胸椎旁间隙超声解剖特征与超声引导胸椎旁神经阻滞技术的临床研究

发布时间：2018-04-29 12:26

本文选题：超声 + 胸椎旁间隙　；参考：《南方医科大学》2014年博士论文

【摘要】：研究背景与目的近年来随着认识的深入,区域阻滞为多模式镇痛治疗方案重要的组成成分已被广泛接受。Kairaluoma研究发现围术期运用胸椎旁神经阻滞可降低术后急性疼痛发生率,同时也可减少术后一年内慢性疼痛的发生。另一项Exadaktylos的研究提示在乳腺癌术后36个月肿瘤复发率的观察中,胸椎旁神经阻滞组低于全麻组,这再次引发大家对胸椎旁神经阻滞的重视。胸椎旁间隙是一个与相应椎体相邻的横截面近似楔形的潜在解剖间隙,该间隙内侧通过椎间孔与硬膜外间隙相通,外侧与肋间间隙相通。通过注射局部麻醉药,可阻滞通过此间隙的感觉、运动、交感神经,从而达到同侧躯体的镇痛与麻醉的目的。同时注射的药液可沿此间隙向上和向下扩散,故通过一个注射点能够产生多个节段范围的麻醉。开展这项技术的最初目的是为了减少椎管内阻滞时潜在的血肿、脊髓损伤、感染等严重并发症及在硬膜外阻滞困难、失败时提供备选方案,然而通过回顾性研究发现：胸椎旁神经阻滞可提供与硬膜外阻滞相当的镇痛疗效,而且相比之下可维持更好的氧合通气指标,并减少低血压、尿潴留等相关并发症。胸椎旁神经阻滞的疗效明确使该项技术越来越多运用于胸科、乳腺、上腹部手术围术期的麻醉镇痛和胸部区域的疼痛诊疗中。早期胸椎旁神经阻滞采用体表标志解剖定位,运用阻力消失法或压力监测定位法,成功率均不理想,并发症发生率高。采用刺激针连接神经刺激仪穿刺亦存在操作的盲目性,不能避免血管内穿刺,而且在并存糖尿病等疾病时,存在神经传导障碍,神经刺激仪的有效性受到影响。超声技术运用于区域阻滞麻醉是近年临床麻醉新开展的技术热点,超声与其它X线、CT、MRI磁共振等影像技术相比,具有无X射线暴露、轻便、快捷、准确等优点。在临床麻醉工作中超声技术能协助确认阻滞靶点并了解其相邻组织结构,同时能确定穿刺针路径并实时引导穿刺。胸椎旁间隙是一个与脊柱硬膜外间隙毗邻的潜在间隙,前端与胸膜、肺脏及胸部大血管紧密相邻,操作时容易导致穿刺损伤。超声技术的可视化、实时化为我们解决上述难题提供强有力的临床诊疗工具。超声技术对于初步接触者尤其是刚开始学习麻醉技能的初学者,掌握这项技术需要较长的学习过程。有研究表明,利用现代化的科技手段如计算机图像技术、模拟器虚拟教学等手段均能提高心肺复苏急救技能的学习效率,提高治疗有效率,同时在模拟气管插管,模拟腔镜手术中也证实了有效性。因此我们拟将其运用于超声引导的神经阻滞教学中,以探讨其有效性、可重复性,努力提高学习效率。本研究目的在于对以下四个方面问题进行探讨：①胸椎旁间隙超声解剖特征及优化穿刺路径的研究；②超声引导胸椎旁间隙置管对肺部肿瘤介入手术术后镇痛安全性的研究；③超声引导胸椎旁神经阻滞对胸部创伤急性疼痛治疗有效性的观察；④超声引导行胸椎旁神经阻滞的学习曲线探讨,分析学习规律,为制定培训细则提供参考依据。 [方法] 1.胸椎旁间隙超声解剖特征及优化穿刺路径的研究：选择择期行开胸手术患者进行研究。分组：旁矢状切面扫描阻滞组(Paramedian Sagittal scan,S组)，，斜轴位横断面扫描阻滞组(Transverse scan,T组)。在胸椎旁间隙进行扫描,记录超声图像特征及解剖变化。分辨椎旁肌群、横突、肋横突上韧带、胸膜及胸膜下的肺脏组织,采用超声引导平面内(in plane)穿刺法,引导针突破肋横突上韧带进入胸椎旁间隙,回抽无血后在超声监测下分次缓慢注射局部麻醉药。观察阻滞操作时间、麻醉起效时间、麻醉效果优良率,并发症发生率4个指标。比较两种阻滞方法的有效性、安全性。 2.超声引导胸椎旁间隙置管对肺部肿瘤介入手术术后镇痛安全性的研究,对超声引导胸椎旁间隙置管方法进行探讨,运用X射线断层扫描对药物的扩散进行观察：选择行经皮肺部肿瘤介入射频消融治疗患者,全麻前运用斜轴位扫描(Transverse scan)外侧肋间入路,采用超声引导平面内(in plane)穿刺法,引导穿刺置管。分次推注含造影剂(Iohexol碘海醇)的局麻药(0.5%罗哌卡因)共20mL。观察麻醉平面及效果,评估含造影剂局部麻醉药在CT横断位胸椎旁间隙扩散情况,同时通过CT冠状位重建,测量药物扩散的节段数。从而评价超声实时引导的胸椎旁神经阻滞及置管法的安全性,有效性。 3.观察超声引导下行胸椎旁间隙置管,罗哌卡因复合舒芬太尼溶液联合胸椎旁持续患者自控镇痛,在多发肋骨骨折患者的镇痛有效性及对患者生活质量的影响。选择单侧多发肋骨骨折患者25例,超声引导下行胸椎旁间隙成功置管后,予0.2%罗哌卡因含5μg/ml肾上腺素,复合0.25pg/ml舒芬太尼0.1ml/kg/h持续镇痛治疗,同时口服塞来昔布200mg每日两次,观察并记录VAS评分和Barthel指数评分,并观察胸椎旁阻滞对循环的影响及其他不良反应。 4.超声引导下行胸椎旁神经阻滞的学习曲线探讨：回顾分析2013年1月～2013年9月由5名麻醉科住院医生完成的超声引导下行胸椎旁神经阻滞的90例手术病人临床资料,按手术时间先后顺序分为6组,每组15例,比较各组的阻滞操作时间、麻醉起效时间、麻醉优良率、并发症发生率4个指标的差异。评估超声引导胸椎旁阻滞的临床学习曲线。 [结果] 1.胸椎旁间隙超声影像学的解剖特征：超声技术可清晰显示椎体横突轮廓,及横突旁肋横突上韧带,胸椎旁间隙,胸膜,胸膜滑动征,胸膜下肺组织。从穿刺针接触皮肤至注药完毕所需时间旁矢状切面扫描组(Paramedian Sagittal scan,S组)平均需要10.2±2.62min:斜轴位横断面扫描组(Transverse scan,T组)阻滞操作时间平均需要7.5±2.07min；两组比较有显著差异(P0.05)；超声测量穿刺点至胸椎旁间隙深度： S组为52±6.6mm, T组为73±9.7mm,两组差异显著。