隐神经穿出收肌管定位在超声引导下收肌管阻滞中的应用
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摘要
目的回顾临床病例资料,并从尸体解剖的角度探讨收肌管阻滞(adductor canal block,ACB)的最佳位置。方法临床部分:回顾性分析接受超声引导下ACB患者19例,男11例,女8例,年龄21~85岁,ASAⅠ~Ⅲ级。其中9例在大腿中段水平,10例在收肌管下口水平,均注射0.5%罗哌卡因10 ml,比较注射后30 min及术后24 h小腿内侧对冰块的温度觉。解剖部分:纳入尸体20具,共40条下肢,男性20条,女性20条。测量髂前上棘至胫骨内侧髁、髂前上棘至收肌管上口、髂前上棘至收肌管下口、髂前上棘至隐神经穿出大收肌腱膜处的距离,记录收肌管的长度、收肌管在下肢的相对位置、隐神经穿出收肌管的位点等数据。结果临床部分:19例均在注射后30 min失去对冰块的温度觉,并在术后24 h恢复。解剖部分:隐神经均在收肌管内向下走行并于近收肌管末端处穿出,与膝降动脉的隐神经支伴行。收肌管长度约为(10.0±2.1)cm。收肌管上口、下口、隐神经穿出收肌管的位置分别为缝匠肌全长的(54.7±3.0)%、(76.0%±3.8)%、(74.1±3.2)%。结论在收肌管下口水平和大腿中段水平进行超声引导下ACB均可以获得满意的隐神经阻滞效果。ACB的最佳位点应为缝匠肌的约中下1/3处。超声引导下在膝降动脉旁注射局麻药可能成为隐神经阻滞的一个新方法。
Objective To study clinical data retrospectively and demonstrate the optimal injection site of adductor canal block by performing a cadaveric study. Methods Clinical part: clinical data from 19 patients,11 males and 8 females,aged 21-85 years,ASA physical status Ⅰ-Ⅲ,who received ultrasoundguided adductor canal block were retrospectively collected. Among whom 9 received a mid-distance injection of 10 ml of 0. 5% ropivacaine and 10 received an injection of the same medication at the outlet of adductor canal. The primary endpoint was complete absence of cold sensation to ice cube on the medial side of calf at30 minutes and 24 hours after injection. Cadaveric part: 40 lower limbs,20 males and 20 females,were finally analyzed in the study. The distances from the anterior superior iliac spine( ASIS) to the medial tibial condyle,from ASIS to the entrance of the adductor canal,from ASIS to the exit of the canal( adductor tendinous opening),from ASIS to the site where saphenous nerve emerges through the aponeurotic covering were measured respectively. The length of adductor canal,the relative location of adductor canal and the site where saphenous nerve pierces in the lower limbs were calculated. Results Clinical part: all 19 cases were successfully recorded with complete absence of cold sensation at 30 minutes after injection of local anesthetic and complete sensory recovery at 24 hours after injection. Cadaveric part: in all specimens,saphenous nerve enters adductor canal and coursed down until emerging at very close to the distal end of the canal with the saphenous branch of descending genicular artery. The length of the adductor canal was( 10. 0 ±2. 1) cm. The entrance and the exit of adductor canal and the emerging site of the saphenous nerve locatedalong the( 54. 7 ± 3. 0) %,( 76. 0% ± 3. 8) % and( 74. 1 ± 3. 2) % of sartorius muscle,respectively.Conclusion Performing ultrasound-guided adductor canal block at either the outlet of adductor canal or mid-distance of thigh can achieve comparable blockade of saphenous nerve. Cadaveric study implicated that the optimal injection site for adductor canal block should be the lower one-third of sartorius muscle. Ultrasound-guided injection of local anesthetics next to the descending genicular artery may possibly become a promising new method of saphenous nerve block.
