Department of Anesthesiology and Pain Medicine, University of Toronto, Canada.
Faculty of Medicine, University of British Columbia, Canada.
Anaesthesia. 2021 Apr;76(4):549-558. doi: 10.1111/anae.15172. Epub 2020 Jun 29.
Phrenic-sparing analgesic techniques for shoulder surgery are desirable. Intra-articular infiltration analgesia is one promising phrenic-sparing modality, but its role remains unclear because of conflicting evidence of analgesic efficacy and theoretical concerns regarding chondrotoxicity. This systematic review and meta-analysis evaluated the benefits and risks of intra-articular infiltration in arthroscopic shoulder surgery compared with systemic analgesia or interscalene brachial plexus block. We sought randomised controlled trials comparing intra-articular infiltration with interscalene brachial plexus block or systemic analgesia (control). Cumulative 24-h postoperative oral morphine equivalent consumption was designated as the primary outcome. Secondary outcomes included visual analogue scale pain scores during the first 24 h postoperatively; time-to-first analgesic request; patient satisfaction; opioid-related side-effects; block-related adverse events; and any indicators of chondrotoxicity. Fifteen trials (863 patients) were included. Compared with control, intra-articular infiltration reduced 24-h postoperative analgesic consumption by a weighted mean difference (95%CI) of -30.9 ([-38.9 to -22.9]; p < 0.001). Intra-articular infiltration also reduced the weighted mean difference (95%CI) pain scores up to 12 h postoperatively, with the greatest reduction at 4 h (-2.2 cm [(-4.4 to -0.04]); p < 0.05). Compared with interscalene brachial plexus block, there was no difference in opioid consumption, but patients receiving interscalene brachial plexus block had better pain scores at 2, 4 and 24 h postoperatively. There was no difference in opioid- or block-related adverse events, and none of the trials reported chondrotoxic effects. Compared with systemic analgesia, intra-articular infiltration provides superior pain control, reduces opioid consumption and enhances patient satisfaction, but it may be inferior to interscalene brachial plexus block patients having arthroscopic shoulder surgery.
对于肩部手术，保留膈神经的镇痛技术是理想的。关节内浸润镇痛是一种有前途的膈神经保留方式，但由于其镇痛效果的证据相互矛盾，以及对软骨毒性的理论担忧，其作用仍不清楚。本系统评价和荟萃分析评估了与全身镇痛或肌间沟臂丛阻滞相比，关节内浸润在关节镜肩部手术中的益处和风险。我们比较了关节内浸润与肌间沟臂丛阻滞或全身镇痛（对照组）的随机对照试验。24 小时术后累积口服吗啡等效消耗量被指定为主要结局。次要结局包括术后 24 小时内视觉模拟评分疼痛；首次镇痛请求时间；患者满意度；阿片类药物相关副作用；阻滞相关不良事件；以及任何软骨毒性的指标。纳入了 15 项试验（863 名患者）。与对照组相比，关节内浸润可减少 24 小时术后镇痛消耗的加权均数差（95%CI）为-30.9（-38.9 至-22.9）；p<0.001）。关节内浸润还降低了至 12 小时的加权均数差（95%CI）疼痛评分，在 4 小时时降幅最大（-2.2cm[-4.4 至-0.04]；p<0.05）。与肌间沟臂丛阻滞相比，阿片类药物消耗无差异，但接受肌间沟臂丛阻滞的患者在术后 2、4 和 24 小时的疼痛评分更好。阿片类药物或阻滞相关不良事件无差异，且无试验报告软骨毒性作用。与全身镇痛相比，关节内浸润可提供更好的疼痛控制，减少阿片类药物消耗并提高患者满意度，但可能不如肌间沟臂丛阻滞的患者进行关节镜肩部手术。
