骶叢坐骨神經(jīng)阻滯課件

骶叢坐骨神經(jīng)阻滯此PPT下載后可任意修改編輯增刪頁面有醫(yī)術(shù)，有醫(yī)道。術(shù)可暫行一時，道則流芳千古。骶叢坐骨神經(jīng)阻滯此PPT下載后可任意修改編輯增刪頁面有醫(yī)術(shù)，1友情提示手機調(diào)成靜音感謝您不吸煙歡迎隨時提問友情提示手機調(diào)成靜音感謝您不吸煙歡迎隨時提問01020304適應(yīng)證解剖阻滯四種方法小結(jié)目錄01020304適應(yīng)證解剖阻滯四種方法小結(jié)目錄3骶叢神經(jīng)阻滯適應(yīng)證?

臀部和坐骨神經(jīng)支配區(qū)域的疼痛治療?

膝關(guān)節(jié)以下部位除了小腿內(nèi)側(cè)條狀帶之外區(qū)域的手術(shù)麻醉和鎮(zhèn)痛? 聯(lián)合腰叢阻滯可用于髖關(guān)節(jié)和更近端下肢手術(shù)麻醉? 單獨阻滯：膝關(guān)節(jié)以下部位除了小腿內(nèi)側(cè)條狀帶之外區(qū)域的小腿、足、踝、跟腱不同類型手術(shù)提供麻醉和鎮(zhèn)痛；?

聯(lián)合應(yīng)用（腰叢、髂腹下神經(jīng)、股外側(cè)皮神經(jīng)、股神經(jīng)、閉孔神經(jīng)）：髖部、膝關(guān)節(jié)和大腿前后的手術(shù)坐骨神經(jīng)阻滯適應(yīng)證骶叢神經(jīng)阻滯適應(yīng)證?臀部和坐骨神經(jīng)支配區(qū)域的疼痛治療4骶從(sacral

Plexus)是由L4-5，全部骶神經(jīng)和尾神經(jīng)前支組成重要分支：臀上神經(jīng)（Glutealnerve

superior臀下神經(jīng)（Glutealnerveinferior股后皮神經(jīng)（Posteriorfemoralcutaneous

nerve）陰部神經(jīng)（Pudendal

nerve）坐骨神經(jīng)（Sciaticnerve）GGPPS）Anatomy骶從(sacralPlexus)是由L4-5，全部骶神經(jīng)5坐骨神經(jīng)(sciatic

nerve)

是由L4、5，S1～3脊神經(jīng)前支組成坐骨神經(jīng)(sciaticnerve)是由L4、5，S1～6坐骨神經(jīng)?

經(jīng)坐骨結(jié)節(jié)和股骨大轉(zhuǎn)子之間，在臀大肌深面、股方肌淺面下行?

沿大腿后坐骨神經(jīng)上部的內(nèi)側(cè)有股后皮神經(jīng)和臀下動脈伴行?

行至在腘窩橫紋上方5～12cm

，分為脛神經(jīng)和腓總神經(jīng)坐骨神經(jīng)?經(jīng)坐骨結(jié)節(jié)和股骨大轉(zhuǎn)子之間，7脛神經(jīng)（tibial

nerve）?

分為足底內(nèi)側(cè)神經(jīng)和足底外側(cè)神經(jīng)二終支?

脛神經(jīng)在腘窩及小腿還發(fā)出肌支支配小腿肌后群?

脛神經(jīng)發(fā)出腓腸內(nèi)側(cè)皮神經(jīng)，在小腿下部與腓腸外側(cè)皮神經(jīng)（發(fā)自腓總神經(jīng)）吻合成腓腸神經(jīng)，經(jīng)外踝后方弓形向前，分布于足背和小趾外側(cè)緣的皮膚。脛神經(jīng)（tibialnerve）?分為足底內(nèi)側(cè)神經(jīng)和足底8腓總神經(jīng)（

common

peroneal

nerve）?