实际穿刺深度：S组为62±6.8mm,T组为8±9.7mm,两组差异显著。引导穿刺时调整穿刺针针道的次数：S组为3.3±1.46次,T组为2.1±1.29次,P值为0.009,有统计学差异。穿刺时遇到骨质次数：S组1.9±1.37次,T组0.7±0.8次,P=0.002,有统计学差异。穿刺时有阻力消失感(例,%)：S组2例(10%),T组1例(5%)。S组有1例(5%)穿刺时损伤血管形成血肿；T组无发现有血管损伤。两组麻醉效果均为优良,S组麻醉效果优者有11例,良者有9例；T组麻醉效果优者有13例,良者有7例。旁矢状切面扫描组有6例(30%)穿刺部位疼痛,余无气胸和局麻药中毒等报道。 2.超声引导胸椎旁间隙置管药物扩散的观察：通过针刺法测定阻滞平面均数为6.2±0.9个节段的脊神经,注药部位感觉阻滞分布：头侧2.1±0.7个节段和尾侧4.1±0.7个节段,自注药点尾侧节段多于头侧节段数(P=0.000)。通过CT冠状位重建,药物弥散的节段数平均为3.4±1.0个节段,注药部位药物弥散分布：注药部位头侧1.2±0.6个和尾侧2.3±0.8个节段,自注药点尾侧大于头侧(P=0.001)。感觉减退总的平面节段数大于药液弥散节段数,有统计学意义(P=0.000)。含造影剂局部麻醉药在CT横断位胸椎旁间隙扩散情况：结果显示药液集聚在椎旁,接近椎间孔和神经根区域的最多,占47%；药物集聚在椎体椎旁水平,接近交感神经干占28%；药物集聚在椎旁,位于椎间孔外侧及肋间隙占18%；还有部分药物集聚在椎旁的肌群内占7%。 3.与阻滞前比较,阻滞后的SBP、DBP、MAP、HR、SpO2值变化均不明显,差异无统计学意义。静息状态下在阻滞后较阻滞前疼痛明显缓解,疼痛评分明显下降(P0.05)。咳嗽咳痰时阻滞后与阻滞前比较疼痛评分也明显下降(P0.05)。在相同时间点咳嗽咳痰时与静息时比较疼痛感差异不明显。患者出院当天、出院后1个月、3个月电话随访VAS评分,静息和咳嗽时均低于3分,且无麻木、疼觉敏感等不适。阻滞前的Barthel指数显示患者日常生活能力为中至重度功能障碍；在阻滞之后24h、48h的Barthel指数评分为轻度功能障碍,能独立完成部分日常活动,与阻滞前比较日常生活活动能力改善(P0.05)。出院后1个月,3个月电话随访Barthel指数评分与出院当日比较有进一步改善(P0.05)。 4.90例患者按手术时间先后顺序分为6组,比较组间麻醉阻滞操作时间,后期所需时间短于前期所需时间,有显著差异(F=54.39,P0.001)。组间麻醉起效时间比较(P=0.682),麻醉优良率比较(P=0.791)无统计学差异。阻滞操作时间随着麻醉例数增加呈下降趋势,曲线拟合效果良好决定系数R2=0.757。曲线函数图可以看到初学者在初期陡直下降后自30例起开始趋于平缓进入平台期。 [结论] 1.超声技术可为胸椎旁间隙的形态学提供新的观察方法,超声能清晰显示其周围组织关系。此外,高频超声可实时引导穿刺针进行神经阻滞,麻醉效果优良。斜轴位扫描外侧肋间入路平面内法,其穿刺不良事件少,患者满意度更高。 2.超声技术可用于引导胸椎旁间隙置管,导管位置多位于椎旁间隙接近椎间孔、神经根。胸椎旁间隙置管可为单侧肺部手术提供良好的镇痛,20毫升局麻药可提供均数6个感觉减退平面,自注药点尾侧大于头侧并大于实际药液弥散节段数。药液可在椎旁间隙沿椎体上下扩散,也可沿肋间隙扩散,部分经过椎间孔扩散到硬膜外腔隙。 3.超声引导下行胸椎旁间隙置管,罗哌卡因复合舒芬太尼持续胸椎旁间隙镇痛用于多发肋骨骨折患者效果好,可改善患者日常生活能力且副作用少。 4.学习超声引导下行胸椎旁神经阻滞是个渐进的过程,无超声引导神经阻滞操作经验的麻醉医师行超声引导胸椎旁阻滞的学习曲线为30例。
[Abstract]:Research background and purpose
In recent years, with the deepening of understanding, regional block as an important component of multimodal analgesic therapy has been widely accepted by the.Kairaluoma study. It is found that peri thoracic paravertebral block can reduce the incidence of acute postoperative pain and also reduce the occurrence of chronic pain within one year after operation. Another Exadaktylos study suggests In the observation of the recurrence rate of the 36 months after breast cancer, the paravertebral block group was lower than the general anesthesia group, which again caused attention to the paravertebral block again. The paravertebral space is a potential dissecting space of approximately wedge-shaped cross section