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。     

压力囊泡指示器指导硬膜外穿刺的效果

目的 评价压力囊泡指示器指导硬膜外穿刺的效果.方法 试验Ⅰ:拟行硬膜外穿刺的患者32例,常规硬膜外穿刺成功后,穿刺针针尾连接压力传感器,测定硬膜外间隙压力.试验Ⅱ:拟行硬膜外穿刺的患者70例,应用压力囊泡指示器指导硬膜外穿刺.囊泡瘪掉后暂停穿刺,依据传统临床指征判断穿刺针是否到达硬膜外腔.记录压力囊泡指示器指导硬膜外穿刺成功情况.结果 硬膜外间隙压力为(10±4)cm H2O;完成压力囊泡指示器指导硬膜外穿刺患者70例,均符合操作要求,并经临床证实穿刺成功,成功率100%.结论 压力囊泡指示器可辅助硬膜外穿刺,准确判断穿刺针尖到达硬膜外间隙,具有临床应用价值.     

B超监测下经小关节突内缘穿刺注射胶原酶治疗腰椎间盘突出症

目的：探讨胶原酶治疗腰椎间盘突出症的超声监测下小关节突内缘穿刺注射技术。方法：对适合侧隐窝穿刺的316例患者，在B超监测引导下，将胶原酶准确注射到椎间盘处或突出物处。结果：共穿刺348个椎间盘，其中LA／5椎间盘183个，穿刺成功率95．1％；L5／S1椎问盘165个，穿刺成功率100％。结论：B超监测下的小关节突内缘穿刺技术定位准确、操作简便。     

马尾神经根松弛症1例

患者男性，60岁。因腰及双下肢疼痛10年，加重伴间歇性跛行1年，于1995年5月28日入院。曾诊断为“坐骨神经痛”，治疗无效。查体见平腰状，下腰段压痛、放射痛、传导叩击痛（＋），双下肢肌肉萎缩，双足底、小腿外侧感觉减退，长伸肌Ⅲ-，双下肢直腿抬高试验30°。CT示L4-5、L5-S1间盘向后突入椎管内，压迫硬膜囊及神经根。以“腰椎间盘突出症”手术治疗。切除L5椎板，见椎管内脂肪消失，局部硬膜囊膨隆，张力大，无搏动，且硬膜囊壁菲薄、透明，可见其囊内的神经根。常规摘除突出的L4-5、L5-S1髓核。切开硬膜囊，无脑脊液流出，局部神…     

胶原酶溶核治疗腰椎间盘突出症的穿刺方法比较

目的比较注射胶原酶治疗腰椎间盘突出症的两种穿刺方法．方法将140例患者随机分为两组．每组70人。A组经骶裂孔硬膜囊前间隙入路．B组经小关节内侧缘入路到侧隐窝。两组患者均注入胶原酶1200U：结果两种不同穿刺方法注射胶原酶治疗腰椎间盘突出症的疗效及不良反应均无统计学差异。结论经小关节内侧缘到侧隐窝路径短．但解制复杂．操作技术有难度。经骶裂孔硬膜囊前间隙法路径长．穿剌及解剖并不复杂。是操作简单有效的方法。     

改良腰大肌间隙阻滞法

作者介绍改良腰大肌间隙阻滞法30例。具体方法为患者侧卧,患肢在上,在L4～5间隙旁开2.5～3.5cm处作为穿刺点。以硬膜外穿刺针垂直进针,抵L5横突后向头端滑过L5横突,于L5上关节突外侧进针约0.5     

硬膜外神经阻滞麻醉致蛛网膜炎1例

1病例报告患者,男,56岁,于2012-6-22以"腰椎间盘突出症"入院,于L4-L5椎间隙小关节内缘行"硬膜外神经阻滞麻醉",注入2%利多卡因注射液5 ml加曲安奈德注射液2 ml(国药准字H33020762)及生理盐水3 ml配成的混合液10 ml。麻醉后第3天出现右侧小腿后外侧蚁爬、麻木感,大腿及小腿后外侧放射痛,足背伸肌力4级,生理     

