股神經(jīng)、髂筋膜、隱神經(jīng)-蔣嘉（課堂PPT）

1、朝陽醫(yī)院超聲麻醉疼痛周朝陽醫(yī)院超聲麻醉疼痛周髂筋膜、股神經(jīng)和髂筋膜、股神經(jīng)和隱神經(jīng)隱神經(jīng)/ /收肌管阻滯收肌管阻滯朝陽醫(yī)院麻醉科 蔣嘉.2膝關(guān)節(jié)置換鎮(zhèn)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; 126:923-37.3膝關(guān)節(jié)置換鎮(zhèn)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; 126:923-37.4與與PCA比比較較(A) Overall pain scores in the first 72 h duringrest(B) overall pain sco

4、res in the first 72 h during movement,(C) overall opioid consumption in the first 72 h( D ) o v e r a l l r a n g e o n 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 T

5、rials.Anesthesiology 2017; 126:923-37.5Ranking 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. Anesthesio

6、logy 2017; 126:923-37.6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).7髂筋膜阻滯阻滯的是什么？.8髂筋膜髂筋膜 外界：髂嵴外界：髂嵴內(nèi)內(nèi)側(cè)緣側(cè)緣 內(nèi)界：小骨內(nèi)界：小骨盆盆的的界線界線 向下一直延向下一直延續(xù)續(xù) 到股骨小轉(zhuǎn)到股骨小轉(zhuǎn)子子 水平水平 覆蓋腰大肌覆蓋腰大肌和和 髂肌髂肌.9髂筋膜髂筋膜閉孔神經(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).10髂筋膜阻滯的擴(kuò)散范圍（MRI）Swenson JD, Davis JJ, et al. Local anesthetic injection deep to

7、 the fascia 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.11超聲引導(dǎo)髂筋膜阻滯的方超聲引導(dǎo)髂筋膜阻滯的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(kuò)散：縫匠肌和髂肌之間 阻滯：股神經(jīng)、股外側(cè)皮神經(jīng)

8、？.12超聲引導(dǎo)髂筋膜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; 36:433438.13超聲引導(dǎo)腹股溝韌帶上髂筋膜阻超聲引導(dǎo)腹股溝韌帶上髂筋膜阻滯滯 尋找髂前上棘、髂肌、腹橫肌 藥液擴(kuò)散：腹橫肌和髂

9、肌之間 阻滯：股神經(jīng)、股外側(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; 36:433438.14股神經(jīng)阻滯如何提高成功率？.15股神經(jīng)解剖股神經(jīng)解剖股神經(jīng)股神經(jīng).16股神經(jīng)超聲影像股神經(jīng)超聲影像 腹股溝水平

10、腹股溝水平 股動(dòng)脈外側(cè)，髂筋膜深部，髂肌表面股動(dòng)脈外側(cè)，髂筋膜深部，髂肌表面 高回聲，寬而扁，橢圓形 深度：深度：13cm.17超聲探頭的最佳位置超聲探頭的最佳位置旋股內(nèi)、外側(cè)動(dòng)脈旋股內(nèi)、外側(cè)動(dòng)脈.18超聲探頭的最佳位置 旋髂深淺動(dòng)脈 必要時(shí)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 Pr

11、ocedure: A Cadaver Study. Clinical Anatomy 30:413420 (2017).19進(jìn)針點(diǎn)？藥液？置管位置？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.20進(jìn)針點(diǎn)？藥液？置管位置？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; 31:23

12、29.21進(jìn)針點(diǎn)？藥液？置管位置？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：vastus lateralis

13、 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(jìn)針，一直到神經(jīng)內(nèi)側(cè)，藥液包繞，神經(jīng)前方置管平面內(nèi)由外向內(nèi)進(jìn)針，一直到神經(jīng)內(nèi)側(cè)，藥液包繞，神經(jīng)前方置管Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014;

14、 31:2329.22辨認(rèn)不清髂筋膜怎么辦？辨認(rèn)不清髂筋膜怎么辦？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）.23股神經(jīng)阻滯尋找G

15、IPM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%.24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)縫匠肌縫匠肌股外側(cè)皮神經(jīng)阻滯股外側(cè)皮神經(jīng)阻滯 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12cm，皮下 0

16、.51cm 變異大：以解剖標(biāo) 志為基礎(chǔ)的傳統(tǒng)阻 滯技術(shù)不可靠.25超聲引導(dǎo)股外側(cè)皮神經(jīng)阻超聲引導(dǎo)股外側(cè)皮神經(jīng)阻滯滯 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(jìn)針路徑：平面內(nèi)或平面外 局麻藥：5ml 目標(biāo)：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(kuò)散.26隱神經(jīng)阻滯與收肌管阻滯？.27隱神經(jīng)阻滯隱神經(jīng)阻滯 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(bǔ)充 不影響股四頭肌力量 局麻藥：低濃度，510ml.28隱神經(jīng)走行隱神經(jīng)走行 股動(dòng)脈伴行，內(nèi)下行 通過收肌

17、管，接近膝 蓋穿出 大腿中段：縫降肌深面，與股動(dòng)脈伴行 膝上：縫匠肌和股內(nèi) 肌之間的收肌管內(nèi)， 與股動(dòng)靜脈伴行 膝下：脛骨粗隆表面，與大隱靜脈伴行.29隱神經(jīng)阻滯入路隱神經(jīng)阻滯入路Subsartorial plexus block（大腿中段） Adductor Canal block（大腿遠(yuǎn)端/收肌管） Subcoutaneous infiltration block（小腿近端）.30.31收肌管收肌管收肌肌腱鍵膜管狀間隙構(gòu)成：股內(nèi)側(cè)肌、縫匠肌、長(zhǎng)收肌和大收肌近端：股三角頂點(diǎn)遠(yuǎn)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(dòng)脈、股靜 脈.32收肌管相關(guān)肌肉.33收肌管超聲起點(diǎn)：股三角（倒）頂點(diǎn)，縫匠肌與長(zhǎng)收肌內(nèi) 側(cè)緣相交處終點(diǎn)：股動(dòng)脈偏離縫匠肌，進(jìn)入股內(nèi)側(cè)肌和大 收肌之間（收肌腱裂孔）S：縫匠?。嚎p匠肌VM：股內(nèi)側(cè)?。汗蓛?nèi)側(cè)肌AL：長(zhǎng)收肌：長(zhǎng)收肌AM：大：大收肌收肌Wong WY, et al. Defining the Location of the Adductor Canal Using Ultrasound.Reg Anesth Pain Med 2017;42: 241245.34股內(nèi)收膜vastoadduct