001ThoracicParavertebralBlock

ThoracicParavertebralBlockSongWei2Case女性，63age，68㎏，162㎝拟行右乳癌改良根治术肌营养不良症（假性肥大型）40余年•双上肢肌力Ⅴ-双下肢肌力Ⅳ•否认呼吸肌、心肌受累高血压36年糖尿病2年ASAⅢ级3PlanforAnesthesia神经阻滞复合静吸喉罩全麻•臂丛0.5%罗哌卡因10ml•胸椎旁神经阻滞T2/3T3/40.5%罗哌卡因各10ml维持•右美30μg，芬太尼80μg，丙泊酚100mg/h•七氟烷1.5-2.0%45Definitioninjectionoflocalanaestheticinaspaceimmediatelylateraltowherethespinalnervesemergefromtheintervertebralforaminaipsilateralsomaticandsympatheticnerveblockadeinmultiplecontiguousthoracicdermatomesaboveandbelowthesiteofinjection6Advantages√√√√√√√7Indications8AnatomyThoracicParavertebralSpace(TPVS)胸椎旁间隙RavinderKB,etal.JAnaesthesiolClinPharmacol2011,27(1):5-11.肋横突韧带肋横突上韧带竖脊肌肋间内肌菱形大肌斜方肌11深筋膜，在壁层胸膜和肋横突上韧带之间贴近肋骨，在椎体的正中与骨膜融合把椎旁间隙分为2个间隔：前面--胸膜外脊柱旁间隔后面--subendothoracic脊柱旁间隔脊神经在此筋膜后方RavinderKB,etal.JAnaesthesiolClinPharmacol2011,27(1):5-11.胸内筋膜12实施胸内筋膜腹侧椎旁注射易化纵向扩散胸内筋膜背侧椎旁注射则易导致不可预计的扩散KarmakarMK,ChungDC.RegAnesthPainMed2000,25:325-7.（运动性）（感觉性）14…•…椎旁间隙内容物脂肪组织肋间神经血管交感神经干交通支脊神经后支分段成束散布在脂肪中，缺乏筋膜鞘，对局部麻醉药特别敏感。15胸椎旁间隙与横向上的肋间隙相通胸椎旁间隙与中间硬膜外腔相通（经过椎间盘）胸椎旁间隙与对侧椎旁间隙相通（经过椎旁的和硬膜外腔隙）胸椎旁间隙顶部的范围还没有定论（观察到在胸椎旁注射放射性造影剂后扩散到颈部区域）腰大肌起点构成尾部边界，通过椎旁间隙向下方腰椎延伸的可能性不大Communication16MechanismofAnesthesia阻滞水平--神经或神经丛的根部包绕脊髓的硬脊膜延伸因此所有的脊柱旁神经根水平阻滞正好位于硬膜外，都是脊柱旁硬膜外阻滞。BoezaartA,etal.CurrentOpinioninAnaesthesiology2009,22(5):637-643.1718Aimcomparedasingle-versusdual-injectiontechniqueforultrasound-guidedparavertebralblockadeinacadavermodelevaluatedthespreadofcontrastdyeandlocationofacatheter19Method10freshcadavers30paravertebralinjections20catheterplacementsasingle20-mLinjectionatT6-7ononesideadual-injectiontechniqueof10-mLatT3-4andT7-8onthecontralateralsideultrasoundprobeinthetransverseplaneusingalineartransducer20首先定位中线的棘突探头侧移定位横突声影和胸膜壁层头侧或尾侧轻移动探头定位肋间隙避免临近肋骨声影2122right,asingle-levelinjection(T6-7)showsparavertebralandintercostalspreadovermultiplesegmentsleft,adual-injectiontechnique(T3-4andT7-8)showsparavertebralandintercostalspreadovermultiplelevelswithdyemostconcentratedatthesiteofinjectionnotealsotheprevertebralspreadofcontrast232425Conclusiontheanalgesicefficacyofathoracicparavertebralblockisfrommultilevelparavertebral,intercostal,andepiduralspreadofinjectate123thespreadofcontrastisoftengreaterbetweenintercostalspacesthanparavertebralspacesafteraparavertebralinjection,contrastcanentertheepiduralspace(40%ofcadavers)andcoverasingleepiduralsegment4adual-injectiontechniqueatseparatelevelsseemstocovermorethoracicdermatomesbecauseofgreatersegmentalintercostalspread(ratherthanparavertebralspread)thanasingleinjectionapproach26Thinkingthespreadofaneasthic27胸椎旁神经阻滞麻醉对于胸腹壁手术后的镇痛是不错的选择，对于一些心肺功能极差的患者的乳腺、肩胛骨手术，也可以用胸椎旁神经来完成，但是必须复合臂丛神经阻滞，原因在于胸大肌是由臂丛分支——胸前内侧、胸前外侧神经支配；冈上肌、冈下肌、大圆肌是臂丛分支——肩胛上神经和肩胛下神经支配28Enjoyeveryday.