股神经、髂筋膜、隐神经 PPT

超声引导髂筋膜阻滞的方法
腹股沟韧带下法
寻找缝匠肌和髂肌 药液扩散：缝匠肌和髂肌之间 阻滞：股神经、股外侧皮神经？
超声引导髂筋膜阻滞
腹股沟韧带上法
Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-GuidedSuprainguinal Fascia Iliaca Technique ProvidesBenefit as an Analgesic Adjunct forPatients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433–438
不影响股四头肌力量
局麻药：低浓度， 5~10ml
隐神经走行
股动脉伴行，内下行 通过收肌管，接近膝 盖穿出
大腿中段：缝降肌深 面，与股动脉伴行
膝上：缝匠肌和股内 肌之间的收肌管内， 与股动静脉伴行
膝下：胫骨粗隆表面 ，与大隐静脉伴行
隐神经阻滞入路
Subsartorial plexus block（大腿中段） Adductor Canal block（大腿远端/收肌管） Subcoutaneous infiltration block（小腿近端）
Ranking F/S (6) F/O(6) LP/S (3) FIC (3) PA (2)
Ranking on highquality studies F/S FIC LP PA ACB
Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37
(functional assessments)
Secondary outcomes: postoperative complications (e.g., nausea, vomiting, falls),
duration of hospitalization, blood loss, procedure failure, and patient withdrawal
收肌管
收肌肌腱键膜管状间隙 构成：股内侧肌、缝匠 肌、长收肌和大收肌 近端：股三角顶点 远端：收肌管裂孔 表面：股内收膜
内容：股神经的股内侧 肌支、隐神经、相关肌肉
收肌管超声
起点：股三角（倒）顶点，缝匠肌与长收肌 内 侧缘相交处
终点：股动脉偏离缝匠肌，进入股内侧肌和 大 收肌之间（收肌腱裂孔）
(D) overall range on motion in the first 72 h.
Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37
股神经阻滞——寻找GIPM旁结构
髂筋膜
GIPM:85% 髂筋膜：68%
Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:23–29
（此处可能已经分支） 进针路径：平面内或平面外 局麻药：5ml
目标：局麻药在神经周围或 阔筋膜张肌和缝匠肌之间阔 筋膜下方扩散
隐神经阻滞
•与收肌管阻滞？
隐神经阻滞
股神经的最大感觉支
支配：内侧膝关节、 髌骨下方、小腿内侧 和足内侧缘的皮肤
适应证：膝关节手术 、大隐静脉手术、坐 骨神经阻滞的补充
进针点？药液？置管位置？
Topographic view of the terminal branches of the femoral nerve
ACN： anterior cutaneous nerve MCN：medial cutaneous nerve PMN ：pectineus muscle nerve; RFMN： rectus femoris muscle nerve SMN： Sartorius muscle nerve SN： saphenous nerve VIMN：vastus intermedius muscle nerve VLMN： vastus lateralis muscle nerve VMMN：vastus medialis muscle nerve
Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Metaanalysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37
骶骨水平
冠状位
Swenson JD, Davis JJ, et al. Local anesthetic injection deep to the fascia iliaca at the level of the inguinal ligament: the pattern of distribution and effects on the obturator nerve. Journal of Clinical Anesthesia (2015) 27, 652–657
股外侧皮神经阻滞
支配：大腿前外侧
适应证：髋部手术 为主
过去：髂前上棘内 下1~2cm，皮下 0.5~1cm
变异大：以解剖标 志为基础的传统阻 滞技术不可靠
阔筋膜张肌
股外侧皮神经 缝匠肌
超声引导股外侧皮神经阻滞
高频探头 扫描方式：阔筋膜张肌和缝
匠肌 超声影像：低回声椭圆形
隐神经部分与神经其他部分可能存在隔断
平面内由外向内进针，一直到神经内侧，药液包绕，神经前方置管
Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:23–29
S：缝匠肌 VM：股内侧肌 AL：长收肌 AM：大收肌
Wong WY, et al. Defining the Location of the Adductor Canal Using Ultrasound.Reg Anesth Pain Med 2017;42: 241–245
置或许最佳
进针点？药液？置管位置？
短轴，平面内法 短轴，平面外法
进针点？药液？置管位置？
Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:23–29
膝关节置换镇痛
Primar y outcomes: (1) acute postoperative pain (during rest and movement) (2) postoperative opioid consumption (3) quality of early postoperative rehabilitation
朝阳医院超声麻醉疼痛周
髂筋膜、股神经和
隐神经/收肌管阻滞
朝阳医院麻醉科 蒋嘉
膝关节置换镇痛
Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Metaanalysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37
股外侧皮神经 闭孔神经 股神经
隐神经
髂筋膜阻滞
•阻滞的是什么？
髂筋膜
外界：髂嵴内 侧缘
内界：小骨盆 的界线
向下一直延续 到股骨小转子 水平
覆盖腰大肌和 髂肌
髂筋膜
闭孔神经与髂肌和髂筋膜并没有密切的联系
闭 孔 神 经
髂筋膜阻滞的扩散范围（MRI）
腹股沟韧带水平髂筋膜阻滞
腹股沟韧带水平
辨认不清髂筋膜怎么办？
GIPM：髂腰肌凹槽（a groove formed by the iliac and lateral psoas muscles）
Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:23–29
股神经阻滞
•如何提高成功率？
股神经解剖
股神经
股神经超声影像
腹股沟水平 股动脉外侧，髂筋膜深部，髂肌表面 高回声，宽而扁，椭圆形 深度：1~3cm
超声探头的最佳位置
旋股内、外侧动脉
超声探头的最佳位置
旋髂深浅动脉
必要时用多普 勒调整位置
腹股沟韧带和
腹横纹中间位
OGAMI K, MURATA H, SAKAI A, et al. Deep and Superficial Circumflex Iliac Arteries and Their Relationship to the Ultrasound-Guided Femoral Nerve Block Procedure: A Cadaver Study. Clinical Anatomy 30:413–420 (2017)
与PCA比较
(A) Overall pain scores in the first 72 h duringrest
(B) overall pain scores in the first 72 h during movement,
(C) overall opioid consumption in the first 72 h
超声引导腹股沟韧带上髂筋膜阻滞
寻找髂前上棘、髂肌、腹横肌 药液扩散：腹横肌和髂肌之间 阻滞：股神经、股外侧皮神经、髂腹股沟神经
Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-Guided Suprainguinal Fascia Iliaca Technique Provides Benefit as an Analgesic Adjunct for Patients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433–438