頸肩部手術神經(jīng)阻滯

1、頸肩部神經(jīng)阻滯第1頁第2頁第3頁Phrenic Nerve Palsy and Regional Anesthesia for Shoulder Surgery Anatomical, Physiologic, and Clinical Considerations Anesthesiology, , 127(1):173區(qū)域麻醉在為肩部手術提供圍手術期鎮(zhèn)痛方面發(fā)揮著主要作用。不過，膈神經(jīng)麻痹是一個嚴重并發(fā)癥，尤其是在高?；颊咧?。該作者描述了與膈神經(jīng)麻痹相關解剖學，生理學和臨床原理。全方面回顧了確保充分肩部手術鎮(zhèn)痛, 怎樣降低膈神經(jīng)麻痹策略及其臨床影響。第4頁 局部解剖第5頁肩部神經(jīng)支配皮膚支

2、配神經(jīng): 包含C5-6 腋神經(jīng)，肩胛上神經(jīng)，和頸叢C3-4鎖骨上神經(jīng)。骨和肩關節(jié)囊支配神經(jīng)：包含肩胛上神經(jīng)，腋神經(jīng)，胸外側(cè)神經(jīng)（C5-7）, 肌皮神經(jīng)（C5-7），胸長神經(jīng)（C5-7）。肩胛上神經(jīng)提供肩關節(jié)70%神經(jīng)支配，其余大部分是腋神經(jīng)支配。El-Boghdadly K, Chin K J, Chan V. Phrenic Nerve Palsy and Regional Anesthesia for Shoulder Surgery: Anatomical, Physiologic, and Clinical ConsiderationsJ. Anesthesiology, , 127(

3、1):173.第6頁肩部神經(jīng)支配肩部肌肉感覺組成：第三和第四頸神經(jīng)腹側(cè)支支配斜方肌。胸前神經(jīng)（C5-C7）支配胸大肌。肩胛背神經(jīng)（C5）支配肩胛提肌和菱形肌。腋神經(jīng)（C5-C6）支配三角肌。肩胛上，肩胛下（C5-C6）和腋神經(jīng)支配肩袖肌肉。第7頁鎖骨上神經(jīng)腋神經(jīng)肩胛上神經(jīng)肩胛上神經(jīng)橈神經(jīng)肩胛下神經(jīng)胸長神經(jīng)和肩胛上神經(jīng)第8頁胸背神經(jīng)第9頁第10頁第11頁第12頁解剖學基礎1、舌骨 hyoid bone 適對第3、4頸椎間盤平面；舌骨體兩側(cè)可捫到舌骨大角，是尋找舌動脈標志。2、甲狀軟骨 thyroid cartilage 上緣平第 4 頸椎上緣，即頸總動脈分叉處：前正中線上突起為喉結(jié)。3、環(huán)狀軟骨

4、 cricoid cartilage 環(huán)狀軟骨弓兩側(cè)平對第 6 頸椎橫突，是喉與氣管、咽與食管分界標志，又可作計數(shù)氣管環(huán)標志。第13頁第14頁 阻滯方法第15頁第16頁超聲引導下頸淺叢阻滯第17頁第18頁第19頁第20頁超聲引導下肌間溝神經(jīng)阻滯第21頁在確認了肌間溝臂叢神經(jīng)位置后。我們確認最表層神經(jīng)結(jié)構(gòu)(可能是C5，或上干)。探頭向頭側(cè)和中間滑動，直到它和肌間溝中其它神經(jīng)結(jié)構(gòu)分離。前中斜角肌經(jīng)常不好分辨。繼續(xù)向頭側(cè)滑動，能夠見到神經(jīng)根以比較大角度進入脊椎。Katherine H. Dobie, Yaping Shi et al. New technique targeting the C5 n

5、erve root proximal to the traditional interscalene sonoanatomical approach is analgesic for outpatient arthroscopic shoulder surgery。journal of Clinical Anesthesia () 34, 7984第22頁A 1 mL test dose of local anesthetic was given to exclude intraneural injection and to assess the spread of the injection

6、 around the structure.15 mL of local anesthetic was injected in incremental doses adjacent to the nerve structure, and, when necessary, minor adjustments were made to ensure spread of local anesthetic around the structure.第23頁Cadaver dissection after new technique performed under ultrasound guidance