自坐骨神經(jīng)發(fā)出后沿股二頭肌內(nèi)側(cè)走向外下，繞腓骨頸外側(cè)向前，穿腓骨長肌分為腓淺和腓深神經(jīng)?

腓總神經(jīng)的分布范圍是小腿前、外側(cè)群肌和小腿外側(cè)、足背和趾背的皮膚腓總神經(jīng)（commonperonealnerve）?9感覺支配感覺支配10坐骨神經(jīng)感覺和肌肉支配坐骨神經(jīng)感覺和肌肉支配111、骶旁神經(jīng)叢阻滯neuroaxial

block1、骶旁神經(jīng)叢阻滯neuroaxialblock12臀上區(qū)短軸掃描LateralMedial臀上區(qū)短軸掃描LateralMedial13臀中區(qū)短軸掃描LateralMedial臀中區(qū)短軸掃描LateralMedial14臀中區(qū)長軸臀中區(qū)長軸15Ultrasound Localization

of

the

Sacral

Plems

Using

a

Parasacral

ApproachAlonY.

Ben-Azi,

M?Rama

Joshi,

lvIOAnna

lJskova,

InfoJacques

E.

Chelly,

MD,

PhD,

MBAIn

this

repor(,

we

describe

the

feasibility

of

l?x:ating

the

sacral

plexus

nerve

using

a

parasacral

approach

and

an

ultrasound-guided

technique.

The

parasacral

region

using

a

curved

probe

(2—S

MHz)

was

scanned

in

17

patients

iii

searchof

the

medialborder

of

the

ischial

bone

and

the

lateral

border

of

the

sacrtim,

which

represent

the

limit

of

the

greater

sciatic

foremen.

In

addition,

attempts

were

made

to

identify

the

pirikirrriis

muscles

and

the

gluteal

arteries.

Tue

sacral

plexus

was

identified

at

the

level

of

tire

sciatir

fnramen

as

a

round

hyperechoic

structure.

The

gluteal

arteries

were

identified

in

10

of

17

patients,

but

we

faded

to

positively

identify

the

pirif-oriiiis

oiusck'

in

any

pafienL

To

con￡

m

localization

of

the

sacral

plexus,

an

insulated

needle

attached

to

a

nerve

stimulates

was

advanced

and,

in

each

case,

a

sacralplexus

motor

response

was

elicited

(plantar

flexion—12,

dorsal

flexi

1,

ham—string

muscle

stimulation—3,

gast-rocneinius

muscle

stimulation—1—not

recorded)

at

a

current

between

0.2

and

0.5

mA.

No

complications

were

observed.

This

report

confimis

the

feasibility

of

using

ultrasound

to

locate

the

sacral

plexus

using

a

parasacral

apprnaclc(meals

Craig

2IXJ8:

108:

1977-DU)Gaata

Trochantsrtm

nsduotfoamenUltrasound Localizationofthe169.3O/o

o71

.7.9.3O/oo71.7.17Table1.

&sRnt

aixi

Block

Eka?stei&?sPahezitTtO.Body

iziaaadcx￡?WRl t1411147523.B19Visualization

ofQuteal

vesselsletted

respOEtB￡?oiAGenderOAOFOFMOFOFMFII

F

F

IIXNoNoNoNnNnHaiiistring

Haiiistrings

mtmcJea

Not

available

Plantarflexion

PlanlarflexionOAFFaFFFFNnNnYeaTable1.&sRntaixiBlockEka18骶叢坐骨神經(jīng)阻滯課件19股骨大轉(zhuǎn)子坐骨結(jié)節(jié)解剖：坐骨結(jié)節(jié)和股骨大轉(zhuǎn)子連線中點，坐骨神經(jīng)淺層為臀大肌，深層為股方肌股骨大轉(zhuǎn)子坐骨結(jié)節(jié)202、坐骨結(jié)節(jié)水平入路QFM坐骨結(jié)節(jié)大轉(zhuǎn)子LateralMedial2、坐骨結(jié)節(jié)水平入路QFM坐骨結(jié)節(jié)大轉(zhuǎn)子LateralMed21?

