Paraplegia following intraoperative celiac plexus injection

The technique for percutaneous and open neurolytic celiac plexus injection, using ethanol or phenol, for relief of intractable pancreatic cancer pain has been well described. Prospective randomized studies, demonstrating safety and efficacy with few complications, have led to widespread acceptance and use of this palliative procedure. The complications of neurolytic celiac plexus injection are rare, and are usually minor. However, transient or permanent paraplegia has been reported previously in 10 cases. The case described herein represents the third reported case of permanent paraplegia following open intraoperative neurolytic celiac plexus injection using 50% ethanol. The literature surveying the indications for this procedure, routes of administration, known complications, and their pathophysiology are reviewed.     

不同病理类型的臂丛神经损伤后变性神经中S-100蛋白的变化

目的探讨不同病理类型的臂丛神经损伤后变性神经中Ｓ－１００蛋白的变化规律,为临床进行术中检测与判定提供理论依据,以进一步指导临床,提高臂丛神经损伤的诊治效果。方法建立ＳＤ大鼠不同病理类型的臂丛神经损伤,用免疫组织化学方法分别在损伤后１、２、３和６个月检测变性的远端神经中Ｓ－１００蛋白的分布和含量变化。结果Ｓ－１００蛋白主要沿轴突四周分布,节后组损伤１个月后Ｓ－１００蛋白呈阴性反应,而节前组术后６个月仍有阳性轴突。结论Ｓ－１００蛋白主要分布于雪旺细胞,节前与节后这两种不同病理类型的臂丛神经损伤中神经变性的程度不同,节前损伤远端神经在术后仍能持续保持Ｓ－１００蛋白阳性。     

全臂丛根性撕脱伤后神经移位联合早期股薄肌移植重建术

目的 探讨重建全臂丛根性撕脱伤后上肢主要功能的新方法。方法 8例全臂丛根性撕脱伤后2～4月一期行膈神经移位修复肩胛上神经,联合对侧股薄肌移植重建屈肘、伸指伸拇5例或屈拇屈指3例。前者其中2例二期再行同侧股薄肌移植重建屈拇屈指等。结果 一期手术1年以上5例,术后4～5月移植肌肉出现收缩,5～7月伸指伸拇或屈拇屈指、屈肘,12月屈肘60°～90°、肌力M_4,伸拇伸指或屈拇屈指M_3～M_4,肩外展30°～60°、M_3。二期手术的1例术后7月移植肌肉收缩,12月屈拇屈指M_4。重建屈拇屈指者可握持物品。结论 神经移位联合早期股薄肌移植,可在短时间内恢复全臂丛根性撕脱伤肢体的部分功能,初步重建手握持功能。     

同侧颈7神经根选择性束组移位术的临床应用

目的　证实同侧选择性颈 7神经根移位术治疗臂丛上干撕脱伤的科学性、可行性与实用性。方法　 1996年 3月至 1997年 2月 ,运用同侧颈 7神经根选择性束组移位术治疗臂丛根性撕脱伤 8例。其中 ,上干撕脱伤 7例 ,上干根性撕脱伤合并颈 7神经根部分损伤 1例。选择颈 7神经根前股或前股前外侧份行移位术 ,直接与上干前股作显微缝合。 5例术后随访 6个月 ,3例因时间短未统计在内。结果　 8例移位后同侧颈 7神经根支配的肌肉均未见明显的功能障碍。颈7神经根前股外侧份移位至上干前股的 5例 ,4例术后 4个月肱二头肌已恢复屈肘动作 ,疗效显著。 1例合并颈7神经根部分损伤患者的功能恢复欠佳。结论　同侧选择性颈 7神经根纤维束组移位 ,提供了治疗臂丛根性撕脱伤新的动力神经源 ,为一种切实可行的新手术方法     

Comparison of transarterial and multiple nerve stimulation techniques for axillary block using a high dose of mepivacaine with adrenaline

