神经内超声引导下坐骨神经阻滞：最小有效容量和电生理效应
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Intraneural Ultrasound-guided Sciatic Nerve Block: Minimum Effective Volume and Electrophysiologic Effects
背景与目的：无论是坐骨神经内和神经外注射均可导致严重地神经轴突损伤。本研究旨在确定神经内注射1%罗哌卡因对90%的患者达到完全感觉-运动阻滞的最小有效容量以及相关的电生理改变。
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方法：47名ASA I-II级患者根据抛硬币法接受超声引导下腘窝坐骨神经阻滞。初始剂量为15ml。完成基础、5周和6个月的电生理检测。评估振幅、潜伏期和速度。随后进行了6个月的电话随访。
结果：对于90％的患者达到完全感觉 - 运动坐骨神经阻滞，1％罗哌卡因的最小有效体积为6.6ml（95％CI，6.4-6.7），起效时间为19±12min。成功率为98％。踝、腓骨、踝和腘窝的动作电位（mV）基线振幅分别为8.4±2.3、 7.1±2.0、 15.4±6.5和11.7±5.1。患者在第五周（4.3±2.1、3.5±1.8、6.9±3.7和5.2±3.0）和第六个月（5.9±2.3、5.1±2.1、10.3±4.0和7.5±2.7）显著减少（ P <0.001）。潜伏期和速度与基线没有变化。在6个月的随访中没有患者报告神经系统症状。
结论：神经内超声引导下行腘窝局部麻醉注射显著降低局部麻醉剂量，实现有效的感觉 - 运动阻滞，降低全身毒性的风险。持续的电生理学变化表明可能有轴突损伤，需要进一步研究。
Cappelleri G, Ambrosoli A L, Gemma M, et al. Intraneural Ultrasound-guided Sciatic Nerve Block: Minimum Effective Volume and Electrophysiologic Effects.[J]. Anesthesiology, 2018:1.
BACKGROUND:Both extra- and intraneural sciatic injection resulted in significant axonal nerve damage. This study aimed to establish the minimum effective volume of intraneural ropivacaine 1% for complete sensory-motor sciatic nerve block in 90% of patients, and related electrophysiologic variations.
METHODS:Forty-seven consecutive American Society of Anesthesiologists physical status I-II patients received an ultrasound-guided popliteal intraneural nerve block following the up-and-down biased coin design. The starting volume was 15 ml. Baseline, 5-week, and 6-month electrophysiologic tests were performed. Amplitude, latency, and velocity were evaluated. A follow-up telephone call at 6 months was also performed.
RESULTS:The minimum effective volume of ropivacaine 1% in 90% of patients for complete sensory-motor sciatic nerve block resulted in 6.6 ml (95% CI, 6.4 to 6.7) with an onset time of 19 ± 12 min. Success rate was 98%. Baseline amplitude of action potential (mV) at ankle, fibula, malleolus, and popliteus were 8.4 ± 2.3, 7.1 ± 2.0, 15.4 ± 6.5, and 11.7 ± 5.1 respectively. They were significantly reduced at the fifth week (4.3 ± 2.1, 3.5 ± 1.8, 6.9 ± 3.7, and 5.2 ± 3.0) and at the sixth month (5.9 ± 2.3, 5.1 ± 2.1, 10.3 ± 4.0, and 7.5 ± 2.7) (P < 0.001 in all cases). Latency and velocity did not change from the baseline. No patient reported neurologic symptoms at 6-month follow-up.
CONCLUSIONS:The intraneural ultrasound-guided popliteal local anesthetic injection significantly reduces the local anesthetic dose to achieve an effective sensory-motor block, decreasing the risk of systemic toxicity. Persistent electrophysiologic changes suggest possible axonal damage that will require further investigation.
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