背景:全肩关节置换术(TSA)后的术后疼痛管理可能具有挑战性。鉴于各种可用的疼痛管理选项,本研究的目的是系统回顾报告肩关节置换术后疼痛控制的随机对照试验的文献.我们试图确定哪些方式在管理术后疼痛和减少术后阿片类药物使用方面最有效。
方法:使用PRISMA(系统评价和Meta分析的首选报告项目)指南进行系统评价。PubMed,Scopus,我们在Cochrane中央对照试验注册中心中搜索了I-II级随机对照试验,这些试验比较了TSA术后疼痛控制的干预措施.疼痛控制措施包括神经阻滞和神经阻滞辅助治疗,局部注射,病人自控镇痛,口服药物,和其他方式。2个主要结果指标是在0-10视觉模拟量表上测量的疼痛水平和阿片类药物的使用。使用CochraneCollaboration的偏差风险2(RoB2)工具分析研究偏差风险和方法学质量。使用频率研究方法和随机效应模型对术后时间点的视觉模拟疼痛评分和阿片类药物使用进行网络荟萃分析,异质性使用I2统计量量化。使用P评分对治疗进行排名,P<0.05,有统计学意义。
结果:最初的搜索产生了2391篇文章(695个重复,1696筛选,53正在进行全文审查)。18篇文章(1358肩;51%的女性患者;平均年龄范围,65-73.7年;4项偏倚风险低的研究,12有一定的风险,和2个高风险)被纳入并分析。在术后4和8小时,与接受连续肌间沟阻滞(cISB)或单次肌间沟阻滞(ssISB)的患者相比,接受局部注射布比卡因脂质体(LB)(4和8小时P<.001)或局部注射罗哌卡因(4小时和8小时P=.019)的患者疼痛明显更多.两种模式之间的阿片类药物使用没有差异(P<0.05)。治疗的P评分表明,ssISB在<24小时的时间点最有利,而术后24小时和48小时的疼痛最好采用cISB或ssISB联合局部LB注射治疗.
结论:在治疗TSA后疼痛方面,肌间沟阻滞优于单独局部注射。一次性肌间沟阻滞是减轻术后早期疼痛(<24小时)的最佳选择,而术后24-48小时的疼痛可能最好使用cISB或ssISB与局部LB注射的组合来管理。
BACKGROUND: Postoperative pain management after total shoulder arthroplasty (TSA) can be challenging. Given the variety of pain management options available, the purpose of this investigation was to systematically
review the literature for randomized controlled trials reporting on pain control after shoulder arthroplasty. We sought to determine which modalities are most effective in managing postoperative pain and reducing postoperative opioid use.
METHODS: A systematic
review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched for Level I-II randomized controlled trials that compared interventions for postoperative pain control after TSA. Pain control measures included nerve blocks and nerve block adjuncts, local injections, patient-controlled analgesia, oral medications, and other modalities. The 2 primary outcome measures were pain level measured on a 0-10 visual analog scale and opioid use. The risk of study bias and methodologic quality were analyzed using The Cochrane Collaboration\'s Risk of Bias 2 (RoB 2) tool. Network meta-analyses were performed for visual analog scale pain scores at postsurgical time points and opioid use using a frequentist approach and random-effects model, with heterogeneity quantified using the I2 statistic. Treatments were ranked using the P score, and statistical significance was set at P < .05.
RESULTS: The initial search yielded 2391 articles (695 duplicates, 1696 screened, 53 undergoing full-text
review). Eighteen articles (1358 shoulders; 51% female patients; mean age range, 65-73.7 years; 4 studies with low risk of bias, 12 with some risk, and 2 with high risk) were included and analyzed. At 4 and 8 hours postoperatively, patients receiving local liposomal bupivacaine (LB) injection (P < .001 for 4 and 8 hours) or local ropivacaine injection (P < .001 for 4 hours and P = .019 for 8 hours) had significantly more pain compared with patients who received either a continuous interscalene block (cISB) or single-shot
interscalene block (ssISB). No differences in opioid use (at P < .05) were detected between modalities. The P scores of treatments demonstrated that ssISBs were most favorable at time points < 24 hours, whereas pain at 24 and 48 hours after surgery was best managed with cISBs or a combination of an ssISB with a local LB injection.
CONCLUSIONS: Interscalene blocks are superior to local injections alone at managing pain after TSA. Single-shot
interscalene blocks are optimal for reducing early postoperative pain (< 24 hours), whereas pain at 24-48 hours after surgery may be best managed with cISBs or a combination of an ssISB with a local LB injection.