Sonographic appearance of a schwannoma mimicking an axillary lymphadenopathy

Schwannomas are benign nerve sheath tumors derived from Schwann cells and are the most common type of peripheral nerve tumor. Schwannomas occur mainly in the extremities, trunk, and head and are rarely manifested in the axilla. Although various solid tumors can develop in the axilla, only a few cases of schwannoma in the axillary cavity have been reported. Herein, we describe the sonographic appearance of a schwannoma arising from the brachial plexus in the axilla.     

超声引导和传统解剖定位在臂丛神经阻滞的应用效果比较

目的比较超声引导和传统解剖定位行肌间沟联合腋路臂丛神经阻滞麻醉的临床效果。方法选择臂丛麻醉下行上肢手术的患者70例,随机均分为2组,各35例。对照组应用传统解剖定位下肌间沟联合腋路臂丛神经阻滞麻醉,观察组应用超声引导下肌间沟联合腋路臂丛神经阻滞麻醉,比较两组麻醉效果和不良反应。结果观察组患者在麻醉完成时间、起效时间比对照组短,观察组阻滞效果比对照组好,并发症发生率也更低,差异有统计学意义(P<0.05)。结论与传统解剖定位臂丛神经阻滞麻醉相比,超声引导定位臂丛神经阻滞麻醉具有操作简单,定位准确,可视下能够避开患者血管和周围重要组织,提高臂丛神经阻滞麻醉的安全性和成功率,减少麻醉不良反应及并发症,简单易学,增加患者的舒适性,具有较高的应用价值,值得临床推广应用。     

臂丛神经联合阻滞与单纯肌间沟阻滞在手部断指再植手术中的效果对比

目的比较手部断指行再植手术采用肌间沟联合腋路臂丛神经实施阻滞同单纯实施肌间沟阻滞的临床效果。方法 90例行断指再植术患者随机分为A、B、C三组,A组(30例)实施肌间沟臂丛神经阻滞,B组(30例)实施腋路臂丛神经阻滞,C组(30例)实施肌间沟联合腋路臂丛神经阻滞。对患者的感觉阻滞情况及麻醉效果进行评价。结果 C组感觉阻滞起效时间为3.44±1.36min,明显短于A组(3.82±1.91min)和B组(5.25±1.52min)(P<0.05)。C组麻醉效果为100%,明显优于A组的90.0%和B组的93.3%(P<0.05)。结论断指再植术采用肌间沟联合腋路臂丛神经实施阻滞,阻滞和麻醉效果显著,值得推广应用。     

Bilateral brachial plexus home going catheters after digital amputation for patient with upper extremity digital gangrene

Peripheral nerve catheter placement is used to control surgical pain. Performing bilateral brachial plexus block with catheters is not frequently performed; and in our case sending patient home with bilateral brachial plexus catheters has not been reported up to our knowledge. Our patient is a 57 years old male patient presented with bilateral upper extremity digital gangrene on digits 2 through 4 on both sides with no thumb involvement. The plan was to do the surgery under sequential axillary blocks. On the day of surgery a right axillary brachial plexus block was performed under ultrasound guidance using 20 ml of 0.75% ropivacaine. Patient was taken to the OR and the right fingers amputation was carried out under mild sedation without problems. Left axillary brachial plexus block was then done as the surgeon was closing the right side, two hours after the first block was performed. The left axillary block was done also under ultrasound using 20 ml of 2% mepivacaine. The brachial plexus blocks were performed in a sequential manner. Surgery was unremarkable, and patient was transferred to post anesthetic care unit in stable condition. Over that first postoperative night, the patient complained of severe pain at the surgical sites with minimal pain relief with parentral opioids. We placed bilateral brachial plexus catheters (right axillary and left infra-clavicular brachial plexus catheters). Ropivacaine 0.2% infusion was started at 7 ml per hour basal rate only with no boluses on each side. The patient was discharged home with the catheters in place after receiving the appropriate education. On discharge both catheters were connected to a single ON-Q (I-flow Corporation, Lake Forest, CA) ball pump with a 750 ml reservoir using a Y connection and were set to deliver a fixed rate of 7 ml for each catheter. The brachial plexus catheters were removed by the patient on day 5 after surgery without any difficulty. Patient's postoperative course was otherwise unremarkable. We concluded that home going catheters are very effective in pain control postoperatively and they shorten the period of hospital stay. KEYWORDS: Brachial plexus; Home going catheters; Post-operative pain.     

