超声引导下收肌管复合四种不同入路坐骨神经阻滞在全膝关节置换术术后镇痛中的比较

Ultrasound-guided adductor canal block combined four approaches to sciatic nerve block for postoperative analgesia after total knee arthroplasty

目的评价超声引导下收肌管复合四种不同入路坐骨神经阻滞在TKA术后镇痛中的应用效果,优化全膝关节置换术(TKA)术后镇痛技术。方法选择择期气管插管全身麻醉下行单侧TKA手术的患者120例,ASAⅡ~Ⅲ级,年龄>65岁,体质指数在18~25 kg/m2之间,术后超声引导下行收肌管联合坐骨神经阻滞镇痛。根据坐骨神经阻滞入路不同,随机均分为四组(n=30):P组(臀下间隙后入路法);A组(大腿中部收肌管处前入路法);LG组(大转子下外侧入路法)和LP组(腘窝上外侧入路法)。记录每组操作完成的时间、坐骨神经阻滞穿刺针深度、超声成像时间、成像清晰度评分、感觉阻滞的起效时间、感觉阻滞的效果、感觉阻滞持续时间、穿刺及阻滞的成功率、患者满意度评分。记录四组术后不同时间点的静息时及主动功能锻炼时视觉模拟评分,术后的膝关节活动度和助行器行走10米的完成率。结果A组在操作完成时间短于其他三组(P<0.05),超声成像时间A组及LP组短于P组及LG组(P<0.05),成像清晰度评分及穿刺成功率A组及LP组高于P组及LG组(P<0.05),穿刺针深度LP组小于其他三组(P<0.05),阻滞成功率LG组低于其他三组(P<0.05),患者满意度A组及LP组高于P组及LG组(P<0.05)。四组术后各时间点静息及活动时VAS疼痛评分、术后不同时间点助行器辅助行走10米完成率及膝关节活动度四组比较差异无统计学意义(P>0.05)。结论在TKA术后超声引导下收肌管复合四种不同入路坐骨神经阻滞镇痛中,大腿中部收肌管前入路法及腘窝上外侧入路优于臀下间隙及大转子下入路,为TKA术后超声引导下收肌管复合坐骨神经阻滞镇痛优化的穿刺技术路径。

Objective To evaluate the efficacy of adductor canal block combined four approaches of sciatic nerve block under ultrasound-guided for postoperative analgesia following total knee arthroplasty(TKA)to optimize postoperative analgesia technique.Methods 120 patients more than 65 years old,ASA physical statusⅡ~Ⅲ,having unilateral total knee replacement(TKA)underwent general anesthesia were performed adductor canal block and sciatic nerve block under ultrasound-guided after operation.All the patients were randomly allocated into four groups according to different approaches of sciatic nerve block(30 cases in each):Group P(posterior approach at sub-gluteal space),Group A(anterior approach at the adductor canal level of midthigh),Group LG(lateral approach under the greater trochanter),Group LP(lateral approach above popliteal fossa).The performance time,the depth of needle,the ultrasound imaging time,imaging definition scores,the onset and duration time of sensory block,effect of sensory block,puncture,the block success rate and patient satisfaction score were recorded for each group.The visual analogue score(VAS)were recorded during rest and active functional movement at different points after operation in the four groups.The range of knee joint motion(ROM)and rate of the ability to walk for 10 meters using the walker(RAW)were also embraced.Results The performance time in Group A was shorter than the other three groups(P<0.05),the ultrasound imaging time in group A and group LP were shorter than group P and group LG(P<0.05),meanwhile the imaging definition scores and the puncture success rate were higher(P<0.05).The depth of needle in group LP was shorter than the other three groups(P<0.05),the block success rate in group LG was lower than the other three groups(P<0.05),patient satisfaction in group A and group LP were higher than those of group P and group LG(P<0.05).The VAS pain scores during rest and active functional movement,the range of knee joint motion(ROM)and the rate of the ability to walk for 10 meters using the walker(RAW)of the four groups showed no statistical significance(P>0.05).Conclusion Ultrasound-guided sciatic nerve block at the adductor canal level of midthigh and lateral sciatic nerve block above popliteal fossa were superior to posterior approach at subgluteal space and lateral approach under the greater trochanter.They were optimization techniques for postoperative analgesia after TKA combined with adductor canal block.