成人非心脏胸外科手术围术期区域镇痛技术 研究进展

Advances in Regional Analgesia for Perioperative Adult Non-Cardiac Thoracic Surgery

摘要: 术后疼痛是影响成人非心脏胸外科手术患者康复的重要因素。完善的围术期镇痛不仅可减轻术后疼痛强度、减少阿片类药物用量，还能降低术后肺部并发症发生率并加速患者康复。目前，临床上常用的围术期区域镇痛技术包括胸段硬膜外阻滞(thoracic epidural analgesia, TEA)、胸椎旁神经阻滞(thoracic paravertebral block, TPVB)、竖脊肌平面阻滞(erector spinae plane block, ESPB)、前锯肌平面阻滞(serratus anterior plane block, SAPB)、椎板后阻滞(retrolaminar block, RLB)及肋间神经阻滞(intercostal nerve block, ICNB)。其中，TEA镇痛效果确切，曾被视为胸科手术镇痛的“金标准”，但穿刺操作难度较大、并发症相对较多；TPVB镇痛效果与TEA相当且安全性更高，已成为胸腔镜手术围术期镇痛的一线方案；ESPB与SAPB操作简单、超声下解剖结构易于辨认、安全性良好，临床应用日益广泛；RLB及ICNB实施便捷，可作为辅助或替代镇痛手段。本文围绕上述各类区域镇痛技术的解剖学基础、作用机制及临床研究现状进行综述，以期为临床制定合理、安全的围术期镇痛方案提供参考。

Abstract: Postoperative pain is a key factor hindering the rehabilitation of adult patients undergoing non-cardiac thoracic surgery. Optimal perioperative analgesia can not only alleviate postoperative pain intensity and reduce opioid consumption, but also lower the incidence of postoperative pulmonary complications and accelerate patient recovery. Currently, commonly used clinical perioperative regional analgesia techniques include thoracic epidural analgesia (TEA), thoracic paravertebral block (TPVB), erector spinae plane block (ESPB), serratus anterior plane block (SAPB), retrolaminar block (RLB) and intercostal nerve block (ICNB). Among them, TEA delivers definite analgesic efficacy and has been once regarded as the gold standard for thoracic surgical analgesia, yet it features difficult puncture operation and relatively high complication risks. TPVB achieves analgesic effects comparable to TEA with superior safety, and has become the first-line perioperative analgesia strategy for thoracoscopic surgery. ESPB and SAPB are characterized by simple operation, easily identifiable anatomical structures under ultrasound and favorable safety, thus gaining increasingly wide clinical application. RLB and ICNB are convenient to perform and can be used as adjuvant or alternative analgesic methods. This article reviews the anatomical basis, mechanism of action and current clinical research status of the above regional analgesia techniques, aiming to provide references for formulating rational and safe perioperative analgesia regimens in clinical practice.