卷 19, 编号 3 (2025)

This review analyzes contemporary components of the multimodal approach to preventing chronic postoperative pain syndrome. The reported prevalence of this complication ranges 5%–75%, depending on the type of surgical procedure. A published data search was performed in PubMed, Ovid MEDLINE, Google Scholar, and ScienceDirect, and 90 publications from 2015 to 2025 were selected. The review discusses key components of the multimodal approach, including regional anesthesia (PECS II and paravertebral blocks), pharmacological interventions (nonsteroidal anti-inflammatory drugs, gabapentinoids, N-methyl-D-aspartate receptor antagonists, and intravenous lidocaine infusion), and nonpharmacological modalities (physiotherapy, cryotherapy, electroanalgesia, and cognitive behavioral therapy). The combination of these techniques facilitates effective control of acute postoperative pain, minimizes the risk of pain chronification, and reduces the opioid load. Particular attention is given to promising techniques, especially intravenous lidocaine infusion, which has demonstrated a marked reduction in the incidence of chronic postoperative pain. Variability in the effectiveness of different components was noted depending on the type of surgery and individual patient factors, including psychological and genetic characteristics. Further multicenter randomized studies are needed to develop personalized clinical protocols and interdisciplinary approaches to integrating multimodal strategies into practice, particularly in the early postoperative period.

BACKGROUND: Arthroscopic anterior cruciate ligament (ACL) reconstruction using a bone–patellar tendon–bone (BTB) autograft is often associated with anterior knee pain at the graft harvest site. It is assumed that an adductor canal block interrupts pain transmission from the graft harvest area, thereby preserving the ability for early quadriceps activation.

AIM: The work aimed to evaluate the effectiveness of adductor canal block as an adjunct to spinal anesthesia during anterior cruciate ligament reconstruction using a BTB autograft.

METHODS: The study included 104 patients with isolated ACL rupture who underwent surgery between 2022 and 2024 using a BTB autograft. The control group consisted of 52 patients who underwent ACL reconstruction under spinal anesthesia alone. In the main group of 52 patients, spinal anesthesia was supplemented with an adductor canal block. Outcomes were assessed based on pain intensity measured using the visual analog scale on postoperative days 1 and 2 and by evaluating knee joint functional recovery using plyometric tests at weeks 6, 12, and 24.

RESULTS: On postoperative days 1 and 2, pain intensity measured by the visual analog scale was significantly lower in the main group (4.19 ± 0.68 and 2.56 ± 0.89 points, respectively; p < 0.0001) than in the control group (8.23 ± 0.7 and 6.46 ± 0.9 points, respectively; p = 0.001). By weeks 6 and 12, the results of the single-leg squat and Y-balance tests were significantly better in the main group than in the control group. At week 24, the proportion of patients whose vertical jump performance on the operated leg reached more than 90٪ of that on the contralateral side was significantly higher in the main group (88.9٪ vs 42.3٪; p < 0.0001). All patients in the main group (100٪) and more than half in the control group (53.8٪; p < 0.0001) successfully performed the single-leg forward jump. Lateral single-leg jumps were also more frequently completed by patients in the main group (70.4٪) than in the control group (42.3٪; p = 0.04).

CONCLUSION: The study reliably confirms the effectiveness of adductor canal block as an additional method of anesthesia during arthroscopic anterior cruciate ligament reconstruction using a BTB autograft.

BACKGROUND: Retrobulbar block is known to cause varying degrees of upper eyelid edema associated with moderate exophthalmos, which may adversely affect surgical conditions. It has been hypothesized that anatomical differences in the ocular adnexa between patients with Asian and European eyelid anatomy may determine the severity of edema following retrobulbar block.

AIM: This study aimed to evaluate the effectiveness of retrobulbar block and the surgeon’s comfort during surgery in patients with Asian and European eyelid anatomy.

METHODS: A prospective controlled study was conducted involving 80 patients aged 51–75 years who underwent retrobulbar block for anesthesia during vitreoretinal surgery. Group 1 (n = 40) included patients with European eyelid anatomy, and group 2 (n = 40) with Asian eyelid anatomy. Changes in intraocular pressure and upper eyelid thickness were assessed at different stages of the block, along with preparation time for surgery, analgesia level, akinesia, and surgeon’s comfort.

RESULTS: In group 1, the upper eyelid thickness increased by 0.9 ± 0.1 mm, whereas in group 2 it increased by 2.8 ± 0.4 mm (p = 0.000), due to postseptal infiltration of the upper eyelid tissue with local anesthetic. The mean akinesia score was 1.0 ± 0.2 in group 1 and 1.4 ± 0.6 in group 2 (p = 0.021), with higher scores indicating reduced akinesia effectiveness. In group 1, intraocular pressure increased to 17.6 ± 1.9 mm Hg after the retrobulbar block and was 15.9 ± 1.9 mm Hg after compression, which corresponded to the baseline values before the block. In group 2, maximal increase in intraocular pressure was recorded after the retrobulbar block—24.9 ± 6.3 mm Hg (p = 0.0000)—and after compression—21.5 ± 5.4 mm Hg (p = 0.0000), which exceeded the baseline values (16.2 ± 1.3 mm Hg). The presence of ocular hypertension resulted in additional preoperative preparation time aimed at reducing intraocular pressure: in 5% of patients in group 1 and 28.75% of patients in group 2. Pain assessment showed residual pain in group 2 (2.6 ± 1.3 on the numeric rating scale), 1.5 times higher than in group 1 (1.6 ± 1.5, p = 0.0001), requiring additional intraoperative analgesia. Surgeon’s comfort in group 2 was reduced due to decreased palpebral fissure width from 21.4 ± 1.1 mm to 14.8 ± 1.9 mm after the retrobulbar block, associated with anesthetic infiltration of the upper eyelid.