经腋路臂丛置管治疗儿童手外伤的护理

目的:探讨使用低浓度罗哌卡因经腋路臂丛置管治疗儿童手外伤的优点及护理方法。方法:对2011年1～12月我科收治的5例经腋路臂丛置管治疗儿童手外伤的患儿进行术后护理及观察。结果:本组患儿术后镇痛效果满意,患儿均可有效配合治疗及护理,术后无血管神经损伤,无术后并发症发生。结论:经腋路臂丛置管的优点是术后镇痛效果佳,提高了患儿对治疗及护理的依从性,减少并发症的发生。     

The brachial plexus

The brachial plexus arises from the lower cervical and upper thoracic spinal nerve roots. It courses between the anterior and middle scalene muscles and adjacent to the subclavian artery. The brachial plexus may be visualized by both MRI and CT. Symptoms of a brachial plexopathy commonly are nonlocalizing. Traumatic injuries and involvement by tumors probably account for the majority of etiologies responsible for these plexopathies. Inflammatory processes also involve the brachial plexus. This article reviews the anatomy of the brachial plexus from both surgical and radiographic approaches and also addresses the symptomatology of brachial plexopathy underlying it.     

The use of train of four monitoring for clinical evaluation of the axillary brachial plexus block

The axillary approach of brachial plexus anesthesia is the most commonly used technique for forearm and hand surgery. Dynamometer is known as objective test for the clinical assessment of motor block of the nerves in brachial plexus block. However, the use of this device may not always be practical in operating room. The train-of-four (TOF) test is a non-invasive peripheral nerve stimulator that shows the level of motor block of muscle relaxants. The aim of the study is to investigate the use of TOF testing as a peripheral nerve stimulator for objective clinical evaluation of motor block at axillary brachial plexus block. 44 patients were randomized according to the development of partial or complete motor in the axillary brachial plexus block. The nerves were selectively localized by nerve stimulation and ultrasound guidance. After obtaining an appropriate peripheral motor response, predetermined volumes of bupivacaine were selectively injected to the 4 nerves. Sensory, motor block levels and TOF values were measured at 10th, 20th, 30th minutes immediately after the axillary brachial plexus block. TOF values were gradually decreased and significant difference was observed between the development of a complete and partial motor block at 30th minute. TOF values were also significantly less in patients of complete sensory block than the patients of partial sensory block at 30th minute. The use of TOF monitoring may be beneficial to assess the objective clinical effect of motor block in the patients with axillary brachial plexus nerve block.     

超声引导下与神经刺激器联合超声引导下腋路臂丛神经阻滞在下肘部位手术患者麻醉中应用比较

[目的]比较神经刺激器联合超声引导及单纯超声引导行腋路臂丛神经阻滞在下肘部位手术患者麻醉中的应用效果.[方法]60例下肘部手术患者,随机分为观察组和对照组,各30例.对照组给予超声引导下腋路臂丛神经阻滞方案,观察组则予以神经刺激器联合超声引导下腋路臂丛神经阻滞方案.比较两组受试者操作时间、相关神经阻滞的起效时间、神经阻滞持续时间及0.5 h内阻滞成功率、一次性穿刺成功率差异及相关并发症发生情况.[结果]观察组0.5 h内臂丛神经阻滞总成功率显著高于对照组(100.0%vs 86.7%),相关并发症发生率则显著低于对照组(6.7%vs 26.7%),且差异均有显著性(P均<0.05).观察组平均操作时间及桡神经、尺神经、正中神经、肌皮神经等阻滞起效时间均显著低于对照组,神经阻滞持续时间则明显长于对照组(P均<0.05);两组一次性穿刺成功率比较差异无显著性(P>0.05).[结论]对下肘部位手术患者予以神经刺激器联合超声引导下腋路臂丛神经阻滞方案,利于提高其定位准确性及臂丛神经阻滞成功率,对降低其手术相关并发症发生风险、延长其神经阻滞持续时间等具有积极影响.     

