颈5-6神经根阻滞技术用于肩关节镜术后镇痛的随机对照研究
|
摘要
目的:比较超声引导下肌间沟臂丛神经阻滞和颈5-6神经根阻滞用于肩关节镜术后镇痛的效果。方法:选取北京大学第三医院运动医学研究所择期全身麻醉行肩关节镜下韧带断裂修复手术患者40例,美国麻醉医师协会(American society of anesthesiologists,ASA)分级Ⅰ～Ⅱ级。随机分为肌间沟臂丛阻滞组(I组)和颈5-6神经根阻滞组(C组),每组20例。40例患者均在全身麻醉前进行超声引导下单次神经阻滞,I组经肌间沟入路行臂丛神经阻滞,推注0. 2%罗哌卡因10 m L; C组经侧颈部入路行颈5-6神经根阻滞,推注0. 2%罗哌卡因10 m L。记录穿刺后感觉及运动阻滞起效时间,手术时间,术后持续镇痛时间,术后1、6、12、24 h数字疼痛强度量表(numerical rating scale,NRS)评分及患者手指运动情况。记录药物不良反应及患者满意度,主要终点为神经阻滞后到术后1 d患者术侧肩关节静息及运动疼痛情况,次要终点为患肢手指运动情况及患者满意度。结果:I组镇痛持续时间(571. 50±70. 11) min,C组(615. 60±112. 15) min,两组差异无统计学意义(P> 0. 05)。C组术后1、6、12 h静态及动态NRS评分均低于I组,差异有统计学意义(P <0. 05),24 h两组间静态及动态NRS评分差异无统计学意义(P> 0. 05)。神经阻滞后患肢手部肌力,C组为5(4,5)级,I组为4(2,4)级,两组间差异有统计学意义(P <0. 01);手部支配区感觉评分,桡神经C组为1(0,2),I组为2(1,2),正中神经C组为0(0,2),I组为2(1,2),尺神经C组为0(0,1),I组为1(1,2),两组间差异均有统计学意义(P <0. 01);术侧肩部感觉评分,C组为2(1,2),I组为2(1,2),两组间差异无统计学意义(P> 0. 05);患者满意度评分,I组为8 (6,9),C组为9 (8,10),差异有统计学意义(P <0. 01)。结论:肌间沟臂丛神经阻滞和颈5-6神经根阻滞都可以满足肩关节镜术后镇痛需求,但颈5-6神经根阻滞后患肢前臂及手部活动不受限,麻木感更为局限,患者满意度更高。
Objective: To compare the effects of ultrasound-guided interscalene brachial plexus block and C5-6 nerve root block for analgesia after shoulder arthroscopy. Methods: In the study,40 patients of ASA Ⅰ-Ⅱ were selected for elective general anesthesia to repair the shoulder ligament rupture in Peking University Third Hospital,who were randomly divided into two groups,respectively for the intermuscular brachial plexus block group(group I) and C5-6 nerve root block group(group C),n = 20. The forty patients underwent ultrasound-guided brachial plexus block or C5-6 nerve root block before general anesthesia. Group I: 0. 2% ropivacaine 10 m L was injected into brachial plexus intermuscular approach; Group C: 0. 2% ropivacaine 10 m L was injected around the nerve roots of C5 and C6,and the ultrasound images showed that the liquid wrapped nerve roots. The time of sensory and motor block after puncture,operation time,the time of postoperative analgesia,numerical rating scale(NRS) scores at 1,6,12,and24 h postoperatively and the finger movements were recorded. The adverse drug reactions and the patient satisfaction were recorded. The primary end point was the study of shoulder rest and movement pain in the patients with postoperative nerve blockage; the secondary end point was the patient's limb movements and thepatient satisfaction. Results: The duration of analgesia was(571. 50 ± 70. 11) min in group I and(615. 60 ± 112. 15) min in group C,and there was no difference between the two groups(P > 0. 05).The static and dynamic NRS scores at 1,6,and 12 h in group C were lower than those in group I(P <0. 05). There was no difference in static and dynamic NRS scores between the two groups during 24 hours(P > 0. 05). There was a significant difference in grade of muscle strength between group C [5(4,5) ]and group I [4(2,4) ]in the patients with nerve block hind limb(P < 0. 01),and there were significant differences between the two groups' sensation in the radial nerve group C [1(0,2) ]and group I[2(1,2) ],the median nerve group C [0(0,2) ]and group I [2(1,2) ],and the ulnar nerves group C[0(0,1) ] and group I [1(1,2) ](P < 0. 01). There was no statistical difference between the two groups in the sencation of the shoulder,group C 2(1,2) and group I 2(1,2),P > 0. 05. Compared with group I 8(6,9),group C 9(8,10) was a significant difference in satisfaction(P < 0. 01). Conclusion: Interscalene brachial plexus block and C5-6 nerve root block could satisfy the needs of analgesia after shoulder arthroscopy,but C5-6 nerve root blockage does not limit the limb activity,the numbness is less,and the patient's satisfaction is higher.
