臂前群肌和胸上肢肌痉挛的肌外及肌内神经阻滞靶点定位

发布时间：2018-05-19 06:07

本文选题：臂前群肌 + 胸上肢肌　；参考：《遵义医学院》2017年硕士论文

【摘要】：目的:借助骨性标志和螺旋CT扫描,准确地定位臂前群肌和胸上肢肌神经入肌点(N点)和肌内神经密集区中心(CINDR)这些靶点在体表的位置和穿刺深度,为治疗这两群肌肌痉挛的肌外化学神经溶解术和肌内化学神经阻滞术提供形态学指导。方法:1.无神经肌肉疾病史、上肢与胸部关节变形的中国成年尸体22具(男,16;女,6),其中10具教学使用过尸体用于大体观察,收集的12具尸体用于靶点定位。仰卧,保持解剖学体位。2.臂前群肌肌外及肌内神经阻滞靶点定位的参考线设计:设计经皮肤连接肩峰至颈静脉切迹最下点间的曲线为喙肱肌靶点的横向参考线(H1),肱骨外上髁至内上髁间的曲线为肱二头肌和肱肌支靶点的横向参考线(H2);肩峰至肱骨外上髁间的曲线为纵向参考线(L)。3.胸上肢肌肌外及肌内神经阻滞靶点定位的参考线设计:紧贴皮肤连接颈静脉切迹最下点到剑胸结合处的曲线为胸上肢肌阻滞靶点的L线,连接肩峰至颈静脉切迹最下点的曲线为胸大肌和胸小肌靶点的横向参考线(H1);经N点连接腋前线与腋后线的曲线为前锯肌靶点的横向参考线(H2)。4.Sihler’s染色法显示肌内神经末梢密集区(INDR)和CINDR。5.解剖暴露N点并确定对侧肌块的CINDR,涂抹硫酸钡,螺旋CT扫描,三维重建。N点和CINDR在体表上的投影点定为P,P点通过N点或CINDR后投射至肢体相反侧体表上的点为P'。将经P的垂线与H线、经P的水平线与L线的交点分别记为PH和PL。Syngo系统下测量与确定PH和PL在H和L线上的百分位置及靶点的深度。6.统计学处理。结果:1.大体解剖发现:臂前群各肌常有1个N点。胸上肢肌中,胸大肌的胸外侧神经支常有2个N点,但彼此靠近,胸内侧神经支仅1个N点;胸小肌有1个N点;胸长神经主干末端从第5肋间隙入肌。这些肌的肌门处均有血管伴行。2.Sihler’s肌内神经染色所示的INDR:喙肱肌、肱二头肌、肱肌、胸大肌、胸小肌内的INDR个数分别为3、2、2、2和1,前锯肌各肌齿内均有1个INDR。3.臂前群肌各N点在体表的位置与深度:肌皮神经喙肱肌支N点的PH位于其H1线的(18.38%±1.78)%处。肱二头肌短头支、长头支和肱肌支N点的PH分别位于其H2线的(56.85%±4.41)%、(52.81%±4.36)%和(57.52%±4.22)%处。它们的PL分别位于其L线的(24.86%±4.52)%、(50.20%±4.89)%、(55.91%±3.89)%和(64.31%±4.32)%处。它们的穿刺深度分别位于其PP'线的(23.16%±2.73)%、(24.68%±2.55)%、(26.32%±3.20)%和(38.19%±3.36)%处;4.胸上肢肌各N点在体表的位置与深度:胸外侧神经胸大肌支、胸内侧神经胸大肌支和胸内侧神经胸小肌支N点的PH分别位于其H1线的(47.83±1.75%)、(32.31±4.18)%(男性)和(34.31±3.03)%处;胸长神经前锯肌支N点的PH位于其H2线的(63.77±3.33)%处。它们的PL分别位于其L线的(-9.84±1.62)%、(36.16±4.51)%(男性)、(2.44±1.16)%和(73.84±2.36)%处。胸外侧神经胸大肌支、胸内侧神经胸大肌支和胸内侧神经胸小肌支N点的深度分别位于其PP'线的(17.76±2.84)%、(17.53±3.14)%(男性)和(25.51±2.31)%处。胸长神经前锯肌支N点的深度为(1.63±0.24)cm。5.臂前群肌各CINDR在体表的位置与深度:喙肱肌CINDR1、2和3的PH位于H1线的(24.22±1.49)%、(18.89±1.49)%和(8.15±1.14)%处,PL分别位于其L线的(21.37±2.48)%、(31.78±2.32)%和(30.07±1.12)%处,穿刺深度分别位于其PP'线的(22.81±1.59)%、(26.76±1.32)%和(27.99±2.04)%处。肱二头肌CINDR1和2的PH分别位于其H2线的(49.68±2.03)%和(40.28±2.58)%处,L线的(56.60±3.35)%和(67.63±3.29)%处,穿刺深度分别位于其PP'线的(14.79±1.35)%和(17.45±1.28)%处。肱肌CINDR1和2的PL分别位于其H2线的(48.34±3.25)%和(52.45±3.47)%处,L线的(71.30±3.06)%和(81.62±4.70)%处。穿刺深度分别位于PP'线的(34.03±1.10)%和(30.26±3.14)%处。6.胸上肢肌各CINDR在体表的位置与深度:胸大肌CINDR1和2的PH分别位于其H1线的(41.95±2.72)%和(55.88±2.06)%处,PL分别位于其L线的(-3.87±0.92)%和(25.29±2.73)%处。穿刺深度分别位于PP'线的(5.23±0.94)%和(6.75±0.98)%处。胸小肌CINDR的PH位于其H1线的(32.58±3.77)%处,PL位于L线的(-7.13±0.99)%处,穿刺深度位于PP'线的(13.73±2.27)%处。前锯肌第七肌齿CINDR的PH位于H2线的(84.08±1.77)%处,PL位于L线的(100±1.86)%处,穿刺深度为(1.86±0.35)cm。结论:1.同一块肌的肌外神经入肌点的体表位置和穿刺深度与肌内神经密集区中心不同;2.这些神经入肌点和肌内神经密集区的准确定位可提高臂前群肌和胸上肢肌痉挛肌外神经溶解术和肌内化学神经阻滞术的效率与疗效;3.以神经入肌点为靶点治疗女性患者胸大肌痉挛时,宜阻滞胸外侧神经支入肌点。4.除前锯肌优先选择肌外神经入肌点外,其它肌可任意选择肌外或肌内靶点阻滞。
[Abstract]:Objective: with the help of bone markers and spiral CT scan, the location and depth of the target points on the body surface and the depth of the center of the intramuscular nerve dense area (N) and the intramuscular nerve dense area (CINDR) are accurately located in the two groups of muscle spasticity and intramuscular chemical nerve block for the treatment of these groups of muscle spasms. Methods: 1. the 22 Chinese adult cadavers (male, 16; female, 6) of the history of the deformity of the upper and chest joints (male, 16, female, 6) were used in 10 teaching, and 12 corpses were used for target location. Supine, the reference line was designed to maintain the location of the target location of the.2. arm anterior group muscle and the intramuscular nerve block. The