2017股神经、髂筋膜、隐神经-蒋嘉

朝阳医院超声麻醉疼痛周髂筋膜、股神经和隐神经/收肌管阻滞朝阳医院麻醉科蒋嘉膝关节置换镇痛TerkawiAS,MavridisD,SesslerDI,etal.PainManagementModalitiesafterTotalKneeArthroplasty.ANetworkMeta-analysisof170RandomizedControlledTrials.Anesthesiology2017;126:923-37膝关节置换镇痛Primaryoutcomes:(1)acutepostoperativepain(duringrestandmovement)(2)postoperativeopioidconsumption(3)qualityofearlypostoperativerehabilitation(functionalassessments)Secondaryoutcomes:postoperativecomplications(e.g.,nausea,vomiting,falls),durationofhospitalization,bloodloss,procedurefailure,andpatientwithdrawalTerkawiAS,MavridisD,SesslerDI,etal.PainManagementModalitiesafterTotalKneeArthroplasty.ANetworkMeta-analysisof170RandomizedControlledTrials.Anesthesiology2017;126:923-37与PCA比较(A)Overallpainscoresinthefirst72hduringrest(B)overallpainscoresinthefirst72hduringmovement,(C)overallopioidconsumptioninthefirst72h(D)overallrangeonmotioninthefirst72h.TerkawiAS,MavridisD,SesslerDI,etal.PainManagementModalitiesafterTotalKneeArthroplasty.ANetworkMeta-analysisof170RandomizedControlledTrials.Anesthesiology2017;126:923-37RankingF/S(6)F/O(6)LP/S(3)FIC(3)PA(2)Rankingonhigh-qualitystudiesF/SFICLPPAACBTerkawiAS,MavridisD,SesslerDI,etal.PainManagementModalitiesafterTotalKneeArthroplasty.ANetworkMeta-analysisof170RandomizedControlledTrials.Anesthesiology2017;126:923-37闭孔神经股神经股外侧皮神经隐神经髂筋膜阻滞•阻滞的是什么？髂筋膜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水平覆盖腰大肌和髂肌髂筋膜闭孔神经与髂肌和髂筋膜并没有密切的联系闭孔神经髂筋膜阻滞的扩散范围（MRI）SwensonJD,DavisJJ,etal.Localanestheticinjectiondeeptothefasciailiacaattheleveloftheinguinalligament:thepatternofdistributionandeffectsontheobturatornerve.JournalofClinicalAnesthesia(2015)27,652–657腹股沟韧带水平骶骨水平冠状位腹股沟韧带水平髂筋膜阻滞超声引导髂筋膜阻滞的方法腹股沟韧带下法寻找缝匠肌和髂肌药液扩散：缝匠肌和髂肌之间阻滞：股神经、股外侧皮神经？超声引导髂筋膜阻滞腹股沟韧带上法BullockWM,YalamuriSM,GregorySH,etal.Ultrasound-GuidedSuprainguinalFasciaIliacaTechniqueProvidesBenefitasanAnalgesicAdjunctforPatientsUndergoingTotalHipArthropla.JUltrasoundMed2017;36:433–438超声引导腹股沟韧带上髂筋膜阻滞寻找髂前上棘、髂肌、腹横肌药液扩散：腹横肌和髂肌之间阻滞：股神经、股外侧皮神经、髂腹股沟神经BullockWM,YalamuriSM,GregorySH,etal.Ultrasound-GuidedSuprainguinalFasciaIliacaTechniqueProvidesBenefitasanAnalgesicAdjunctforPatientsUndergoingTotalHipArthropla.JUltrasoundMed2017;36:433–438股神经阻滞•如何提高成功率？股神经解剖股神经股神经超声影像腹股沟水平股动脉外侧，髂筋膜深部，髂肌表面高回声，宽而扁，椭圆形深度：1~3cm超声探头的最佳位置旋股内、外侧动脉超声探头的最佳位置旋髂深浅动脉必要时用多普勒调整位置腹股沟韧带和腹横纹中间位置或许最佳OGAMIK,MURATAH,SAKAIA,etal.DeepandSuperficialCircumflexIliacArteriesandTheirRelationshiptotheUltrasound-GuidedFemoralNerveBlockProcedure:ACadaverStudy.ClinicalAnatomy30:413–420(2017)进针点？药液？置管位置？短轴，平面内法短轴，平面外法进针点？药液？置管位置？BenoitFanara,Jean-LucChristophe,AnnieBoillot,etal.Ultrasoundguidanceofneedletippositionforfemoralnerveblockade.Anobservationalstudy.EurJAnaesthesiol2014;31:23–29进针点？药液？置管位置？TopographicviewoftheterminalbranchesofthefemoralnerveACN：anteriorcutaneousnerveMCN：medialcutaneousnervePMN：pectineusmusclenerve;RFMN：rectusfemorismusclenerveSMN：SartoriusmusclenerveSN：saphenousnerveVIMN：vastusintermediusmusclenerveVLMN：vastuslateralismusclenerveVMMN：vastusmedialismusclenerve隐神经部分与神经其他部分可能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BenoitFanara,Jean-LucChristophe,AnnieBoillot,etal.Ultrasoundguidanceofneedletippositionforfemoralnerveblockade.Anobservationalstudy.EurJAnaesthesiol2014;31:23–29辨认不清髂筋膜怎么办？BenoitFanara,Jean-LucChristophe,AnnieBoillot,etal.Ultrasoundguidanceofneedletippositionforfemoralnerveblockade.Anobservationalstudy.EurJAnaesthesiol2014;31:23–29GIPM：髂腰肌凹槽（agrooveformedbytheiliacandlateralpsoasmuscles）股神经阻滞——寻找GIPM旁结构BenoitFanara,Jean-LucChristophe,AnnieBoillot,etal.Ultrasoundguidanceofneedletippositionforfemoralnerveblockade.Anobservationalstudy.EurJAnaesthesiol2014;31:23–29髂筋膜GIPM:85%髂筋膜：68%阔筋膜张肌股外侧皮神经缝匠肌股外侧皮神经阻滞支配：大腿前外侧适应证：髋部手术为主过去：髂前上棘内下1~2cm，皮下0.5~1cm变异大：以解剖标志为基础的传统阻滞技术不可靠超声引导股外侧皮神经阻滞高频探头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隐神经阻滞•与收肌管阻滞？隐神经阻滞股神经的最大感觉支支配：内侧膝关节、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局麻药：低浓度，5~10ml隐神经走行股动脉伴行，内下行通过收肌管，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，与大隐静脉伴行隐神经阻滞入路Subsartorialplexusblock（大腿中段）AdductorCanalblock（大腿远端/收肌管）Subcoutaneousinfiltrationblock（小腿近端）收肌管收肌肌腱键膜管状间隙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、股静脉收肌管相关肌肉收肌管超声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WongWY,etal.DefiningtheLocationoftheAdductorCanalUsingUltrasound.RegAnesthPainMed2017;42:241–245股内收膜vastoadductormembraneWongWY,etal.DefiningtheLocationoftheAdductorCanalUsingUltrasound.RegAnesthPainMed2017;42:241–245小结髂筋膜阻滞：阻滞：股神经+股外侧皮神经腹股沟上髂筋膜阻滞（更佳）：髂前上棘、髂肌和腹横肌腹股沟下髂筋膜阻滞：缝匠肌和髂肌股神经一般：股动脉和髂筋膜特殊：GIPM旁结构外侧进针平面内法、药液包绕、神经前方置管隐神经收肌管水平最佳：缝匠肌和股外侧肌膝关节置换：股神经联合坐骨神经阻滞最佳