超声引导连续隐神经阻滞对全膝关节置换术后镇痛效果影响的随机对照研究

A Randomized Controlled Study of Ultrasound-guided Continuous Saphenous Nerve Block for Postoperative Analgesia After Total Knee Arthroplasty

目的：探讨超声引导连续隐神经阻滞（ saphenous nerve block ，SNB）对全膝关节置换术（ total knee arthroplasty ， TKA）后镇痛效果的影响。方法经我院伦理委员会批准，选择2016年3～5月我院择期TKA 60例，采用随机数字表将患者随机分为隐神经组（n＝30）与股神经组（n＝30）。2组操作均在术后进行，持续输注0．2％罗哌卡因PCA背景量5 ml／h，患者自控镇痛剂量每次5 ml，锁定时间30 min，使用时间48 h。采用数字疼痛评分法（ numeric pain rating scale ，NPRS）评估阻滞后4、8、12、24、36、48 h静息和运动时的疼痛程度，同时记录股四头肌肌力，比较2组患者术后哌替啶使用率、阿片类药物不良反应发生率和48 h患者满意度评分。结果2组阻滞后4、8、12、24、36、48 h静息痛与运动痛评分无明显差异（ P＞0.05）。隐神经组阻滞后8、12、24、36 h股四头肌肌力明显高于股神经组（Z＝－3．637，P＝0．000；Z＝－4．618，P＝0．000；Z＝－4．461，P＝0．000；Z＝－3．908，P＝0．006）。隐神经组术后哌替啶使用率13．3％（4／30），股神经组为16．7％（5／30），差异无统计学意义（χ^2＝0．000，P＝1．000）。隐神经组术后阿片类药物不良反应发生率为10．0％（3／30），股神经组为6．7％（2／30），差异无统计学意义（χ^2＝0．000，P＝1．000）。 SNB组48 h患者满意度评分为（8．7±0．8）分，明显高于FNB组（6．1±0．7）（t＝13．517，P＝0．000）。结论2种阻滞方法均能为TKA术后提供有效镇痛，但与连续FNB相比，连续SNB对股四头肌肌力影响较小，可促进患者早期活动和患肢功能恢复。

Objective To explore the efficacy of ultrasound-guided continuous saphenous nerve block （S N B ） forpostoperative analgesia after total knee arthroplasty （T K A ）. Methods Approved by the ethics committee, sixty patients underwentselective TKA in our hospital from March 2016 to May 2016. The patients were randomly divided into either SNB group （ n = 30） orfemoral nerve block （F N B ） group （ n = 3 0 ）. Ultrasound-guided SNB or FNB was administered postoperatively, with 5 ml/h of 0. 2%ropivacaine continuously infused plus a bonus of 5 ml every 30 min in both groups. The numeric pain rating scale （ NPRS） was used toassess pain intensity at 4 , 8 , 12, 24, 36, and 48 h after block at rest and during functional exercise. The quadriceps muscle strengthat 4 , 8 , 12, 24, 36, and 48 h was recorded. The usage of pethidine postoperatively, the incidence of opioid related adverse effects,and patient satisfaction scores at 48 h were also recorded. Results The pain scores at rest and during active and passive functionalexercise at 4 , 8, 12, 24, 36, and 48 h had no significantly differences between the two groups （P 〉 0 . 0 5 ）. The quadriceps musclestrength at 8 , 12 , 24, and 36 h in the SNB group was higher than that in the FNB group （Z = - 3. 637 , P = 0. 000 ; Z = - 4 . 618 ,P = 0. 000 ; Z = - 4 . 461, P = 0. 000 ; Z = - 3. 908 , P = 0. 0 0 6 ）. The usage of pethidine postoperatively was 13.3% （4 /3 0 ） in theSNB group and 16.7% （5 /3 0 ） in the FNB group, without significant difference （x = 0.000, P - 1 .0 0 0 ）. The incidence of opioidrelated adverse effects was 10. 0% （3 /3 0 ） in the SNB group and 6 .7 % （ 2 /3 0 ） in the FNB group, without significant difference（X^2 = 0.000, P = 1 .0 0 0 ）. The patient satisfaction score at 48 h was （ 8 .7 ± 0 .8 ） points in the SNB group, which was significantlyhigher than the FNB group [ （ 6 . 1 ± 0. 7 ） points, t = 13. 5 1 7 , P = 0. 000 ] . Conclusion Both SNB and FNB can offer effectiveanalgesic results after TKA, but SNB has less influence on quadriceps muscle strength than FNB. Therefore, SNB group are superior toFNB group in patients , early activity and motor function recovery.