摘要
目的应用高频超声追寻观察及神经刺激器辅助定位,观察腋窝胸大肌外侧缘处,臂丛各分支神经的超声解剖学特征,为超声引导下腋入路臂丛神经阻滞的实施提供超声解剖学基础。方法选择2015年12月至2017年3月于北京积水潭医院手外科就诊并拟于腋入路臂丛神经阻滞麻醉下行上肢手术的患者333例,所有阻滞均在超声引导联合神经刺激器定位下实施。将超声探头置于腋窝近端垂直肢体长轴放置,采集胸大肌外侧缘与肱二头肌交汇处的横断面图像,通过近远端移动超声探头追寻明确各组织结构的位置及形态;使用神经刺激器分别定位并记录各分支神经的位置;记录腋动脉上缘距离皮肤深度及腋鞘内静脉数量。结果腋窝处臂丛神经分支可呈现为圆形、椭圆形或扁平状高回声或低回声结构。333例患者中胸大肌外侧缘处正中神经主要分布在腋动脉的前外侧紧邻肱二头肌走行(250例,75.1%),尺神经主要分布在腋动脉的前内侧(306例,91.9%),桡神经主要分布在腋动脉的后内侧走行于肱三头肌表面(299例,89.8%),正中、尺、桡神经总是按顺时针顺序分布。大部分情况下肌皮神经位于腋鞘外(254例,76.3%),部分患者位于腋鞘内(71例,21.3%),并与正中神经伴行,有8例患者在此处未找到明确的肌皮神经结构。163例(48.9%)患者可在尺神经的尺侧视及一细小神经,该神经可能为前臂内侧皮神经。333例患者中,腋鞘内静脉数量为1~4条,腋动脉上缘距离皮肤深度为(0.7±0.3)cm。结论腋窝胸大肌外侧缘处,正中神经、尺神经和桡神经在腋鞘内围绕腋动脉按顺时针方向排列分布,其相对于腋动脉位置存在高度解剖变异,在尺神经附近部分患者可视及前臂内侧皮神经位于腋鞘内,肌皮神经在腋鞘内外均有分布,腋动脉周围有多条静脉伴行。
Objective To observe the anatomical characteristics of the main nerve branches of the brachial plexus using high-frequency ultrasound and neurostimulator to assist in localization at the lateral border of the pectoralis major muscle,to provide anatomical basis for ultrasound guided axillary brachial plexus block.Methods A total of 333 patients receiving upper limb surgeries under brachial plexus block through axillary approach in Beijing Jishuitan Hospital from Dec.2015 to Mar.2017 were enrolled in this study.All nerve blocks were performed under ultrasound-guidance combined with nerve stimulator.The ultrasound probe was placed vertical to upper limb long axis,and the cross-sectional ultrasonic images were collected at the junction of the lateral border of the pectoralis major and the biceps.The position and shape of each tissue structure were collected by moving ultrasonic probe through the near and far end.A nerve stimulator was used to locate and identify each nerve;the depth of the upper margin of the axillary artery and the number of axillary veins in the sheath were recorded.Results The branches of the brachial plexus in the armpits might appear as round,elliptical,or flat hyperechoic or hypoechoic structures.The median nerve was mainly distributed in the anterolateral of the axillary artery and adjacent to biceps brachii(250 cases,75.1%).The ulnar nerve was mainly distributed in the anteromedial side of the radial artery(306 cases,91.9%).The radial nerve was mainly distributed posteromedially to the axillary artery on the surface of the triceps brachii(299 cases,89.8%).The relative positions of the three nerves were fixed:the medial,ulnar and radial nerves were arranged clockwise.Most of the musculocutaneous nerves were located outside the axillary sheath(254 cases,76.3%),and some located in the axillary sheath(71 cases,21.3%),often accompanied by median nerve,however there were still 8 patients whose musculocutaneous nerve could not be observed at this position.A small nerve might be noticed on the ulnar
作者
郑媛芳
郗扬
周雁
种皓
李文军
ZHENG Yuanfang;XI Yang;ZHOU Yan;CHONG Hao;LI Wenjun(Department of Anesthesiology,Beijing Jishuitan Hospital,Beijing 100035,China;Department of Hand Surgery,Beijing Jishuitan Hospital,Beijing 100035,China)
出处
《医学综述》
2019年第23期4600-4606,共7页
Medical Recapitulate
基金
北京市属医院科研培育计划项目(PX2018017)
关键词
臂丛神经阻滞
超声引导
神经刺激
解剖
Brachial plexus block
Ultrasound guidance
Nerve stimulation
Anatomy
