2017股神經(jīng)、髂筋膜、隱神經(jīng)-蔣嘉

1、朝陽朝陽醫(yī)院醫(yī)院超超聲麻聲麻醉醉疼痛疼痛周周髂筋膜髂筋膜、股神經(jīng)和、股神經(jīng)和隱神經(jīng)隱神經(jīng)/ /收肌管阻滯收肌管阻滯膝膝關(guān)關(guān)節(jié)置節(jié)置換換鎮(zhèn)鎮(zhèn)痛痛Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta- analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37膝膝關(guān)節(jié)關(guān)節(jié)置置換鎮(zhèn)換鎮(zhèn)痛痛Primary outcomes:(1)

2、acute postoperative pain (during rest and movement)(2) postoperative opioid consumption(3) quality of early postoperative rehabilitation (functional assessments)Secondary outcomes:postoperative complications (e.g., nausea, vomiting, falls), duration of hospitalization, blood loss, procedure failure,

3、 and patient withdrawalTerkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta- analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37與與PCA比較比較(A ) Overall pain scores in the first 72 h duringrest(B) overall pain scor

4、es in the first 72 h during movement,(C) overall opioid consumption in the first 72 h(D) overall range on motion in the first 72 h.Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Trials.Anesthes

5、iology 2017; 126:923-37Ranking F/S (6) F/O(6) LP/S (3)FIC (3) PA (2)Ranking on high-quality studiesF/SFICLPPAACBTerkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:9

6、23-37閉孔神經(jīng)閉孔神經(jīng)股神經(jīng)股神經(jīng)股外側(cè)皮神經(jīng)股外側(cè)皮神經(jīng)隱神經(jīng)隱神經(jīng)髂髂筋筋膜阻滯膜阻滯阻滯的是什么？髂髂筋膜筋膜 外界：髂嵴內(nèi)外界：髂嵴內(nèi)側(cè)緣側(cè)緣 內(nèi)界：小骨盆內(nèi)界：小骨盆的的界線界線 向下一直延續(xù)向下一直延續(xù) 到股骨小轉(zhuǎn)子到股骨小轉(zhuǎn)子 水平水平 覆蓋腰大肌和覆蓋腰大肌和 髂肌髂肌髂髂筋膜筋膜閉孔神經(jīng)與髂肌和髂筋膜并沒有密切的聯(lián)系閉孔神經(jīng)與髂肌和髂筋膜并沒有密切的聯(lián)系閉閉 孔孔 神神 經(jīng)經(jīng)髂筋膜阻滯髂筋膜阻滯的的擴擴散散范圍范圍（MRI）Swenson JD, Davis JJ, et al. Local anesthetic injection deep to the fascia

7、iliaca at the level of the inguinal ligament: the pattern of distribution and effects on the obturator nerve. Journal of Clinical Anesthesia (2015) 27, 652657腹股溝韌帶水平腹股溝韌帶水平骶骨水平骶骨水平冠狀位冠狀位腹股溝韌帶水平髂筋膜阻滯腹股溝韌帶水平髂筋膜阻滯超超聲引聲引導(dǎo)導(dǎo)髂筋髂筋膜膜阻滯阻滯的的方方法法腹股溝韌帶下法腹股溝韌帶下法 尋找縫匠肌和髂肌 藥液擴散：縫匠肌和髂肌之間 阻滯：股神經(jīng)、股外側(cè)皮神經(jīng)？超超聲聲引導(dǎo)引導(dǎo)髂髂筋膜筋膜

8、阻滯阻滯腹股溝韌帶上法腹股溝韌帶上法Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-GuidedSuprainguinal Fascia Iliaca Technique ProvidesBenefit as an Analgesic Adjunct forPatients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433438超超聲引聲引導(dǎo)導(dǎo)腹股腹股溝溝韌帶韌帶上上髂筋髂筋膜膜阻阻滯滯 尋找髂前上棘、髂肌、腹橫肌 藥液擴散：腹橫肌和髂肌之間 阻滯：股神經(jīng)、股

9、外側(cè)皮神經(jīng)、髂腹股溝神經(jīng)Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-Guided Suprainguinal Fascia Iliaca Technique Provides Benefit as an Analgesic Adjunct for Patients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433438股股神神經(jīng)阻滯經(jīng)阻滯如何提高成功率？股神經(jīng)解剖股神經(jīng)解剖股神經(jīng)股神經(jīng)股股神神經(jīng)經(jīng)超超聲影像聲影像 腹股溝水平腹股溝水平 股動脈外側(cè)，髂筋膜深

10、部，髂股動脈外側(cè)，髂筋膜深部，髂肌肌表面表面 高回聲，寬而扁，橢圓形 深度：深度：13cm超超聲聲探頭探頭的的最佳最佳位置位置旋股內(nèi)、外側(cè)動脈旋股內(nèi)、外側(cè)動脈超超聲探聲探頭頭的最的最佳佳位位置置 旋髂深淺動脈 必要時用多普勒調(diào)整位置 腹股溝韌帶和 腹橫紋中間位置或許最佳OGAMI K, MURATA H, SAKAI A, et al. Deep and Superficial Circumflex Iliac Arteries and Their Relationship to the Ultrasound-Guided Femoral Nerve Block Procedure: A Ca