adjacent to the corresponding vertebral body. The medial interspace through the intervertebral space passes through the intervertebral foramen and extradural space. The side of the intercostal space interconnects. By injecting a local anesthetic, it can block the sensation, movement, and sympathetic nerve through this space, so as to achieve the purpose of analgesia and anesthesia in the same side of the body. At the same time, the injection of the liquid can spread up and down along the gap, so the technique can be used to produce multiple segments of the anesthetic through an injection point. The initial aim was to reduce the potential hematoma, spinal cord injury, infection, and other severe complications, such as the epidural block, and the alternative options when the intradural block was blocked. However, a retrospective study found that paraspinal nerve block could provide an analgesic effect comparable to that of epidural block, and can be maintained better than that of the epidural block. The effect of the paravertebral block is clearly made more and more used in the chest, the breast, the peri operation of the breast, and the pain diagnosis and treatment of the chest region.
The early thoracic paravertebral nerve block using the body surface marker anatomic location, using the method of resistance disappearance or pressure monitoring and positioning, the success rate is not ideal and the incidence of complications is high. The puncture of the stimulation needle connected to the nerve stimulator also has the blindness of operation, and it can not avoid the intravascular puncture, and there is a neural transmission in the coexistence of diabetes and other diseases. The effectiveness of the neurostimulator is affected by obstruction.
Ultrasound technique used in regional anesthesia is a new technical hotspot in clinical anesthesia in recent years. Compared with other imaging techniques, such as ultrasound and other X-ray, CT, and MRI magnetic resonance imaging techniques, it has the advantages of no X ray exposure, light, quick, accurate and so on. In clinical anesthesia, ultrasound technique can assist in identifying the block target and understanding its adjacent tissue structure, and simultaneously can The paravertebral space is a potential gap adjacent to the spinal epidural space. The front-end is closely adjacent to the pleura, the lungs and the large blood vessels of the chest. The operation can easily lead to puncture injury. The visualization of ultrasonic technology provides a powerful clinical tool for solving the above problems.
