Smith Institute for Urology at Lenox Hill, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA.
James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
J Endourol. 2022 Jan;36(1):38-46. doi: 10.1089/end.2021.0402. Epub 2021 Dec 1.
Multimodal analgesic regimens incorporating peripheral nerve blocks (PNBs) have demonstrated reduced postoperative pain, opioid use, and recovery time in various disease states. However, this remains a subject of limited investigation in the percutaneous nephrolithotomy (PCNL) domain. In the face of an ongoing opioid epidemic and collective push to enhance prescribing stewardship, we sought to examine the potential opioid-sparing effect of PNBs in PCNL. A systematic review of Embase and PubMed was performed to identify all randomized controlled trials evaluating the use of a PNB with general anesthesia (GA) GA alone for pain control following PCNL. Studies evaluating neuraxial (epidural and spinal) anesthesia and those without GA as the control arm were excluded. Seventeen trials evaluating 1,012 procedures were included. Five different blocks were identified and evaluated: paravertebral ( = 8), intercostal nerve ( = 3), quadratus lumborum ( = 2), transversus abdominis plane ( = 1), and erector spinae ( = 3). Nine of 16 (56%) studies observed lower pain scores with PNB use throughout the 24-hour postop period. By comparison, improved pain scores with PNBs were limited to the early (<6 hours) recovery period in five studies and two found no difference. Total analgesic and opioid requirements were significantly higher in the GA control arm in nearly all studies (12/14, 86%). Operative times were similar and there were no differences in rates of intercostal access or nephrostomy tube insertion between study arms in any trial. While greater analgesic use with GA alone likely minimizes or obscures differences in patient-reported pain scores, PNBs may offer a significant opioid-sparing analgesic effect during postoperative recovery after PCNL.
多模式镇痛方案包括外周神经阻滞（PNB），已在各种疾病状态下证明可减少术后疼痛、阿片类药物使用和康复时间。然而，这在经皮肾镜碎石术（PCNL）领域仍是一个研究有限的课题。面对阿片类药物流行和集体推动加强处方管理的情况，我们试图研究 PNB 在 PCNL 中可能具有的节省阿片类药物的效果。对 Embase 和 PubMed 进行了系统回顾，以确定所有评估 PNB 与全身麻醉（GA）联合使用或单独用于 PCNL 后疼痛控制的随机对照试验。评估脊神经（硬膜外和脊髓）麻醉和没有 GA 作为对照组的研究被排除在外。共纳入了 17 项评估 1012 例手术的试验。确定并评估了 5 种不同的阻滞：椎旁阻滞（ = 8）、肋间神经阻滞（ = 3）、腰方肌阻滞（ = 2）、腹横肌平面阻滞（ = 1）和竖脊肌阻滞（ = 3）。在 16 项研究中有 9 项（56%）观察到在整个术后 24 小时期间，PNB 使用时疼痛评分较低。相比之下，5 项研究中 PNB 可改善早期（<6 小时）恢复期的疼痛评分，2 项研究则发现无差异。在几乎所有研究中，GA 对照组的总镇痛和阿片类药物需求均显著更高（12/14，86%）。手术时间相似，在任何试验中，研究组之间肋间穿刺或肾造瘘管插入的发生率均无差异。虽然单独使用 GA 时需要更多的镇痛药物可能会最小化或掩盖患者报告的疼痛评分差异，但 PNB 在 PCNL 后恢复期间可能具有显著的节省阿片类药物的镇痛效果。