BACKGROUND: High-dose transarterial (TA) technique results in high effectiveness of the axillary block. The technique is fast and simple, but does not produce a satisfactory success rate when using the manufacturer's recommended dose of mepivacaine. The multiple nerve stimulation (MNS) technique requires more time and experience. This double-blind study compared effectiveness, safety and the time used to obtain an effective analgesia in 101 patients, having an axillary block by either TA or MNS techniques. METHODS: Mepivacaine with adrenaline (MEPA), 850 mg, was used for the initial block. Five millilitres of 1% solution was injected subcutaneously. In the TA group, 20 mL of 2% solution was injected deep to, and 20 mL superficial to the axillary artery. In the MNS group, four terminal motor nerves were electrolocated in the axilla, and injected with 10 mL each. Analgesia was assessed every 10 min and, when needed, supplemented after 30 min. The block was effective when analgesia was present in all sensory nerve areas distal to the elbow. RESULTS: The MNS group required median 11 min for block performance compared with 8 min for the TA group (P < 0.001). Latency of the initial block was shorter and the frequency of supplemental analgesia lower in the MNS group (median 10 min and 6%) than in the TA group (30 min and 36%, respectively), P < 0.001. All incomplete blocks were successfully supplemented. However, the total time to obtain an effective block was shorter in the MNS group (23 min) than in the TA group (37 min), P < 0.001. Two patients in each group had signs and symptoms of systemic toxicity, the most serious being atrial fibrillation and temporary loss of consciousness in a cardiovascularly medicated patient. The local adverse effects (intravascular injections and haematomas) were fewer in the MNS group, P < 0.001. CONCLUSION: The MNS technique of axillary block by four injections of 10 mL of 2% MEPA produces faster and more extensive block than the TA technique by two injections of 20 mL. Therefore, the MNS technique requires fewer supplementary blocks and results in faster patient readiness for surgery. However, high doses of MEPA may result in dangerous systemic toxic reactions.     

Ultrasound-guided combined intermediate and deep cervical plexus nerve block for regional anaesthesia in oral and maxillofacial surgery

Objectives:

We examined the application of an ultrasound-guided combined intermediate and deep cervical plexus nerve block for regional anaesthesia in patients undergoing oral and maxillofacial surgery.

Methods:

A total of 19 patients receiving ultrasound-guided combined intermediate and deep cervical plexus anaesthesia followed by neck surgery were examined prospectively. The sternocleidomastoid and the levator of the scapula muscles as well as the cervical transverse processes were used as easily depicted ultrasound landmarks for the injection of local anaesthetics. Under ultrasound guidance, a needle was advanced in the fascial band between the sternocleidomastoid and the levator of the scapula muscles and 15 ml of ropivacaine 0.75% was injected. Afterwards, the needle was advanced between the levator of the scapula and the hyperechoic contour of the cervical transverse processes and a further 15 ml of ropivacaine 0.75% was injected. The sensory block of the cervical nerve plexus, the analgesic efficacy of the block within 24 h after injection and potential block-related complications were assessed.

Results:

All patients showed a complete cervical plexus nerve block. No patient required analgesics within the first 24 h after anaesthesia. Two cases of blood aspiration were recorded. No further cervical plexus block-related complications were observed.

Conclusions:

Ultrasound-guided combined intermediate and deep cervical plexus block is a feasible, effective and safe method for oral and maxillofacial surgical procedures.     

臂丛区神经源性肿瘤的X线平片、CT及MRI表现（附5例报告）

报道５例臂丛神经源性肿瘤，主要描述其影像学表现。５例中，男性４例，女性１例，年龄３２岁～６６岁，临床症状无特殊。影像学检查方法包括胸部正、侧位片（ｎ＝４），颈椎平片（ｎ＝３），ＣＴ扫描（ｎ＝４）及ＭＲＩ检查（ｎ＝４）。病变位于右侧者４例，左侧１例，均经手术及病理证实，其中神经鞘瘤３例，神经纤维瘤２例。普通Ｘ线表现包括肺尖区肿块（ｎ＝３），椎间孔扩大（ｎ＝１）。ＣＴ所见：肿块呈梭形（ｎ＝２）或哑铃状（ｎ＝２），平扫密度与肌肉ＣＴ值相近，注射造影剂后肿块增强幅度高于肌肉。ＭＲＩ表现：Ｔ１加权像上肿瘤信号与肌肉相近３例，略低于肌肉信号１例；Ｔ２加权像显示病变均为高信号。初步结论：根据病变的分布及上述影像学表现，臂丛神经源性肿瘤可于手术前做出诊断。     

