Alemanno Fernando, Capozzoli Giuseppe, Egarter-Vigl Eduard, Gottin Leonardo, Alberto Bartoloni
Department of Anesthesiology, Moro-Girelli Hospital, Don Carlo Gnocchi Foundation, Brescia, Italy.
Reg Anesth Pain Med. 2006 Nov-Dec;31(6):563-8. doi: 10.1016/j.rapm.2006.05.015.
A variety of brachial plexus block techniques via the interscalene approach have been proposed. We describe here a new middle interscalene perivascular approach to the brachial plexus. To verify its effectiveness, we studied 719 patients scheduled for shoulder arthroscopy. Furthermore, to verify the accuracy of the proposed bony landmarks to use in the case of inability to palpate the subclavian artery pulse, we simulated the block on 10 cadavers.
The aim of our technique is to cannulate the neurovascular bundle by inserting a 35-mm needle lateral to the subclavian arterial pulse near the midpoint of the upper edge of the clavicle in a horizontal or slightly cephalad direction while pointing toward the seventh cervical vertebra. If the pulse of the subclavian artery is not palpable, we localize the direction of the needle with reference to 3 bony landmarks (the middle point of the clavicle, the spinous process of C7, and the sternoclavicular joint). By connecting these 3 landmarks, we obtain an angle whose apex lies at the midpoint of the clavicle and its bisecting line points to the plexus. The needle is introduced in the transverse plane of C7.
The block was performed successfully in 692 of 719 cases (96.2%). Horner's syndrome occurred in 93.5% of the cases, arterial puncture with hematoma occurred in <1%, phrenic nerve block without respiratory impairment in 60%, with transient respiratory failure in <1%, and laryngeal nerve block in <1%. The incidence of severe complications or permanent injuries was zero (upper limit 95% confidence interval = 0.4% or 1:250 patients). The technique performed on cadavers showed that the previously mentioned bony landmarks were reliable reference points in reaching the brachial plexus.
Our technique via a middle interscalene approach is easy to perform and provides a high success rate. Even in the absence of a subclavian artery pulse, the easily recognizable bony landmarks reliably guide us in the insertion of the needle. Furthermore, this technique appears to avoid complications that are theoretically possible in other supraclavicular perivascular approaches (pneumothorax) and paravertebral approaches (injection into the vertebral artery and subarachnoidal injection). However, further comparative studies will be required to assess the clinical relevance of the block.
已经提出了多种经肌间沟入路的臂丛神经阻滞技术。我们在此描述一种新的经肌间沟中间血管周围臂丛神经阻滞方法。为验证其有效性，我们研究了719例计划行肩关节镜检查的患者。此外，为验证在无法触及锁骨下动脉搏动时所提出的骨性标志的准确性，我们在10具尸体上模拟了该阻滞操作。
我们技术的目的是通过在锁骨上缘中点附近、锁骨下动脉搏动外侧插入一根35毫米的穿刺针，沿水平方向或略向上头侧方向、同时指向第七颈椎来穿刺神经血管束。如果无法触及锁骨下动脉搏动，我们参照3个骨性标志（锁骨中点、C7棘突和胸锁关节）来确定穿刺针的方向。通过连接这3个标志，我们得到一个角，其顶点位于锁骨中点，其平分线指向臂丛神经。穿刺针在C7的横平面内进针。
719例中有692例（96.2%）阻滞成功。93.5%的病例出现霍纳综合征，动脉穿刺伴血肿发生率<1%，膈神经阻滞无呼吸功能障碍发生率为60%，短暂呼吸衰竭发生率<1%，喉返神经阻滞发生率<1%。严重并发症或永久性损伤的发生率为零（95%置信区间上限 = 0.4%或1:250例患者）。在尸体上进行的该技术操作表明，上述骨性标志是到达臂丛神经的可靠参考点。
我们经肌间沟中间入路的技术操作简便，成功率高。即使在没有锁骨下动脉搏动时，易于识别的骨性标志也能可靠地指导我们进针。此外，该技术似乎避免了其他锁骨上血管周围入路（气胸）和椎旁入路（注入椎动脉和蛛网膜下腔注射）理论上可能出现的并发症。然而，需要进一步的比较研究来评估该阻滞的临床相关性。