人体腰段硬膜下蛛网膜外间隙的解剖学研究

1975年Boys和Norman描述了一种硬膜外麻醉并发症—无意中刺入硬膜下蛛网膜外间隙。自那以后,另外几位作者也作了类似报告。1977年Mehta和Maher有意思的作了治疗性的硬膜下穿刺。1985年Mehta报道了一组由训练有素的麻醉医师操作的100例硬膜外穿刺,放射学证实有7例穿刺针部分位于硬膜下。因此认为即使有经验的麻醉者在硬膜外穿刺时也可能刺入硬膜下间隙。作者对15例尸检的病例用脊柱镜作了腰段硬膜下蛛网膜外间隙的观察研究。方法.本组15例,47～83岁,男11.女4.首先将18号Tuohy穿刺针经直入法(1例用旁正中法)置入L3—4硬膜外腔(经注气阻力消失证实)。然后借助套针和针鞘经L2—3间隙(两例碰到困难,     

两种穿刺途径行臭氧髓核消融术治疗L5S1椎间盘突出症56例临床观察

臭氧髓核消融术在腰椎间盘突出症得到广泛应用,而穿刺技术是影响本病疗效的重要环节。L5S1椎间隙由于受髂骨的阻挡,针尖不易达到理想的位置。2007-2009年间,我们采取小关节突内缘和侧后方入路两种穿刺途径治疗L5S1椎间盘突出症56例,分析如下。     

微创经椎间孔腰椎椎间融合术的应用解剖学研究

目的:探讨微创经椎间孔腰椎椎间融合(TLIF)术的解剖要点及手术方法.方法:在40套正常腰椎MRI片上测量与TUF手术人路相关的解剖学参数,包括:手术切口旁开中线距离(m)、手术路径长度(n)、手术通道倾斜角(α).根据测量结果在5具人尸体标本上模拟微创通道下TLIF,切除上下关节突后显露硬膜囊及上位出口神经根,用卡尺测量硬膜囊边缘以外的椎间盘宽度(a)及神经根下缘到人字缝顶点的距离(b).结果:手术切口距中线距离为3.78±1.38cm,手术通道内倾斜角平均15.8°±3.3°,不同腰椎节段无统计学差异(P＞0.05).手术路径长度为5.89±2.14cm(4.98～7.62cm).在多裂肌和最长肌之间存在疏松软组织肌肉间隙,通过该间隙可以比较容易地将微创通道放置到小关节突附近.在微创通道下切除小关节突进入椎间孔获得的"矩形区域"可显露椎间盘的有效宽度分别为:L3/4 11.3±3.1mm,L4/5 13.1±2.6mm,L5/S1 14.1±3.8mm:各腰椎上位出口神经根下缘与同节段腰椎人字缝的距离分别为:L3/4 17.7±3.5mm,L4/5 16.7±3.8mm,L5/S1 15.6±4.0mm.结论:在椎膀肌存在一个天然的组织间隙,可以很容易将工作管道放置到小关节附近,在上下小关节下方有一个安全的椎间盘"矩形区域",在该区域内切除椎间盘和置人融合器时不需牵拉硬膜囊和神经根.     

Prepuncture ultrasound-measured distance: an accurate reflection of epidural depth in infants and small children

BACKGROUND AND OBJECTIVES: Epidural cannulation is technically difficult in children who have small anatomic structures. Ultrasound information regarding the distance of skin-to-ligament flavum may be useful, leading to an increase in success rate without dural puncture. This study was performed to assess whether ultrasound-measured, skin-to-ligament flavum distance would reflect the needle depth during epidural puncture in infants and children. METHODS: The study compromised 180 children, aged 2 to 84 months, undergoing urologic surgery. After induction of anesthesia, ultrasound images of the longitudinal median and transverse views were acquired from L4-L5 in lateral decubitus position. Measured distance of skin-to-ligament flavum in each view was compared with the perpendicular skin-to-epidural depth, which was obtained from needle depth and angle by use of a trigonometric ratio equation. Additionally, we evaluated the ultrasound visibility of the ligament flavum and dura mater, number of puncture attempts, and complications. RESULTS: The correlation coefficient between measured distance and perpendicular epidural depth was slightly higher in longitudinal median view (R2 = 0.848) than in transverse view (R2 = 0.788). The visibility of ligament flavum and dura mater was "good" in 91 and 170 of 180 patients, respectively, and "sufficient" in the remaining subjects. The epidural space was located on first puncture attempt in 179 of 180 cases (99.4%). No incidents of dural puncture or bloody tap occurred. CONCLUSIONS: Ultrasound, particularly in the longitudinal median view, provides accurate information on the distance of skin-to-ligament flavum in infants and children. With reference to the measured distance, epidural puncture can be performed with minimal risk of dural puncture (upper limit of 95% CI = 1.67%).     