transverse reference line (H1) for the target of the beak brachial muscle was designed by the curve of the skin connecting the shoulder peak to the jugular vein. The curve between the epicondyle and the inner condyle of the humerus was the lateral reference line (H2) of the biceps and brachial branches. The curve between the shoulder and the outer condyle of the humerus was the longitudinal reference line (L).3. outside of the upper limb of the chest and the intramuscular nerve resistance. The design of the reference line of the stagnation target location: the L line that closely connects the lower point of the jugular vein incisor to the combination of the sword chest is the target of the thoracic upper limb muscle block. The curve connecting the acromion to the jugular notch is the lateral reference line (H1) for the pectoralis major and the pectoralis minor targets. The curve of the front and the rear lines of the axillary front and the axillary line via N points is the target of the anterior sawing muscle. The point of the transverse reference line (H2).4.Sihler 's staining showed that the intramuscular nerve end dense area (INDR) and the CINDR.5. anatomy exposed N points and determined the CINDR of the contralateral muscle mass, smear barium sulfate, spiral CT scan, the three-dimensional reconstruction of.N points and CINDR on the body surface, the projection point was determined to be P, P points passed the dots or projected to the opposite side of the body surface. The intersection of the P's vertical line and the H line, the intersection of the horizontal line of P and the L line as the PH and PL.Syngo system, respectively, to measure and determine the depth of the percentile and target depth of the PH and PL on the H and L lines. Results: 1. gross anatomy found that there are 1 N points in the muscles of the anterior arm group. In the chest upper limbs, the thoracic lateral nerve branches of the pectoralis major muscle often have 2 points, But close to each other, the nerve branches of the medial chest were only 1 N points; the pectoralis minor muscle had 1 N points; the end of the trunk of the thoracic nerve was from the fifth rib space into the muscle. There were the INDR: beak brachial muscles, the biceps brachii, the brachii muscle, the pectoralis major and the pectoralis minor muscle, respectively, 3,2,2,2 and 1, and the anterior sasawing muscles. The position and depth of each N point in the body surface of 1 INDR.3. arm anterior group muscles in the teeth: the PH of the N point of the brachial muscle branch of the musculocutaneous nerve beak is located at (18.38% + 1.78)% of its H1 line. The PH of the biceps brachii muscle, the long head and the N point of the brachial muscle is located at (56.85% + 4.41)%, (52.81% + 4.36)% and (57.52% + 4.22)% at its H2 line, respectively. Their PL is located on its L line, respectively. (24.86% + 4.52)%, (50.20% + 4.89)%, (55.91% + 3.89)% and (64.31% + 4.32)%. Their puncture depth was located (23.16% + 2.73)%, (24.68% + 2.55)%, (24.68% + 2.55)%, (26.32% +)% and (55.91%)%, respectively. The position and depth of each N point in the upper limb muscles of the chest: the lateral thoracic pectoralis major muscle branch, the pectoralis pectoralis major muscle branch