股神经髂筋膜隐神经蒋嘉学习教案

1、会计学1股神经股神经(shnjng)髂筋膜隐神经髂筋膜隐神经(shnjng)蒋嘉蒋嘉第一页，共35页。Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta- analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37第1页/共34页第二页，共35页。Primary outcomes:(1) acute postoperati

2、ve pain (during rest and movement)(2) postoperative opioid consumption(3) quality of early postoperative rehabilitation (functional assessments)Secondary outcomes:postoperative complications (e.g., nausea, vomiting, falls), duration of hospitalization, blood loss, procedure failure, and patient with

3、drawalTerkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta- analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37第2页/共34页第三页，共35页。与与PCAPCA比较比较(bjio)(bjio)(A) Overall pain scores in the first 72 h duringrest(B) ove

4、rall pain scores in the first 72 h during movement,(C) overall opioid consumption in the first 72 h(D) overall range on motion in the first 72 h.Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled T

5、rials.Anesthesiology 2017; 126:923-37第3页/共34页第四页，共35页。Ranking F/S (6) F/O(6) LP/S (3)FIC (3) PA (2)Ranking on high-quality studiesF/SFICLPPAACBTerkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Tri

6、als. Anesthesiology 2017; 126:923-37第4页/共34页第五页，共35页。闭孔神经闭孔神经(shnjng)(shnjng)股神经股神经(shnjng)(shnjng)股外侧股外侧(wi c)(wi c)皮神经皮神经隐神经隐神经(shnjng)(shnjng)第5页/共34页第六页，共35页。阻滞(z zh)的是什么？第6页/共34页第七页，共35页。髂筋膜髂筋膜(jn (jn m)m) 外界：髂嵴内侧缘 内界：小骨盆的界线 向下一直延续 到股骨小转子(zhun z) 水平 覆盖腰大肌和 髂肌第7页/共34页第八页，共35页。髂筋膜髂筋膜(jn (jn m)m)闭

7、孔神经闭孔神经(shnjng)(shnjng)与髂肌和髂筋膜并没有密切的联与髂肌和髂筋膜并没有密切的联系系闭闭 孔孔 神神 经经第8页/共34页第九页，共35页。Swenson JD, Davis JJ, et al. Local anesthetic injection deep to the fascia iliaca at the level of the inguinal ligament: the pattern of distribution and effects on the obturator nerve. Journal of Clinical Anesthesia (20

8、15) 27, 652657腹股沟韧带腹股沟韧带(rndi)(rndi)水平水平骶骨骶骨(dg)(dg)水平水平冠状位冠状位腹股沟韧带水平髂筋膜阻滞腹股沟韧带水平髂筋膜阻滞第9页/共34页第十页，共35页。超声引导超声引导(yndo)(yndo)髂筋膜阻髂筋膜阻滞的方法滞的方法第10页/共34页第十一页，共35页。腹股沟韧带腹股沟韧带(rndi)(rndi)上法上法Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-GuidedSuprainguinal Fascia Iliaca Technique ProvidesBenefit a

9、s an Analgesic Adjunct forPatients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433438第11页/共34页第十二页，共35页。超声引导超声引导(yndo)(yndo)腹股沟韧带上髂腹股沟韧带上髂筋膜阻滞筋膜阻滞Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-Guided Suprainguinal Fascia Iliaca Technique Provides Benefit as an Analgesic Adjunct

10、 for Patients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433438第12页/共34页第十三页，共35页。如何(rh)提高成功率？第13页/共34页第十四页，共35页。股神经股神经(shnjng)(shnjng)解解剖剖股神经股神经(shnjng)(shnjng)第14页/共34页第十五页，共35页。股神经股神经(shnjng)(shnjng)超超声影像声影像第15页/共34页第十六页，共35页。超声探头的最佳超声探头的最佳(zu (zu ji)ji)位置位置旋股内、外侧旋股内、外侧(wi c)(wi c)

11、动脉动脉第16页/共34页第十七页，共35页。 旋髂深浅动脉 必要(byo)时用多普勒调整位置 腹股沟韧带和 腹横纹中间位置或许(hux)最佳OGAMI K, MURATA H, SAKAI A, et al. Deep and Superficial Circumflex Iliac Arteries and Their Relationship to the Ultrasound-Guided Femoral Nerve Block Procedure: A Cadaver Study. Clinical Anatomy 30:413420 (2017)第17页/共34页第十八页，共35页

