超声引导下腰丛神经阻滞与骶管阻滞复合全麻在小儿髋关节手术中的比较

目的比较超声引导下腰丛神经阻滞与传统骶管阻滞复合全麻在小儿髋关节手术中的临床应用效果。方法择期行先天性髋关节手术患儿40例,年龄1~6岁,随机分为两组,分别采用超声引导下腰丛神经阻滞(L组)或骶管阻滞(C组)。两组均使用0.2%罗哌卡因1ml/kg。记录术中芬太尼的用量,术后CHEOPS疼痛评分,以及术后首次使用PCA的时间和PCA总量。记录术中低血压、心动过缓的发生率,拔除导尿管的时间以及术后恶心呕吐的发生率。结果 L组首次使用PCA时间明显晚于C组,PCA总量明显低于C组,拔除导尿管的时间明显早于C组(P0.05)。两组在术中芬太尼的用量,术后CHEOPS疼痛评分,术中低血压、心动过缓的发生率,术后恶心呕吐的发生率差异无统计学意义。结论超声引导下腰丛神经阻滞较骶管阻滞在小儿髋关节手术中镇痛时间更久,可安全有效地应用于临床。     

腰丛-坐骨神经联合阻滞用于老年患者下肢手术的临床研究

目的探讨腰丛-坐骨神经联合阻滞在老年患者下肢手术应用的可行性。方法40例60岁以上拟行单侧下肢手术的患者随机均分为两组。A组采用神经刺激器定位技术,正确定位腰丛和坐骨神经后分别给予0.375%罗哌卡因20～25ml和0.5%罗哌卡因15～20ml;B组选择L2～3或L3～4间隙行硬膜外麻醉,给予0.75%罗哌卡因10～15ml。观察两组血流动力学变化、阻滞效果及其不良反应。结果B组麻醉15min后各时点的SBP、DBP均明显低于麻醉前及A组(P<0.05或P<0.01);A组镇痛持续时间长于B组(P<0.05),但运动阻滞持续时间短于B组(P<0.05);B组术中使用麻黄碱的例数及输液量高于A组(P<0.05);B组患者围术期恶心、呕吐、尿潴留等不良反应的发生率明显高于A组(P<0.01)。结论腰丛-坐骨神经联合阻滞对血流动力学影响小,术后镇痛时间长,并发症少,适用于老年患者下肢手术。     

Three cases of reflex sympathetic dystrophy in the lower extremity treated with lumbar sympathetic ganglion block

Key words  reflex sympathetic dystrophy - lumbar sympathetic ganglion block - plantar core temperature     

腰段自主神经的解剖学研究及临床意义

目的 :描述腰段自主神经的解剖学特征,为前路腰椎手术提供详实的神经解剖学资料。方法 :取10具防腐男性胸腰骶部标本(年龄36～78岁,平均56岁)。仔细剔除腹腔器官及双侧腰大肌,找出腰段自主神经并去除周围软组织。观察腰段自主神经的走行、起始位置和分布特点。使用游标卡尺测量各腰内脏神经发出点与对应节段腰椎体下终板之间的距离,同侧相邻腰内脏神经发出点之间的距离,腰椎椎间孔前缘以及各腰椎间盘平面上左、右两侧腰交感干后缘分别与腰椎椎体前缘在矢状面上的距离,以及上腹下丛右侧缘在L5椎体下终板和S1椎体上终板平面上与中线的距离。使用量角器测量各腰内脏神经与水平面所成的夹角。结果:在10具标本上共发现72条腰内脏神经,其中58条起源于L3椎体下终板颅侧的腰交感干。第1、2、3、4腰内脏神经的发出点分别位于L1椎体下终板尾侧9.35±10.62mm,L2椎体下终板尾侧5.23±7.08mm,L3椎体下终板颅侧9.34±6.36mm及L4椎体下终板尾侧9.21±8.55mm。第3腰内脏神经与第1、2、4腰内脏神经发出点位置分布有差别(H=32.227,P=0.000),其余腰内脏神经发出点位置分布及左侧...     