11、daver Study. Clinical Anatomy 30:413420 (2017)進進針點針點？藥液藥液？置管置管位位置置？短軸，平面內(nèi)法短軸，平面內(nèi)法短軸，平面外法短軸，平面外法進進針針點？點？藥藥液？液？置置管位管位置？置？Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:

12、2329進進針針點？點？藥藥液？液？置置管位管位置？置？Topographic view of the terminal branches of the femoral nerveACN： anterior cutaneous nerve MCN：medial cutaneous nerve PMN：pectineus muscle nerve; RFMN：rectus femoris muscle nerve SMN：Sartorius muscle nerve SN：saphenous nerveVIMN：vastus intermedius muscle nerve VLMN：vastu

13、s lateralis muscle nerve VMMN：vastus medialis muscle nerve隱神經(jīng)部分與神經(jīng)其他部分可能存在隔斷平面內(nèi)由外向內(nèi)進針，一直平面內(nèi)由外向內(nèi)進針，一直到到神經(jīng)神經(jīng)內(nèi)內(nèi)側(cè)，側(cè)，藥藥液包繞液包繞，神經(jīng)神經(jīng)前前方置管方置管Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthe

14、siol 2014; 31:2329辨辨認不認不清清髂筋髂筋膜膜怎么怎么辦辦？Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. Anobservational study. Eur J Anaesthesiol 2014; 31:2329GIPM：髂腰肌凹槽髂腰肌凹槽（a groove formed by the iliac and lateral psoas muscles）股神經(jīng)阻滯股

15、神經(jīng)阻滯尋找尋找GIPM旁結(jié)構(gòu)旁結(jié)構(gòu)Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. Anobservational study. Eur J Anaesthesiol 2014; 31:2329髂筋膜髂筋膜GIPM:85% 髂筋膜：68%闊筋膜張肌闊筋膜張肌 股外側(cè)皮神經(jīng)股外側(cè)皮神經(jīng)縫匠肌縫匠肌股股外側(cè)外側(cè)皮皮神經(jīng)神經(jīng)阻阻滯滯 支配：大腿前外側(cè) 適應(yīng)證：髖部手術(shù)為主 過去：髂前上棘內(nèi) 下

16、12cm，皮下 0.51cm 變異大：以解剖標 志為基礎(chǔ)的傳統(tǒng)阻 滯技術(shù)不可靠超超聲聲引導(dǎo)引導(dǎo)股股外側(cè)外側(cè)皮皮神經(jīng)神經(jīng)阻滯阻滯 高頻探頭 掃描方式：闊筋膜張肌和縫匠肌 超聲影像：低回聲橢圓形（此處可能已經(jīng)分支） 進針路徑：平面內(nèi)或平面外 局麻藥：5ml 目標：局麻藥在神經(jīng)周圍或 闊筋膜張肌和縫匠肌之間闊 筋膜下方擴散隱隱神神經(jīng)阻滯經(jīng)阻滯與收肌管阻滯？隱隱神經(jīng)神經(jīng)阻阻滯滯 股神經(jīng)的最大感覺支 支配：內(nèi)側(cè)膝關(guān)節(jié)、 髕骨下方、小腿內(nèi)側(cè) 和足內(nèi)側(cè)緣的皮膚 適應(yīng)證：膝關(guān)節(jié)手術(shù)、大隱靜脈手術(shù)、坐 骨神經(jīng)阻滯的補充 不影響股四頭肌力量 局麻藥：低濃度，510ml隱隱神經(jīng)神經(jīng)走走行行 股動脈伴行，內(nèi)下行 通過

17、收肌管，接近膝 蓋穿出 大腿中段：縫降肌深面，與股動脈伴行 膝上：縫匠肌和股內(nèi) 肌之間的收肌管內(nèi)， 與股動靜脈伴行 膝下：脛骨粗隆表面，與大隱靜脈伴行隱隱神經(jīng)神經(jīng)阻阻滯入滯入路路Subsartorial plexus block（大腿中段） Adductor Canal block（大腿遠端/收肌管） Subcoutaneous infiltration block（小腿近端）收收肌肌管管收肌肌腱鍵膜管狀間隙構(gòu)成：股內(nèi)側(cè)肌、縫匠肌、長收肌和大收肌近端：股三角頂點遠端：收肌管裂孔表面：股內(nèi)收膜內(nèi)容：股神經(jīng)的股內(nèi)側(cè)肌支、隱神經(jīng)、股中間皮神經(jīng)、股動脈、股靜 脈收收肌肌管相管相關(guān)關(guān)肌肌肉肉收收肌肌管超管超聲聲起點：股三角（倒）頂點，縫匠肌與長收肌內(nèi) 側(cè)緣相交處終點：股動脈偏離縫匠肌，進入股內(nèi)側(cè)肌和大 收肌之間（收肌腱裂孔）S：縫匠：縫匠肌肌VM：股內(nèi)側(cè)：股內(nèi)側(cè)肌肌AL：長收：長收肌肌AM：大收?。捍笫占ong WY, et al. Defining the Location of the Adductor Canal Using Ultrasound.Reg Anesth Pain Med 2017;42: 241245股內(nèi)收膜股內(nèi)收膜vastoadducto