Cedars-Sinai Medical Center, Los Angeles, CA, USA.
Foot Ankle Int. 2022 Apr;43(4):504-508. doi: 10.1177/10711007211060038. Epub 2021 Dec 10.
Outpatient surgical deformity correction for Charcot-Marie-Tooth (CMT) disease is limited by effective postoperative pain control. Our previous institutional protocol for foot and ankle surgery in this population included preoperative single-injection nerve blocks, but patients often experienced uncontrolled pain when the block wore off postoperative day 0 or 1, resulting in high opioid requirements and unplanned emergency department visits. The use of ultrasonography-guided continuous nerve catheters in CMT patients has not previously been studied. We aimed to prospectively investigate the safety and efficacy of ultrasonography-guided indwelling popliteal catheters in CMT patients undergoing outpatient foot deformity correction surgery.
Twenty CMT patients, average 28 (range 13-53) years old, undergoing reconstructive surgery by a single foot and ankle attending surgeon were consented for preoperative ultrasonography-guided popliteal catheters. This series included 24 total outpatient procedures; 4 were staged bilateral. Indwelling popliteal catheters were maintained on discharge, providing continuous infusion until postoperative day (POD) 3, and then self-discontinued. Patients were prescribed oxycodone 5 mg (60-80 pills) as needed for breakthrough pain. Outcomes collected included daily pain scores (0-10), an opioid pill count on POD 14, and patient satisfaction ratings. Neurologic evaluation by 5-point 10g Semmes-Weinstein monofilament testing was performed preoperatively and on POD 14.
There were no observed catheter-site infections or hematomas. Nine of the patients had pre-existing sensory deficits involving at least 2 areas on the 5-point monofilament test. Postoperative testing showed these deficits were unchanged and there were no instances of new sensory deficits. Postoperative pain scores were typically low, with median values (interquartile ranges [IQRs]) of 3.5 (2.0-5.0) on POD 1, 2.5 (2.0-5.0) on POD 2, and 2.5 (1.0-3.75) on POD 3. At POD 14, pain was 1.0 (0-1.0). Patients consumed a median of 25 oxycodone pills (IQR 8-43) over 2 weeks, less than half the prescribed number. Patient satisfaction was high. All patients reported they would choose to have a nerve catheter again for a similar surgery.
This cases series demonstrated that regional anesthesia using ultrasonography-guided indwelling popliteal catheters was safe and effective for pain control in CMT patients undergoing outpatient foot and ankle surgery. Opioid consumption was comparable to published rates following major bony procedures, and no patients required emergent treatment or hospital admission for uncontrolled pain. No new sensory deficits were detected and patients with underlying sensory deficits remained unchanged. Patients were highly satisfied.
Level IV, case series.
门诊外科畸形矫正治疗 Charcot-Marie-Tooth（CMT）疾病受到有效术后疼痛控制的限制。我们之前为该人群进行足部和踝关节手术的机构方案包括术前单次神经阻滞，但患者在术后第 0 天或第 1 天阻滞消退时经常出现无法控制的疼痛，导致需要大量阿片类药物和计划外急诊就诊。超声引导连续神经导管在 CMT 患者中的应用尚未得到研究。我们旨在前瞻性研究超声引导隐神经置管在接受门诊足部畸形矫正手术的 CMT 患者中的安全性和有效性。
20 例 CMT 患者，平均年龄 28 岁（13-53 岁），由一名足部和踝关节主治医生进行重建手术，同意进行术前超声引导隐神经置管。本系列包括 24 例总门诊手术；4 例为双侧分期手术。隐神经导管在出院时保留，持续输注至术后第 3 天，然后自行停用。患者按需服用羟考酮 5mg（60-80 片）治疗突破性疼痛。收集的结果包括每日疼痛评分（0-10）、术后第 14 天的阿片类药物片数和患者满意度评分。术前和术后第 14 天进行 5 点 10g Semmes-Weinstein 单丝试验进行神经学评估。
未观察到导管部位感染或血肿。9 例患者术前存在至少 2 个区域的感觉缺失，在 5 点单丝测试中为 5 分。术后测试显示这些缺失没有变化，也没有新的感觉缺失。术后疼痛评分通常较低，术后第 1 天中位数（四分位间距 [IQR]）为 3.5（2.0-5.0），第 2 天为 2.5（2.0-5.0），第 3 天为 2.5（1.0-3.75）。术后第 14 天疼痛为 1.0（0-1.0）。患者在 2 周内中位数（IQR）消耗羟考酮 25 片（8-43 片），不到规定数量的一半。患者满意度高。所有患者均表示他们会选择再次使用神经导管进行类似手术。
本病例系列表明，超声引导隐神经置管的区域麻醉对接受门诊足部和踝关节手术的 CMT 患者的疼痛控制是安全有效的。阿片类药物的使用与主要骨手术后的公布比率相当，没有患者因无法控制的疼痛而需要紧急治疗或住院治疗。未发现新的感觉缺失，并且有潜在感觉缺失的患者保持不变。患者非常满意。
IV 级，病例系列。