腹腔镜下腰交感神经节切除术治疗血栓闭塞性脉管炎

目的 评价CT引导下腰交感神经节阻滞试验在筛选适合腰交感神经节切除术(LGS)的血栓闭塞性脉管炎(TAO)患者中的价值,及腹膜后腹腔镜下腰交感神经节切除术(LLGS)治疗TAO的疗效.方法 选择我院2003年4月～2010年1月期间,戒烟后症状不缓解的32例患者行腰交感神经节阻滞试验,采用LLGS治疗阻滞试验阳性的TAO患者17例.结果 阻滞试验阳性的17例筛选进行LLGS,术后病理证实切除组织为神经节组织.手术后24小时内,17例患者共19条下肢皮温明显升高,均大于2℃.本组病例未发生严重并发症,仅1例术中出现皮下气肿,经对症处理3天后完全恢复正常;1例术后病理报告淋巴结,且症状无缓解,故再次行LLGS.17例患者住院时间(11±10)天,随访时间(24.5±32)个月,17例患者皮温正常,无静息痛,无肢端坏疽,并能耐受一般轻体力劳动.结论 术前腰交感神经节阻滞试验有助于筛选适合进行LLGS的TAO患者;与传统LGS相比,LLGS具有术野清晰,定位准确,手术创伤小,恢复快,住院时间短等优势.     

股中远段局部组织氧饱和度评估腰丛阻滞后股神经支配区域阻滞效果

目的 观察单侧腰丛神经阻滞患者股神经支配区局部组织氧饱和度(regional oxygen saturation, rSO₂)变化与阻滞效果的关系,探讨rSO₂预测阻滞效果的准确性。
方法 选择择期单侧下肢手术患者31例,男14例,女17例,年龄18～80岁,ASA Ⅰ—Ⅲ级,根据是否阻滞成功将患者分为两组:阻滞成功组(n=26)和阻滞失败组(n=5)。腰丛阻滞后15 min内连续监测股神经支配的股中段及远段区域的rSO₂,与对侧肢体相同部位校正后,股中段和股远段分别记录为ΔrSO₂-M和ΔrSO₂-D,采用受试者工作特征(ROC)曲线分析rSO₂预测股神经阻滞效果的诊断临界值。
结果 腰丛阻滞后15 min内阻滞成功组ΔrSO₂-M和ΔrSO₂-D明显升高(P<0.05),阻滞失败组无明显变化。ΔrSO₂-M升高预测的曲线下面积(area under curve, AUC)明显高于ΔrSO₂ D和针刺试验。ΔrSO₂ M预测的最大曲线下面积为0.885 (95％CI 0.742～1.000),临界值取6.5时,灵敏度和特异度分别为69.2％和100.0％。阻滞后15 min,ΔrSO₂-M联合针刺试验预测的AUC、灵敏度和特异度分别为0.954 (95％CI 0.881～1.000)、88.5％和100.0％。
结论 rSO₂变化可用于预测腰丛阻滞后股神经支配区域是否阻滞成功。与针刺试验以及ΔrSO₂-D变化比较,ΔrSO₂-M升高预测的准确性更高。ΔrSO₂-M联合针刺试验可进一步提高其预测准确性。     

右美托咪定不同途径给药对罗哌卡因腰丛-坐骨神经联合阻滞效果的影响

目的 评价右美托咪定(dexmedetomidine,Dex)不同途径给药方式对0.375％罗哌卡因腰丛挫骨神经联合阻滞(combined lumber plexus and sciatic nerve block,CLPSNB)效果的影响. 方法 90例CLPSNB患者按随机数字表法分为3组(每组30例):罗哌卡因组(R组),0.375％罗哌卡因50 ml行CLPSNB;罗哌卡因+Dex静脉注射组(D+R组),静脉输注Dex 1 μg/kg(输注时间10 min)同时0.375％罗哌卡因50 ml行CLPSNB;罗哌卡因局部麻醉药液混合Dex组(DR组),局部麻醉药Dex 1 μg/kg+0.375％罗哌卡因至50 ml行CLPSNB.R组和DR组同时静脉输注与D+R组相同容量的生理盐水.记录感觉阻滞和运动阻滞的起效时间和维持时间、术者的满意情况及副作用发生情况. 结果 3组感觉阻滞和运动阻滞的起效时间差异无统计学意义(P＞0.05);运动阻滞持续时间和首次使用镇痛药的时间DR组[(768±246) min和(1 080±300) min]、D+R组[(732±204) min和(1 050±288) min]显著长于R组[(420±126) min和(840±306) min] (P＜0.05);感觉阻滞持续时间DR组[(1008±258) min]显著长于R组[(624±216) min]、D+R组[(672±144) min](P＜0.05),而R组与D+R组比较,差异无统计学意义(P＞0.05).术者满意率DR组(100％)高于R组(85％)(P＜0.05).3组患者均未出现恶心、呕吐、低血压、呼吸抑制等副作用. 结论 Dex混合于0.375％罗哌卡因行CLPSNB麻醉效果及术者满意度佳.     

