Zorrilla-Vaca Andres, Li Jinlei
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 455, Baltimore, MD, USA.
Faculty of Health, Universidad del Valle School of Medicine, Cali, Colombia.
J Anesth. 2018 Jun;32(3):341-350. doi: 10.1007/s00540-018-2480-1. Epub 2018 Mar 8.
Femoral nerve block (FNB) appears to have higher postoperative analgesic benefits compared with the patient-controlled analgesia (PCA) in total knee arthroplasty (TKA). However, the role of sciatic nerve block (SNB) as a complement to FNB remains controversial. We performed a meta-analysis assessing the benefits of the SNB as a complement to FNB, as well as comparing the efficacy of single-injection versus continuous SNB in TKA.
Our group conducted a systematic literature search in PubMed, EMBASE and Google Scholar. We retrieved randomized trials comparing either SNB versus placebo or continuous versus single-injection SNB. The intervention group was the use of SNB as a complement to FNB, while the control group was FNB alone. Pain score at rest and movement (at 4, 12, 24, 48 and 72 h), patient-controlled intravenous opioid consumption, length of hospital stay, and incidence of nausea were extracted from each study. Random-effects model was used for meta-analysis and standardized mean difference (SMD) was used as the effect size.
Ten articles comprising 514 patients were included to compare the effects of SNB combined with FNB versus FNB alone. Interventional group was found to significantly reduce pain score at for 4 h (SMD = - 0.94, 95% CI - 1.42 to - 0.47, P < 0.001, I = 76.5%) compared with the control group. Pain score at rest was significantly reduced at movement for 12 h (SMD = - 0.29, 95% CI - 0.54 to - 0.04, P = 0.02, I = 0%). Opioid consumption was significantly reduced at 24 (SMD = - 0.60, 95% CI - 1.01 to - 0.17, P = 0.01, I = 69.1%) and 48 h (SMD = - 1.04, 95% CI - 1.46 to - 0.61, P < 0.001, I = 43.4%) after TKA using SNB as a complement to FNB. Three articles were additionally meta-analyzed to compare the efficacy of single-injection (n = 79) versus continuous SNB (n = 79), being the latter one significantly associated with less pain score at 24 (SMD = -0.77, 95% CI - 1.10 to - 0.45, P < 0.001, I = 0%) and 48 h (SMD = - 0.69, 95% CI - 1.01 to - 0.36, P < 0.001, I = 0%), but not at 12 h (SMD = - 0.34, 95% CI - 0.73 to - 0.06, P = 0.10, I = 0%).
This meta-analysis provides evidence-based supports to the benefits of SNB as a complement to FNB in TKA. The combination sciatic-femoral nerve block appears to be the optimal choice for patients in high risk of postoperative opioids consumption or acute pain after TKA.
在全膝关节置换术（TKA）中，股神经阻滞（FNB）似乎比患者自控镇痛（PCA）具有更高的术后镇痛效果。然而，坐骨神经阻滞（SNB）作为FNB补充的作用仍存在争议。我们进行了一项荟萃分析，评估SNB作为FNB补充的益处，并比较单次注射与连续SNB在TKA中的疗效。
我们的团队在PubMed、EMBASE和谷歌学术上进行了系统的文献检索。我们检索了比较SNB与安慰剂或连续与单次注射SNB的随机试验。干预组为使用SNB作为FNB的补充，而对照组为单纯FNB。从每项研究中提取静息和活动时的疼痛评分（4、12、24、48和72小时）、患者自控静脉使用阿片类药物的量、住院时间和恶心发生率。采用随机效应模型进行荟萃分析，并使用标准化均数差（SMD）作为效应量。
纳入了10篇包含514例患者的文章，以比较SNB联合FNB与单纯FNB的效果。发现干预组与对照组相比，在术后4小时疼痛评分显著降低（SMD = -0.94，95%CI -1.42至-0.47，P < 0.001，I = 76.5%）。静息时疼痛评分在活动12小时时显著降低（SMD = -0.29，95%CI -0.54至-0.04，P = 0.02，I = 0%）。在TKA后使用SNB作为FNB补充时，24小时（SMD = -0.60，95%CI -1.01至-0.17，P = 0.01，I = 69.1%）和48小时（SMD = -1.04，95%CI -1.46至-0.61，P < 0.001，I = 43.4%）时阿片类药物消耗量显著降低。另外对3篇文章进行荟萃分析，以比较单次注射（n = 79）与连续SNB（n = 79）的疗效，结果显示后者在24小时（SMD = -0.77，95%CI -1.10至-0.45，P < 0.001，I = 0%）和48小时（SMD = -0.69，95%CI -1.01至-0.36，P < 0.001，I = 0%）时与疼痛评分降低显著相关，但在12小时时无显著差异（SMD = -0.34，95%CI -0.73至-0.06，P = 0.10，I = 0%）。
这项荟萃分析为SNB作为TKA中FNB补充的益处提供了循证支持。坐骨 - 股神经联合阻滞似乎是TKA后阿片类药物消耗高风险或急性疼痛患者的最佳选择。
