颈段硬膜外腔侧隐窝穿刺置管进路的研究和应用

目的 研究能将药物更直接集中注射到颈段硬膜囊前间隙或／和侧隐窝的穿刺置管进路。方法 颈椎钩状突外缘与关节柱内缘重叠且均与小人缘在同一矢状面上，因此测量钩状突外缘间距便可得知小关节内缘间距，我们测量结果为23－25mm（C5－6－7水平），平均24mm；选择病变间隙的下1－2个间隙的下位棘突为穿刺水平。旁开距离为测得的该小关节内缘间距除以2，再减去2mm。用16G硬膜外穿刺针，经进针点垂直皮面进针，直到左侧椎板，稍退针2mm，改朝头端45－60度角进针，使穿刺针勺状面背侧紧贴左侧椎板及其上缘滑入小关节内缘，遇到韧性阻力为黄韧带，一旦消失，有落空感，为突破黄韧带进入侧隐窝。选择45例颈椎间盘突出症病人，利用该进路进行溶盘治疗。其中10例病人经造影观察了导管的位置和造影剂的分布。结果 45例病人治疗效果满意。10例造影病人，造影剂均集中分布在患侧侧隐窝或／和硬膜囊前间隙。结论 经颈椎小关节内缘穿刺置管可将药物集中注入硬膜外腔侧隐窝或／和硬膜囊前间隙，更好地发挥治疗作用，减少不良反应。     

Microcatheterization of the cervical epidural space via lumbar puncture: technical note

OBJECTIVE: Deposition of opiates, corticosteroids, or local anesthetics into the epidural space is useful for the management of painful maladies of the cervical and thoracic spine. We describe a novel technique for epidural medication delivery via an angiographic microcatheter inserted at or below the conus and advanced cephalad under fluoroscopic guidance. Unlike commercial kits used by anesthesiologists, this method uses a radiopaque catheter that can be precisely targeted to the levels of interest. The hazards of direct puncture, such as "wet tap" or injury to the cervical cord, are minimized. METHODS: An 18-gauge Tuohy needle is inserted into the lumbar epidural space. A 2.3-French microcatheter and a 0.018-inch steerable guidewire are then introduced through the lumen of the needle. The catheter is fluoroscopically advanced to the cervical epidural space, where Depo-Medrol (Pharmacia & Upjohn, Kalamazoo, MI) is administered. As the catheter is withdrawn, additional corticosteroid can be delivered to the thoracic epidural space, together with long-acting morphine compounds or local anesthetics. Regional pressures within the epidural space and other physiological parameters can be measured, and the local microenvironment can be sampled. RESULTS: To date, we have performed 16 procedures for 13 patients. All patients reported improvement, of varying extent and duration. There have been no complications. CONCLUSION: Our system of accessing the epidural space has many advantages, compared with direct puncture and commercially available kits. It provides a safe means of delivering epidural medication to multiple spinal levels and permits measurement of physiological variables that may be useful in the diagnosis and treatment of cervical and thoracic spine disease.     

The distance from the skin to the epidural space

To determine whether there is any systemic relationship between the distance from the skin to the epidural space and physical constitution, the distance from the skin to the epidural space was measured in 1007 epidural punctures. The distance from the skin to the epidural space in male was greater than that in female (P 0.001). However, the analysis of the distance from the skin to the epidural space of the selected patients who had both a weight of 50–60kg and a height of 1.5–1.7m indicated no statistical difference between male and female. The best correlation was found between the distance from the skin to the epidural space and body weight. The correlation between the distance from the skin to the epidural space and height was less striking. Ninety-five percent of the patients who received epidural puncture at the thoraco-cervical area (C7-T2) had a distance to the epidural space of 4.0–6.9cm; 87% at the lower-thoracic area (T8–T10), 4.0–6.9cm; 93% at the thoraco-lumbar area (T12-L2), 3.0–4.9cm; 85% at the mid-lumbar area (L2–L4), 3.0–4.9cm. These results may be useful for young anesthesiologists to master epidural block safely and efficiently.(Hirabayashi Y, Matsuda I, Inoue S et al.: The distance from the skin to the epidural space. J Anesth 2: 198–201, 1988)     

Anatomy of the epidural space

Despite the importance of anatomical knowledge in the safe and effective conduct of thoraco-lumbar epidural anaesthesia there are widespread misunderstandings about the detailed anatomy of this complex region. Current textbooks and teaching continue to propagate misleading information.     

The morphology and clinical significance of the dorsal meningovertebra ligaments in the cervical epidural space

Background contextThe dural sac is anchored within the vertebral canal by connective tissue called meningovertebral ligaments in the epidural space. During flavectomy and laminectomy, inadvertent disruption of the dorsal meningovertebral ligaments may lead to dura laceration and cerebrospinal fluid (CSF) leaks. All the described dorsal meningovertebral ligaments were located in the lumbar region. A rare study is available about dorsal meningovertebral ligaments of the cervical spinal dura to the adjacent vertebrae.PurposeTo identify and describe the dorsal meningovertebral ligaments at each cervical level and discuss their clinical significance.Study designA dissection-based study of 22 embalmed cadavers.MethodsThe anatomy was studied in 22 whole cervical cadavers (11 females, 11males), prepared with formaldehyde, whose ages at the time of death ranged from 55 to 78 years. The vertebral canal was divided to expose the dural sac and the spinal nerve roots. At all levels of the cervical vertebra, the morphology, quantity, origin, insertion, and spatial orientation of the dorsal meningovertebral ligaments were determined and the length, width or diameter, and thickness of the ligaments were measured with vernier calipers.ResultsThe dorsal meningovertebral ligaments in the cervical region anchored the posterior dural sac to the ligamentum flavum or laminae. The number of attachment points on the ligamentum flavum was relatively larger than that on the lamina, and the occurrence rate of dorsal meningovertebral ligaments was 100% at C1–C2 and C4––C5. The thickest ligaments were observed at the C1 and C2 vertebrae. The length of the ligaments varied from 1.50 to 35.22 mm, and the orientation of the ligaments mostly was craniocaudal. The morphology of the dorsal meningovertebral ligaments was divided into four types: strip type, cord type, grid type, and thin slice type.ConclusionsIn the cervical spine, the dorsal meningovertebral ligaments exist between the posterior dural sac and the ligamentum flavum or lamina. The dorsal meningovertebral ligaments may be of clinical importance to surgeons. Dissecting the dorsal meningovertebral ligaments before the cervical flavectomy and laminectomy may be an important step in reducing postoperative dura laceration and CSF leaks, which may result in significant benefits for patients and health-care organizations.