骶管加基础麻醉用于小儿肛瘘手术

探讨骶管加基础麻醉用于小儿肛瘘手术效果,并与硬膜外加基础麻醉比较。将40例肛瘘随机分为两组：骶管加基础麻醉（A组）和硬膜外加基础麻醉（B组）。每组20例,分别记录麻醉前、基础麻醉后、骶管和硬膜外阻滞后血压（BP）、血氧饱和度（SpO2）和脉率（P）。结果短示,两组各项指标无明显差异。B组有2例行硬膜外穿刺时穿透硬脊膜．改行全身麻醉。结果表明,骶管麻醉和硬膜外麻醉用于小儿肛瘘手术麻醉效果及对生命体征的影响无差异．骶管麻醉操作简便,穿透硬脊膜的危险相对较小。     

Extradural extrusion of roots of the cauda equina.

For lumbar spondylotic stenosis causing progressive disability, multiple laminectomy was about to be completed. Suddenly roots of the cauda equina herniated through the myelography puncture site in the dura mater, resembling redundant nerve roots. This case is being reported not only because such sudden extradural extrusion is rare, but also to raise the question of the relationship of redundancy of nerve roots to spondylotic stenosis.     

Structural changes in implanted cardiac valvular bioprostheses constructed of glycerol-treated human dura mater

Histological, scanning and transmission electron microscope studies were made of normal human dura mater and cardiac valvular bioprostheses made of glycerol-treated human dura mater recovered after having been implanted in the aortic position (8 patients) or the mitral position (1 patient) for periods up to 4 years. Human dura mater has two layers: an inner or meningeal layer and an outer or endosteal layer. The surface of the inner layer is smoother than that of the outer layer. Both layers are composed mainly of large, wavy collagen fibrils (which are thought to correspond to type I collagen) and are relatively poor in elastic fibers and proteoglycans. Small calcific deposits were found in normal dura from older patients. Changes occurring in dura mater bioprostheses within 2 days after implantation consisted mainly of small surface thrombi. Calcific nodules, degenerated collagen and evidence of penetration of erythrocytes and plasma proteins into the cusps were observed in bioprostheses that had failed after being in place for 1-4 years. The calcific deposits and the degenerated collagen appeared structurally similar to those in glutaraldehyde-treated porcine aortic valvular bioprostheses. However, collagen fibrils in the latter were smaller than those in dura mater. Platelet aggregates on the cuspal surfaces were much less numerous in dura mater bioprostheses than in porcine aortic valvular bioprostheses. It is postulated that this difference is a function of the size of the collagen fibrils in the bioprostheses and that this accounts for the very low incidence of clinically evident thromboembolism in patients with implanted dura mater valves.     

Effectiveness of epidural blood patch in the management of post-dural puncture headache

BACKGROUND: Lumbar epidural blood patch (EBP) is a common treatment of post-dural puncture headache, but its effectiveness and mode of action remain a matter of debate. The aim of this study was to assess both the effectiveness and the predictive factors of failure of EBP on severe post-dural puncture headache. METHODS: This prospective observational study includes all patients treated in the authors' hospital with EBP for incapacitating post-dural puncture headache, from 1988 to 2000. The EBP effect was classified into complete relief (disappearance of all symptoms), incomplete relief of symptoms (clinically improved patients who recovered sufficiently to perform normal daily activity), and failure (persistence of severe symptoms). The following data were analyzed using a logistic regression to identify predictive factors of failure of EBP: (1) patient characteristics; (2) circumstances of dural puncture; (3) delay between dural puncture and EBP; and (4) the volume of blood injected for EBP. RESULTS: A total of 504 patients were analyzed. The frequency rates of complete relief, incomplete relief of symptoms, and failure after EBP were 75% (n = 377), 18% (n = 93), and 7% (n = 34), respectively. In a multivariate analysis, only the diameter of the needle used to perform dura mater puncture (odds ratio = 5.96; 95% confidence interval, 2.63-13.47; P < 0.001) and a delay in EBP less than 4 days (odds ratio = 2.63; 95% confidence interval, 1.06-6.51; P = 0.037) were independent significant risk factors for a failure of EBP. CONCLUSIONS: Epidural blood patch is an effective treatment of severe post-dural puncture headache. Its effectiveness is decreased if dura mater puncture is caused by a large bore needle.     