Thoracic herniation after lumbar spine fusion

We report on a 65-year-old male patient with rapid onset of incomplete paraparesis, based on a massive thoracic herniation following adjacent instability of the thoracolumbar spine after lumbar fusions with transpedicular instrumentation.     

Contrast radiography and effects of thoracic sympathetic ganglion block

Thoracic sympathetic ganglion block is less effective than lumbar sympathetic ganglion block due to differences in the anatomical structure of these regions. Contrast radiographic findings and an analysis of the effects of lumbar sympathetic ganglion block have been reported, but there are few reports concerning thoracic sympathetic ganglion block. The relationship between contrast radiography findings and the effects of thoracic sympathetic ganglion block were studied in 131 block procedures which mainly had hyperhidrosis.(Ohseto K: Contrast radiography and effects of thoracic sympathetic ganglion block. J Anesth 5: 132–141, 1991)     

Combined neurolytic block of celiac, inferior mesenteric, and superior hypogastric plexuses for incapacitating abdominal and/or pelvic cancer pain

Thirty-five patients with extensive abdominal or pelvic cancer who suffered uncontrolled, diffuse, extensive, and incapacitating pain were treated with a combination of neurolytic celiac plexus block (CPB), inferior mesenteric plexus block (IMPB), and superior hypogastric plexus block (SHGPB). The combination of neurolytic CPB, IMPB, and SHGPB was performed with alcohol, mainly using a transintervetebral disc approach. The combination neurolysis produced effective immediate pain relief in all the patients (visual analog scale (VAS), reduced from 8.8 ± 0.2 to 0). This pain relief persisted during the first 3 months (VAS, 2.3 ± 0.5) or until death. Morphine consumption was significantly decreased for the first 1 month (from 96 ± 29 mg to 31 ± 10 mg per day) after the neurolysis and thereafter continued to be lower than before the surgery, though not significantly so. No serious complications were observed to have been caused by the neurolytic procedure on the three sympathetic plexuses. Our preliminary clinical results suggest that the combination of neurolytic CPB, IMPB, and SHGPB improves the quality of life of patients who have incapacitating cancer pain, by reducing both the intensity of the pain and their opioid consumption, without serious complications. This combination procedure may provide a new therapeutic option for pain relief in patients with advanced cancer.     

不同浓度罗比卡因腰丛联合坐骨神经阻滞用于膝关节镜手术的比较

目的观察一定剂量的罗比卡因配成不同浓度溶液用于腰丛联合坐骨神经阻滞在膝关节镜手术的麻醉效果比较.方法40例拟行单侧膝关节镜手术患者随机分为A、B两组,每组20例,均在神经刺激仪定位下行腰丛联合坐骨神经阻滞,在腰丛神经和坐骨神经处均分别注入罗比卡因150 mg.A组将150 mg罗比卡因稀释到20 ml使用,即浓度为0.75%;B组稀释到30 ml,即浓度为0.5%.观察患者感觉和运动阻滞起效时间及维持时间,以及麻醉满意程度.结果两组患者感觉阻滞维持时间差异无显著性（P＞0.05）,感觉及运动阻滞起效时间A组比B组明显缩短（P＜0.05）,而运动阻滞维持时间A组明显延长（P＜0.05）,麻醉满意度B组明显优于A组（P＜0.05）.结论A组麻醉比B组起效快,但只运动阻滞时间明显延长,且麻醉满意度较差.所以在相同剂量的情况下,用0.5%的罗比卡因比用0.75%的罗比卡因行腰丛联合坐骨神经阻滞更适合于膝关节镜手术.     

腰丛的解剖及其在腰椎前外侧入路微创手术中的临床意义

目的 了解腰丛在腰椎前外侧入路微创手术中的应用解剖学特点.方法 通过15具成人腰椎标本、2具腰段的断层图片和3个数字人腰段数据集,观察腰丛的走行及其与腰大肌及腰椎横突的关系.结果 L2-5腰丛在腰椎侧方的组成具有一定的规律性,正面按从外到内的顺序排列,侧面按从腹侧到背侧的方向排列.腰神经出椎间孔的角度从L1到L5逐渐增加.横突与腰丛的关系紧密.断层解剖显示,腰丛在不同节段始终位于腰大肌的后1/3,因此在切开腰大肌暴露腰椎时,切开位置不宜超过腰大肌的后1/3,腰大肌的前2/3是切开安全区.结论 暴露腰椎侧前方切开腰大肌时,注意不要超过腰大肌的前2/3,以避免腰丛的损伤.横突可以作为手术中的解剖学标志,用以明确腰丛的解剖位置,避免术中腰丛损伤.     