12、。短轴，平面短轴，平面(pngmin)(pngmin)内法内法短轴，平面短轴，平面(pngmin)(pngmin)外法外法第18页/共34页第十九页，共35页。Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:2329第19页/共34页第二十页，共35页。隐神经部分与神经其他部分可能(k

13、nng)存在隔断平面内由外向内进针，一直到神经内侧，药液包绕，神经前方置管Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:2329第20页/共34页第二十一页，共35页。辨认辨认(binrn)(binrn)不清髂筋不清髂筋膜怎么办？膜怎么办？Benoit Fanara, Jean-Lu

14、c Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. Anobservational study. Eur J Anaesthesiol 2014; 31:2329GIPM：髂腰肌凹槽（髂腰肌凹槽（a groove formed by the iliac and lateral psoas muscles）第21页/共34页第二十二页，共35页。Benoit Fanara, Jean-Luc Christophe, Annie Boil

15、lot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. Anobservational study. Eur J Anaesthesiol 2014; 31:2329髂筋膜髂筋膜(jn m)(jn m)GIPM:85% 髂筋膜(jn m)：68%第22页/共34页第二十三页，共35页。阔筋膜张肌阔筋膜张肌 股外侧股外侧(wi c)(wi c)皮神经皮神经缝匠肌缝匠肌股外侧皮神经股外侧皮神经(shnjng)(shnjng)阻滞阻滞 支配(zhpi)：大腿前外侧 适应证：髋部手术为主 过去

16、：髂前上棘内 下12cm，皮下 0.51cm 变异大：以解剖标 志为基础的传统阻 滞技术不可靠第23页/共34页第二十四页，共35页。超声引导股外侧超声引导股外侧(wi c)(wi c)皮神皮神经阻滞经阻滞 高频(o pn)探头 扫描方式：阔筋膜张肌和缝匠肌 超声影像：低回声椭圆形（此处可能已经分支） 进针路径：平面内或平面外 局麻药：5ml 目标：局麻药在神经周围或 阔筋膜张肌和缝匠肌之间阔 筋膜下方扩散第24页/共34页第二十五页，共35页。与收肌管阻滞(z zh)？第25页/共34页第二十六页，共35页。隐神经隐神经(shnjng)(shnjng)阻滞阻滞 股神经的最大感觉支 支配：内侧

17、膝关节、 髌骨下方、小腿内侧 和足内侧缘的皮肤 适应证：膝关节手术、大隐静脉手术、坐 骨神经阻滞的补充 不影响股四头肌力量(l ling) 局麻药：低浓度，510ml第26页/共34页第二十七页，共35页。隐神经隐神经(shnjng)(shnjng)走行走行 股 动 脉 伴 行 ， 内 下 行(xixng) 通过收肌管，接近膝 盖穿出 大腿中段：缝降肌深面，与股动脉伴行 膝上：缝匠肌和股内 肌之间的收肌管内， 与股动静脉伴行 膝下：胫骨粗隆表面，与大隐静脉伴行第27页/共34页第二十八页，共35页。隐神经阻滞隐神经阻滞(z zh)(z zh)入路入路Subsartorial plexus bl

18、ockSubsartorial plexus block（大腿中段）大腿中段） Adductor Canal Adductor Canal blockblock（大腿远端（大腿远端/ /收肌管）收肌管） Subcoutaneous infiltration Subcoutaneous infiltration blockblock（小腿近端）（小腿近端）第28页/共34页第二十九页，共35页。收肌管收肌管收肌肌腱(jjin)键膜管状间隙构成：股内侧肌、缝匠肌、长收肌和大收肌近端：股三角(snjio)顶点远端：收肌管裂孔表面：股内收膜内容：股神经的股内侧肌支、隐神经、股中间皮神经、股动脉、股静 脉第29页/共34页第三十页，共35页。第30页/共34页第三十一页，共35页。起点：股三角（倒）顶点，缝匠肌与长收肌内 侧缘相交处终点：股动脉(dngmi)偏离缝匠肌，进入股内侧肌和大 收肌之间（收肌腱裂孔）S：缝匠肌VM：股内侧肌AL：长收肌AM：大收肌Wong WY, et al. Defining the Location of the Adductor Canal Using Ultrasound.Reg Anesth Pain Med 2017;42: 241245第31页/共34页第三十二页，共35页。vastoadductor membran