Ip Vivian H Y, Kotteeswaran Yuvaraj, Prete Savannah, Sondekoppam Rakesh V, Tsui Ban C H
Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton, AB, Canada.
Department of Anesthesiology, Thunder Bay Regional Health Sciences Centre, Thunder, ON, Canada.
Can J Anaesth. 2023 Feb;70(2):273-279. doi: 10.1007/s12630-022-02373-3. Epub 2022 Dec 13.
Postamputation pain is challenging because of complex mechanisms involving a multitude of pain pathways and psychological factors. This patient population also tends to have extensive comorbidities with or without a background of chronic pain. Electrical neuromodulation such as peripheral nerve stimulation has gained traction in the realm of chronic pain. Recently, the off-label use of hybrid perineural nerve stimulation in combination with locoregional block via the stimulating nerve block catheter has been described in single-center case reports.
Herein, we present a case series of six patients from two different Canadian hospitals using such a hybrid technique in three different clinical scenarios. These scenarios were (1) local anesthetic dose minimization in the presence of multiple nerve block catheters, (2) analgesia augmentation when local anesthetic alone is insufficient, and (3) provision of an analgesic adjunct as part of a multimodal regimen. A stimulating sciatic nerve block catheter was inserted under ultrasound and nerve stimulation guidance for these cases. Patients tended to experience pain on the subsequent postoperative days whereby the off-label use of nerve stimulation successfully reduced their pain score and stabilized or decreased their opioid consumption or minimized the need to increase the local anesthetic dose when doing so could have precipitated local anesthetic toxicity.
Our case series supports the feasibility of using a combination of low-frequency perineural stimulation and local anesthetic infusion via a single perineural nerve block catheter to manage challenging postamputation pain.
截肢后疼痛具有挑战性，因为其机制复杂，涉及多种疼痛通路和心理因素。这类患者群体往往还伴有广泛的合并症，无论有无慢性疼痛背景。诸如外周神经刺激等电神经调节疗法在慢性疼痛领域已受到关注。最近，单中心病例报告中描述了通过刺激神经阻滞导管将混合性经神经刺激与局部区域阻滞联合使用的非标签用法。
在此，我们展示了来自加拿大两家不同医院的6例患者的病例系列，他们在三种不同的临床场景中使用了这种混合技术。这些场景分别为：（1）在存在多个神经阻滞导管的情况下尽量减少局部麻醉剂用量；（2）当单独使用局部麻醉剂镇痛不足时增强镇痛效果；（3）作为多模式方案的一部分提供镇痛辅助药物。在超声和神经刺激引导下为这些病例插入了刺激坐骨神经阻滞导管。患者在术后随后几天往往会经历疼痛，而神经刺激的非标签用法成功降低了他们的疼痛评分，稳定或减少了阿片类药物的用量，或者在增加局部麻醉剂用量可能引发局部麻醉剂毒性时尽量减少了这种需求。
我们的病例系列支持通过单一经神经阻滞导管联合使用低频经神经刺激和局部麻醉剂输注来处理具有挑战性的截肢后疼痛的可行性。