CONCLUSION: Retrobulbar block in patients with Asian eyelid anatomy was associated with a significant increase in eyelid thickness and intraocular pressure, prolonged surgical preparation time, and the need for additional intravenous analgesia, resulting in reduced surgeon comfort during ophthalmic procedures.

BACKGROUND: In thoracic surgery, pain intensity resulting from nociceptive stimulation due to skin incision, muscle trauma, rib retraction, and pleural dissection contributes to central sensitization and the development of severe postoperative pain, particularly in the early postoperative period. Intrathecal administration of morphine represents an alternative opioid-sparing component of multimodal acute pain management.

AIM: The work aimed to clinically evaluate the analgesic efficacy of intrathecal morphine in patients undergoing thoracic surgery.

METHODS: The study included 255 patients who underwent thoracoscopic lobectomy. Patients were allocated into three groups: group 1 (n = 85) received intrathecal morphine; group 2 (n = 85) received systemic opioid analgesics; and group 3 (n = 85) received intercostal nerve blockade with ropivacaine. Pain intensity was assessed 2 and 24 hours postoperatively, along with the need for rescue analgesia (trimeperidine or tramadol) and the incidence of postoperative nausea and vomiting, pruritus, urinary retention requiring bladder catheterization, and delayed respiratory depression.

RESULTS: Two hours after surgery, pain intensity was lowest in the intercostal nerve block group (4 [3–4] cm on the visual analog scale [VAS]) and slightly higher in the intrathecal morphine group (4 [4–5] cm on the VAS). Both groups demonstrated a significantly greater analgesic effect compared with the systemic opioid analgesia group (6 [5–6] cm on the VAS; p < 0.001). At 24 hours postoperatively, pain intensity in group 1 decreased to 3 [2–3] cm on the VAS, whereas in group 2 it increased to 6 [5–6] cm, comparable with group 3 (6 [5–6] cm; p < 0.001). Trimeperidine consumption was significantly lower in group 1 (p < 0.001). The frequency of tramadol administration was also reduced (p < 0.001). The highest incidence of postoperative nausea and vomiting was observed in group 2 (p < 0.001). The incidence of pruritus and urinary retention did not differ significantly among groups. No cases of delayed respiratory depression were reported.

CONCLUSION: Intrathecal administration of morphine significantly reduced pain intensity, decreased the need for opioid analgesics, and was associated with a low incidence of pruritus within the first 24 hours after surgery. The incidence of postoperative nausea and vomiting was lower compared with both systemic opioid analgesia and intercostal nerve block. The need for urinary catheterization did not differ among groups. No delayed respiratory depression was observed.

relevance: Patients with morbid obesity undergoing general anesthesia for laparoscopic surgery are highly sensitive to complications, including transient hypoxemia, hemodynamic instability, delayed awakening, opioid hypersensitivity, postoperative pulmonary complications, and postoperative nausea and vomiting. Optimization of anesthesia management without opioids remains an important clinical challenge.

CASE DESCRIPTION: A 35-year-old female patient (height 164 cm, weight 180 kg, body mass index 66.9 kg/m²) underwent robot-assisted hysterectomy for recurrent endometrial hyperplasia under combined anesthesia (general anesthesia with epidural analgesia).

The mean qCON (consciousness index) during surgery was 50.2. The analgesic component of anesthesia was achieved through epidural administration of 0.1% ropivacaine hydrochloride solution, 10 mL every 30 minutes, at an infusion rate of 250 mL/hour during bolus delivery. The mean qNOX (nociception index) was 29.8. The mean total duration of qNOX peaks was 98.2 seconds over the 2 hours 35 minutes of surgery. Intraoperative hemodynamics were stable: blood pressure ranged from 120/70 to 140/80 mm Hg, heart rate 70–80 bpm, and SpO₂ 98–100%. Muscle relaxation was not maintained by additional administration of rocuronium bromide due to adequate relaxation of the abdominal wall and absence of inspiratory triggering from the patient. The TOF neuromuscular transmission ratio ranged from 40% to 50%, and electromyography (EMG) values ranged from 10 to 25, indicating adequate relaxation of the anterior abdominal wall muscles. The postoperative period was uneventful. The patient was discharged on postoperative day 6 in satisfactory condition with no active complaints.

CONCLUSION: In this clinical case, the chosen anesthesia management tactic provided effective analgesia and enabled early mobilization of the patient.