Objective: To compare the effects of ultrasound-guided interscalene brachial plexus block and C5-6 nerve root block for analgesia after shoulder arthroscopy. Methods: In the study,40 patients of ASA Ⅰ-Ⅱ were selected for elective general anesthesia to repair the shoulder ligament rupture in Peking University Third Hospital,who were randomly divided into two groups,respectively for the intermuscular brachial plexus block group(group I) and C5-6 nerve root block group(group C),n = 20. The forty patients underwent ultrasound-guided brachial plexus block or C5-6 nerve root block before general anesthesia. Group I: 0. 2% ropivacaine 10 m L was injected into brachial plexus intermuscular approach; Group C: 0. 2% ropivacaine 10 m L was injected around the nerve roots of C5 and C6,and the ultrasound images showed that the liquid wrapped nerve roots. The time of sensory and motor block after puncture,operation time,the time of postoperative analgesia,numerical rating scale(NRS) scores at 1,6,12,and24 h postoperatively and the finger movements were recorded. The adverse drug reactions and the patient satisfaction were recorded. The primary end point was the study of shoulder rest and movement pain in the patients with postoperative nerve blockage; the secondary end point was the patient's limb movements and thepatient satisfaction. Results: The duration of analgesia was(571. 50 ± 70. 11) min in group I and(615. 60 ± 112. 15) min in group C,and there was no difference between the two groups(P > 0. 05).The static and dynamic NRS scores at 1,6,and 12 h in group C were lower than those in group I(P <0. 05). There was no difference in static and dynamic NRS scores between the two groups during 24 hours(P > 0. 05). There was a significant difference in grade of muscle strength between group C [5(4,5) ]and group I [4(2,4) ]in the patients with nerve block hind limb(P < 0. 01),and there were significant differences between the two groups' sensation in the radial nerve group C [1(0,2) ]and group I[2(1,2) ],the median nerve group C [0(0,2) ]and group I [2(1,2) ],and the ulnar nerves group C[0(0,1) ] and group I [1(1,2) ](P < 0. 01). There was no statistical difference between the two groups in the sencation of the shoulder,group C 2(1,2) and group I 2(1,2),P > 0. 05. Compared with group I 8(6,9),group C 9(8,10) was a significant difference in satisfaction(P < 0. 01). Conclusion: Interscalene brachial plexus block and C5-6 nerve root block could satisfy the needs of analgesia after shoulder arthroscopy,but C5-6 nerve root blockage does not limit the limb activity,the numbness is less,and the patient's satisfaction is higher.
引文
[1] Hussain N,Goldar G,Raqina N. Suprascapular and interscalene nerve block for shoulder surgery:a systematic review and meta analysis[J]. Anesthesiology,2017,127(6):998-1013.
[2] Marhofer P,Harrop-Griffiths W,Willschke H,et al. Fifteen years of ultrasound guidance in regional anaesthesia:part 2. recent developments in block techniques[J]. Br J Anaesth,2010,104(6):673-683.
[3] Madison SJ,Humsi J,Loland VJ,et al. Ultrasound-guided root/trunk(interscalene)block for hand and forearm anesthesia[J].Reg Anesth Pain Med,2013,38(3):226-232.
[4] Dhir S,Sondekoppam RV,Sharma R. A comparison of combined suprascapular and axillary nerve blocks to interscalene nerve block for analgesia in arthroscopic shoulder surgery:an equivalence study[J]. Reg Anesth Pain Med,2016,41(5):564-571.
[5] Riazi S,Carmichael N,Awad L,et al. Effect of local anaesthetic volume(20 vs. 5 m L)on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block[J]. Br J Anaesth,2008,101(4):549-556.
[6] Lang RS,Kentor ML,Vallejo M,et al. The impact of local anesthetic distribution on block onset in ultrasound-guided interscalene block[J]. Acta Anaesthesiol Scand,2012,56(9):1146-1151.
[7] Sinha SK,Abrams JH,Barnett JT,et al. Decreasing the local anesthetic volume from 20 to 10 m L for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis[J]. Reg Anesth Pain Med,2011,36(1):17-20.
[8] Vandepitte C,Gautier P,Xu D,et al. Effective volume of ropivicaine 0. 75%through a catheter required for interscalene brachial plexus blockade[J]. Anesthesiology,2013,118(4):863-867.
[9] Winnie AP. Interscalene brachial plexus block[J]. Anesth Analg,1970,49:455-466.
[10] Mendelsohn AH,Deconde A,Lambert HW,et al. Cervical variations of the phrenic nerve[J]. Laryngoscope,2011,121(9):1920-1923.
[11] Lee J,Kim K,Kim S. Threatment of a symptomatic cervical perineural cyst with ultrasound-guided cervical selective nerve root block:a case report[J]. Medicine(Baltimore),2018,97(37):e12412.
[12] van Geffen GJ,Moayeri N,Bruhn J,et al. Correlation between ultrasound imaging,cross-sectional anatomy,and histology of the brachial plexus:a review[J]. Reg Anesth Pain Med,2009,34(5):490-497.
[13] Kapral S,Greher M,Huber G,et al. Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade[J]. Reg Anesth Pain Med,2008,33(3):253-258.