and the chest inside the chest The PH of the N point of the lateral nerve branch of the lateral nerve was located at its H1 line (47.83 + 1.75%), (32.31 + 4.18)% (male) and (34.31 + 3.03)%; the PH of the N point of the anterior sawing muscle of the thoracic long nerve was located at (63.77 + 3.33)% of its H2 line. Their PL was located (-9.84 + 1.62)% (36.16 + 4.51)% (36.16 +%), and (2.44 + 1.16)% and (73.84 +)%)%. The depth of the N points of the pectoralis major branch, the pectoralis major pectoralis major branch and the medial pectoralis minor muscle branch at the PP'line (17.76 + 2.84)%, (17.53 + 3.14)% (male) and (25.51 + 2.31)%. The depth of the N point of the anterior segment of the thoracic long nerve was (1.63 + 0.24) the position and depth of CINDR in the body surface of the anterior group of the cm.5. arm: CINDR1,2 of the beak brachial muscle and the PH position of 3. At the H1 line (24.22 + 1.49)%, (18.89 + 1.49)% and (8.15 + 1.14)%, PL was located at (21.37 + 2.48)%, (31.78 + 2.32)% and (30.07 + 1.12)% respectively at its L line, and the puncture depth was located at the PP'line (22.81 +%)% and (1.14%)% respectively. The CINDR1 and PH of the biceps brachii were located on the H2 line respectively. ) at% (56.60 + 3.35)% and (67.63 + 3.29)% of the L line, the puncture depth is located at (14.79 + 1.35)% and (17.45 + 1.28)% of the PP'line respectively. The CINDR1 and 2 of the brachial muscle are located at (48.34 + 3.25)% and (52.45 + 3.47)% of the H2 line respectively, and the L line is located at the PP' line, respectively. .14) the position and depth of CINDR in the upper limb muscle of.6. in the body surface: the CINDR1 and 2 PH of the pectoralis major muscle were located at (41.95 + 2.72)% and (55.88 + 2.06)% of the H1 line respectively. The PL was located at (-3.87 + 0.92)% and (25.29 + 2.73)% respectively in its L line. The puncture depth was located at (5.23 + 0.94)% and 6.75 0.98)% respectively. The CINDR PH of the pectoralis minor muscle was located on its thread. At (32.58 + 3.77)%, PL was located at (-7.13 + 0.99)% of the L line, the puncture depth was located at (13.73 + 2.27)% of the PP'line. The PH of the anterior sawing muscle CINDR was located at (84.08 + 1.77)% of the H2 line, PL was located at (100 + 1.86)% of the L line, and the puncture depth was (1.86 + 0.35) cm. conclusion: the body surface position and puncture depth of the extricardial nerve into the muscle of the same muscle. The center of intramuscular nerve is different from the center of intramuscular nerve; 2. the accurate localization of these nerve entry points and intramuscular nerve dense areas can improve the efficiency and effect of the extricardiac and intramuscular nerve blockade of the anterior arm and upper limb muscle spasm, and 3. the lateral deity should be blocked in the treatment of the female patients with the pectoralis major spasm with the nerve entry point as the target. Through insertion of.4. into the muscle, apart from the anterior serratus muscle to select the extra muscular nerve entry point, the other muscles can selectively choose out of muscle or intramuscular target block.
【学位授予单位】：遵义医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R741

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