膝窩部ブロック下または足関節ブロック下で手術を受けた患者における反跳痛の発生の違い (CBFR)
Rebound Pain Occurrence in Patients Undergoing Forefoot Bone Surgery Under Popliteal Sciatic Nerve Block or Distal Sensory Ankle Block: a Randomized Clinical Trial
This single-center, prospective, randomized controlled trial compared rebound pain (RP) occurrence following popliteal sciatic nerve block versus ankle block in patients undergoing elective forefoot bone surgery.
Patients were randomized to receive one of the two ultrasound-guided, single-injection peripheral nerve block techniques, combined with standardized general anesthesia induced and maintained using propofol target-controlled infusion.
The primary objective was to compare RP incidence between the two block techniques. Secondary exploratory objectives included assessing postoperative pain trajectories and perioperative changes in skin temperature and tissue oxygen saturation as indirect indicators of local vasomotor and/or inflammatory responses.
Rebound pain was operationally defined as initially mild postoperative pain (NRS <4 at post-anesthesia care unit discharge), followed by severe pain (NRS ≥7) in the context of block resolution, typically described within 12-24 hours after block resolution. The exact interval between sensory recovery and severe pain onset was not systematically recorded.
調査の概要
詳細な説明
This prospective, randomized, single-center controlled trial compared popliteal sciatic nerve block with ankle block in patients undergoing elective forefoot bone surgery. Participants were randomly allocated in a 1:1 ratio to either regional anesthetic technique, combined with standardized general anesthesia.
All peripheral nerve blocks were performed under ultrasound guidance before surgery using ropivacaine 0.5% with adrenaline (1:400,000) and clonidine (75 µg). Ankle blocks targeted the nerves supplying the surgical territory, while popliteal sciatic nerve blocks were supplemented by saphenous nerve blockade when required.
Before recruitment, the general anesthesia protocol was modified from the initially registered regimen involving sevoflurane maintenance to propofol target-controlled infusion for both induction and maintenance. This modification aimed to standardize anesthetic management and limit potential confounding effects on postoperative pain assessment. Sufentanil was reserved for intraoperative rescue analgesia but was not required. No intravenous ketamine, dexmedetomidine, or dexamethasone was administered.
Perioperative physiological assessments included infrared skin temperature measurements and tissue oxygen saturation monitoring using INVOS near-infrared spectroscopy on the operated and contralateral limbs. The originally planned Periflux measurements were discontinued before recruitment because the local heating required by this technique could interfere with skin temperature assessment. Preoperative hs-CRP and neutrophil-to-lymphocyte ratio measurements were performed, but the originally planned postoperative biomarker assessments were not conducted.
Postoperative analgesia was standardized using paracetamol and ibuprofen, with tramadol available as rescue medication. Patients remained hospitalized for approximately 24-48 hours, allowing clinical monitoring during sensory block regression and recovery. Follow-up assessments were conducted during hospitalization and by telephone on postoperative days 4 and 30 and at 3 months.
The study primarily compared rebound pain occurrence between the two regional anesthetic techniques. However, the exact onset of severe pain was not systematically timestamped, preventing reliable reconstruction of the originally registered 24-hour endpoint. The operational assessment and corresponding sensitivity analysis are specified in the Outcome Measures section.
研究の種類
入学 (実際)
段階
- 適用できない
連絡先と場所
研究場所
-
-
-
Brussels、ベルギー、1200
- Cliniques universitaires Saint-Luc
-
-
参加基準
適格基準
就学可能な年齢
健康ボランティアの受け入れ
受講資格のある性別
説明
Inclusion Criteria:
- Any surgery of the bones of the lower limbs performed as part of a PNB associated with general anaesthesia after lower limb bone surgery
- Patient aged between 18 and 75 years old.
Exclusion Criteria:
- refusal to participate
- contraindication to the use of local anesthetics
- contraindication to the use of general anesthesia
- contraindication to regular use of postoperative analgesics like non-steroidal anti-inflammatory drugs and paracetamol
- cognitive disorders
- inability to answer perioperative questionnaires (language problem).
