Comparison of Analgesic Level of Ultrasound-guided Paravertebral，Erector Spinae and Serratus Anterior Plane Blocks in Thoracic Surgery
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摘要:
目的 通过对比现阶段胸科手术常用的3种神经阻滞方法（胸椎旁神经阻滞、竖脊肌平面阻滞和前锯肌平面阻滞）的皮区痛觉阻滞平面差异，比较何种神经阻滞联合术后镇痛更适合胸科手术患者。 方法 选择在昆明医科大学第一附属医院行胸腔镜手术的胸科患者共75例，随机分为胸椎旁神经阻滞组（T组）、竖脊肌平面阻滞组（E组）和前锯肌平面阻滞组（S组）3组。T组：局麻药物注入胸7椎旁间隙；E组：局麻药物注入胸6、胸7横突外侧竖脊肌与肋间肌之间的筋膜层；S组：局麻药物注入腋后线第6、7肋骨处背阔肌和前锯肌的筋膜间隙。3组患者均在超声引导下确保针尖位置无误后注入0.5%盐酸罗哌卡因注射液（15±3）mL，注入局麻药20 min后，以针刺法测定麻醉阻滞效果和平面。 结果 T组对于胸前壁（锁骨中线、腋前线处）阻滞平面比E组和S组更广泛，T组均值分别为12.04（P < 0.05）、9.76（P < 0.05）；而对于胸侧壁（腋中线、腋后线处）的阻滞范围则是S组更广泛，S组均值分别为9.8（P < 0.05）、10.48（P < 0.05）。 结论 对于胸科手术特别是胸腔镜手术的患者，选择胸椎旁神经阻滞作为辅助术中麻醉效果和加强术后镇痛方法更为合理；而前锯肌平面阻滞可能更适合辅助乳腺手术。 Abstract:Objective To compare the difference of cutaneous nociceptive block plane of three commonly used nerve blocks （thoracic paravertebral block, erector spinae plane block and serratus anterior plane block） in thoracic surgery, and to identify the optimal nerve block combined with postoperative analgesia for thoracic surgery patients. Methods A total of 75 thoracic patients who underwent thoracoscopic surgery in our hospital were selected and randomly divided into three groups: Thoracic paravertebral nerve block group （T group）, erector spinae plane block group （E group） and serratus anterior plane block group （S group）. Group T: local anesthesia was injected into T7 paravertebral space; Group E: local anesthesia was injected into the fascia layer between the lateral erector spinae muscle and the intercostal muscle of the transverse process of T6 and T7. Group S: local anesthesia was injected into the fascial spaces of the latissimus dorsi and serratus anterior at ribs 6 and 7 in the posterior axillary line. All patients in the three groups were injected with 0.5% ropivacaine hydrochloride （15±3） mL under the guidance of ultrasound to ensure the correct position of the needle tip. After 20 minutes of local anesthetic injection, the anesthetic block effect and plane were measured by needle pricking. Results The block plane of the chest wall （midclavicular line and anterior axillary line） in group T was more extensive than that in group E and group S, the mean values of T group were 12.04 （P < 0.05）, 9.76 （P < 0.05）; while the block range of the thoracic wall （midaxillary line and posterior axillary line） in group S was more extensive, the mean values of S group were 9.8 （P < 0.05）, 10.48 （P < 0.05）. Conclusion For patients undergoing thoracic surgery, especially thoracoscopic surgery, it is more reasonable to use thoracic paravertebral nerve block as an auxiliary method for intraoperative anesthesia and postoperative analgesia. Serratus anterior plane block may be more suitable for breast surgery. -
表 1 3组患者一般情况比较[（n = 25），（$ \bar x \pm s $）]
Table 1. Comparison of general conditions of the three groups [（n = 25），（$ \bar x \pm s $）]
组别 性别（男/女） 年龄（岁） BMI（kg/m2） T组 12/13 51.84 ± 8.158 23.86 ± 3.03 E组 7/18 51.64 ± 8.855 22.88 ± 4.876 S组 13/12 53 ± 7.371 22.78 ± 2.187 P 0.185 0.817 0.497 
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表 2 3组患者各部位向上阻滞节段数[（$ \bar x \pm s $）个，n = 25]
Table 2. The number of upward block segments in each part of the three groups [（$ \bar x \pm s $）n，n = 25]
分组 锁骨中线 腋前线 腋中线 腋后线 T组 6.68 ± 0.90 5.28 ± 1.51 5.24 ± 1.61 5.2 ± 1.26 E组 4.68 ± 1.73* 3.72 ± 1.65* 4.44 ± 1.42 5.12 ± 1.20 S组 5.18 ± 0.98* 5.84 ± 1.25Δ 6.72 ± 0.94*Δ 6.32 ± 1.03*Δ P < 0.001* < 0.001* < 0.001* 0.001* 与T组比较，*P < 0.05；与E组比较，ΔP < 0.05。
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表 3 3组患者各部位向下阻滞节段数[（$ \bar x \pm s $）个，n = 25]
Table 3. The number of segments of downward block in each site in the three groups [（$ \bar x \pm s $）n，n = 25]
分组 锁骨中线 腋前线 腋中线 腋后线 T组 5.32 ± 1.03 4.48 ± 1.26 3.68 ± 2.04 3.92 ± 1.04 E组 3.44 ± 1.56* 2.72 ± 1.60* 3.44 ± 1.42 4.52 ± 1.61 S组 2.2 ± 1.71*Δ 1.92 ± 1.53*Δ 3.08 ± 1.32 4.16 ± 1.21 P < 0.001* < 0.001* 0.055 0.271 与T组比较，*P < 0.05；E组比较，ΔP < 0.05。
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表 4 3组患者皮肤痛觉阻滞总节段范围[（$ \bar x \pm s $）个，n = 25]
Table 4. Total segmental range of skin nociceptive block in the three groups [（$ \bar x \pm s $）n，n = 25]
锁骨中线 腋前线 腋中线 腋后线 n 25 25 25 25 T组 12.04 ± 1.37 9.76 ± 2.28 8.84 ± 1.93 8.88 ± 1.92 E组 8.16 ± 2.34* 6.32 ± 2.27* 8.12 ± 1.97 9.88 ± 2.03 S组 7.28 ± 1.76* 6.84 ± 1.64* 9.8 ± 1.50Δ 10.48 ± 1.58* P < 0.001* < 0.001* 0.006* 0.012* 与T组比较，*P < 0.05；E组比较，ΔP < 0.05。
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