操作：低頻凸陣探頭，短軸平面內(nèi)技術(shù)坐骨神經(jīng)為更靠近坐骨結(jié)節(jié)的橢圓形或三角形的高回聲結(jié)構(gòu)?操作：低頻凸陣探頭，短軸平面內(nèi)技術(shù)坐骨神經(jīng)為更靠近坐骨結(jié)22臨床應(yīng)用（髖關(guān)節(jié)手術(shù)）?

股骨頭置換術(shù)后外側(cè)入路切口起自髂后上棘外下方約6厘米處，沿臀大肌纖維方向至股骨大轉(zhuǎn)子后緣，繼轉(zhuǎn)向股骨干方向延伸約5厘米，切口全長10-15厘米。?

骶旁神經(jīng)叢入路較其他入路更接近骶叢，臀上、下等神經(jīng)阻滯成功率高。?

腰叢聯(lián)合坐骨結(jié)節(jié)水平及以上的坐骨神經(jīng)阻滯用于髖關(guān)節(jié)置換／股骨頭置換術(shù)臨床上均有報道。臨床應(yīng)用（髖關(guān)節(jié)手術(shù)）?股骨頭置換術(shù)后外側(cè)入路切口23阻滯的神經(jīng)包括：?

腰叢神經(jīng)髂腹下神經(jīng)?

骶叢神經(jīng)?

肋下神經(jīng)?

臀上皮神經(jīng)（起自T12~L4脊神經(jīng)后支的外側(cè)支）阻滯的神經(jīng)包括：髂腹下神經(jīng)24骶叢坐骨神經(jīng)阻滯課件253、腘窩坐骨神經(jīng)阻滯?

能為膝以下隱神經(jīng)支配區(qū)域以外部分提供麻醉和鎮(zhèn)痛，用于小腿、踝、足的手術(shù)，膝關(guān)節(jié)手術(shù)術(shù)后鎮(zhèn)痛?

能夠在皮下阻滯坐骨神經(jīng)是腘窩阻滯法主要優(yōu)點，感覺阻滯的范圍與臀下入路基本相同?

脛神經(jīng)和腓總神經(jīng)分叉處與腘窩皮膚橫紋的距離變異較大SUPINE

POSITION3、腘窩坐骨神經(jīng)阻滯?能為膝以下隱神經(jīng)支配區(qū)域以外部分提26腘窩后入路腘窩后入路腘窩后入路腘窩后入路27骶叢坐骨神經(jīng)阻滯課件28SHORT

AXISORT

ASHORTAXISORTA29腘窩橫紋處脛神經(jīng)內(nèi)側(cè)腘動脈半膜肌LateralMedial外側(cè)腘窩橫紋處脛神經(jīng)內(nèi)側(cè)腘動脈半膜肌LateralMedi30njeubparaneuralrapteratenjecnjeubparaneuralrapteratnjec31骶叢坐骨神經(jīng)阻滯課件32腘窩側(cè)入路?

俯臥困難或俯臥位會對機體產(chǎn)生不良影響?

患者仰臥稍半坐位，患側(cè)膝關(guān)節(jié)稍屈曲?

在大腿后外側(cè)找到股外側(cè)肌與股二頭肌肌間溝?

從腘窩橫紋沿肌間溝向頭側(cè)6～8cm處為進針點腘窩側(cè)入路?俯臥困難或俯臥位會對機體產(chǎn)生不良影響33腘窩側(cè)入路距探頭外側(cè)緣2-3厘米進針，短軸平面內(nèi)技術(shù)腘窩側(cè)入路距探頭外側(cè)緣2-3厘米進針，短軸平面內(nèi)技術(shù)34麻醉藥選擇?

麻醉：0.5%羅哌卡因

25-30mL（或者0.4-0.6mL/kg）（腘窩上入路）0.5%羅哌卡因

15-20mL（其他入路）?

鎮(zhèn)痛：0.2%羅哌卡因

5m