It is shown that the use of modern technology such as computer image technology and simulator virtual teaching can improve the learning efficiency of cardiopulmonary resuscitation skills and improve the effectiveness of treatment. At the same time, it is also proved to be effective in simulated tracheal intubation and simulated endoscopic surgery. Therefore, we intend to apply it to the teaching of ultrasound guided nerve block in order to explore its effectiveness, repeatability and improve the learning efficiency.
The purpose of this study is to discuss the following four aspects: (1) the ultrasonic anatomical characteristics of the paravertebral space and the study of the optimization of the puncture path; (2) the study of the safety of the paravertebral space by ultrasound guided intervertebral space catheterization for the postoperative analgesia of the pulmonary tumor; and (3) the treatment of acute pain in the thoracic trauma by ultrasound guided thoracic paravertebral blockade Observation of effectiveness. 4. Learning curve of thoracic paravertebral nerve block guided by ultrasound and analysis of learning rules, so as to provide reference for making training rules.
[method]
The ultrasonic anatomical features of the 1. paravertebral space and the optimization of the puncture path: select the patients undergoing elective thoracotomy. Group: parasagittal section scan block group (Paramedian Sagittal scan, S), oblique axis transverse section block group (Transverse scan, T group). The paravertebral space was scanned in the paravertebral space, and the characteristics of ultrasonic images were recorded and the characteristics of the ultrasound images were recorded and The paravertebral muscle group, the transverse process, the transverse process, the ligament of the transverse process, the lung tissue under the pleura and the pleura, the ultrasound guided in plane puncture method, the guide needle break through the ligaments of the transverse process to the paravertebral space, and the local anesthetic after the ultrasonic monitoring. There were 4 indexes of time, the excellent and good rate of anesthetic effect and the incidence of complications. The efficacy and safety of the two methods were compared.
