- 期刊
Ultrasonographic Examination to Search out the Optimal Upper Arm Position for Coracoid Approach to Infraclavicular Brachial Plexus Block-A Volunteer Study
以超音波檢查評估鎖骨下臂神經叢阻斷術之最佳上臂姿勢
摘要
背景：鎖骨下臂神經叢阻斷術，因有良好的麻醉效果與容易施行，臨床上廣泛運用於肱骨中段以下之上肢手術麻醉。施行此術比腋下臂神經叢阻斷術方式更簡便、且比鎖骨上臂神經叢阻斷術引起相關併發症（如氣胸）的機率更低。本試驗主要在探討上臂不同擺位對施行阻斷術之影響。 方法：收集40名健康自願者，以超音波儀器檢測，採隨機分配決定檢測部位為左側或右側。實驗方法以超音波檢查鎖骨下區域之相對解剖位置並比較四種上臂姿勢，內收、外展60°、外展90°及外展120°之差異。分別記錄四種上臂姿勢時，體表至臂神經叢之距離、臂神經叢的三條神經索、肋膜是否可辨識，臂神經叢與腋下動靜脈的相對解剖位置及紀錄超音波指引下最佳穿刺點與解剖標記定位點之垂直距離。 結果：上臂外展90°比起其它三種姿勢，臂神經叢離體表較近（1.67公分），離肋膜較遠（1.15公分）。在此姿勢以下三者（臂神經叢前移、三條神經索均可辨識、肋膜可辨識）的比例分別為53.8%、64.1%及87.2%。當上臂姿勢由內收至外展時，最佳穿刺點有下移的趨勢。 結論：鎖骨下臂神經叢阻斷術的最佳姿勢為上臂外展90°與肩部外旋。我們建議常規使用超音波指引施行此術；然而，若無超音波指引時，以解剖標記定位，上臂外展90°，亦不失為一個可接受的準確穿刺點。
並列摘要
Background: Infraclavicular brachial plexus block has been widely used for surgical procedures below the mid humerus owing to its excellent anesthetic quality and ease of practice. However, what is the optimal upper arm position for carrying out the procedure still lacks consensus of opinion. The primary goal of this study was to determine the optimal upper arm position for coracoid infraclavicular block by ultrasonographic examination. Methods: High-frequency (5-10 MHz) ultrasonographic examination on the vertical line 2 cm medial to the coracoid process was performed in 40 volunteers. We assessed the influence of four different upper arm positions on the topographic anatomy of the infraclavicular region. Ultrasonography-derived distances and morphometric measurements were applied to evaluate the optimal puncture site. The deviation of coracoid puncture site from the ultrasonographically modified ideal puncture site in distance was also recorded. Results: When the upper arm was abducted 90°, the brachial plexus was much closer to the skin (1.67 cm) and farther from the pleura (1.15 cm) as compared with other positions. In this position, the revealation of anterosuperior plexus relative to artery, identification of all three cords and pleura were 53.8%, 64.1% and 87.2%, respectively. We also found that as the upper arm was drawing from abduction to adduction the ideal puncture site tended to shift more inferiorly. Conclusions: We recommend the most optimal position for carrying out coracoid infraclavicular brachial plexus block is to abduct the upper arm 90° with external rotation of the shoulder. Though ultrasonographic guidance is suggested for infraclaricular brachial plexus block, an optimal position for puncture site determined by anatomical landmark is also acceptable.