研究計画
研究はどのように設計されていますか？
デザインの詳細
- 主な目的：他の
- 割り当て：ランダム化
- 介入モデル：並列代入
- マスキング：なし（オープンラベル）
武器と介入
参加者グループ / アーム |
介入・治療 |
|---|---|
|
他の：Popliteal sciatic nerve block
An ultrasound-guided popliteal sciatic nerve block was performed using ropivacaine 0.5% combined with adrenaline (1:400,000) and clonidine (75 μg). The popliteal block generally required 20-30 mL of local anesthetic solution. An additional ultrasound-guided saphenous nerve block was performed when indicated by the surgical territory, with total administered volumes reaching up to 40 mL. The maximum permitted ropivacaine dose was 4 mg/kg, not exceeding 300 mg. The regional anesthesia technique was combined with standardized general anesthesia induced and maintained using propofol target-controlled infusion (TCI). |
Elective forefoot bone surgery under popliteal sciatic nerve Elective forefoot bone surgery under an ankle block |
|
他の：Ankle block
An ultrasound-guided ankle block was performed using 15-20 mL of ropivacaine 0.5% combined with adrenaline (1:400,000) and clonidine (75 μg). The block targeted the saphenous, superficial peroneal, deep peroneal, and tibial nerves. The maximum permitted ropivacaine dose was 4 mg/kg, not exceeding 300 mg. The regional anesthesia technique was combined with standardized general anesthesia induced and maintained using propofol target-controlled infusion (TCI). |
Elective forefoot bone surgery under popliteal sciatic nerve Elective forefoot bone surgery under an ankle block |
この研究は何を測定していますか？
主要な結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
|---|---|---|
|
Incidence of rebound pain following peripheral nerve block resolution
時間枠：During postoperative hospitalization (approximately 24-48 hours), including the period of sensory block resolution.
|
Rebound pain was assessed as severe postoperative pain (NRS ≥7) following initially mild pain (NRS <4) at post-anesthesia care unit discharge, in the context of peripheral nerve block resolution. Incidence was compared between popliteal sciatic nerve block and ankle block groups. A sensitivity analysis used the stricter NRS >7 threshold. The exact onset of severe pain was not systematically timestamped; therefore, the originally registered 24-hour endpoint could not be reliably reconstructed. |
During postoperative hospitalization (approximately 24-48 hours), including the period of sensory block resolution.
|
二次結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
|---|---|---|
|
Perioperative changes in skin temperature
時間枠：Perioperative period (before and after peripheral nerve block, at emergence from general anesthesia) and postoperative day 1 (POD1).
|
Skin temperature (°C) was measured using infrared thermometry on the operated and contralateral feet before and after peripheral nerve block, at emergence from general anesthesia, and on postoperative day 1. Changes over time and their association with rebound pain occurrence were explored. |
Perioperative period (before and after peripheral nerve block, at emergence from general anesthesia) and postoperative day 1 (POD1).
|
|
Perioperative changes in tissue oxygen saturation
時間枠：Perioperative period (before and after peripheral nerve block, at emergence from general anesthesia) and postoperative day 1 (POD1).
|
Tissue oxygen saturation (%) was measured using near-infrared spectroscopy (INVOS) on the operated and contralateral feet before and after peripheral nerve block, at emergence from general anesthesia, and on postoperative day 1. Changes over time and their association with rebound pain occurrence were explored. |
Perioperative period (before and after peripheral nerve block, at emergence from general anesthesia) and postoperative day 1 (POD1).
|
|
Preoperative Pain Catastrophizing Scale (PCS) score
時間枠：Preoperatively, before peripheral nerve block administration.
|
The Pain Catastrophizing Scale (PCS) was administered preoperatively to assess pain-related catastrophizing. The total score ranges from 0 to 52, with higher scores indicating greater pain catastrophizing. The PCS score was descriptively reported as a baseline patient characteristic and compared between the popliteal sciatic nerve block and ankle block groups. |
Preoperatively, before peripheral nerve block administration.
|
|
Preoperative Amsterdam Preoperative Anxiety and Information Scale (APAIS) score
時間枠：Preoperatively, before peripheral nerve block administration.
