細說臂叢神經(jīng)阻滯內容提要1肌間溝神經(jīng)阻滯的那些“坑”2肩胛骨骨折的患者如何進行神經(jīng)阻滯鎮(zhèn)痛？3前臂內側皮神經(jīng)聯(lián)合肌皮神經(jīng)阻滯臂從神經(jīng)解剖臂叢神經(jīng)解剖1胸長神經(jīng)2肩胛背神經(jīng)3肩胛上神經(jīng)4鎖骨下肌神經(jīng)5正中神經(jīng)外側根6肌皮神經(jīng)7胸外側神經(jīng)8上肩胛下神經(jīng)9下肩胛下神經(jīng)10胸背神經(jīng).11腋神經(jīng)12橈神經(jīng)13胸內側神經(jīng)14正中神經(jīng)內側根15尺神經(jīng)16前臂內側皮神經(jīng)17臂內側皮神經(jīng)18正中神經(jīng)19肋間臂神經(jīng)20頸長肌、斜角肌支臂叢神經(jīng)解剖1胸長神經(jīng)2肩胛背神經(jīng)3肩胛上神經(jīng)4鎖骨下肌神經(jīng)5正中神經(jīng)外側根6肌皮神經(jīng)7胸外側神經(jīng)8上肩胛下神經(jīng)9下肩胛下神經(jīng)10胸背神經(jīng).11腋神經(jīng)12橈神經(jīng)13胸內側神經(jīng)14正中神經(jīng)內側根15尺神經(jīng)16前臂內側皮神經(jīng)17臂內側皮神經(jīng)18正中神經(jīng)19肋間臂神經(jīng)20頸長肌、斜角肌支胸長神經(jīng)

ThelongthoracicnerveThelongthoracicnerve(externalrespiratorynerveofBell;posteriorthoracicnerve)suppliestheserratusanteriormuscle.Thisnervecharacteristicallyarisesfromtheanteriorramiofthreespinalnerveroots:thefifth,sixth,andseventhcervicalnerves(C5-C7)althoughtherootfromC7maybeabsent.TherootsfromC5andC6piercethroughthescalenusmedius,whiletheC7rootpassesinfrontofthemuscle.Thenervedescendsthroughthecervicoaxillarycanalbehind(posteriorto)thebrachialplexusandtheaxillaryarteryandvein,restingontheoutersurfaceoftheserratusanterior.Itextendsalongthesideofthethoraxtothelowerborderofthatmuscle,supplyingfilamentstoeachofitsdigitations(finger-likeprojectionsLTNwasclearlyvisibleinallanatomicalspecimensandvolunteersusingHRUSandcouldbefolloweduntilthesecondslipoftheserratusanteriormusclefromthesupraclavicularregion.Inanatomicalspecimens,dissectionconfirmed,HRUSfindings.Forallvolunteers,consensuswasobtained.Themeannervediameterwas1.6mm±0.3(range1.1–2.1mm)aftertheformationofthemaintrunk.Fig.2aExampleofsonographicfindingoftheLTNwithintheinterscalenetriangleinventromedialtransverseview(Abbreviationsused:C5-C8=cervicalroots,ScA=anteriorscalenemuscle,SM=middlescalenemuscle,SP=posteriorscalenemuscle);bExampleofsonographicfindingatthemostdistalpointvisiblefromthesupraclavicularregion(Abbreviationsused:OM=omohyoidmuscle,SA=Serratusanteriormuscle,SSN=suprascapularnerve).Fig.3aExampleoffindingindissectionsaftermarkingoftheLTN(whitearrow)atproximalsite(alsoshowingunionofC5andC6cervicalroots)(Abbreviationused:PS=posteriorscalenemuscle);bExampleoffindingindissectionsaftermarkingoftheLTN(whitearrow)atthemostdistalpointvisiblefromthesupraclavicularregion(Abbreviationsused:MS=middlescalenemuscle,PS=posteriorscalenemuscle).肩胛背神經(jīng)Thedorsalscapularnervearisesfromthebrachialplexus,usuallyfromtheplexusroot(anterior/ventralramus)ofC5.Itprovidesmotorinnervationtotherhomboidmuscles,whichpullthescapulatowardsthespineandlevatorscapulaemuscle,whichelevatesthescapula.Injurytothisnerveisusuallyapparentwhenthescapulaononesideislocatedfartherfromthemidline.OncethenerveleavesC5itcommonlypiercesthemiddlescalenemuscle,andcontinuesdeeptolevatorscapulaeandtherhomboids.Itisaccompaniedbyoneoftwoarteries:eitherthedorsalscapularartery(theonlyarterythatcomesoffthethirdpartofthesubclavian,althoughitsoriginishighlyvariableindifferentpeople)or,whenthedorsalscapulararteryisabsent,thedeepbranchofthetransversecervicalartery(anarterycomingoffthethyrocervicaltrunk,abranchofthefirstpartofthesubclavianartery,theothertwobranchesbeingvertebralarteryandinternalthoracicartery).Thepatientunderwentgeneralanesthesiaduringthe3.5-hourcase,thenwasbroughttotherecoveryroomawakewithapainscoreof2onan11-pointscale.Thepatienthadfullmotorfunctionofheripsilateralarminthepostoperativeperiod.Shewastransferredtotheshort-stayunit,but14hoursaftertheinitialnerveblocksheexperiencedsignificantintractablepain,ratedat10/10.Atthepatient’srequest,acontinuousnerveblockcatheterwasplacedadjacenttothedorsalscapularnerve.Aninfusionof4mL/hr+2mLbolusevery30minuteswasstarted.Thepatientexperiencedalmostimmediatereliefofherpainafterplacementofthecontinuousnerveblock.Shewasdischargedhomeonpostoperativeday(POD)1afterthisblockplacement.SelectiveblockadeofthedorsalscapularnerveSelectiveblockadeofthedorsalscapularnerveSelectiveblockadeofthedorsalscapularnerve平面內肌間溝阻滯注意？肩胛上神經(jīng)Thesuprascapularnervearisesfromtheuppertrunkofthebrachialplexuswhichisformedbytheunionoftheventralramiofthefifthandsixthcervicalnerves.Afterbranchingfromtheuppertrunk,thenervepassesacrosstheposteriortriangleoftheneckparalleltotheinferiorbellyoftheomohyoidmuscleanddeeptothetrapeziusmuscle.Itthenrunsalongthesuperiorborderofthescapula,passesthroughthesuprascapularnotchinferiortothesuperiortransversescapularligamentandentersthesupraspinousfossa.Itthenpassesbeneaththesupraspinatus,andcurvesaroundthelateralborderofthespineofthescapulatotheinfraspinousfossa.

Exampleofsonographicfindingatthemostdistalpointv