呕吐、过度镇静和呼吸抑制等安全性指标上，氢吗啡酮未见明显劣势。结合UBE手术创伤中等、强调早期下地活动的特点，氢吗啡酮快速起效、无活性代谢产物蓄积的特性与其镇痛需求具有较好的理论适配性，但其成本效益仍需审慎评估。在多模式镇痛框架下，将氢吗啡酮与非甾体抗炎药及竖脊肌平面阻滞等区域阻滞技术有机组合，有望为UBE术后疼痛管理提供兼顾有效性与安全性的解决方案。当前直接证据稀缺，未来亟需开展设计严谨的前瞻性研究以明确其最佳应用方案。

Abstract: Unilateral biportal endoscopy (UBE) has become an important minimally invasive technique for lumbar degenerative diseases, where postoperative pain control directly affects early recovery and long-term prognosis. Hydromorphone, a potent μ-opioid receptor agonist, has gained increasing attention in perioperative analgesia. However, it must be acknowledged that no high-level clinical study directly targeting UBE surgery has been published to date. Therefore, this article conducts an extrapolative systematic analysis based on indirect evidence derived from other types of spinal surgeries and different surgical populations, aiming to evaluate the efficacy and safety of hydromorphone in minimally invasive spine surgery analgesia and to explore its implications for UBE postoperative pain management. By searching PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wanfang databases, relevant systematic reviews and randomized controlled trials were incorporated. Available evidence demonstrates that hydromorphone patient-controlled intravenous analgesia shows no statistical difference from morphine in pain scores at various time points, but its incidence of pruritus is significantly lower. Although neuraxial administration produces certain analgesic effects, it is accompanied by increased pruritus risk with limited net benefit. In terms of nausea, vomiting, sedation, and respiratory depression, hydromorphone shows no obvious disadvantage. Considering the moderate trauma and emphasis on early ambulation in UBE surgery, hydromorphone’s rapid onset and lack of active metabolite accumulation theoretically align well with its analgesic requirements, though cost-effectiveness warrants careful assessment. Within a multimodal analgesia framework, combining hydromorphone with NSAIDs and regional block techniques such as erector spinae plane block may provide effective and safe solutions for UBE postoperative pain management. Given the scarcity of direct evidence, rigorously designed prospective studies are urgently needed.