|
The Amsterdam Preoperative Anxiety and Information Scale (APAIS) was administered preoperatively to assess anxiety and information needs related to anesthesia and surgery. The total APAIS score ranges from 6 to 30, with higher scores indicating greater preoperative anxiety and/or information needs. The total score was descriptively reported as a baseline patient characteristic and compared between the popliteal sciatic nerve block and ankle block groups. |
Preoperatively, before peripheral nerve block administration.
|
|
Preoperative Central Sensitization Inventory (CSI-9) score
時間枠：Preoperatively, before peripheral nerve block administration.
|
The nine-item Central Sensitization Inventory (CSI-9) was administered preoperatively to assess symptoms associated with central sensitization. The total score ranges from 0 to 36, with higher scores indicating a greater burden of symptoms associated with central sensitization. The CSI-9 score was descriptively reported as a baseline patient characteristic and compared between the popliteal sciatic nerve block and ankle block groups. |
Preoperatively, before peripheral nerve block administration.
|
|
Preoperative DN4 questionnaire score
時間枠：Preoperatively, before peripheral nerve block administration.
|
The Douleur Neuropathique en 4 Questions (DN4) questionnaire was administered preoperatively to assess neuropathic pain characteristics. The total score ranges from 0 to 10, with higher scores indicating more neuropathic pain features. A score of 4 or higher suggests a neuropathic pain component. The DN4 score was descriptively reported as a baseline patient characteristic and compared between the popliteal sciatic nerve block and ankle block groups. |
Preoperatively, before peripheral nerve block administration.
|
|
Postoperative DN2 score at day 4
時間枠：Postoperative day 4.
|
The Douleur Neuropathique en 2 Questions (DN2) questionnaire was administered on postoperative day 4 to assess neuropathic pain symptoms. The questionnaire comprises seven items derived from the DN4, each scored as present (1) or absent (0). The total score ranges from 0 to 7, with higher scores indicating more neuropathic pain symptoms. Scores were compared between the popliteal sciatic nerve block and ankle block groups. |
Postoperative day 4.
|
|
Postoperative DN2 score at day 30
時間枠：Postoperative day 30.
|
The Douleur Neuropathique en 2 Questions (DN2) questionnaire was administered on postoperative day 30 to assess neuropathic pain symptoms. The questionnaire comprises seven items derived from the DN4, each scored as present (1) or absent (0). The total score ranges from 0 to 7, with higher scores indicating more neuropathic pain symptoms. Scores were compared between the popliteal sciatic nerve block and ankle block groups. |
Postoperative day 30.
|
|
Postoperative DN2 score at 3 months
時間枠：3 months after surgery.
|
The Douleur Neuropathique en 2 Questions (DN2) questionnaire was administered three months after surgery to assess neuropathic pain symptoms. The questionnaire comprises seven items derived from the DN4, each scored as present (1) or absent (0). The total score ranges from 0 to 7, with higher scores indicating more neuropathic pain symptoms. Scores were compared between the popliteal sciatic nerve block and ankle block groups. |
3 months after surgery.
|
|
Preoperative high-sensitivity C-reactive protein (hs-CRP) level
時間枠：Preoperatively, before surgery.
|
High-sensitivity C-reactive protein (hs-CRP) levels were measured preoperatively (mg/L) as an exploratory marker of baseline systemic inflammation. Values were descriptively compared between the popliteal sciatic nerve block and ankle block groups. Postoperative hs-CRP measurements originally planned in the study protocol were not performed. |
Preoperatively, before surgery.
|
|
Preoperative neutrophil-to-lymphocyte ratio (NLR)
時間枠：Preoperatively, before surgery.
|
The neutrophil-to-lymphocyte ratio (NLR) was calculated from preoperative blood cell counts as an exploratory marker of baseline systemic inflammation. This dimensionless ratio was descriptively compared between the popliteal sciatic nerve block and ankle block groups. Postoperative NLR measurements originally planned in the study protocol were not performed. |
Preoperatively, before surgery.
|
協力者と研究者
捜査官
- 主任研究者：Nassim TOUIL, MD、Cliniques universitaires Saint-Luc- Université Catholique de Louvain
出版物と役立つリンク
一般刊行物
- Barry GS, Bailey JG, Sardinha J, Brousseau P, Uppal V. Factors associated with rebound pain after peripheral nerve block for ambulatory surgery. Br J Anaesth. 2021 Apr;126(4):862-871. doi: 10.1016/j.bja.2020.10.035. Epub 2020 Dec 31.