Prolonged blocking of the brachial plexus by axillary approach in children

Surgical interventions were carried out under combined total anesthesia with prolonged blocking of the brachial plexus via axillary approach in 40 children aged 4-14 years with surgical diseases of the arms. Prolonged axillary blockade maintained adequate analgesia in the lower third of the brachial bone, ulnar joint, forearm, and hand for 24-48 h. The proposed protocols of lidocaine and bupivacaine infusion into the axillary space of the brachial plexus caused no toxic reactions in children of this age group. The method can be used in children during and after surgery.     

臂丛神经的超声解剖学研究

目的 应用超声研究臂丛神经解剖学特点,为超声引导臂丛神经阻滞提供解剖学依据.方法 应用高频超声研究24例健康人臂丛神经在腋路和肌间沟的解剖分布特点.结果 24例健康人臂丛神经完全显示.臂丛神经在腋路主要沿腋动脉走行;在肌间沟水平,臂丛神经分布于前、中斜角肌组成的肌间沟内.结论 超声能清晰显示臂丛神经各个主要分支.     

Axillary brachial plexus block--an underused technique in the accident and emergency department.

OBJECTIVE: To compare axillary brachial plexus block and Bier's block as methods of providing upper limb anaesthesia. METHODS: Axillary brachial plexus or Bier's blocks were performed on all patients requiring upper limb anaesthesia in a three month period. For Bier's block, a single cuff tourniquet and 3 mg/kg 0.5% prilocaine were used. For axillary plexus block, 40 ml 1% lignocaine with adrenaline (1:200,000) were used, given by perivascular or transarterial technique. Prospective analysis was made of time to complete limb anaesthesia, type of procedure performed, and duration of limb anaesthesia. Patient perception of analgesia and satisfaction with the method of anaesthesia was assessed using a 10 point visual analogue scale. RESULTS: 75 patients underwent procedures requiring upper limb anaesthesia; 39 received axillary plexus block and 36 Bier's block. 72% of Bier's blocks and 77% of axillary plexus provided complete anaesthesia without the need for supplemental analgesia. The median time to onset of anaesthesia was 10 min for Bier's block and 32.5 min for axillary block (P < 0.001). The median duration of anaesthesia was 15 min for Bier's block and 240 min for axillary block (P < 0.001). Mean scores for analgesia were 9.7 for axillary blocks and 8.8 for Bier's block (P < 0.001). 87% of the axillary block group were completely satisfied with the method of anaesthesia, compared with 56% of the Bier's block group. CONCLUSIONS: Brachial plexus blocks are an alternative form of providing upper limb anaesthesia in the accident and emergency department. They are relatively simple to perform, well tolerated by patients, and have the advantage of providing prolonged analgesia without the need for additional medication.     