7、 in Fig. 2 with .2 cc methylene blue injected at C5 nerve root; remainder of brachial plexus in view. Arrow shows methylene blue at C5 nerve root. Forceps shown at distal brachial plexus in relation to injection at C5.第24頁第25頁第26頁第27頁 膈神經(jīng)麻痹第28頁膈神經(jīng)麻痹在表面上，暫時膈神經(jīng)麻痹似乎沒有什么臨床意義在客觀（呼吸支持）和主觀方面（呼吸困難）功效。隨機控制試驗

8、通常排除肺部疾病，肥胖，或阻塞性睡眠呼吸暫停。連續(xù)性膈神經(jīng)麻痹。發(fā)生率范圍從1/到1/100。有些文件報道了連續(xù)性膈神經(jīng)麻痹出現(xiàn)潛在原因，如在體表標志法肌間溝神經(jīng)阻滯后膈神經(jīng)麻痹阻滯與直接針頭損傷或神經(jīng)鞘內(nèi)注射引發(fā)神經(jīng)損傷注射相關。第29頁第30頁膈神經(jīng)麻痹膈神經(jīng)主要起源于第四頸神經(jīng)腹側(cè)支，但也有部分來至第三和第五頸神經(jīng)腹側(cè)支，以及頸交感神經(jīng)節(jié)或胸交感神經(jīng)叢。這些小神經(jīng)在斜角肌前部上部外側(cè)緣形成，在前斜角肌表面向著沿著斜下方朝向其內(nèi)側(cè)邊緣下行。膈神經(jīng)在甲狀軟骨水平距離C5水平平均距離為18至20mm，伴隨膈神經(jīng)沿著前斜角肌表面下降，每下降1cm遠離3mm。第31頁第32頁副膈神經(jīng)大多發(fā)自第5、

9、或第5、6、第4頸神經(jīng)。多為單側(cè)。副膈神經(jīng)與臂叢關系要比與頸叢關系更為親密。副膈神經(jīng)與膈神經(jīng)遲早必將合并為一。依據(jù)膈神經(jīng)與副膈神經(jīng)支數(shù)多少,可歸納成五個類型:第一型一支,即膈神經(jīng)本身。第二型二支,即膈神經(jīng)與副膈神經(jīng)各一支。第三型三支,即膈神經(jīng)一支,副膈神經(jīng)二支。五型中以第一型(占43.1%)與第二型(占43.3%)最多,均可列為國人之標準型第33頁肥胖患者Using 30 mL of 0.5% ropivacaine with epinephrine 1:400,000.All participants demonstrated hemidiaphragmatic paresis after

10、ISB.ISB is associated with greater FVC and FEV1 reductions in obese participants compared to normal-weight participants. Despite these changes, obesity was not associated with increased clinical respiratory symptoms or events.Melton M S, Monroe H E, Qi W, et al. Effect of Interscalene Brachial Plexu

11、s Block on the Pulmonary Function of Obese Patients: A Prospective, Observational Cohort Study.J. Anesthesia & Analgesia, .第34頁第35頁膈神經(jīng)麻痹最大程度地降低膈神經(jīng)麻痹取決于降低局部麻醉藥品到達這些神經(jīng)結(jié)構(gòu)劑量。經(jīng)過改變局部麻醉藥品劑量來實現(xiàn)（體積和濃度）、注射部位和操作技術，從而實現(xiàn)降低膈神經(jīng)麻痹發(fā)生率。或經(jīng)過使用不一樣位置神經(jīng)阻滯，使用不一樣局部麻醉技術共同實現(xiàn)。第36頁膈神經(jīng)麻痹超聲引導下神經(jīng)阻滯增加局部麻醉藥注射位置準確性，有利于使用較低麻醉藥品劑量可視化技術

12、增加了藥品注射可能位置范圍。第37頁藥品體積影響在C5-C6神經(jīng)根周圍注射20ml或更大劑量藥品不可防止地產(chǎn)生膈神經(jīng)麻痹，不論是否使用可視化技術。當使用超聲引導技術時。10毫升藥品能夠降低膈神經(jīng)麻痹發(fā)生率至60。5毫升體積降低到27%與45%之間，而且不影響二十四小時止痛效果。第38頁局部麻醉劑濃度幾項研究表明進行肌間溝阻滯時，降低局部麻醉藥濃度而不是體積，來降低藥品總劑量，也能夠降低了膈神經(jīng)麻痹發(fā)生率，改進肺功效。在超聲引導下給予從0.2至0.120ml羅哌卡因，膈神經(jīng)麻痹發(fā)生率從71降至42。但這種降低膈神經(jīng)麻痹普通似乎是以犧牲鎮(zhèn)痛效果為代價。第39頁注射距離另一個防止膈神經(jīng)麻痹策略是遠離

