细说臂丛神经阻滞

细说臂丛神经阻滞佛山市禅城区中心医院李志鹏内容提要•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臂从神经解剖臂丛神经解剖•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、斜角肌支胸长神经Thelongthoracicnerve•Thelongthoracicnerve(externalrespiratorynerveofBell;posteriorthoracicnerve)suppliestheserratusanteriormuscle.Thisnervecharacteristicallyarisesfromtheanteriorramiofthreespinalnerveroots:thefifth,sixth,andseventhcervicalnerves(C5-C7)althoughtherootfromC7maybeabsent.TherootsfromC5andC6piercethroughthescalenusmedius,whiletheC7rootpassesinfrontofthemuscle.•Thenervedescendsthroughthecervicoaxillarycanalbehind(posteriorto)thebrachialplexusandtheaxillaryarteryandvein,restingontheoutersurfaceoftheserratusanterior.Itextendsalongthesideofthethoraxtothelowerborderofthatmuscle,supplyingfilamentstoeachofitsdigitations(finger-likeprojections•LTNwasclearlyvisibleinallanatomicalspecimensandvolunteersusingHRUSandcouldbefolloweduntilthesecondslipoftheserratusanteriormusclefromthesupraclavicularregion.•Inanatomicalspecimens,dissectionconfirmed,HRUSfindings.Forallvolunteers,consensuswasobtained.Themeannervediameterwas1.6mm±0.3(range1.1–2.1mm)aftertheformationofthemaintrunk.Fig.2aExampleofsonographicfindingoftheLTNwithintheinterscalenetriangleinventromedialtransverseview(Abbreviationsused:C5-C8=cervicalroots,ScA=anteriorscalenemuscle,SM=middlescalenemuscle,SP=posteriorscalenemuscle);bExampleofsonographicfindingatthemostdistalpointvisiblefromthesupraclavicularregion(Abbreviationsused:OM=omohyoidmuscle,SA=Serratusanteriormuscle,SSN=suprascapularnerve).Fig.3aExampleoffindingindissectionsaftermarkingoftheLTN(whitearrow)atproximalsite(alsoshowingunionofC5andC6cervicalroots)(Abbreviationused:PS=posteriorscalenemuscle);bExampleoffindingindissectionsaftermarkingoftheLTN(whitearrow)atthemostdistalpointvisiblefromthesupraclavicularregion(Abbreviationsused:MS=middlescalenemuscle,PS=posteriorscalenemuscle).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).•Thepatientunderwentgeneralanesthesiaduringthe3.5-hourcase,thenwasbroughttotherecoveryroomawakewithapainscoreof2onan11-pointscale.Thepatienthadfullmotorfunctionofheripsilateralarminthepostoperativeperiod.Shewastransferredtotheshort-stayunit,but14hoursaftertheinitialnerveblocksheexperiencedsignificantintractablepain,ratedat10/10.•Atthepatient’srequest,acontinuousnerveblockcatheterwasplacedadjacenttothe•dorsalscapularnerve.Aninfusionof4mL/hr+2mLbolusevery30minuteswasstarted.Thepatientexperiencedalmostimmediatereliefofherpainafterplacementofthecontinuous•nerveblock.Shewasdischargedhomeonpostoperativeday•(POD)1afterthisblockplacement.SelectiveblockadeofthedorsalscapularnerveSelectiveblockadeofthedorsalscapularnerveSelectiveblockadeofthedorsalscapularnerve平面内肌间沟阻滞注意？肩胛上神经•Thesuprascapularnervearisesfromtheuppertrunkofthebrachialplexuswhichisformedbytheunionoftheventralramiofthefifthandsixthcervicalnerves.Afterbranchingfromtheuppertrunk,thenervepassesacrosstheposteriortriangleoftheneckparalleltotheinferiorbellyoftheomohyoidmuscleanddeeptothetrapeziusmuscle.•Itthenrunsalongthesuperiorborderofthescapula,passesthroughthesuprascapularnotchinferiortothesuperiortransversescapularligamentandentersthesupraspinousfossa.Itthenpassesbeneaththesupraspinatus,andcurvesaroundthelateralborderofthespineofthescapulatotheinfraspinousfossa.Exampleofsonographicfindingatthemostdistalpointvisiblefromthesupraclavicularregion(Abbreviationsused:OM=omohyoidmuscle,SA=Serratusanteriormuscle,SSN=suprascapularnerve).前臂内侧皮神经•前臂内侧皮神经是起自臂丛内侧束，在腋动、静脉之间下行，继而沿肱二头肌内侧沟下行，居于肱动脉内侧，在臂中部贵要静脉穿深筋膜处，此神经分前、后两支。•前支走在贵要静脉外侧，分布于前臂内侧皮肤；后支走在贵要静脉内侧，分布于前臂内后侧皮肤。Thanks