高频超声在正常臂丛神经检查中的应用

目的 探讨高频超声显示臂丛神经的可行性及方法学。方法 用高频超声检查12例正常人臂丛神经，确认其与周围组织解剖定位关系。结果 正常臂丛神经长轴显示多条线性平行回声，短轴呈圆形中等回声，内有点状弱回声，斜角肌间隙、锁骨下动脉和颈深动脉是检查中的重要标志，C5-7显示率100％（12／12例），C8、T1显示率83．3％（10／12例）。结论 高频超声可为臂丛神经的形态学观察提供新的影像检查方法。     

分娩性臂丛神经损伤后患肢主要动脉的彩色多普勒超声观察

目的 探讨彩声多普勒超声观察分娩性臂丛神经损伤后患肢主要动脉的管径和血流速度变化,为临床观测患儿上肢发育状况提供一定的参考价值.方法 对31例分娩性臂丛神经损伤患儿进行彩色多普勒超声检查,测量腋动脉、肱动脉管径及血流峰值速度,并行患、健侧对比.结果 患侧腋动脉和肱动脉管径较健侧细,腋动脉平均管径患侧为(0.22±0.0...     

Brachial plexus anesthesia for outpatient surgical procedures on an upper extremity

We retrospectively reviewed 543 brachial plexus blocks performed on 526 outpatients. Most (98%) of the blocks were performed by means of the axillary approach. Various techniques were used, including paresthesia, transarterial fixation, nerve stimulation, or a combination of techniques; a high success rate was achieved with each of them. Only 7% of the blocks were incomplete and thus necessitated either general anesthesia or block supplementation with thiopental sodium and nitrous oxide. No persistent neurologic deficit was ascribed to the anesthetic technique. This review indicates that brachial plexus block, especially with use of the axillary approach, is a safe and effective option for outpatient surgical procedures on an upper extremity.     

腋窝入路桡神经肱三头肌支转位移植修复腋神经的应用解剖

背景:上臂后上切口入路肱三头肌肌支转位移植修复腋神经牵拉三角肌时易损伤腋神经后支及锁骨上臂丛,探查和联合其他神经转位时需变更体位.目的:分析腋窝入路桡神经肱三头肌支转位移植修复腋神经的可行性.方法:取常规甲醛固定成人上肢标本10具20侧,于标本平卧,上肢外展外旋位,腋窝入路,对腋窝处神经血管进行显微解剖.测量腋神经起始处至分支处距离及其分支起始处的横径,肱三头肌各肌支起始处横径,各肌支由入肌点向近端进行无损伤分离长度.结果与结论:腋神经肩胛下肌下缘分成前后两支,前支横径平均为2.5(1.6~3.4) mm.桡神经肱三头肌长头支,起点处横径为2.2(1.4-2.8) mm.桡神经与腋神经距离平均为18.2(10.2~30.0) mm.腋神经前支与桡神经肱三头肌支横径相似,距离短.表明腋窝入路可暴露和辨别腋神经前后分支,桡神经肱三头肌支在背阔肌腱表面水平靠近腋神经,可选择任一肌支转位移植修复腋神经.     

高频超声对臂丛神经显像和定位的价值

目的评价高频超声对臂丛神经显像和定位的价值。方法采用高频超声对30例志愿者行臂丛神经检查，主要在肌间沟、锁骨上、锁骨下及腋下4个部位。11例志愿者臂丛分布的4个部位上，在实时超声引导下进针及定位神经，然后在电神经器刺激下确认是否为神经。所有臂丛神经声像图特征、解剖的变化、进针和神经定位均被动态记录。结果臂丛神经在横断面上表现为圆形或椭圆形的低回声结构，内部由点状回声组成，肌间沟、锁骨上及腋下臂丛神经显示率均为100％，锁骨下臂丛神经显示率为97％。11例志愿者臂丛声像图上低回声结构在超声引导下行电刺激均被证实为神经组织。结论高频超声能提供高质量的臂丛神经声像图。超声引导下穿刺对臂丛神经阻滞麻醉有潜在应用价值。     

