From the Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
Department of Plastic Surgery, Lange Land Hospital, Zoetermeer, The Netherlandsand.
Anesth Analg. 2023 Aug 1;137(2):365-374. doi: 10.1213/ANE.0000000000006529. Epub 2023 Jul 14.
Chronic pain is a recognized complication of surgery, and it has been hypothesized that regional anesthesia might reduce the risk of development of chronic pain after upper extremity surgery.
A systematic literature review was performed to assess whether in patients undergoing elective upper extremity surgery (P), regional anesthesia (I), compared to general anesthesia (C), would result in lower long-term (>3 months) postoperative pain intensity (O). We included randomized and nonrandomized controlled trials (RCTs). Our primary outcome was numerical rating score or visual analogue scale for pain, at >3 months postoperatively. The Embase, Medline ALL, Web of Science Core Collections, Cochrane Central Register of Controlled Trials, and Google Scholar databases were searched for all reports assessing pain at >3 months after upper extremity surgery under general versus regional anesthesia. Secondary outcomes were: opioid prescription filling, complex regional pain syndrome (CRPS) incidence, the Mayo Wrist Score (MWS), and scores on the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Quality (or certainty) of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Risk-of-bias was assessed using the Cochrane tool for randomized trials (RoB 2.0) and nonrandomized trials (ROBINS-I).
This review included 14 studies, comprising 7 RCTs and 7 nonrandomized studies. Six of the 7 studies (4 RCTs, N = 273; 2 nonrandomized studies, N = 305) using a pain score, our primary outcome, report comparable long-term postoperative pain scores after regional and general anesthesia. Six of the 7 studies using our secondary outcomes report comparable long-term outcomes in terms of opioid prescription filling (2 retrospective cohort studies [RCSs], N = 89,256), CRPS incidence (1 RCT, N = 301), MWS (1 RCT and 1 RCS, N = 215), and DASH score (1 RCT, N = 36). Comparable outcomes were reported in all 7 RCTs (N = 778) and in 5 of the 7 nonrandomized studies, comprising 5 RCSs (N = 89,608). Two prospective observational studies (POSTs), comprising 279 patients, report a statistically significant difference in outcomes, with less pain and better DASH scores after brachial plexus anesthesia. All 14 studies provided moderate to very low certainty evidence, and there was a serious risk of bias due to confounding bias in 5 of the 7 nonrandomized studies (N = 631).
The results of this review indicate that upper extremity regional anesthesia, compared to general anesthesia, is unlikely to change pain intensity at >3 months postoperatively.
慢性疼痛是手术的一种公认并发症，有人假设区域麻醉可能会降低上肢手术后发生慢性疼痛的风险。
系统文献回顾评估了在接受择期上肢手术的患者（P）中，与全身麻醉（C）相比，区域麻醉（I）是否会导致术后长期（>3 个月）疼痛强度降低（O）。我们纳入了随机和非随机对照试验（RCT）。我们的主要结局是在术后>3 个月时使用数字评分或视觉模拟量表评估疼痛。Embase、Medline ALL、Web of Science 核心合集、Cochrane 对照试验中心注册库和 Google Scholar 数据库检索了所有评估上肢手术中全身麻醉与区域麻醉后>3 个月疼痛的报告。次要结局为：阿片类药物处方填写、复杂性区域疼痛综合征（CRPS）发生率、 Mayo 腕关节评分（MWS）和上肢残疾问卷（DASH）评分。使用 Grading of Recommendations Assessment, Development and Evaluation（GRADE）评估证据质量（或确定性）。使用 Cochrane 随机试验工具（RoB 2.0）和非随机试验工具（ROBINS-I）评估偏倚风险。
本综述纳入了 14 项研究，包括 7 项 RCT 和 7 项非随机研究。7 项研究中的 6 项（4 项 RCT，N=273；2 项非随机研究，N=305）使用疼痛评分作为我们的主要结局，报告了区域麻醉和全身麻醉后长期相似的术后疼痛评分。7 项研究中的 6 项（2 项回顾性队列研究[RCS]，N=89256）使用我们的次要结局报告了长期相似的阿片类药物处方填写情况，CRPS 发生率（1 项 RCT，N=301），MWS（1 项 RCT 和 1 项 RCS，N=215）和 DASH 评分（1 项 RCT，N=36）。在所有 7 项 RCT（N=778）和 7 项非随机研究中的 5 项（包括 5 项 RCS，N=89608）中报告了可比的结局。2 项前瞻性观察研究（POST），共纳入 279 例患者，报告了结果的统计学显著差异，臂丛麻醉后疼痛减轻，DASH 评分更好。所有 14 项研究均提供了中等至非常低确定性证据，在 7 项非随机研究中的 5 项（N=631）中，由于混杂偏倚，存在严重的偏倚风险。
本综述的结果表明，与全身麻醉相比，上肢区域麻醉不太可能改变术后>3 个月的疼痛强度。
