细说臂丛神经阻滞

细说臂丛神经阻滞第1页/共34页内容提要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第2页/共34页臂从神经解剖第3页/共34页臂丛神经解剖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、斜角肌支第4页/共34页第5页/共34页臂丛神经解剖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、斜角肌支第6页/共34页胸长神经第7页/共34页

ThelongthoracicnerveThelongthoracicnerve(externalrespiratorynerveofBell;posteriorthoracicnerve)suppliestheserratusanteriormuscle.Thisnervecharacteristicallyarisesfromtheanteriorramiofthreespinalnerveroots:thefifth,sixth,andseventhcervicalnerves(C5-C7)althoughtherootfromC7maybeabsent.TherootsfromC5andC6piercethroughthescalenusmedius,

whiletheC7rootpassesinfrontofthemuscle.Thenervedescendsthroughthecervicoaxillarycanalbehind(posteriorto)thebrachialplexusandtheaxillaryarteryandvein,restingontheoutersurfaceoftheserratusanterior.Itextendsalongthesideofthethoraxtothelowerborderofthatmuscle,supplyingfilamentstoeachofitsdigitations(finger-likeprojections第8页/共34页第9页/共34页LTNwasclearlyvisibleinallanatomicalspecimensandvolunteersusingHRUSandcouldbefolloweduntilthesecondslipoftheserratusanteriormusclefromthesupraclavicularregion.Inanatomicalspecimens,dissectionconfirmed,HRUSfindings.Forallvolunteers,consensuswasobtained.Themeannervediameterwas1.6mm±0.3(range1.1–2.1mm)aftertheformationofthemaintrunk.第10页/共34页Fig.2aExampleofsonographicfindingoftheLTNwithintheinterscalenetriangleinventromedialtransverseview(Abbreviationsused:C5-C8=cervicalroots,ScA=anteriorscalenemuscle,SM=middlescalenemuscle,SP=posteriorscalenemuscle);bExampleofsonographicfindingatthemostdistalpointvisiblefromthesupraclavicularregion(Abbreviationsused:OM=omohyoidmuscle,SA=Serratusanteriormuscle,SSN=suprascapularnerve).第11页/共34页Fig.3aExampleoffindingindissectionsaftermarkingoftheLTN(whitearrow)atproximalsite(alsoshowingunionofC5andC6cervicalroots)(Abbreviationused:PS=posteriorscalenemuscle);bExampleoffindingindissectionsaftermarkingoftheLTN(whitearrow)atthemostdistalpointvisiblefromthesupraclavicularregion(Abbreviationsused:MS=middlescalenemuscle,PS=posteriorscalenemuscle).第12页/共34页第13页/共34页第14页/共34页肩胛背神经Thedorsalscapularnervearisesfromthebrachialplexus,usuallyfromtheplexusroot(anterior/ventralramus)ofC5.Itprovidesmotorinnervationtotherhomboidmuscles,whichpullthescapulatowardsthespineandlevatorscapulaemuscle,whichelevatesthescapula.Injurytothisnerveisusuallyapparentwhenthescapulaononesideislocatedfartherfromthemidline.OncethenerveleavesC5itcommonlypiercesthemiddlescalenemuscle,andcontinuesdeeptolevatorscapulaeandtherhomboids.Itisaccompaniedbyoneoftwoarteries:eitherthedorsalscapularartery(theonlyarterythatcomesoffthethirdpartofthesubclavian,althoughitsoriginishighlyvariableindifferentpeople)or,whenthedorsalscapulararteryisabsent,thedeepbranchofthetransversecervicalartery(anarterycomingoffthethyrocervicaltrunk,abranchofthefirstpartofthesubclavianartery,theothertwobranchesbeingvertebralarteryandinternalthoracicartery).第15页/共34页第16页/共34页Thepatientunderwentgeneralanesthesiaduringthe3.5-hourcase,thenwasbroughttotherecoveryroomawakewithapainscoreof2onan11-pointscale.Thepatienthadfullmotorfunctionofheripsilateralarminthepostoperativeperiod.Shewastransferredtotheshort-stayunit,but14hoursaftertheinitialnerveblocksheexperiencedsignificantintractablepain,ratedat10/10.Atthepatient’srequest,acontinuousnerveblockcatheterwasplacedadjacenttothedorsalscapularnerve.Aninfusionof4mL/hr+2mLbolusevery30minuteswasstarted.Thepatientexperiencedalmostimmediatereliefofherpainafterplacementofthecontinuousnerveblock.Shewasdischargedhomeonpostoperativeday(POD)1afterthisblockplacement.第17页/共34页Selectiveblockadeofthedorsalscapularnerve第18页/共34页Selectiveblockadeofthedorsalscapularnerve第19页/共34页Selectiveblockadeofthedorsalscapularnerve第20页/共34页平面内肌间沟阻滞注意？第21页/共34页第22页/共34页第23页/共34页肩胛上神经Thesuprascapularnervearisesfromtheuppertrunkofthebrachialplexuswhichisformedbytheunionoftheventralramiofthefifthandsixthcervicalnerves.Afterbranchingfromtheuppertrunk,thenervepassesacrosstheposteriortriangleoftheneckparalleltotheinferiorbellyoftheomohyoidmuscleanddeeptothetrapeziusmuscle.Itthenrunsalongthesuperiorborderofthescapula,passesthroughthesuprascapularnotchinferiortothesuperiortransversescapularligamentandentersthesupraspinousfossa.Itthenpassesbeneaththesupraspinatus,andcurvesar