Objective To study clinical data retrospectively and demonstrate the optimal injection site of adductor canal block by performing a cadaveric study. Methods Clinical part: clinical data from 19 patients,11 males and 8 females,aged 21-85 years,ASA physical status Ⅰ-Ⅲ,who received ultrasoundguided adductor canal block were retrospectively collected. Among whom 9 received a mid-distance injection of 10 ml of 0. 5% ropivacaine and 10 received an injection of the same medication at the outlet of adductor canal. The primary endpoint was complete absence of cold sensation to ice cube on the medial side of calf at30 minutes and 24 hours after injection. Cadaveric part: 40 lower limbs,20 males and 20 females,were finally analyzed in the study. The distances from the anterior superior iliac spine( ASIS) to the medial tibial condyle,from ASIS to the entrance of the adductor canal,from ASIS to the exit of the canal( adductor tendinous opening),from ASIS to the site where saphenous nerve emerges through the aponeurotic covering were measured respectively. The length of adductor canal,the relative location of adductor canal and the site where saphenous nerve pierces in the lower limbs were calculated. Results Clinical part: all 19 cases were successfully recorded with complete absence of cold sensation at 30 minutes after injection of local anesthetic and complete sensory recovery at 24 hours after injection. Cadaveric part: in all specimens,saphenous nerve enters adductor canal and coursed down until emerging at very close to the distal end of the canal with the saphenous branch of descending genicular artery. The length of the adductor canal was( 10. 0 ±2. 1) cm. The entrance and the exit of adductor canal and the emerging site of the saphenous nerve locatedalong the( 54. 7 ± 3. 0) %,( 76. 0% ± 3. 8) % and( 74. 1 ± 3. 2) % of sartorius muscle,respectively.Conclusion Performing ultrasound-guided adductor canal block at either the outlet of adductor canal or mid-distance of thigh can achieve comparable blockade of saphenous nerve. Cadaveric study implicated that the optimal injection site for adductor canal block should be the lower one-third of sartorius muscle. Ultrasound-guided injection of local anesthetics next to the descending genicular artery may possibly become a promising new method of saphenous nerve block.
引文
[1]Espelund M,Fomsgaard JS,Haraszuk J,et al.Analgesic efficacy of ultrasound-guided adductor canal blockade after arthroscopic anterior cruciate ligament reconstruction:a randomised controlled trial.Eur J Anaesthesiol,2013,30(7):422-428.
[2]Jenstrup MT,Jaeger P,Lund J,et al.Effects of adductor-canalblockade on pain and ambulation after total knee arthroplasty:a randomized study.Acta Anaesthesiol Scand,2012,56(3):357-364.
[3]Grevstad U,Mathiesen O,Valentiner LS,et al.Effect of adductor canal block versus femoral nerve block on quadriceps strength,mobilization,and pain after total knee arthroplasty:a randomized,blinded study.Reg Anesth Pain Med,2015,40(1):3-10.
[4]Burckett-St Laurant D,Peng P,Girón Arango L,et al.The nerves of the adductor canal and the innervation of the knee:an anatomic study.Reg Anesth Pain Med,2016,41(3):321-327.
[5]Anagnostopoulou S,Anagnostis G,Saranteas T,et al.Saphenous and infrapatellar nerves at the adductor canal:anatomy and implications in regional anesthesia.Orthopedics,2016,39(2):e259-e262.
[6]Jaeger P,Nielsen ZJ,Henningsen MH,et al.Adductor canal block versus femoral nerve block and quadriceps strength:a randomized,double-blind,placebo-controlled,crossover study in healthy volunteers.Anesthesiology,2013,118(2):409-415.
[7]Standring S.Gray's Anatomy:The anatomical basis of clinical practice,41st ed.Edinburgh:Churchill Livingstone,2015:1399.
[8]孙水林,陈玲珑,陈宪福,等.隐神经收肌管段的应用解剖.中国临床解剖学杂志,1992,10(2):100-102.
[2]Jenstrup MT,Jaeger P,Lund J,et al.Effects of adductor-canalblockade on pain and ambulation after total knee arthroplasty:a randomized study.Acta Anaesthesiol Scand,2012,56(3):357-364.
[3]Grevstad U,Mathiesen O,Valentiner LS,et al.Effect of adductor canal block versus femoral nerve block on quadriceps strength,mobilization,and pain after total knee arthroplasty:a randomized,blinded study.Reg Anesth Pain Med,2015,40(1):3-10.
[4]Burckett-St Laurant D,Peng P,Girón Arango L,et al.The nerves of the adductor canal and the innervation of the knee:an anatomic study.Reg Anesth Pain Med,2016,41(3):321-327.
[5]Anagnostopoulou S,Anagnostis G,Saranteas T,et al.Saphenous and infrapatellar nerves at the adductor canal:anatomy and implications in regional anesthesia.Orthopedics,2016,39(2):e259-e262.
[6]Jaeger P,Nielsen ZJ,Henningsen MH,et al.Adductor canal block versus femoral nerve block and quadriceps strength:a randomized,double-blind,placebo-controlled,crossover study in healthy volunteers.Anesthesiology,2013,118(2):409-415.
[7]Standring S.Gray's Anatomy:The anatomical basis of clinical practice,41st ed.Edinburgh:Churchill Livingstone,2015:1399.
[8]孙水林,陈玲珑,陈宪福,等.隐神经收肌管段的应用解剖.中国临床解剖学杂志,1992,10(2):100-102.