13、C5、C6根和膈神經(jīng)。部位注射局麻藥品。Renes等報道：超聲引導下圍繞C7神經(jīng)根注射10 ml0.75羅哌卡因，產(chǎn)生在類似鎮(zhèn)痛，但只有13膈神經(jīng)麻痹，相比在神經(jīng)刺激引導下肌間溝阻滯使用相同劑量局部麻醉劑有93患者發(fā)生膈神經(jīng)麻痹。Renes S H, Rettig H C, Gielen M J, et al. Ultrasound-guided low-dose interscalene brachial plexus block reduces the incidence of hemidiaphragmatic paresis.J. Regional Anesthesia & Pain

14、Medicine, , 34(5):498-502.第40頁Sonogram at C7 vertebral level. * indicates root C7;ASM： anterior scalene muscle;Black arrows：needle; CA, carotid artery;MSM： middle scalene muscle; VA： vertebral artery; X：后結(jié)節(jié). The anterior tubercle is absent.第41頁Extrafascial injection for interscalene brachial plexus

15、block reduces respiratory complications compared with a conventional intrafascial injectionThe final needle tip position was 4 mm lateral to the brachial plexus sheath, at a level equidistant between C5 and C6 roots. The distance of 4 mm was chosen according to the calculated success rate over 90% r

16、eported recently and our daily experience in a university teaching hospital. The on-screen caliper measurement tool was used to define this distance of 4 mmPalhais N, Brull R, Kern C, et al. Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with

17、 a conventional intrafascial injection: a randomized, controlled, double-blind trialJ. British Journal of Anaesthesia, , 116(4):531.第42頁第43頁Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injectionThe incidence

18、s of hemidiaphragmatic paresis were 90% and 21% in the conventional and extrafascial injection groups, respectively (P0.0001). 圍神經(jīng)叢注射相比神經(jīng)叢內(nèi)注射， FEV1，用力肺活量和呼氣峰值流速分別下降16和28，17次vs 28，8和24。The mean time to first opioid request was similar between groups .Palhais N, Brull R, Kern C, et al. Extrafascial in

19、jection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: a randomized, controlled, double-blind trialJ. British Journal of Anaesthesia, , 116(4):531.第44頁肩胛上神經(jīng)和腋神經(jīng)阻滯在關節(jié)鏡手術中，相對于撫慰劑或肩峰下局部麻醉藥浸潤注射，肩胛上神經(jīng)阻斷單獨或與腋神經(jīng)阻滯結(jié)合已被證實提供優(yōu)越鎮(zhèn)痛。與肌

20、間溝神經(jīng)阻滯相比，效果較差。這個外周神經(jīng)阻滯技術主要針正確是這個肩關節(jié)囊神經(jīng)支配，在開放或廣泛肩部手術效果欠佳。第45頁Suprascapular and Interscalene Nerve Block for Shoulder Surgery A Systematic Review and Meta-analysisThis review suggests that there are no clinically meaningful analgesic differences between suprascapular block and interscalene block excep

21、t for interscalene block providing better pain control during recovery room stay.Suprascapular block has fewer side effects. These findings suggest that suprascapular block may be considered an effective and safe interscalene block alternative for shoulder surgery.Hussain N, Ghazaleh G, Ragina N, et

22、 al. Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysisJ. Anesthesiology, :1.第46頁A Comparison of Combined Suprascapular and Axillary Nerve Blocks to Interscalene Nerve Block for Analgesia in Arthroscopic Shoulder Surgery An Equivalence Study和ISB相比，

23、聯(lián)合肩胛上和腋神經(jīng)阻滯可認為肩關節(jié)關節(jié)鏡提供非等效鎮(zhèn)痛效果。在二十四小時時SSAX對靜息痛可以提供更好質(zhì)量疼痛緩解，且不良影響更少，ISB術后即刻鎮(zhèn)痛效果更佳。對于肩關節(jié)鏡手術，SSAX可以是一種臨床上可接收止痛劑選擇與不一樣鎮(zhèn)痛劑特征相比較與ISB。Marty P, Rontes O, Delbos A. A Comparison of Combined Suprascapular and Axillary Nerve Blocks to Interscalene Block: Interpret With Caution.J. Regional Anesthesia & Pain Medicine, , 42(2):273.第47頁第48頁肩胛上神經(jīng)阻滯第49頁岡上肌斜