2. ultrasound guided paravertebral space catheterization was used to study the safety of postoperative analgesia after interventional surgery for pulmonary tumor. Ultrasound guided catheterization of the paravertebral space was explored. The diffusion of drugs was observed by X ray tomography: percutaneous pulmonary tumor interventional radiofrequency ablation was selected and oblique axis scan was used before general anesthesia (Tran Sverse scan) on the lateral intercostal approach, using the ultrasound guided plane (in plane) puncture method to guide the puncture and catheterization. The anesthetic level and effect of the local anesthetic (0.5% ropivacaine) containing contrast agent (iodipivacaine) were injected into a total of 20mL. (0.5% ropivacaine). The diffusion of the local anesthetic in the paravertebral space of the CT transverse position and the CT crown were evaluated. In order to evaluate the safety and effectiveness of real-time ultrasound guided thoracic paravertebral nerve block and catheterization, we measured the number of segments of drug diffusion.
3. ultrasound guided paravertebral space catheterization, ropivacaine combined with sufentanil combined with paravertebral continuous patient controlled analgesia, analgesic effectiveness and quality of life in patients with multiple ribs fracture. 25 cases of unilateral multiple rib fractures were selected and the paravertebral space was successfully placed under supersonic guidance to 0. 2% ropivacaine containing 5 g/ml adrenaline, combined with 0.25pg/ml sufentanil 0.1ml/kg/h for continuous analgesia, and two times a day with celecoxib 200mg, observed and recorded the VAS score and the Barthel index score, and observed the effects of paravertebral block on circulation and other adverse reactions.
Study on the learning curve of paravertebral nerve block under 4. ultrasound guidance: a retrospective analysis of the clinical data of 90 patients undergoing ultrasound guided thoracic paravertebral block from 5 anesthesiologists from January 2013 to September 2013, and divided into 6 groups according to the order of operation time, 15 cases in each group, and compared the anesthesia time of each group. The difference between the 4 indicators of intoxication onset time, the excellent rate of anesthesia and the incidence of complications were evaluated.
[results]
1. ultrasound imaging features of the paravertebral space: ultrasound technique can clearly display the outline of the transverse process of the vertebral body, the ligament of the transverse process of the parapleura, the paravertebral space, the pleura, the pleural slipping sign, the lower pleural lung tissue. The average paracental scan group (Paramedian Sagittal scan, S) from the puncture needle to the end of the injection The average needs of the 10.2 + 2.62min: oblique axial scan group (Transverse scan, T group) block operation time averaged 7.5 + 2.07min; the two groups were significantly different (P0.05); the puncture point to the paravertebral space depth: S group was 52 + 6.6mm, T group was 73 + 9.7mm, and the two groups were significantly different. The actual puncture depth was 62 + 6.8mm. 8 + 9.7mm, the two groups had significant differences. The number of needle channels adjusted to puncture needle was 3.3 + 1.46 times, T group was 2.1 + 1.29 times, and P was 0.009, there were statistical differences. There were 1.9 + 1.37 times in S group, 0.7 + 0.8 times in group T, P=0.002, with statistical difference. There were 3.3 cases (10%) in:S group, and T group 1 cases when piercing. In group.S, there were 1 cases (5%) injured blood vessels and hemangioma, no vascular injury was found in group T. The anesthetic effect of two groups was excellent, group S was anesthetized in 11 cases, good in 9 cases, and in group T, there were 13 cases of anesthetic effect and 7 cases. There were 6 cases (30%) puncture site pain in parasagittal section scan group, no pneumothorax and intoxication of local anesthetics. Avenue.
