硬膜外镇痛和肋间神经冷冻镇痛对开胸术后急性和慢性疼痛的影响

COMPARISON OF INTERCOSTAL NERVE CRYOANALGESIA WITH EPIDURAL ANALGESIA FOR POST-THORACOTOMY ACUTE AND CHRONIC PAIN

摘要:

目的:比较开胸术后硬膜外镇痛和肋间神经冷冻的短期镇痛效果以及慢性疼痛发生率。方法:87位择期后外侧开胸手术的患者,随机分为硬膜外组(E组,n=46)和肋间神经冷冻组(C组,n=41)。术毕E组接硬膜外病人自控镇痛泵。C组于关胸前行切口、上下各一肋间以及胸引管处肋间神经冷冻(-70℃,90s)。记录术后3天内NRS评分、镇痛满意度、副作用。电话随访术后12个月内慢性疼痛的发生率。结果:两组术后3天内疼痛评分和镇痛满意度无统计学差异。E组皮肤瘙痒发生率显著高于C组(P<0.01)。C组在术后3、6、12个月时总体慢性疼痛发生率和触诱发痛发生率均高于E组,其中触诱发痛发生率在术后6个月时差异有统计学意义(P<0.05)。结论:开胸术后硬膜外镇痛能提供有效的术后镇痛,但硬膜外吗啡皮肤瘙痒发生率高。肋间神经冷冻有可能增加开胸术后慢性疼痛的发生率,其推广还有待研究。

Abstract:

Objective: To compare the post-thoracotomy acute and chronic pain using epidural analgesia or intercostal nerve cryoanalgesia. Methods: Eighty-seven adult patients undergoing elective thoracotomy were allocated randomly to receive thoracic epidural analgesia or intercostal nerve cryoanalgesia. Numeral rating pain scores at rest or on coughing were recorded during the three postoperative days, the patient satisfaction and side effects. Chronic pain was inquired by telephone on the 1st, 3rd, 6th and 12th month post-operation. Results: There was no significant difference on numeral rating pain scores or patient satisfaction between the two groups within 3 days after operation. Mild pruritus appeared more often among patients in epidural group (P<0.01). Both groups showed high incidence of chronic pain (50%~70%). The incidences of chronic pain and allodynia in group C were higher than those in group E on the 3rd, 6th and 12th month post-operation. Significance was noted on the sixth month post-operation, with respect to the incidence of allodynia (P<0.05). Conclusion: Both epidural analgesia and intercostal nerve cryoanalgesia are effective methods for post-thoracotomy pain control. Epidural morphine increases the incidence of purities. Cryoanalgesia may be one of the factors that increase the incidence of post-thoracotomy chronic pain, especially neuropathic pain.