连续臂丛神经阻滞治疗上肢带状疱疹后遗神经痛的临床分析

目的探讨连续臂丛神经阻滞治疗上肢带状疱疹后遗神经痛的临床效果。方法回顾性分析自2008～2011年68例进行连续臂丛神经阻滞治疗上肢带状疱疹后遗神经痛患者的临床资料,对比同期行口服药物、外用药物及针灸理疗(保守治疗)的患者。结果治疗后重新进行疼痛视觉模拟评分并综合评估,连续臂丛治疗组的治疗优良率为92.4%,对比的保守治疗组的治疗优良率为79.0%,两组优良率差异具有统计学差异(P<0.05)。臂丛组治疗后共出现不良反应例数22例,其主要不良反应为患区后遗症状,如痒感,蚁行感和牵拉或紧束感仍然存在,19例患者均能够耐受,并在治疗后1个月内缓解。3例患者在天气骤变后出现暂时性疼痛加重,气温升高后缓解。保守治疗组治疗后共出现不良反应例数9例,其中恶心、呕吐4例,复视、视物模糊3例,晕针现象2例,均于停药及停止针炙治疗后好转。结论连续臂丛阻滞在治疗带状疱疹后遗神经痛较传统的药物和理疗具有治疗效果确切,镇痛完全的特点,可成为治疗带状疱疹后遗神经痛的重要临床治疗手段。     

甲磺酸罗哌卡因在腋路远端臂丛神经阻滞显微手外科中的应用效果观察

目的观察0.5%甲磺酸罗哌卡因和0.375%左旋布比卡因行腋路远端臂丛神经阻滞的效果。方法 50例手外科肘部以下手术患者,分为观察组和对照组各25例,观察组给予0.5%甲磺酸罗哌卡因,对照组给予0.375%左旋布比卡因,两组均采用相同麻醉方法。比较两组患者麻醉效果评级、感觉和运动阻滞完善时间及消退时间、不良反应情况。结果两组患者麻醉效果评级比较,差异无统计学意义(P>0.05);感觉阻滞完善时间及消退时间观察组明显长于对照组,差异有显著统计学意义(P<0.01);运动阻滞完善时间及消退时间观察组明显短于对照组,差异有统计学意义(P<0.05)。两组均未发生蛛网膜下腔或硬膜外阻滞、喉返神经或膈神经阻滞、霍纳综合征、气胸、局麻药中毒等并发症。结论 0.5%甲磺酸罗哌卡因的麻醉效果优于0.375%左旋布比卡因,更适合较长时间手术的显微手外科手术患者。     

肌内效贴对新生儿上干型分娩性臂丛神经损伤的疗效分析

目的：评价肌内效贴治疗新生儿上干型分娩性臂丛神经损伤的临床疗效,为其临床治疗提供部分参考依据。方法：新生儿上干型分娩性臂丛神经损伤的患儿22例,随机分为肌贴组和对照组各11例,对照组进行常规康复治疗,肌贴组在常规康复治疗的基础上增加并全程接受肌内效贴治疗。2组分别在治疗前后测试臂丛功能综合评价、粗大运动功能测试A区(GMFM-A)评分以及神经肌电图检测腋神经、肌皮神经、正中神经的复合动作电位波幅值。结果：2组患儿在治疗3个月后,测试结果均优于治疗前测试结果(P<0.05)。治疗3个月后,肌贴组患儿臂丛功能综合评价、GMFM-A得分优于对照组(P<0.05)。肌贴组的肌电图检查显示腋神经、肌皮神经、正中神经的复合肌肉动作电位波幅明显高于对照组(P<0.05)。结论：肌内效贴对新生儿上干型分娩性臂丛神经损伤的上肢功能的恢复有良好的效果,有一定的临床借鉴意义。     

Fentanyl branchial plexus block for paediatric postoperative analgesia

The aim of this study was to evaluate axillary injection of fentanyl into the brachial plexus using the axillary approach. Twenty-six patients, aged 2 to 11 years (ASA I and II), undergoing upper limb surgery, participated in the study. They were divided into two groups: Group 1 (n=15) received 2 μg kg⁻¹ fentanyl and Group 2 (n=11) received saline only. All patients received inhalational general anaesthesia. The interval between onset of anaesthesia and pain was 809 minutes for Group 1 and 199 minutes for Group 2.