超声引导下前锯肌平面阻滞对乳腺癌术后疼痛综合征的影响

Effects of ultrasound-guided serratus anterior plane block on post-mastectomy pain syndrome

目的:观察超声引导下前锯肌平面阻滞(serratus plane block,SPB)用于乳腺癌改良根治术围术期镇痛的疗效,探讨其对预防乳腺癌术后疼痛综合征(post-mastectomy pain syndrome,PMPS)的作用。方法:择期拟行单侧乳腺癌改良根治术的女性患者100例,采用随机数字表法分为2组,全麻组(G组)和全麻联合神经阻滞组(GB组)。麻醉诱导前,GB组行超声引导下术测SPB,注射0.33%罗哌卡因30 mL;G组行模拟阻滞,相同位置注射等量生理盐水。术后2组均给予静脉自控镇痛(patient controlled intravenous analgesia,PCIA)。随访术后4 h、12 h、24 h、48 h疼痛数字等级(numerical rating scale,NRS)评分及术后补救镇痛情况;记录术后3个月、6个月、9个月、12个月NRS评分和PMPS发生率。结果:①GB组术后4 h(P=0.000)、12 h(P=0.000)、24 h(P=0.000)、48 h(P=0.001)静息NRS评分低于G组;术后4 h(P=0.000)、12 h(P=0.000)、24 h(P=0.002)、48 h(P=0.001)活动NRS评分低于G组;②GB组术后PCA按压次数(0.07±0.34)比G组(0.56±0.82)减少(P=0.001);镇痛补救比例(4.77%)比G组(35.90%)降低(P=0.000)。③GB组患者术后6个月(47.62%)PMPS发生率低于G组(71.80%)(P=0.041);术后9个月(35.71%)PMPS发生率低于G组(61.54%)(P=0.020)。④GB组在术后6个月(P=0.020)、9个月(P=0.016)静息NRS评分均明显低于G组。⑤急性NRS评分与术后慢性NRS评分有一定相关性。结论:超声引导下SPB可显著改善乳腺癌改良根治术围术期疼痛、减少阿片类药物消耗,并降低PMPS发生率及疼痛程度。此外,术后急性疼痛NRS评分和PMPS严重程度具有相关性。

Objective:To investigate the effect of ultrasound-guided serratus anterior plane block on perioperative analgesia in patients after modified radical mastectomy(MRM)and to explore its role in preventing post-mastectomy pain syndrome(PMPS).Methods:One hundred female patients scheduled for modified radical mastectomy,aged 28 to 75,were randoly divided into 2 groups the general anesthesia group(G)and the general anesthesia group combined with nerve block group(GB).Before induction of anesthesia,patients in the GB group were injected with 0.33%ropivacaine for 30 mL in the serratus anterior plane under ultrasound guidance.Patients in the group G were injected with the same amount of saline at the same location.Patients in the two groups underwent tracheal intuba-tion,followed by static suction combined anesthesia.Patients in both groups were given patient controlled intravenous analgesia(PCIA)after surgery.The times of effective delivered doses 48 h postoperatively,the cases of remedial analgesia were recorded.Numerical rating scale(NRS)was used to evaluated the pain severity at 4 hours,12 hours,24 hours,and 48 hours postoperatively and at3 months,6 months,9 months,12 months postoperatively in both groups.PMPS incidence will also be recorded.Results:①The NRS scores at rest in GB group were significantly lower than that of the G group at 4 h(P=0.000),12 h(P=0.000),24 h(P=0.000),and 48 h(P=0.001)postoperatively;NRS scores at movement in in GB group were significantly lower than that of the G group at 4 h(P=0.000),12 h(P=0.000),24 h(P=0.002),and 48 h(P=0.001)postoperatively.②The number of effective analgesia pump pressing within 48 h in GB(0.07±0.34)was significantly less than that in the G group(0.56±0.82)(P=0.001);the remedial analgesic ratio in GB group(4.77%)was lower than G group(35.90%)(P=0.000).③The NRS scores in the GB group at 6(P=0.020)and 9 months(P=0.016)after surgery were significantly lower than those in the G group.④The incidence of PMPS in GB group at 6 months(47.62%)and 9 months(61.54%)postoperatively was significantly lower than that in the G group at 6 months(71.80%,P=0.041)and 9 months(61.54%,P=0.020)postoperatively.⑤There was a correlation between the acute NRS scores and the chronic NRS scores.Conclusion:Ultrasound-guided serratus anterior plane block applied to modified radical mastectomy for breast cancer can not only improve acute pain scores,reduce perioperative opioid consumption,but also reduce the incidence and severity of PMPS.In addition,the postoperative acute pain NRS score was related to the severity of PMPS.