The observation of the drug diffusion of 2. ultrasound guided paravertebral space catheterization: the spinal nerve was measured by acupuncture at 6.2 + 0.9 segments by acupuncture. The distribution of sensory block in the injection site: 2.1 + 0.7 segments at the cephalic side and 4.1 + 0.7 segments at the tail side, and the end segment of the injection point was more than the number of the cephalic segments (P=0.000). The drug was reconstructed by CT coronal position. The average number of diffuse segments was 3.4 + 1 segments, and the distribution of drugs at the injection site was 1.2 + 0.6 and 2.3 + 0.8 segments at the tail side. The end side of the injection point was larger than the head side (P=0.001). The total number of plane segments in the sensory degeneration was larger than the number of dispersive segments of the liquid medicine (P=0.000). The local anesthetics containing contrast agents were transverse to CT. The diffusion of paravertebral space in the intervertebral space: the results showed that the liquid was gathered around the vertebra, near the intervertebral foramen and the nerve root area, accounting for 47%. The drugs gathered at the vertebral paravertebral level and nearly 28% of the sympathetic trunk; the drugs gathered at the paravertebral, located in the lateral and intercostal spaces of the intervertebral foramen and the intercostal space of 18%, and some of the drugs gathered in the paravertebral muscles of 7. It is.
3. compared with pre block, the changes of SBP, DBP, MAP, HR, and SpO2 were not significant. The pain was significantly relieved and the pain score decreased significantly (P0.05) in the resting state after block anesthesia. The pain scores of cough expectoration and before block were also significantly decreased (P0.05). At the same time, cough expectoration at the same time point. On the day of discharge, the patient was discharged on the day of discharge, 1 months after discharge and 3 months after the hospital was followed up with VAS scores, while resting and coughing were lower than 3, without numbness and pain sensitivity. The pre block Barthel index showed that the patient's daily living ability was moderate to severe dysfunction; and after block, 24h, 48h Barthel index The score was mild dysfunction, it was able to perform some daily activities independently and compared with the daily living activity before block (P0.05). 1 months after discharge, the Barthel index score of the 3 month follow-up telephone was further improved than that of the day of discharge (P0.05).
4.90 patients were divided into 6 groups according to the order of operation time. The time of anesthesia block operation between the groups was compared with the time required in the later period. There were significant differences (F=54.39, P0.001). The time of anesthesia initiation was compared (P=0.682), and the comparison of the excellent rate of anesthesia (P=0.791) was not statistically significant. The time of block operation was increased with the number of anesthetic cases. The decline trend, the curve fitting effect good determination coefficient R2=0.757. curve function diagram can see the beginner in the initial steep descent after 30 cases began to gradually become flat into the platform period.
[Conclusion]
1. ultrasound technique can provide a new observation method for the morphology of the paravertebral space, and the ultrasound can clearly show the surrounding tissue. In addition, high frequency ultrasound can guide the puncture needle for nerve block in real time, and the effect of anesthesia is excellent. The oblique axis scan of the lateral intercostal approach is less and the patient's satisfaction is higher.
2. ultrasound technique can be used to guide the paravertebral space and catheterization. The position of the catheter is located near the intervertebral space. The nerve root and the paravertebral space tube can provide good analgesia for unilateral pulmonary surgery. The 20 ml anesthetic can provide 6 sensory hypothictic planes. The end of the injection point is larger than the head side and is larger than the number of the actual dispersive segments. The liquid can diffuse along the vertebral body in the paraspinal space, and can also diffuse along the intercostal space, and partly spread through the intervertebral foramen to the epidural space.
3. ultrasound guided paravertebral space catheterization, ropivacaine combined with sufentanil continuous paravertebral space analgesia for multiple ribs fracture patients with good results, can improve the patient's daily life ability and less side effects.
4. learning ultrasound guided paravertebral block is a gradual process, and the anesthesiologist without the experience of ultrasound-guided nerve block operation is guided by ultrasound guided thoracic paravertebral block

【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R614

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