Bouman Esther A C, Sieben Judith M, Balthasar Andrea J R, Joosten Elbert A, Gramke Hans-Fritz, van Kleef Maarten, Lataster Arno
Department of Anesthesiology and Pain Management, Maastricht University Medical Center+, P. Debyelaan 25, 6202 AZ, Maastricht, The Netherlands.
Department of Anatomy and Embryology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
Surg Radiol Anat. 2017 Oct;39(10):1117-1125. doi: 10.1007/s00276-017-1857-4. Epub 2017 Apr 25.
Thoracic paravertebral block (TPVB) may be an alternative to thoracic epidural analgesia. A detailed knowledge of the anatomy of the TPV-space (TPVS), content and adnexa is essential in understanding the clinical consequences of TPVB. The exploration of the posterior TPVS accessibility in this study allows (1) determination of the anatomical boundaries, content and adnexa, (2) description of an ultrasound-guided spread of low and high viscous liquid.
In two formalin-fixed specimens, stratification of the several layers and the 3D-architecture of the TPVS were dissected, observed and photographed. In a third unembalmed specimen, ultrasound-guided posterolateral injections at several levels of the TPVS were performed with different fluids.
TPVS communicated with all surrounding spaces including the segmental dorsal intercostal compartments (SDICs) and the prevertebral space. TPVS transitions to the SDICs were wide, whereas the SDICs showed narrowed transitions to the lateral intercostal spaces at the costal angle. Internal subdivision of the TPVS in a subendothoracic and an extra-pleural compartment by the endothoracic fascia was not observed. Caudally injected fluids spread posteriorly to the costodiaphragmatic recess, showing segmental intercostal and slight prevertebral spread.
Our detailed anatomical study shows that TPVS is a potential space continuous with the SDICs. The separation of the TPVS in a subendothoracic and an extra-pleural compartment by the endothoracic fascia was not observed. Based on the ultrasound-guided liquid spread we conclude that the use of a more lateral approach might increase the probability of intravascular puncture or catheter position.
胸段椎旁阻滞（TPVB）可能是胸段硬膜外镇痛的一种替代方法。深入了解胸段椎旁间隙（TPVS）的解剖结构、内容物及附属结构对于理解TPVB的临床效果至关重要。本研究对TPVS后方可及性的探索能够（1）确定解剖边界、内容物及附属结构，（2）描述超声引导下低粘度和高粘度液体的扩散情况。
在两个经福尔马林固定的标本中，对TPVS的多层结构分层及三维结构进行解剖、观察并拍照。在第三个未防腐处理的标本中，在TPVS的多个层面进行超声引导下的后外侧注射，使用不同的液体。
TPVS与所有周围间隙相通，包括节段性背侧肋间间隙（SDICs）和椎前间隙。TPVS向SDICs的过渡较宽，而SDICs在肋角处向外侧肋间间隙的过渡变窄。未观察到胸内筋膜将TPVS在胸内和胸膜外间隙进行内部分隔。向尾端注射的液体向后扩散至肋膈隐窝，显示节段性肋间及轻微的椎前扩散。
我们详细的解剖学研究表明，TPVS是一个与SDICs连续的潜在间隙。未观察到胸内筋膜将TPVS在胸内和胸膜外间隙进行分隔。基于超声引导下液体的扩散情况，我们得出结论，采用更外侧的进针路径可能会增加血管穿刺或导管置入的概率。
