細說臂叢神經阻滯

細說臂叢神經阻滯內容提要1肌間溝神經阻滯的那些“坑”2肩胛骨骨折的患者如何進行神經阻滯鎮(zhèn)痛？3前臂內側皮神經聯(lián)合肌皮神經阻滯臂從神經解剖臂叢神經解剖1胸長神經2肩胛背神經3肩胛上神經4鎖骨下肌神經5正中神經外側根6肌皮神經7胸外側神經8上肩胛下神經9下肩胛下神經10胸背神經.11腋神經12橈神經13胸內側神經14正中神經內側根15尺神經16前臂內側皮神經17臂內側皮神經18正中神經19肋間臂神經20頸長肌、斜角肌支臂叢神經解剖1胸長神經2肩胛背神經3肩胛上神經4鎖骨下肌神經5正中神經外側根6肌皮神經7胸外側神經8上肩胛下神經9下肩胛下神經10胸背神經.11腋神經12橈神經13胸內側神經14正中神經內側根15尺神經16前臂內側皮神經17臂內側皮神經18正中神經19肋間臂神經20頸長肌、斜角肌支胸長神經

ThelongthoracicnerveThelongthoracicnerve(externalrespiratorynerveofBell;posteriorthoracicnerve)suppliestheserratusanteriormuscle.Thisnervecharacteristicallyarisesfromtheanteriorramiofthreespinalnerveroots:thefifth,sixth,andseventhcervicalnerves(C5-C7)althoughtherootfromC7maybeabsent.TherootsfromC5andC6piercethroughthescalenusmedius,whiletheC7rootpassesinfrontofthemuscle.Thenervedescendsthroughthecervicoaxillarycanalbehind(posteriorto)thebrachialplexusandtheaxillaryarteryandvein,restingontheoutersurfaceoftheserratusanterior.Itextendsalongthesideofthethoraxtothelowerborderofthatmuscle,supplyingfilamentstoeachofitsdigitations(finger-likeprojectionsLTNwasclearlyvisibleinallanatomicalspecimensandvolunteersusingHRUSandcouldbefolloweduntilthesecondslipoftheserratusanteriormusclefromthesupraclavicularregion.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).肩胛背神經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,acontinuousnerveblockcatheterwasplacedadjacenttothedorsalscapularnerve.Aninfusionof4mL/hr+2mLbolusevery30minuteswasstarted.Thepatientexperiencedalmostimmediatereliefofherpainafterplacementofthecontinuousnerveblock.Shewasdischargedhomeonpostoperativeday(POD)1afterthisblockplacement.SelectiveblockadeofthedorsalscapularnerveSelectiveblockadeofthedorsalscapularnerveSelectiveblockadeofthedorsalscapularnerve平面內肌間溝阻滯注意？肩胛上神經Thesuprascapularnervearisesfromtheuppertrunkofthebrachialplexuswhichisformedbytheunionoftheventralramiofthefifthandsixthcervicalnerves.Afterbranchingfromtheuppertrunk,thenervepassesacrosstheposteriortriangleoftheneckparalleltotheinferiorbellyoftheomohyoidmuscleanddeeptothetrapeziusmuscle.Itthenrunsalongthesuperiorborderofthescapula,passesthroughthesuprascapularnotchinferiortothesuperiortransversescapularligamentandentersthesupraspinousfossa.Itthenpassesbeneaththesupraspinatus,andcurvesaroundthelateralborderofthespineofthescapulatotheinfraspinousfossa.

Exampleofsonographicfindingatthemostdistalpointv