Terkawi Abdullah S, Tsang Siny, Sessler Daniel I, Terkawi Rayan S, Nunemaker Megan S, Durieux Marcel E, Shilling Ashley
Department of Epidemiology, Columbia University, New York, NY.
Department of Anesthesiology, King Fahad medical city, Riyadh, Saudi Arabia.
Pain Physician. 2015 Sep-Oct;18(5):E757-80.
While most trials of thoracic paravertebral nerve blocks (TPVB) for breast surgery show benefit, their effect on postoperative pain intensity, opioid consumption, and prevention of chronic postsurgical pain varies substantially across studies. Variability may result from use of different drugs and techniques.
To examine the use of TPVB in breast surgery, and to determine which method(s) provide optimal efficacy and safety.
Mixed-Effects Meta-Analysis.
We conducted a systematic review of randomized trials comparing TPVB to no intervention using random-effects models. To evaluate the contributions of various techniques, clinical approaches were included as moderators in mixed-effects models.
A total of 24 randomized controlled trials (RCTs) with 1,822 patients were included. Use of TPVB decreased postoperative pain scores at rest and movement at the first 2, 24, 48, and 72 hours. TPVB modestly decreased intraoperative and postoperative opioid consumption, reduced nausea and vomiting, and shortened hospitalization, but to a probably clinically irrelevant degree. Blocks also appeared to reduce the incidence of chronic postsurgical pain at 6 months. Adding fentanyl to the TPVB improved pain at rest (at 24, 48, and 72 hours) and movement (at 24 and 72 hours). Multilevel blocks provided better postoperative pain control, but only during movement (at 2, 48, and 72 hours). Fewer procedural complications (especially hypotension, epidural spread, and Horner's syndrome) occurred when anatomical landmarks were supplemented with ultrasound guidance.
The number of studies available was limited in the meta-analytic model of incidence of chronic post-surgical pain.
TPVB reduces postoperative pain and opioid consumption, and has a limited beneficial effect on the quality of recovery. From all the techniques that were evaluated, only the addition of fentanyl, and performing multilevel blocks were associated with improved acute analgesia. TPVB may reduce chronic postsurgical pain at 6 months.
虽然大多数关于胸段椎旁神经阻滞（TPVB）用于乳腺手术的试验显示出益处，但它们对术后疼痛强度、阿片类药物消耗量以及慢性术后疼痛预防的影响在不同研究中差异很大。这种变异性可能源于使用了不同的药物和技术。
研究TPVB在乳腺手术中的应用，并确定哪种方法能提供最佳疗效和安全性。
混合效应荟萃分析。
我们使用随机效应模型对比较TPVB与无干预的随机试验进行了系统评价。为了评估各种技术的贡献，临床方法被纳入混合效应模型作为调节因素。
共纳入24项随机对照试验（RCT），涉及1822例患者。使用TPVB可降低术后第2、24、48和72小时静息及活动时的疼痛评分。TPVB适度降低了术中及术后阿片类药物的消耗量，减少了恶心和呕吐，并缩短了住院时间，但可能在临床上无显著意义。神经阻滞似乎也降低了6个月时慢性术后疼痛的发生率。在TPVB中添加芬太尼可改善静息（在24、48和72小时）及活动（在24和72小时）时的疼痛。多级阻滞可提供更好的术后疼痛控制，但仅在活动时（在2、48和72小时）。当使用超声引导补充解剖标志时，手术并发症（尤其是低血压、硬膜外扩散和霍纳综合征）较少。
在慢性术后疼痛发生率的荟萃分析模型中，可用的研究数量有限。
TPVB可减轻术后疼痛和阿片类药物消耗，并对恢复质量有有限的有益影响。在所有评估的技术中，只有添加芬太尼和进行多级阻滞与改善急性镇痛有关。TPVB可能降低6个月时的慢性术后疼痛。
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