- 期刊
應用斜角肌間臂神經叢阻斷術合併何氏頸椎第3-4節神經阻斷術於肩部及高位上臂手術之臨床經驗
Clinical Experience in Interscalene Brachial Plexus Block Combined with Ho's Method of C3-4 Block for Shoulder and Proximal Upper Extremity Surgeries
摘要
在1889年Halsted首先應用臂神經叢阻斷術，之後它被廣泛使用於肩部及高位上肢手術麻醉。但是，由於單獨使用斜角肌間臂神經叢阻斷術不能涵蓋整個手術範圍，特別是肩深部組織的手術。若使用大量局部麻醉藥（40 ml）來阻斷頸椎第三及四節神經（C 3-4），常會出現Horner's syndrome及隔神經麻痺。由於C-3、C-4之標點很難定位，欲獨立阻斷C-3、C-4神經，施術上比較困難，因此，本研究旨發明一種新方法－何氏方法來阻斷C-3、C-4並合併使用斜角肌間臂神經叢阻斷術應用於肩部及高位上臂手術。方法：選擇65位ASA分類I-III，年齡15-65歲，男性42位、女性23位，在1985年過去十個月內，分別接受斜角肌間併何氏方法阻斷術，用以接受肩部及高位上臂手術。C-3、C-4同時阻斷術注射之標點在外頸靜脈與胸鎖乳凸肌交會點之上緣外側。注射方向，以垂直下針為原則，並以碰到C-4椎體橫突外部下緣為止，同時注射局部麻醉藥。麻醉藥的選用：在斜角肌間臂神經叢阻斷術方面選用0.5％ bupivacaine 10 ml與2％lidocaine 10 ml之混合液；在何氏方法C-3、C-4同時阻斷術上選用2％ lidocaine 10ml。結果：六十五個病例裹有3個病例失敗，須改用全身麻醉。成功率95.4％。失敗原因均出在斜角肌間臂神經叢阻斷術只有部份阻斷成功。在65個病例中，有一例原本是安排接受全身麻醉的，但由於在麻醉誘導時發現患者出現嘴嚼肌有強直現象。而無法插管；該患者在三天後改接受斜角肌間臂神經叢併何氏方法C-3、C-4之神經同時阻斷術以完成手術。手術過程中患者之血壓、心電圖、SaO_2之變化與手術前之比較差異不大。在三小時內之手術過程裹均得到令人滿意之結果。結論：斜角肌間臂神經叢阻斷術併C-3、C-4之神經阻斷術不但安全、經濟、且成功率高、有足夠之麻醉範圍，故不失為一種好的麻醉方法。當然為了減低併發症之發生與降低失敗率，還是由有經驗之麻醉醫師來做比較安全。
並列摘要
Background: Brachial plexus block, first performed in 1889 by Halsted, has been widely used for surgery of shoulder and upper third of upper extremity. But the level of block is inadequate for surgery of the deeper tissue. If high volume of local anesthetic (40 ml) is used to block C3-4, complications like Horner's syndrome and phenic nerve palsy would be frequent. The landmark of C-3 and C-4 nerve root is difficult to identify. The purpose of this study was to design a new method to block easily the C-3 and C-4 nerve roots for surgery of shoulder deep tissue. Methods: Sixty-five patients with ASA physical status I-III and age from 15 to 65 yr were studied. They included 42 male and 23 female patients who received interscalene brachial plexus block together with Ho's method of C-3, C-4 block in the space of 10 mon since 1985. The Ho's point which circumscribes the landmark for C3-4 block is a point at which the outer margin of the external jugular vein intersects the sternocleidomastoid muscle. In this technique we punctured the skin with a needle vertically at the chosen point until it touched the anterolateral side of the C-4 transverse process, normally, not deeper than 1.25 cm. This block was usually done for surgery of the shoulder and upper third of upper extremity. We used 0.5% buplvacaine 10 mI combined with 2% lidocaine 10 ml for interscalene brachial plexus block and 2% lidocaine 10 ml only for C3-4 block. Results: Only 3 out of total 65 blocks failed. For these 3 cases we shifted the regimen from nerve block to general anesthesia. The successful rate was 95.4%. One case was initially planned for general anesthesia. However, difficult intubation was encountered due to masseter muscle spasm/rigidity during anesthetic induction. Three days later, this case was successfully anesthetized with this block. BP, EKG, and SaO_2 did not differ preoperatively and intraoperatively. If the operation time is limited to 3 h, the result has always been satisfactory. Conclusions: Interscalene brachial plexus block combined with Ho's method of C3-4 block is technically safe and economical for patients receiving shoulder and proximal third of upper extremity surgery. We must make selection of patients carefully and exclude those whose anatomical landmarks are difficultly identified. As such, good result is expected.