隐神经阻滞在踝关节大手术后镇痛中的重要性：一项随机的，对照的，双盲的研究
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The Importance of the Saphenous Nerve Block for Analgesia Following Major Ankle Surgery：A Randomized, Controlled, Double-Blind Study
背景与目的
踝关节大手术后常伴随严重的术后疼痛。目前坐骨神经阻滞在其术后镇痛中的重要性已经明确，而补充性隐神经阻滞的临床意义尚未通过前瞻性、随机、双盲、安慰剂对照研究中得以确定。本研究中假设隐神经阻滞能够减少踝关节大手术后伴随严重疼痛的患者比例。
方 法
研究共计纳入18例接受腘窝坐骨神经阻滞的患者（所有患者在手术开始前完成腘窝上坐骨神经阻滞）。坐骨神经阻滞完成后，所有患者接受全身麻醉（喉罩或者气管插管）。患者被随机分为隐神经阻滞组（单次注射0.5％布比卡因10 ml +1:200 000肾上腺素；图1）和安慰剂对照组（单次注射生理盐水10 ml），全麻诱导完成后，所有患者接受隐神经药物注射操作。主要研究目标为存在显著临床疼痛（数字评定量表上评分>3分）的患者比例。次要研究目标是隐神经髌下支的皮肤支配区域的最大疼痛和镇痛情况。疼痛评价时间点为手术结后30min、45min、60min、75min、90min和105min。如果患者出现踝关节内侧区域的显著临床疼痛（NRS>3），则针对患者的疼痛观察结束。
结 果
安慰剂对照组中9例患者中8例出现显著的临床疼痛，而隐神经阻滞组9例患者中有1例（P = 0.003）。与安慰剂对照组相比，隐神经阻滞组的最大疼痛程度显著降低（中位数，0 [0-0] vs. 5 [4-6]; P = 0.001）。所有在术后30min内出现隐神经支配皮区的突发性疼痛的病例NRS评价均大于3分。对隐神经髌下支的皮肤支配区域的感觉测试结果显示，在前内侧踝关节区域中出现的疼痛与在前内侧膝关节区域的皮肤感觉阻滞强度之间存在相关性。
结 论
隐神经与踝关节大手术后疼痛密切相关；隐神经阻滞作为腘窝坐骨神经阻滞的补充，能够显著降低踝关节大手术后30min内出现的明显临床疼痛。
原始文献摘要
The Importance of the Saphenous Nerve Block for Analgesia Following Major Ankle Surgery: A Randomized, Controlled, Double-Blind Study. Regional An00000000764
Background and Objectives: Major ankle surgery causes intense postoperative pain, and whereas the importance of a sciatic nerve block is well established, the clinical significance of a supplemental saphenous nerve block has never been determined in a prospective, randomized, double-blind, placebo-controlled trial. We hypothesized that a saphenous nerve block reduces the proportion of patients experiencing significant clinical pain after major ankle surgery
Methods: Eighteen patients were enrolled and received a popliteal sciatic nerve block. Patients were randomized to single-injection saphenous nerve block with 10 mL 0.5% bupivacaine with 1:200,000 epinephrine or 10 mL saline (Fig. 1). Primary outcome was the proportion of patients reporting significant clinical pain, defined as a score greater than 3 on the numerical rating scale. Secondary outcomes were maximal pain and analgesia of the cutaneous territory of the infrapatellar branch of the saphenous nerve.
Results: Eight of 9 patients in the placebo group reported significant clinical pain versus 1 of 9 patients in the bupivacaine-epinephrine group (P = 0.003). Maximal pain was significantly lower in the active compared with the placebo group (median, 0 [0–0] vs 5 [4–6]; P = 0.001). Breakthrough pain from the saphenous territory began within 30 minutes after surgery in all cases. Sensory testing of the cutaneous territory of the infrapatellar branch of the saphenous nerve showed correlation between pain reported in the anteromedial ankle region and the intensity of cutaneous sensory block in the anteromedial knee region.
Conclusions: The saphenous nerve is an important contributor to postoperative pain after major ankle surgery, with significant clinical pain appearing within 30 minutes after surgery.
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