Szűcs Szilárd, Morau Didier, Sultan Syed F, Iohom Gabriella, Shorten George
Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital and University College Cork, Cork, Ireland.
BMC Anesthesiol. 2014 Jan 25;14:6. doi: 10.1186/1471-2253-14-6.
Fractured neck of femur generally requires operative fixation and is a common cause of admission to hospital. The combination of femoral nerve block and spinal anesthesia is a common anesthetic technique used to facilitate the surgical procedure. The optimal disposition of local anesthetic (LA) relative the femoral nerve (FN) has not been defined. Our hypothesis was: that the deposition of LA relative to the FN influences the quality of analgesia for positioning of the patient for performance of spinal anesthesia. The primary outcome was verbal rating (VRS) pain scores 0-10 assessed immediately after positioning the patient to perform spinal anesthesia.
With Institutional ethical approval and having obtained written informed consent from each, 52 patients were studied. The study was registered with ClinicalTrials.gov (NCT01527812). Patients were randomly allocated to undergo to one of three groups namely: intention to deposit lidocaine 2% (15 ml) i. above (Group A), ii. below (Group B), iii. circumferential (Group C) to the FN. A blinded observer assessed i. the sensory nerve block (cold) in the areas of the terminal branches of the FN and ii. VRS pain scores on passive movement from block completion at 5 minutes intervals for 30 minutes. Immediately after positioning the patient for spinal anesthesia, VRS pain scores were recorded.
Pain VRS scores during positioning were similar in the three groups [Above group/Below group/Circumferential group: 2(0-9)/0(0-10)/3(0-10), median(range), p:0.32]. The block was deemed to have failed in 20%, 47% and 12% in the Above group, Below group and Circumferential group respectively. The median number of needle passes was greater in the Circumferential group compared with the Above group (p:0.009). Patient satisfaction was greatest in the Circumferential group [mean satisfaction scores were 83.5(19.8)/88.1(20.5)/93.8(12.3), [mean(SD), p=0.04] in the Above, Below and Circumferential groups respectively.
We conclude that there is no clinical advantage to attempting to deposit LA circumferential to the femoral nerve (relative to depositing LA either above or below the nerve), during femoral nerve block in this setting.
股骨颈骨折通常需要手术固定，是住院的常见原因。股神经阻滞联合脊髓麻醉是一种常用的麻醉技术，用于辅助手术操作。局部麻醉药（LA）相对于股神经（FN）的最佳注射位置尚未明确。我们的假设是：LA相对于FN的注射位置会影响患者在脊髓麻醉定位时的镇痛质量。主要结局指标是在患者为进行脊髓麻醉而定位后立即评估的0至10分的语言评分量表（VRS）疼痛评分。
经机构伦理批准并获得每位患者的书面知情同意后，对52例患者进行了研究。该研究已在ClinicalTrials.gov（NCT01527812）注册。患者被随机分配至三组之一，即：将2%利多卡因（15毫升）注射至i. FN上方（A组）、ii. FN下方（B组）、iii. FN周围（C组）。一名盲法观察者评估i. FN终末支区域的感觉神经阻滞（冷觉），以及ii. 自阻滞完成后每隔5分钟进行30分钟被动活动时的VRS疼痛评分。在患者为进行脊髓麻醉而定位后立即记录VRS疼痛评分。
三组在定位期间的疼痛VRS评分相似[上方组/下方组/周围组：2(0 - 9)/0(0 - 10)/3(0 - 10)，中位数（范围），p = 0.32]。上方组、下方组和周围组的阻滞失败率分别为20%、47%和12%。与上方组相比，周围组的平均穿刺次数更多（p = 0.009）。周围组患者满意度最高[上方组、下方组和周围组的平均满意度评分分别为83.5(19.8)/88.1(20.5)/93.8(12.3)，[平均值（标准差），p = 0.04]。
我们得出结论，在这种情况下进行股神经阻滞时，相对于将LA注射在神经上方或下方，试图将LA注射在股神经周围并无临床优势。