- Streb T, Schneider A, Wiesmann T, Riecke J, Schubert AK, Dinges HC, Volberg C. [Rebound pain-From definition to treatment]. Anaesthesiologie. 2022 Aug;71(8):638-645. doi: 10.1007/s00101-022-01120-z. Epub 2022 May 5. German.
- Hamilton DL. Rebound pain: distinct pain phenomenon or nonentity? Br J Anaesth. 2021 Apr;126(4):761-763. doi: 10.1016/j.bja.2020.12.034. Epub 2021 Feb 5. No abstract available.
- Touil N, Pavlopoulou A, Barbier O, Libouton X, Lavand'homme P. Evaluation of intraoperative ketamine on the prevention of severe rebound pain upon cessation of peripheral nerve block: a prospective randomised, double-blind, placebo-controlled study. Br J Anaesth. 2022 Apr;128(4):734-741. doi: 10.1016/j.bja.2021.11.043. Epub 2022 Feb 23.
- Sort R, Brorson S, Gogenur I, Nielsen JK, Moller AM. Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: An exploratory pilot study. Acta Anaesthesiol Scand. 2019 Mar;63(3):396-402. doi: 10.1111/aas.13290. Epub 2018 Nov 8.
- Sort R, Brorson S, Gogenur I, Hald LL, Nielsen JK, Salling N, Hougaard S, Foss NB, Tengberg PT, Klausen TW, Moller AM. Peripheral nerve block anaesthesia and postoperative pain in acute ankle fracture surgery: the AnAnkle randomised trial. Br J Anaesth. 2021 Apr;126(4):881-888. doi: 10.1016/j.bja.2020.12.037. Epub 2021 Feb 2.
- Jen TTH, Ke JXC, Wing KJ, Denomme J, McIsaac DI, Huang SC, Ree RM, Prabhakar C, Schwarz SKW, Yarnold CH. Development and internal validation of a multivariable risk prediction model for severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block. Br J Anaesth. 2022 Jul;129(1):127-135. doi: 10.1016/j.bja.2022.03.030. Epub 2022 May 12.
- Yamada T, Hasegawa-Moriyama M, Kurimoto T, Saito T, Kuwaki T, Kanmura Y. Peripheral Nerve Block Facilitates Acute Inflammatory Responses Induced by Surgical Incision in Mice. Reg Anesth Pain Med. 2016 Sep-Oct;41(5):593-600. doi: 10.1097/AAP.0000000000000458.
- Tighe PJ, Elliott CE, Lucas SD, Boezaart AP. Noninvasive tissue oxygen saturation determined by near-infrared spectroscopy following peripheral nerve block. Acta Anaesthesiol Scand. 2011 Nov;55(10):1239-46. doi: 10.1111/j.1399-6576.2011.02533.x. Epub 2011 Sep 26.
- Goldstein RY, Montero N, Jain SK, Egol KA, Tejwani NC. Efficacy of popliteal block in postoperative pain control after ankle fracture fixation: a prospective randomized study. J Orthop Trauma. 2012 Oct;26(10):557-61. doi: 10.1097/BOT.0b013e3182638b25.
研究記録日
主要日程の研究
研究開始 (実際)
一次修了 (実際)
研究の完了 (実際)
試験登録日
最初に提出
QC基準を満たした最初の提出物
最初の投稿 (実際)
学習記録の更新
投稿された最後の更新 (実際)
QC基準を満たした最後の更新が送信されました
最終確認日
詳しくは
この情報は、Web サイト clinicaltrials.gov から変更なしで直接取得したものです。研究の詳細を変更、削除、または更新するリクエストがある場合は、register@clinicaltrials.gov。 までご連絡ください。 clinicaltrials.gov に変更が加えられるとすぐに、ウェブサイトでも自動的に更新されます。