细说臂丛神经阻滞PPT课件

细说臂丛神经阻滞,佛山市禅城区中心医院李志鹏,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,2,-,臂从神经解剖,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,4,-,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,6,-,胸长神经,7,-,Thelongthoracicnerve,Thelongthoracicnerve(externalrespiratorynerveofBell;posteriorthoracicnerve)suppliestheserratusanteriormuscle.Thisnervecharacteristicallyarisesfromtheanteriorramiofthreespinalnerveroots:thefifth,sixth,andseventhcervicalnerves(C5-C7)althoughtherootfromC7maybeabsent.TherootsfromC5andC6piercethroughthescalenusmedius,whiletheC7rootpassesinfrontofthemuscle.,Thenervedescendsthroughthecervicoaxillarycanalbehind(posteriorto)thebrachialplexusandtheaxillaryarteryandvein,restingontheoutersurfaceoftheserratusanterior.Itextendsalongthesideofthethoraxtothelowerborderofthatmuscle,supplyingfilamentstoeachofitsdigitations(finger-likeprojections,8,-,9,-,LTNwasclearlyvisibleinallanatomicalspecimensandvolunteersusingHRUSandcouldbefolloweduntilthesecondslipoftheserratusanteriormusclefromthesupraclavicularregion.Inanatomicalspecimens,dissectionconfirmed,HRUSfindings.Forallvolunteers,consensuswasobtained.Themeannervediameterwas1.6mm0.3(range1.12.1mm)aftertheformationofthemaintrunk.,10,-,Fig.2aExampleofsonographicfindingoftheLTNwithintheinterscalenetriangleinventromedialtransverseview(Abbreviationsused:C5-C8=cervicalroots,ScA=anteriorscalenemuscle,SM=middlescalenemuscle,SP=posteriorscalenemuscle);bExampleofsonographicfindingatthemostdistalpointvisiblefromthesupraclavicularregion(Abbreviationsused:OM=omohyoidmuscle,SA=Serratusanteriormuscle,SSN=suprascapularnerve).,11,-,Fig.3aExampleoffindingindissectionsaftermarkingoftheLTN(whitearrow)atproximalsite(alsoshowingunionofC5andC6cervicalroots)(Abbreviationused:PS=posteriorscalenemuscle);bExampleoffindingindissectionsaftermarkingoftheLTN(whitearrow)atthemostdistalpointvisiblefromthesupraclavicularregion(Abbreviationsused:MS=middlescalenemuscle,PS=posteriorscalenemuscle).,12,-,13,-,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).,15,-,16,-,Thepatientunderwentgeneralanesthesiaduringthe3.5-hourcase,thenwasbroughttotherecoveryroomawakewithapainscoreof2onan11-pointscale.Thepatienthadfullmotorfunctionofheripsilateralarminthepostoperativeperiod.Shewastransferredtotheshort-stayunit,but14hoursaftertheinitialnerveblocksheexperiencedsignificantintractablepain,ratedat10/10.,Atthepatientsrequest,acontinuousnerveblockcatheterwasplacedadjacenttothedorsalscapularnerve.Aninfusionof4mL/hr+2mLbolusevery30minuteswasstarted.Thepatientexperiencedalmostimmediatereliefofherpainafterplacementofthecontinuousnerveblock.Shewasdischargedhomeonpostoperativeday(POD)1afterthisblockplacement.,17,-,Selectiveblockadeofthedorsalscapularnerve,18,-,Selectiveblockadeofthedorsalscapularnerve,19,-,Selectiveblockadeofthedorsalscapularnerve,20,-,平面内肌间沟阻滞注意？,21,-,22,-,23,-,肩胛上神经,Thesuprascapularnervearisesfromtheuppertrunkofthebrachialplexuswhichisformedbytheunionoftheventralramiofthefifthandsixthcervicalnerves.Afterbranchingfromtheuppertrunk,thenervepassesacrosstheposteriortriangleoftheneckparalleltotheinferiorbellyoftheomohyoidmuscleanddeeptothetrapeziusmuscle.,Itthenrunsalongthesuperiorborderofthescapula,passesthroughthesuprascapularnotchinferiortothesuperiortransversescapularligamentandentersthesupraspinousfossa.Itthenpassesbeneaththesupraspinatus,andcurvesaroundthelateralborderofthespineofthescapulatotheinfraspinousfossa.,24,-,25,-,26,-,Exampleofsonographicfindingatthemostdistalpointvisiblefromthesupraclavicularregion(Abbreviationsused