细说臂丛神经阻滞

细说臂丛神经阻滞,佛山市禅城区中心医院李志鹏,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,臂从神经解剖,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,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,胸长神经,The long thoracic nerve,The long thoracic nerve (external respiratory nerve of Bell; posterior thoracic nerve) supplies the serratus anterior muscle. This nerve characteristically arises from the anterior rami of three spinal nerve roots: the fifth, sixth, and seventh cervical nerves (C5-C7) although the root from C7 may be absent. The roots from C5 and C6 pierce through the scalenus medius, while the C7 root passes in front of the muscle.,The nerve descends through the cervicoaxillary canal behind (posterior to) the brachial plexus and the axillary artery and vein, resting on the outer surface of the serratus anterior. It extends along the side of the thorax to the lower border of that muscle, supplying filaments to each of its digitations (finger-like projections,LTN was clearly visible in all anatomical specimens and volunteers using HRUS and could be followed until the second slip of the serratus anterior muscle from the supraclavicular region.In anatomical specimens, dissection confirmed,HRUS findings. For all volunteers, consensus was obtained. The mean nerve diameter was 1.6mm 0.3 (range 1.1 2.1mm) after the formation of the main trunk.,Fig. 2 a Example of sonographic finding of the LTN within the interscalenetriangle in ventromedial transverse view (Abbreviations used: C5-C8 = cervicalroots, ScA = anterior scalene muscle, SM=middle scalene muscle,SP = posterior scalene muscle); b Example of sonographic finding at themost distal point visible from the supraclavicular region (Abbreviationsused: OM= omohyoid muscle, SA = Serratus anterior muscle, SSN = suprascapularnerve).,Fig. 3 a Example of finding in dissections after marking of the LTN (whitearrow) at proximal site (also showing union of C5 and C6 cervical roots)(Abbreviation used: PS = posterior scalene muscle); b Example of finding indissections after marking of the LTN (white arrow) at the most distal pointvisible from the supraclavicular region (Abbreviations used: MS=middlescalene muscle, PS = posterior scalene muscle).,肩胛背神经,The dorsal scapular nerve arises from the brachial plexus, usually from the plexus root (anterior/ventral ramus) of C5.It provides motor innervation to the rhomboid muscles, which pull the scapula towards the spine and levator scapulae muscle, which elevates the scapula.Injury to this nerve is usually apparent when the scapula on one side is located farther from the midline.,Once the nerve leaves C5 it commonly pierces the middle scalene muscle, and continues deep to levator scapulae and the rhomboids. It is accompanied by one of two arteries: either the dorsal scapular artery (the only artery that comes off the third part of the subclavian, although its origin is highly variable in different people) or, when the dorsal scapular artery is absent, the deep branch of the transverse cervical artery (an artery coming off the thyrocervical trunk, a branch of the first part of the subclavian artery, the other two branches being vertebral artery and internal thoracic artery).,The patient underwent general anesthesia during the3.5-hour case, then was brought to the recovery room awakewith a pain score of 2 on an 11-point scale. The patient hadfull motor function of her ipsilateral arm in the postoperativeperiod.She was transferred to the short-stay unit, but 14 hours after the initial nerve block she experienced significant intractable pain, rated at 10/10.,At the patients request, a continuous nerve block catheter was placed adjacent to thedorsal scapular nerve. An infusion of 4 mL/hr + 2 mL bolus every 30 minutes was started. The patient experienced almost immediate relief of her pain after placement of the continuousnerve block. She was discharged home on postoperative day(POD) 1 after this block placement.,Selective blockade of the dorsal scapular nerve,Selective blockade of the dorsal scapular nerve,Selective blockade of the dorsal scapular nerve,平面内肌间沟阻滞 注意？,肩胛上神经,The suprascapular nerve arises from the upper trunk of the brachial plexus which is formed by the union of the ventral rami of the fifth and sixth cervical nerves. After branching from the upper trunk, the nerve passes across the posterior triangle of the neck parallel to the inferior belly of the omohyoid muscle and deep to the trapezius muscle.,It then runs along the superior border of the scapula, passes through the suprascapular notch inferior to the superior transverse scapular ligament and enters the supraspinous fossa. It then passes beneath the supraspinatus, and curves around the lateral border of the spine of the scapula to the infraspinous fossa.,Example of sonographic finding at the most distal point visibl