[14] Shin HJ,Na HS,Oh AY,et a1. A prospective,randomized and controlled study of interscalene brachiaI plexus block for arthroscopic shoulder surgery:a comparison of C5 and con-ventional approach,a CONSORT-compliant article[J]. Medicine(Baltimore),2016,95(37):e4921.
[15] Marhofer P,Greher M,Kapral S. Ultrasound guidance in regional anaesthesia[J]. Br J Anaesth,2005,94(1):7-17.
[16]周玉弟,姜慧丽,汤洋,等.超声引导下选择性颈神经根阻滞在肩关节镜术后镇痛中的应用[J].临床麻醉学杂志,2017,12(33):1167-1170.
[17] Junq HS,Seo KH,Kanq JH. Optimal dose of perineural dexmedetomidine for inerscalene brachial plexus block to control postoperative pain in patients undergoing arthroscopic shoulder surgery:a prospective, double-blind,randomized controlled study[J]. Medicine(Baltimore),2018,97(16):e0440.
[18] Marhofer D,Marhofer P,Triffterer L,et al. Dislocation rates of perineural catheters:a volunteer study[J]. Br J Anaesth,2013,111(5):800-806.
[19]张大志,刘永盛,周海滨.舒芬太尼与地塞米松对罗哌卡因神经阻滞作用影响的比较研究[J].中国药物警戒,2012,9(12):710-712.
[2] Marhofer P,Harrop-Griffiths W,Willschke H,et al. Fifteen years of ultrasound guidance in regional anaesthesia:part 2. recent developments in block techniques[J]. Br J Anaesth,2010,104(6):673-683.
[3] Madison SJ,Humsi J,Loland VJ,et al. Ultrasound-guided root/trunk(interscalene)block for hand and forearm anesthesia[J].Reg Anesth Pain Med,2013,38(3):226-232.
[4] Dhir S,Sondekoppam RV,Sharma R. A comparison of combined suprascapular and axillary nerve blocks to interscalene nerve block for analgesia in arthroscopic shoulder surgery:an equivalence study[J]. Reg Anesth Pain Med,2016,41(5):564-571.
[5] Riazi S,Carmichael N,Awad L,et al. Effect of local anaesthetic volume(20 vs. 5 m L)on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block[J]. Br J Anaesth,2008,101(4):549-556.
[6] Lang RS,Kentor ML,Vallejo M,et al. The impact of local anesthetic distribution on block onset in ultrasound-guided interscalene block[J]. Acta Anaesthesiol Scand,2012,56(9):1146-1151.
[7] Sinha SK,Abrams JH,Barnett JT,et al. Decreasing the local anesthetic volume from 20 to 10 m L for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis[J]. Reg Anesth Pain Med,2011,36(1):17-20.
[8] Vandepitte C,Gautier P,Xu D,et al. Effective volume of ropivicaine 0. 75%through a catheter required for interscalene brachial plexus blockade[J]. Anesthesiology,2013,118(4):863-867.
[9] Winnie AP. Interscalene brachial plexus block[J]. Anesth Analg,1970,49:455-466.
[10] Mendelsohn AH,Deconde A,Lambert HW,et al. Cervical variations of the phrenic nerve[J]. Laryngoscope,2011,121(9):1920-1923.
[11] Lee J,Kim K,Kim S. Threatment of a symptomatic cervical perineural cyst with ultrasound-guided cervical selective nerve root block:a case report[J]. Medicine(Baltimore),2018,97(37):e12412.
[12] van Geffen GJ,Moayeri N,Bruhn J,et al. Correlation between ultrasound imaging,cross-sectional anatomy,and histology of the brachial plexus:a review[J]. Reg Anesth Pain Med,2009,34(5):490-497.
[13] Kapral S,Greher M,Huber G,et al. Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade[J]. Reg Anesth Pain Med,2008,33(3):253-258.
[14] Shin HJ,Na HS,Oh AY,et a1. A prospective,randomized and controlled study of interscalene brachiaI plexus block for arthroscopic shoulder surgery:a comparison of C5 and con-ventional approach,a CONSORT-compliant article[J]. Medicine(Baltimore),2016,95(37):e4921.
[15] Marhofer P,Greher M,Kapral S. Ultrasound guidance in regional anaesthesia[J]. Br J Anaesth,2005,94(1):7-17.
[16]周玉弟,姜慧丽,汤洋,等.超声引导下选择性颈神经根阻滞在肩关节镜术后镇痛中的应用[J].临床麻醉学杂志,2017,12(33):1167-1170.
[17] Junq HS,Seo KH,Kanq JH. Optimal dose of perineural dexmedetomidine for inerscalene brachial plexus block to control postoperative pain in patients undergoing arthroscopic shoulder surgery:a prospective, double-blind,randomized controlled study[J]. Medicine(Baltimore),2018,97(16):e0440.
[18] Marhofer D,Marhofer P,Triffterer L,et al. Dislocation rates of perineural catheters:a volunteer study[J]. Br J Anaesth,2013,111(5):800-806.
[19]张大志,刘永盛,周海滨.舒芬太尼与地塞米松对罗哌卡因神经阻滞作用影响的比较研究[J].中国药物警戒,2012,9(12):710-712.