【罂粟摘要】术前椎旁神经阻滞与乳腺癌术后慢性疼痛的关系：一项双盲随机试验

2021-12-10 09:53

术前椎旁神经阻滞与乳腺癌术后慢性疼痛的关系：一项双盲随机试验

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术前椎旁神经阻滞与乳腺癌术后慢性疼痛的关系：一项双盲随机试验

贵州医科大学麻醉与心脏电生理课题组

翻译：任文鑫编辑：张中伟审校：曹莹

背景

椎旁神经阻滞在预防乳腺手术后慢性疼痛方面的有效性仍然存在争议。本研究的主要假设是椎旁神经阻滞可降低乳腺癌术后3个月慢性疼痛的发生率。

方法

在这项前瞻性、多中心、随机、双盲、平行组、安慰剂对照研究中，380名接受部分或完全乳房切除术并进行或不进行淋巴结清扫的妇女随机接受0.35ml/kg 0.75%罗哌卡因（椎旁组）术前椎旁神经阻滞，或生理盐水（对照组）术前椎旁神经阻滞。两组患者均采用全身多模式镇痛法。主要结果是术后3个月，视觉模拟量表（VAS）评分大于或等于3分的慢性疼痛的发生率。次要结果为急性疼痛、镇痛药消耗、恶心呕吐、6个月和12个月时的慢性疼痛、神经病理性疼痛、疼痛干预、焦虑和抑郁。

结果

总体而言，178例患者接受了罗哌卡因治疗，174例患者接受了生理盐水治疗。3个月时，椎旁组178名患者中有93名（52.2%）出现慢性疼痛，对照组174名患者中有83名（47.7%）出现慢性疼痛（优势比为1.20[95%置信区间，0.79-1.82]，P=0.394）。在6个月和12个月时，椎旁组178名患者中分别有104名（58.4%）和105名（59.0%）出现慢性疼痛，对照组174名患者中分别有79名（45.4%）和93名（53.4%）出现慢性疼痛。对照组在0至2小时内观察到更大的急性术后疼痛（休息时的接收器操作特征曲线下的面积，4.3±2.8 vs. 2.9±2.8 VAS评分单位×小时，P<0.001），且在这个时间段内达到最大值（3.8±2.1 vs. 2.5±2.5，P<0.001），而且在任何其他时间段内没有观察到。椎旁组术后吗啡使用减少73%（优势比，0.272[95%置信区间，0.171-0.429]；P<0.001）。

结论

椎旁神经阻滞并没有减少乳房手术后慢性疼痛的发生率。椎旁神经阻滞确实使术后即时疼痛减少，但在术后结果方面没有其他显著差异。

原始文献来源

Aline Albi-Feldzer, Sylvain Dureau,Abdelmalek Ghimouz, et al.Preoperative Paravertebral Block and Chronic Pain after Breast Cancer Surgery: A Double-blind Randomized Trial.Anesthesiology 2021; 135:1091–103.

Preoperative Paravertebral Block and Chronic Pain after Breast Cancer

Surgery: A Double-blind Randomized Trial

ABSTRACT

Background: The effectiveness of paravertebral block in preventing chronic pain after breast surgery remains controversial. The primary hypothesis of this study was that paravertebral block reduces the incidence of chronic pain 3 months after breast cancer surgery.

Methods: In this prospective, multicenter, randomized, double-blind, parallelgroup, placebo-controlled study, 380 women undergoing partial or complete mastectomy with or without lymph node dissection were randomized to receive preoperative paravertebral block with either 0.35ml/kg 0.75% ropivacaine(paravertebral group) or saline (control group). Systemic multimodal analgesia was administered in both groups. The primary endpoint was the incidence of chronic pain with a visual analogue scale (VAS) score greater than or equal to 3 out of 10, 3 months after surgery. The secondary outcomes were acute pain, analgesic consumption, nausea and vomiting, chronic pain at 6 and 12 months, neuropathic pain, pain interference, anxiety, and depression.

Results: Overall, 178 patients received ropivacaine, and 174 received saline.At 3 months, chronic pain was reported in 93 of 178 (52.2%) and 83 of 174(47.7%) patients in the paravertebral and control groups, respectively (odds ratio, 1.20 [95% CI, 0.79 to 1.82], P = 0.394). At 6 and 12 months, chronic pain occurred in 104 of 178 (58.4%) versus 79 of 174 (45.4%) and 105 of 178 (59.0%) versus 93 of 174 (53.4%) patients in the paravertebral and control groups, respectively. Greater acute postoperative pain was observed in the control group 0 to 2 h (area under the receiver operating characteristics

curve at rest, 4.3 ± 2.8 vs. 2.9 ± 2.8 VAS score units × hours, P < 0.001) and when maximal in this interval (3.8 ± 2.1 vs. 2.5 ± 2.5, P < 0.001) but not during any other interval. Postoperative morphine use was 73% less in the paravertebral group (odds ratio, 0.272 [95% CI, 0.171 to 0.429]; P < 0.001).

Conclusions: Paravertebral block did not reduce the incidence of chronic pain after breast surgery. Paravertebral block did result in less immediate postoperative pain, but there were no other significant differences in postoperative outcomes.