Incidence of accidental dura mater punctures in a university hospital: a prospective observational study

ObjectiveAccidental dura mater puncture is a potential complication during epidural block, and may be associated with multiple factors. Our objective was to determine the prevalence and risk factors of accidental dural puncture in a university hospital, evaluating the differences in the number of complications during different working hours.Material and methodsA prospective observational study was conducted on all women who requested regional anaesthesia in the Epidural Analgesia Unit between 1 January 2009 and 1 January 2011, and who fulfilled the inclusion criteria. The technique employed to control labour pains was epidural analgesia.ResultsA total of 12,480 pregnant women were included. The prevalence of accidental dura mater puncture was 0.4% (50 patients). Of these, 28% were due to medical residents. More accidental dura mater punctures were observed during September and in the afternoon shift.ConclusionsThe prevalence of accidental dura mater puncture is similar to other patient series. In ours, tiredness or lack of sleep did not influence the incidence of complications in analgesia for labour pains in a 24 hour care unit. This may be due to the distribution of on-call shifts not exceeding more than 6 hours.     

Lumbar discogram resulting from lumbar interlaminar epidural injection

Lumbar discography is a diagnostic modality to determine whether the intervertebral disc is the cause of pain. The injection of radiopaque contrast into the nucleus pulposus of the disc can reveal the internal details of the disc. We describe a case of inadvertent lumbar discogram resulting from an attempted lumbar interlaminar epidural injection at L5-S1 under fluoroscopy. The patient did not have a postdural puncture headache or nerve root irritation. The potential triangle in the lateral aspect of spinal cord may be the explanation for this situation, because this triangle is composed of the exiting nerve root laterally, the lateral margin of the dura medially, and the pedicle as its base. The L5-S1 disc is located in the center of the triangle. In our case, the Tuohy needle was placed possibly in the center of the triangle, too laterally to puncture the dura. Hence, the patient did not suffer from postdural puncture headache. The needle was probably inferior to the nerve root, and no obvious nerve root trauma or irritation occurred. This potential triangle may provide alternative access for lumbar discography at the L5-S1 level.     

Lumbar neuraxial anatomical changes throughout pregnancy: a longitudinal study using serial ultrasound scans

This observational study was designed to investigate the anatomical changes of the lumbar spine over the course of pregnancy using serial ultrasound scans. We performed paramedian scans on 58 women at the L2–3, L3–4 and L4–5 levels; these were done at four periods of 11+0–13+6, 19+0–23+0, 28+0–32+0 and 38+0–40+0 weeks gestation. At each intervertebral level, the length of the interlaminar space, length of the visible intervertebral posterior dura and depth of the posterior dura mater from the skin were measured. The length of the interlaminar space and length of the visible intervertebral posterior dura mater were longer, and the depth of the posterior dura mater was shallower, with ascending spinal interspace. The depth of the posterior dura mater increased during pregnancy, although it plateaued between the third and fourth measurement periods. The other spinal measurements were not affected by gestation. These findings indicate that the L2–3 level is the most appropriate puncture site for epidural anaesthesia in pregnant women. Our results ought to be embraced as a departure point towards developing neuraxial insertion techniques guided or aided by ultrasound.     

Orientation of fibers in human dorsal lumbar dura mater in relation to lumbar puncture

Longitudinal insertion of a lumbar puncture needle bevel is less likely to cause post-lumbar puncture headache than is transverse insertion. The reason for this has not been entirely clear. We investigated the direction of dural fibers in posterior L3-4 dura mater obtained from three autopsies and tallied it in three orthogonal planes. Under low-power light microscopy the tissue appeared to be composed of lamellae branching irregularly and directed concentrically to the spinal cord. Electron micrographs (x5000) revealed that the lamellae consisted mainly of bundles of collagen fibers that pursued wavy courses in various directions. The lamellae also contained branching elastic fibers, many of which were directed longitudinally. This arrangement of fibers probably minimizes the tendency of a dural puncture hole to gape under tension if the needle bevel is directed longitudinally.     

Spontaneous bilateral extradural hematomas. Case report

Spontaneous extradural hematomas are rare and may be caused by pericranial infections, bleeding tendencies, or vascular abnormalities of the dura mater. The authors describe a case of spontaneous bilateral extradural hematomas assumed to be caused by a bleeding tendency with hypofibrinogenemia. A brief review of the literature is reported.