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1、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
2、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,The long thoracic nerve,The long thoracic nerve (external respiratory nerve of Bell; posterior thoracic nerve) supplies the serratus anterior muscl
3、e. This nerve characteristically arises from the anterior rami of three spinal nerve roots: the fifth, sixth, and seventh cervical nerves (C5-C7) although the root from C7 may be absent. The roots from C5 and C6 pierce through the scalenus medius, while the C7 root passes in front of the muscle.,The
4、 nerve descends through the cervicoaxillary canal behind (posterior to) the brachial plexus and the axillary artery and vein, resting on the outer surface of the serratus anterior. It extends along the side of the thorax to the lower border of that muscle, supplying filaments to each of its digitati
5、ons (finger-like projections,LTN was clearly visible in all anatomical specimens and volunteers using HRUS and could be followed until the second slip of the serratus anterior muscle from the supraclavicular region. In anatomical specimens, dissection confirmed,HRUS findings. For all volunteers, con
6、sensus was obtained. The mean nerve diameter was 1.6mm 0.3 (range 1.1 2.1mm) after the formation of the main trunk.,Fig. 2 a Example of sonographic finding of the LTN within the interscalene triangle in ventromedial transverse view (Abbreviations used: C5-C8 = cervical roots, ScA = anterior scalene
7、muscle, SM=middle scalene muscle, SP = posterior scalene muscle); b Example of sonographic finding at the most distal point visible from the supraclavicular region (Abbreviations used: OM= omohyoid muscle, SA = Serratus anterior muscle, SSN = suprascapular nerve).,Fig. 3 a Example of finding in diss
8、ections after marking of the LTN (white arrow) at proximal site (also showing union of C5 and C6 cervical roots) (Abbreviation used: PS = posterior scalene muscle); b Example of finding in dissections after marking of the LTN (white arrow) at the most distal point visible from the supraclavicular re
9、gion (Abbreviations used: MS=middle scalene muscle, PS = posterior scalene muscle).,肩胛背神经,The dorsal scapular nerve arises from the brachial plexus, usually from the plexus root (anterior/ventral ramus) of C5.It provides motor innervation to the rhomboid muscles, which pull the scapula towards the s
10、pine and levator scapulae muscle, which elevates the scapula.Injury to this nerve is usually apparent when the scapula on one side is located farther from the midline.,Once the nerve leaves C5 it commonly pierces the middle scalene muscle, and continues deep to levator scapulae and the rhomboids. It
11、 is accompanied by one of two arteries: either the dorsal scapular artery (the only artery that comes off the third part of the subclavian, although its origin is highly variable in different people) or, when the dorsal scapular artery is absent, the deep branch of the transverse cervical artery (an
12、 artery coming off the thyrocervical trunk, a branch of the first part of the subclavian artery, the other two branches being vertebral artery and internal thoracic artery).,The patient underwent general anesthesia during the3.5-hour case, then was brought to the recovery room awakewith a pain score
13、 of 2 on an 11-point scale. The patient hadfull motor function of her ipsilateral arm in the postoperativeperiod.She was transferred to the short-stay unit, but 14 hours after the initial nerve block she experienced significant intractable pain, rated at 10/10.,At the patients request, a continuous
14、nerve block catheter was placed adjacent to the dorsal scapular nerve. An infusion of 4 mL/hr + 2 mL bolus every 30 minutes was started. The patient experienced almost immediate relief of her pain after placement of the continuous nerve block. She was discharged home on postoperative day (POD) 1 aft
15、er this block placement.,Selective blockade of the dorsal scapular nerve,Selective blockade of the dorsal scapular nerve,Selective blockade of the dorsal scapular nerve,平面内肌间沟阻滞 注意？,肩胛上神经,The suprascapular nerve arises from the upper trunk of the brachial plexus which is formed by the union of the v
16、entral rami of the fifth and sixth cervical nerves. After branching from the upper trunk, the nerve passes across the posterior triangle of the neck parallel to the inferior belly of the omohyoid muscle and deep to the trapezius muscle.,It then runs along the superior border of the scapula, passes through the suprascapular notch inferior to the superior transverse scapular ligament and enters the supraspinous fossa. It then passes beneath the supraspinatus, and curves around the lateral border of the spine of the scapula to the infraspinous fossa.,
