【原】超声引导下腹横肌平面阻滞与触发点注射治疗慢性腹壁疼痛：一项随机临床试验（七）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Moeschler SM, Pollard EM, Pingree MJ, Pittelkow TP, Bendel MA, Mauck WD, Watson JC, Eldrige JS, Loftus CG, Hooten WM. Pain. 2021 Jun 1;162(6):1800-1805.  本次学习由阎芳副主任医师主讲。

The findings of this trial are consistent with other reports of TPIs and TAP blocks for chronic AWP. For example, in a retrospective study that involved 139 patients with ACNES, 81% reported at least 50% pain reduction immediately following a single non-image guided TPI performed with 10 mL 1% lidocaine, and 33% reported complete resolution of pain at a maximum follow-up of 72 weeks. Comparable outcomes were reported in a retrospective case series of 9 patients with ACNES where 6 patients reported at least 50% pain reduction at a median follow-up period of 12 weeks following an ultrasound guided TPI performed with up to 3 mL of 0.5% bupivacaine with 40 mg triamcinolone. Few published studies exist for the use of TAP blocks for chronic AWP. In a retrospective study, 30 patients with chronic AWP received 20 unilateral and 25 bilateral ultrasound guided TAP blocks. Unilateral blocks were performed using 8 mL 0.25% bupivacaine with 80 mg triamcinolone and bilateral blocks were performed using 9 mL 0.25% bupivacaine with 40 mg triamcinolone on each side. The mean reduction in pain scores was 54.7% for an average duration of 84 days. Finally, in a small case series that involved 5 patients with chronic AWP, 4 patients reported at least 50% reduction in pain scores following an ultrasound guided TAP block using various doses of ropivacaine and triamcinolone, and 2 patients reported low levels of pain at 6- and 12-month follow-up.

本试验的结果与其它使用TPIs和TAP阻滞治疗慢性AWP的报告一致。例如，在一项涉及139名ACNES患者的回顾性研究中，81%的患者在使用10 mL 1%利多卡因进行单次非影像引导TPI后即刻疼痛减轻至少50%，在术后最多72周的随访中，33%的患者疼痛完全缓解。在另一项包含9例ACNES患者的回顾性病例报道中报告了类似的结果，其中6例患者在超声引导下行最多3 mL 0.5%布比卡因和40 mg曲安奈德的TPI后，在12周的中位随访期内疼痛减轻至少50%。关于使用TAP阻滞治疗慢性AWP的已发表研究很少。在一项回顾性研究中，30例慢性AWP患者共接受了20人次单侧和25人次双侧超声引导TAP阻滞。单侧阻滞使用8 mL 0.25%布比卡因和80 mg曲安奈德，双侧阻滞每侧使用9 mL 0.25%布比卡因和40 mg曲安奈德。疼痛评分平均减少54.7%，平均持续84天。最后，在一个涉及5名慢性AWP患者的小规模病例报道中，使用不同剂量的罗哌卡因和曲安奈德在超声引导下进行TAP阻滞，4名患者阻滞后疼痛评分至少降低50%，2名患者在术后6个月和12个月的随访时保持轻度疼痛。

The findings of this study have clinical and future research implications. First, TPIs and TAP blocks were associated with significant improvements in pain from baseline to month 3 follow-up. The effect sizes of the change in pain scores were large for the TPI group and medium for the TAP block group. Although the statistic used to estimate effect size was developed for behavioral outcomes, it has been widely used to assess outcomes of procedural trials. Patients with focal AWP are good candidates for a TPI; however, a TAP block may be a reasonable secondary intervention if the patient does not have a favorable or sustained response to a TPI. Second, randomized placebo-controlled trials are needed to determine the efficacy of ultrasound-guided TPIs and TAP blocks for chronic AWP due to ACNES. These trials could also incorporate immediate post-procedural, short- and long-term interval assessments to better characterize the temporal effects of TPIs and TAP blocks compared to placebo. Third, randomized trials need to be developed to investigate the effects of high versus low volume TPIs on pain outcomes. This is important because hydrodissection of the entrapped nerve may be an additional mechanism associated with sustained pain relief. Fourth, randomized trials are needed to determine the independent effects of local anesthetics and corticosteroids on pain outcomes. This type of clinical trial would also provide the opportunity to investigate the potential differential effects of particulate versus non-particulate corticosteroids on pain outcomes. Finally, although no significant association was observed between month 3 pain scores and baseline CES-D and PCS scores, appropriately designed and powered prospective trials are needed to investigate the potential effects of depressive symptoms and pain catastrophizing on pain outcomes.

本研究的发现对临床治疗和未来的研究均有意义。首先，从基线检查到第3个月随访，TPIs和TAP阻滞与疼痛的改善显著相关。TPI组疼痛评分变化的效应量较大，TAP阻滞组为中等。虽然用于估计效应大小的统计方法是针对行为结果设计的，但它已广泛用于评估操作性试验的结果。局部AWP是TPI的良好适应症；然而，如果TPI没有获得良好或持续的效果，TAP阻滞可能是一种合理的二次干预。其次，需要进行随机安慰剂对照试验，以确定超声引导下TPI和TAP阻滞对ACNES所致慢性AWP的疗效。这些试验还可以纳入术后即刻、短期和长期评估，以更好地观察TPI和TAP阻滞组与安慰剂组比较的时间效应。第三，需要有进一步的随机试验来研究高容量和低容量TPI对疼痛结果的影响。这一点很重要，因为药物容量对受累神经的水分离作用可能是持续疼痛缓解的另一个机制。第四，需要进行随机试验，以确定局部麻醉剂和皮质类固醇对疼痛结果的独立影响。我么也可以通过这种类型的临床试验来研究颗粒性和非颗粒性皮质类固醇对疼痛结局的潜在差异影响。最后，尽管未观察到第3个月疼痛评分与基线CES-D和PCS评分之间存在显著相关性，我们仍需通过设计合理和有效的前瞻性试验，以调查抑郁症状和疼痛灾难化对疼痛结果的潜在影响。

往期回顾：

超声引导下腹横肌平面阻滞与触发点注射治疗慢性腹壁疼痛：一项随机临床试验（六）

超声引导下腹横肌平面阻滞与触发点注射治疗慢性腹壁疼痛：一项随机临床试验（五）

超声引导下腹横肌平面阻滞与触发点注射治疗慢性腹壁疼痛：一项随机临床试验（四）