颈臂丛联合神经阻滞麻醉应用于锁骨骨折手术中的临床体会

目的探讨颈臂丛联合神经阻滞麻醉应用锁骨骨折手术中的临床效果。方法选取锁骨骨折手术患者115例,随机分为观察组和对照组。观察组采用颈臂丛联合阻滞麻醉,对照组采用颈浅丛神经阻滞麻醉。观察2组麻醉效果的优良率、心率、平均动脉压、氧饱和度以及不良反应。结果 2组患者心率与平均动脉压比较差异具有统计学意义P<0.01,氧饱和度比较差异无统计学意义P>0.05。观察组麻醉优良率明显高于对照组,x2=7.9367,P<0.05。2组患者麻醉后不良反应发生率比较,x2=0.2413,P>0.05。结论颈臂丛联合阻滞是一种较好的麻醉方法,、效果理想、并发症少,适合锁骨骨折手术推广使用。     

臂丛神经根性撕脱伤的治疗

神经移位术是治疗臂丛根性撕脱伤的主要方法。臂丛丛外移位神经包括肋间神经(Tsuyama1969)、副神经(Kotani1970)、颈丛运动支(Brunelli1977)、膈神经(顾玉东1970)、健侧颈7神经根(顾玉东1986)等。其中，健侧颈7根移位神经纤维数量最多，安全有效，已被国内外广泛应用。近年来，胸腔镜下超长切取膈神经，有效缩短了神经再生时间。对颈5、6根性撕脱伤，改良的Oberlin术式——臂丛丛内部分尺神经或正中神经移位修复肌皮神经肱二头肌支，手术简单，屈肘功能疗效肯定；同侧颈7根移位术有效且能恢复多组肌肉功能。对颈8胸1根性撕脱伤，肌皮神经肱肌肌支移位修复正中神经屈指肌束或骨间前神经以恢复屈指功能。对全臂丛根性撕脱伤，改良的Doi术式——双股薄肌移位联合神经移位较好恢复了手握持功能；肢体短缩，健侧颈7移位直接修复正中、尺神经，能恢复屈拇屈指功能，但手内肌功能仍无恢复。如何重建手内肌仍需作进一步探索。     

健侧C7移位至桡神经治疗全臂丛神经根性撕脱伤改良术的解剖学基础

目的寻求健侧C7神经根移位治疗全臂丛神经根性撕脱伤手术中尺神经与桡神经的最佳吻合部位。方法在10具20侧福尔马林固定的成人尸体上肢标本上观察桡神经及其肱三头肌肌支的解剖学特征;尺神经的解剖学特征;尺神经不同水平与对侧颈根部的距离。结果桡神经从后侧束发出部位到发出肱三头肌长头的第一支肌支之间的距离为(8.2±1.4)cm,从发出长头的第一个肌支部位到外侧头最后一个肌支发出部位之间的距离为(4.8±0.7)cm。尺神经肘部以上几乎无分支,尺神经在发出部位的直径为(6.7±0.6)mm;在肘部的直径为(6.3±0.5)mm;在腕部的直径为(4.0±0.4)mm;从锁骨下尺神经发出部位到肘部的长度为(29.0±2.6)cm;从锁骨下尺神经发出点到对侧颈根部的距离为(18.0±1.8)cm。结论健侧C7神经根移位修复桡神经,尺神经与桡神经的最佳吻合部位是锁骨下区,在此部位吻合不但能保证肱三头肌功能恢复,而且大大缩短桥接神经的长度。