Successfully-treated asymptomatic celiac artery aneurysm: A case report

BackgroundCeliac artery aneurysm is a rare vascular lesion. It is frequently discovered after rupture, which leads to death in most cases. We present a case of an asymptomatic celiac artery aneurysm discovered in a 72-year-old female during an evaluation for high grade fever and general fatigue.Case presentationThe patient visited our department with complaints of fever and general fatigue. The patient’s medical history included type 2 diabetes mellitus with poor control and hypertension. Blood culture and urine culture that were submitted at arrival presented E. Coli. Then, she was diagnosed with bacteremia by urinary tract infection. Transesophageal echocardiography revealed no vegetation at her valves. Computed tomography was performed for investigating her urological abnormalities, revealing a 28 × 30 mm aneurysm at the trunk of the celiac artery. Blood and urine cultures submitted at arrival were positive for E. coli. Surgical repair performed after the improvement of her urinary tract infection revealed a non-infective aneurysm; thus, aneurysm closure and prosthetic grafting were conducted.ConclusionClinician awareness regarding this rare entity and discovery efforts to discover the splanchnic aneurysm before rupturing are imperative.     

神经刺激器定位腰丛-坐骨神经联合阻滞在老年人下肢手术的应用

目的探讨神经刺激器定位下行腰丛-坐骨神经联合阻滞在老年人下肢手术中的应用,以硬膜外麻醉作对照,观察其对老年病人血流动力学的影响和术后的不良反应。方法60例拟行单侧下肢手术的老年病人,随机分为腰丛-坐骨神经联合阻滞（NER）和硬膜外麻醉（EPI）。记录麻醉前,麻醉开始后15、30、45、60min,术后1h的收缩压（SBP）、舒张压（DBP）和心率（HR）,以及感觉、运动神经阻滞起效及恢复时间、镇痛维持时间、效果。结果麻醉开始后15min。EPI组病人DBP降低明显,随后30、45、60min及术后1hEPI组病人的SBP、DBP均明显低于NER组;NER组感觉、运动神经阻滞起效时间均小于EPI组,恢复时间明显长于EPI组。结论神经刺激器定位下行腰丛-坐骨神经联合阻滞,成功率高,血流动力学平稳,并发症少,起效迅速,镇痛时间长,是老年病人进行单侧下肢手术较好的麻醉方法。     

A comparison of intraoperative celiac plexus block with pharmacological therapy as a treatment for pain of unresectable pancreatic cancer

Background/Purpose: The efficacy of intraoperative celiac plexus block was compared with that of pharmacological therapy in the treatment of pain caused by unresectable pancreatic cancer. Methods: Twenty-one patients were included in the study: 15 patients underwent intraoperative celiac plexus block (group 1) and 6 received pharmacological therapy (group 2). The effectiveness at 1 week after treatment and from treatment to death was evaluated at follow-up by looking at mean analgesic consumption, mortality and morbidity, and any postoperative complications. Statistical analysis was performed using unpaired t-tests. Results: One week after the operation, the analgesic consumption of 14 patients in group 1 was the same as that before treatment, and 1 patient's consumption had decreased. Pain in 4 patients in group 2 did not change, but in 2 patients it increased. Mean opioid consumption was significantly lower in group 1. Complications related to the block were transient diarrhea and hypotension (P not significant between groups). There was no operative mortality or major complication related to the block. The incidence of adverse drug-related effects, such as constipation, nausea, and vomiting, was significantly lower in group 1 than in group 2. Conclusions: Intraoperative celiac plexus block made pain control possible with reduced opioid consumption, representing an effective, safe, and simple tool for the treatment of pain caused by unresectable pancreatic cancer. Received: November 16, 2001 / accepted: February 28, 2002     

Thoracic paravertebral block: a method of pain control

The adverse effects of pain on acutely ill or traumatized patients are well documented. A variety of pain-relieving techniques are now available to meet the varied requirements for pain relief. This paper presents the results of a single, large-volume injection of bupivacaine 0.5% in the thoracic paravertebral space, achieving pain relief over several thoracic dermatomes in patients with respiratory compromise secondary to thoracic or upper abdominal injury. The block proved quick and simple to perform, with excellent clinical results of long duration and virtually no complications. Although not previously described, this single, large-volume injection approach to achieving an extensive thoracic paravertebral block may well become an important pain management technique in appropriate patients.