Mariano Edward R, Loland Vanessa J, Ilfeld Brian M
Department of Anesthesiology, University of California, San Diego, San Diego, CA 92103-8770, USA.
Reg Anesth Pain Med. 2009 Jan-Feb;34(1):60-3. doi: 10.1097/AAP.0b013e3181933af7.
The posterior approach to the brachial plexus--or cervical paravertebral block--has advantages over the anterolateral interscalene approach, but concerns regarding "blind" needle placement near the neuraxis have limited the acceptance of this useful technique. We present a technique to place an interscalene perineural catheter that potentially decreases neuraxial involvement with the use of ultrasound guidance.
A 55-year-old man scheduled for total shoulder arthroplasty underwent placement of an interscalene perineural catheter. The posterior approach was selected to avoid the external jugular vein and anticipated sterile surgical field. Under in-plane ultrasound guidance, a 17-gauge insulated Tuohy-tip needle was inserted between the levator scapulae and trapezius muscles, and guided through the middle scalene muscle, remaining less than 2 cm below the skin throughout. Deltoid and biceps contractions were elicited at a current of 0.6 mA, and a 19-gauge stimulating catheter was advanced 5 cm beyond the needle tip, without a concomitant decrease in motor response.
The initial 40 mL 0.5% ropivacaine bolus via the catheter resulted in unilateral anesthesia typical of an interscalene block; and subsequent perineural infusion of 0.2% ropivacaine was delivered via portable infusion pump through postoperative day 4.
Continuous interscalene block using an ultrasound-guided posterior approach is an alternative technique that retains the benefits of posterior catheter insertion, but potentially reduces the risk of complications that may result from blind needle insertion.
臂丛神经后入路——即颈旁神经阻滞——相较于前外侧斜角肌间沟入路具有优势，但由于担心在神经轴附近“盲目”进针，限制了这一实用技术的应用。我们介绍一种在超声引导下放置斜角肌间沟神经周围导管的技术，该技术可能会减少神经轴受累情况。
一名计划行全肩关节置换术的55岁男性接受了斜角肌间沟神经周围导管置入术。选择后入路以避开颈外静脉和预期的无菌手术区域。在平面内超声引导下，将一根17号绝缘Tuohy头针插入肩胛提肌和斜方肌之间，并引导其穿过中斜角肌，全程保持在皮肤下方不到2 cm处。在0.6 mA电流下引发三角肌和肱二头肌收缩，将一根19号刺激导管推进至针尖以外5 cm处，同时运动反应未减弱。
通过导管首次推注40 mL 0.5%罗哌卡因产生了典型的斜角肌间沟阻滞单侧麻醉效果；术后第4天，通过便携式输液泵经神经周围持续输注0.2%罗哌卡因。
采用超声引导后入路的连续斜角肌间沟阻滞是一种替代技术，保留了后入路导管置入的优点，但可能降低盲目进针所致并发症的风险。
