细说臂丛神经阻滞PPT课件.pptx

细说臂丛神经阻滞 佛山市禅城区中心医院李志鹏 2020 1 7 1 内容提要 1肌间沟神经阻滞的那些 坑 2肩胛骨骨折的患者如何进行神经阻滞镇痛 3前臂内侧皮神经联合肌皮神经阻滞 2020 1 7 2 臂从神经解剖 2020 1 7 3 臂丛神经解剖 1胸长神经2肩胛背神经3肩胛上神经4锁骨下肌神经5正中神经外侧根6肌皮神经7胸外侧神经8上肩胛下神经9下肩胛下神经10胸背神经 11腋神经12桡神经13胸内侧神经14正中神经内侧根15尺神经16前臂内侧皮神经17臂内侧皮神经18正中神经19肋间臂神经20颈长肌 斜角肌支 2020 1 7 4 2020 1 7 5 臂丛神经解剖 1胸长神经2肩胛背神经3肩胛上神经4锁骨下肌神经5正中神经外侧根6肌皮神经7胸外侧神经8上肩胛下神经9下肩胛下神经10胸背神经 11腋神经12桡神经13胸内侧神经14正中神经内侧根15尺神经16前臂内侧皮神经17臂内侧皮神经18正中神经19肋间臂神经20颈长肌 斜角肌支 2020 1 7 6 胸长神经 2020 1 7 7 Thelongthoracicnerve Thelongthoracicnerve externalrespiratorynerveofBell posteriorthoracicnerve suppliestheserratusanteriormuscle Thisnervecharacteristicallyarisesfromtheanteriorramiofthreespinalnerveroots thefifth sixth andseventhcervicalnerves C5 C7 althoughtherootfromC7maybeabsent TherootsfromC5andC6piercethroughthescalenusmedius whiletheC7rootpassesinfrontofthemuscle Thenervedescendsthroughthecervicoaxillarycanalbehind posteriorto thebrachialplexusandtheaxillaryarteryandvein restingontheoutersurfaceoftheserratusanterior Itextendsalongthesideofthethoraxtothelowerborderofthatmuscle supplyingfilamentstoeachofitsdigitations finger likeprojections 2020 1 7 8 2020 1 7 9 LTNwasclearlyvisibleinallanatomicalspecimensandvolunteersusingHRUSandcouldbefolloweduntilthesecondslipoftheserratusanteriormusclefromthesupraclavicularregion Inanatomicalspecimens dissectionconfirmed HRUSfindings Forallvolunteers consensuswasobtained Themeannervediameterwas1 6mm 0 3 range1 1 2 1mm aftertheformationofthemaintrunk 2020 1 7 10 Fig 2aExampleofsonographicfindingoftheLTNwithintheinterscalenetriangleinventromedialtransverseview Abbreviationsused C5 C8 cervicalroots ScA anteriorscalenemuscle SM middlescalenemuscle SP posteriorscalenemuscle bExampleofsonographicfindingatthemostdistalpointvisiblefromthesupraclavicularregion Abbreviationsused OM omohyoidmuscle SA Serratusanteriormuscle SSN suprascapularnerve 2020 1 7 11 Fig 3aExampleoffindingindissectionsaftermarkingoftheLTN whitearrow atproximalsite alsoshowingunionofC5andC6cervicalroots Abbreviationused PS posteriorscalenemuscle bExampleoffindingindissectionsaftermarkingoftheLTN whitearrow atthemostdistalpointvisiblefromthesupraclavicularregion Abbreviationsused MS middlescalenemuscle PS posteriorscalenemuscle 2020 1 7 12 2020 1 7 13 2020 1 7 14 肩胛背神经 Thedorsalscapularnervearisesfromthebrachialplexus usuallyfromtheplexusroot anterior ventralramus ofC5 Itprovidesmotorinnervationtotherhomboidmuscles whichpullthescapulatowardsthespineandlevatorscapulaemuscle whichelevatesthescapula Injurytothisnerveisusuallyapparentwhenthescapulaononesideislocatedfartherfromthemidline OncethenerveleavesC5itcommonlypiercesthemiddlescalenemuscle andcontinuesdeeptolevatorscapulaeandtherhomboids Itisaccompaniedbyoneoftwoarteries eitherthedorsalscapularartery theonlyarterythatcomesoffthethirdpartofthesubclavian althoughitsoriginishighlyvariableindifferentpeople or whenthedorsalscapulararteryisabsent thedeepbranchofthetransversecervicalartery anarterycomingoffthethyrocervicaltrunk abranchofthefirstpartofthesubclavianartery theothertwobranchesbeingvertebralarteryandinternalthoracicartery 2020 1 7 15 2020 1 7 16 Thepatientunderwentgeneralanesthesiaduringthe3 5 hourcase thenwasbroughttotherecoveryroomawakewithapainscoreof2onan11 pointscale Thepatienthadfullmotorfunctionofheripsilateralarminthepostoperativeperiod Shewastransferredtotheshort stayunit but14hoursaftertheinitialnerveblocksheexperiencedsignificantintractablepain ratedat10 10 Atthepatient srequest acontinuousnerveblockcatheterwasplacedadjacenttothedorsalscapularnerve Aninfusionof4mL hr 2mLbolusevery30minuteswasstarted Thepatientexperiencedalmostimmediatereliefofherpainafterplacementofthecontinuousnerveblock Shewasdischargedhomeonpostoperativeday POD 1afterthisblockplacement 2020 1 7 17 2020 1 7 18 Selectiveblockadeofthedorsalscapularnerve 2020 1 7 19 Selectiveblockadeofthedorsalscapularnerve 2020 1 7 20 Selectiveblockadeofthedorsalscapularnerve 2020 1 7 21 平面内肌间沟阻滞注意 2020 1 7 22 2020 1 7 23 2020 1 7 24 肩胛上神经 Thesuprascapularnervearisesfromtheuppertrunkofthebrachialplexuswhichisformedbytheunionoftheventralramiofthefifthandsixthcervicalnerves Afterbranchingfromtheuppertrunk thenervepassesacrosstheposteriortriangleoftheneckparalleltotheinferiorbellyoftheomohyoidmuscleanddeeptothetrapeziusmuscle Itthenrunsalongthesuperiorborderofthescapula passesthroughthesuprascapularnotchinferiortothesuperiortransversescapularligamentandentersthesupraspinousfossa Itthenpassesbeneaththesupraspinatus andcurvesaroundthelateralborderofthespineofthescapulatotheinfraspinousfossa 2020 1 7 25 2020 1 7 26 2020 1 7 27 Exampleofsonographicfindingatthemostdistalpointvisiblefromthesupraclavicularregion Abbreviationsused OM omohyoidmuscle SA Serratusanteriormuscle