Heller Axel R, Fuchs Alexander, Rössel Thomas, Vicent Oliver, Wiessner Diana, Funk Richard H W, Koch Thea, Litz Rainer J
Clinic of Anesthesiology and Intensive Care Medicine, Carl Gustav Carus University Hospital, University of Technology, Dresden, Germany.
Anesthesiology. 2009 Sep;111(3):525-32. doi: 10.1097/ALN.0b013e3181af64b6.
Traditional methods for approaching the lumbar plexus from the posterior rely on finding the intersection of lines that are drawn based on surface landmarks. These methods may be inaccurate in many cases. The aim of this study was to determine the accuracy of these traditional approaches and determine if modifications could increase their accuracy.
The lumbar plexus region of 48 cadavers (78 +/- 7 yr; 167 +/- 6 cm; 60 +/- 13 kg; men/women: 29/19) was dissected, and relevant anatomic structures were marked. Needle proximity curves were obtained by triangulation for the five traditional approaches and for vectors from the posterior superior iliac spine directed towards the lumbar spinous processes of L3 and towards L4.
Proximity curves (mean +/- SD) showed that except Pandin's approach (13 +/- 5 mm too medial), all others were too lateral: Winnie (17 +/- 8 mm), Chayen (8 +/- 5 mm), Capdevila (6 +/- 4 mm), and Dekrey (17 +/- 6 mm). Further, the curves had a narrow parabolic shape and thus a narrow margin of error. Both diagonal vectors had a significantly higher proximity to the lumbar plexus as compared with traditional approaches with a wide parabola, indicating more error tolerance. Using the vector posterior superior iliac spine-L3 with a length between 1/6-1/3 (= 16-22 mm) of the distance posterior superior iliac spine-L3, a proximity to the lumbar plexus < 5.0 +/- 0.3 mm was reached.
Improvement of both the proximity and the margin of error is possible by using diagonal landmark vectors. Relying on the position of the posterior superior iliac spine eliminates the sex and sided differences and individual body size, which can be problematic if firm metric distances are used in determining the entry point.
传统的从后方入路至腰丛的方法依赖于根据体表标志绘制的线的交点。这些方法在许多情况下可能不准确。本研究的目的是确定这些传统入路的准确性，并确定修改是否可以提高其准确性。
解剖48具尸体（78±7岁；167±6厘米；60±13千克；男/女：29/19）的腰丛区域，并标记相关解剖结构。通过三角测量法获得了五种传统入路以及从髂后上棘指向L3和L4腰椎棘突的向量的针接近曲线。
接近曲线（平均值±标准差）显示，除了潘丁入路（向内13±5毫米）外，其他所有入路都过于靠外：温尼入路（向外17±8毫米）、查延入路（向外8±5毫米）、卡德维拉入路（向外6±4毫米）和德克雷入路（向外17±6毫米）。此外，曲线呈狭窄的抛物线形状，因此误差范围较窄。与具有宽抛物线的传统入路相比，两个对角线向量与腰丛的接近度明显更高，表明误差容忍度更高。使用长度为髂后上棘-L3距离的1/6-1/3（=16-22毫米）的髂后上棘-L3向量，与腰丛的接近度<5.0±0.3毫米。
使用对角线体表标志向量可以提高接近度和误差范围。依靠髂后上棘的位置消除了性别和侧别差异以及个体身体大小的影响，如果在确定进针点时使用固定的测量距离，这些因素可能会带来问题。
