Ho C S, Wong N P
Department of Anesthesiology, Taiwan Adventist Hospital, Taipei Medical College Hospital.
Acta Anaesthesiol Sin. 1996 Sep;34(3):135-40.
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.
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% bupivacaine 10 ml combined with 2% lidocaine 10 ml for interscalene brachial plexus block and 2% lidocaine 10 ml only for C3-4 block.
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 SaO2 did not differ preoperatively and intraoperatively. If the operation time is limited to 3 h, the result has always been satisfactory.
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 difficulty identified. As such, good result is expected.
臂丛神经阻滞由霍尔斯特德于1889年首次实施，已广泛应用于肩部及上肢上三分之一部位的手术。但该阻滞平面对于更深层组织的手术而言并不充分。若使用大容量局部麻醉药（40毫升）阻滞C3 - 4，霍纳综合征和膈神经麻痹等并发症会频繁发生。C3和C4神经根的体表标志难以识别。本研究的目的是设计一种新方法，以便在肩部深层组织手术时能轻松阻滞C3和C4神经根。
研究了65例美国麻醉医师协会（ASA）身体状况分级为I - III级、年龄在15至65岁的患者。其中包括42例男性和23例女性患者，自1985年起，他们在10个月内接受了肌间沟臂丛神经阻滞及何氏C3、C4阻滞法。何氏点是颈外静脉外缘与胸锁乳突肌相交处，它界定了C3 - 4阻滞的体表标志。在该技术中，我们在选定的点垂直进针直至触及C4横突前外侧，通常深度不超过1.25厘米。此阻滞通常用于肩部及上肢上三分之一部位的手术。我们使用0.5%布比卡因10毫升联合2%利多卡因10毫升进行肌间沟臂丛神经阻滞，仅使用2%利多卡因10毫升进行C3 - 4阻滞。
65例阻滞中仅3例失败。对于这3例，我们将麻醉方案从神经阻滞改为全身麻醉。成功率为95.4%。有1例最初计划行全身麻醉。然而，麻醉诱导期间因咬肌痉挛/强直导致插管困难。三天后，该例使用此阻滞成功麻醉。术前和术中血压、心电图及脉搏血氧饱和度（SaO2）无差异。若手术时间限制在3小时以内，结果一直令人满意。
对于接受肩部及上肢近端三分之一部位手术的患者，肌间沟臂丛神经阻滞联合何氏C3 - 4阻滞法在技术上是安全且经济的。我们必须仔细挑选患者，排除那些体表标志难以识别的患者。如此，有望获得良好的效果。
