Objective

Controlling pain after major lower limb amputation (MLLA) is of critical importance to patients and clinicians. The aim of this systematic review and meta-analysis was to assess the effect of perineural catheters (PNCs) on post-operative pain, post-operative morphine requirement, in-hospital mortality, long term phantom limb pain, and chronic stump pain.

Methods

A systematic review using PubMed, EMBASE via OVID and the Cochrane library from database inception (1946) to 20 October 2020 was performed according to PRISMA guidelines. Studies involving patients undergoing MLLA which reported on post-operative morphine requirement, pain scores, in-hospital mortality, phantom limb pain (PLP), and chronic stump pain were included. Studies comparing PNC use with epidural or wound site local anaesthetic infusions were excluded. Outcome data were extracted from individual studies and meta-analysis was performed using a random effects (Mantel-Haenszel) model for dichotomous data using an odds ratio (OR) summary statistic with 95% confidence intervals (CI), and with an inverse variance random effects model for continuous data using a standardised mean difference (SMD) summary statistic with 95% CIs. Sensitivity analyses were performed for post-operative pain scores and post-operative morphine requirement. Study quality was assessed using the Downs and Black score, and outcomes were assessed using the GRADE tool.

Results

Ten studies reporting on 731 patients were included, with 350 patients receiving a PNC and 381 receiving standard care. PNC use is associated with a reduction in post-operative pain (SMD −0.30, 95% CI −0.58 – −0.01, p = .040, I² = 54%, GRADE quality of evidence: low) and post-operative morphine requirements (SMD −0.63, 95% CI −1.03 – −0.23, p = .002, I² = 75%, GRADE quality of evidence: moderate), although the effect of PNC on reduced post-operative morphine requirements is lost on sensitivity analysis of randomised trials only (p = .40). No demonstrable effect was found on in-hospital mortality, PLP, or chronic stump pain (GRADE quality of evidence: low).

Conclusion

PNC use in amputees is associated with a significant reduction in post-operative pain scores and post-operative morphine requirements, although this latter finding is lost on sensitivity analysis of randomised trials only.

中文翻译：

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神经周围导管在大下肢截肢中的作用的系统评价和荟萃分析

客观的

控制大下肢截肢 (MLLA) 后的疼痛对患者和临床医生至关重要。本系统评价和荟萃分析的目的是评估神经周围导管 (PNC) 对术后疼痛、术后吗啡需求、院内死亡率、长期幻肢痛和慢性残肢痛的影响。

方法

根据 PRISMA 指南，使用 PubMed、EMBASE 通过 OVID 和 Cochrane 库从数据库创建（1946 年）到 2020 年 10 月 20 日进行了系统评价。包括接受 MLLA 患者的研究，这些研究报告了术后吗啡需求、疼痛评分、院内死亡率、幻肢痛 (PLP) 和慢性残肢痛。比较 PNC 使用与硬膜外或伤口部位局部麻醉输注的研究被排除在外。从个别研究中提取结果数据，并使用随机效应 (Mantel-Haenszel) 模型对二分类数据进行荟萃分析，使用优势比 (OR) 汇总统计量和 95% 置信区间 (CI)，并使用逆方差随机使用具有 95% CI 的标准化平均差 (SMD) 汇总统计量的连续数据效应模型。对术后疼痛评分和术后吗啡需求量进行敏感性分析。使用 Downs 和 Black 评分评估研究质量，使用 GRADE 工具评估结果。

结果

10 项研究报告了 731 名患者，其中 350 名患者接受了 PNC，381 名患者接受了标准治疗。PNC 的使用与术后疼痛（SMD -0.30，95% CI -0.58 – -0.01，p  = .040，I ²  = 54%，GRADE 证据质量：低）和术后吗啡需求量的减少相关（SMD -0.63, 95% CI -1.03 – -0.23, p  = .002, I ²  = 75%, GRADE 证据质量：中等），尽管在敏感性分析中失去了 PNC 对减少术后吗啡需求的影响仅随机试验 ( p  = .40)。未发现对住院死亡率、PLP 或慢性残端疼痛有明显影响（证据等级：低）。

结论

在截肢者中使用 PNC 与术后疼痛评分和术后吗啡需求量的显着降低有关，尽管后一发现仅在随机试验的敏感性分析中丢失。