超声引导下老年患者硬膜外穿刺二例

2019-02-20 费昱达 崔旭蕾 临床麻醉学杂志

例1患者,女,80岁,身高165 cm,体重56kg,BMI 21kg/m2,拟行“左侧人工股骨头置换术”既往合并严重骨质疏松症,体格检查脊柱无明显异常,告知患者风险后同意接受椎管内麻醉,常规三导联ECG、无创血压、SpO2监护,开放静脉通路后辅以咪达唑仑1mg镇静,面罩吸氧,患者取左侧卧位,常规消毒铺单后,住院医师采用传统体表定位法行正中入路L3~4棘突间隙穿刺2次未成功,由上级麻醉医师接手,尝

例1患者,女,80岁,身高165 cm,体重56kg,BMI 21kg/m2,拟行“左侧人工股骨头置换术”既往合并严重骨质疏松症,体格检查脊柱无明显异常,告知患者风险后同意接受椎管内麻醉,常规三导联ECG、无创血压、SpO2监护,开放静脉通路后辅以咪达唑仑1mg镇静,面罩吸氧,患者取左侧卧位,常规消毒铺单后,住院医师采用传统体表定位法行正中入路L3~4棘突间隙穿刺2次未成功,由上级麻醉医师接手,尝试对同一间隙及L2~3棘突间隙进行正中入路及旁入路穿刺后均未成功,决定行超声引导下硬膜外穿刺。
 
患者保持左侧卧位,便携式超声(CX-50)探头(2~5MHZ凸阵探头)无菌处理后行脊柱超声扫描,横切面下L2~3棘突间隙和L3~4棘突间隙均可见关节突、横突,未见高回声且相互平行的“前联合体”“后联合体”(“前联合体”是由椎体、腹侧硬脊膜和后纵韧带构成的超声下的高回声影,后联合体”由黄韧带、背侧硬脊膜构成的超声下的高回声影),右侧旁矢状面倾斜位下L2~3棘突间隙和L3~4棘突间隙均可见椎板、高回声且相互平行的“前联合体”“后联合体”使用BD麻醉穿刺包,17G硬膜外穿刺针采用平面内法在旁矢状面倾斜位下L2~3间隙进行实时引导穿刺,左手持探头,右手持穿刺针由尾端向头侧穿刺,确定针尖刺破黄韧带后改为双手持穿刺针连接无阻力注射器继续进针,寻找阻力消失感,确定针尖进入硬膜外腔后用25G腰麻针刺破硬脊膜可见脑脊液流出,注入重比重布比卡因10mg,退出腰麻针,顺利置入硬膜外导管。转为平卧位后,测试感觉阻滞平面可达到T8,麻醉效果良好,满足手术条件。手术顺利,术后随访48h,患者无不适。
 
例2患者,男,78岁,身高170 cm,体重58kg,BMI20kg/m2,双膝骨关节炎,拟行“右侧人工膝关节表面置换术”既往高血压10年,阻塞性通气功能障碍(FEW712%\FVC842%),否认其他慢性疾病及手术外伤史,体格检查脊柱未及明显异常,拟行腰^硬联合麻醉,经患者知情同意后,决定行超声实时引导下穿刺。患者入室后取左侧卧位,行监护、开放静脉通路、吸氧、镇静等同前述。便携式超声探头(2~5MHz凸阵探头)扫描显示L3~4棘突间隙横切面下仅可见关节突、横突,未见高回声且相互平行的“前联合体”“后联合体”L2~3棘突间隙横切面下可见关节突、横突以及高回声且相互平行的“前联合体”“后联合体”右侧旁矢状面倾斜位下L2~3棘突间隙和L3~4棘突间隙均可见椎板、高回声且相互平行的“前联合体”“后联合体”采用平面内法在旁矢状面倾斜位下L2~3棘突间隙进行实时引导穿刺操作同上述。转为平卧,未予硬膜外腔注药,术后随访48h,患者无不适。
 
讨论
 
老年患者常因退行性病变、椎体压缩、椎间隙缩小、骨赘形成、腰椎弯曲度下降等原因1,造成体表定位困难(29%)穿刺失败率高(116%)。棘突、关节突的增生以及棘上韧带的钙化也在一定程度上给穿刺带来诸多的困难。
 
超声定位及实时引导技术的发展提高了困难椎管内麻醉的穿刺成功率,减少穿刺并发症的发生率。既往研究证实,通过不同平面的超声成像来判断穿刺难度、选择穿刺点和入路,制定更精准的穿刺策略可以提高老年患者椎管内麻醉时一次穿刺的成功率。大量研究证实了超声扫描在硬膜外穿刺中的应用价值,借助超声的可视化技术可以获得椎管内穿刺相关的解剖信息,定位穿刺点、指导穿刺角度和方向、预估穿刺深度等;并描述了双人操作的超声实时引导正中入路硬膜外穿刺技术。实时引导穿刺一定程度上克服穿刺点定位的不准确和穿刺角度可能存在的偏差。
 
本文2例患者,第1例为未预计的穿刺困难,第2例为超声扫描提示可疑的穿刺困难,两者均采用上述Karmakar等所用方法,在超声实时引导下旁矢状倾斜面成功完成椎管内穿刺。与此同时,在对两例患者在进行横切面超声扫描时均在不同间隙出现棘突间隙成像欠佳、未见高回声且相互平行的“前联合体”“后联合体”的情况,推测可能是由于棘间韧带钙化产生声影导致其下方的结构无法清晰成像所致。目前,尚未见有关棘间韧带钙化超声成像特性的相关报道,本文上述所见与患者实际棘突间隙组织学改变及其临床应用价值有待于进一步研究。既往超声辅助定位选择穿刺点时,亦尽量选择成像清晰的椎间隙进行,在一定程度上也避免由可疑棘间韧带钙化引起的穿刺困难。上述2例患者选择旁矢状面进行穿刺,从而很好地避开了棘上韧带和棘间韧带。
 
需要指出的是,目前确定超声实时引导下硬膜外穿刺成功的金标准仍是阻力消失法。此外,实时引导的旁矢状面倾斜位下的平面内椎管穿刺技术常要求操作者具备较高的超声引导区域操作技巧,包括对于相关解剖结构的超声图像识别能力以及协调控制穿刺针和探头的操纵能力。即使对于经验丰富的操作者而言,获取并且维持穿刺针和椎板间声窗超声束的稳定性仍然面临一定的挑战。随着超声设备和技术的快速发展、GPS导航针定位等技术的出现,有望在一定程度上降低操作的难度、利于该技术的推广。
 
本文报道两例患者初步提示,对于老年患者进行常规的脊柱超声扫描,根据成像结果制定穿刺策略有可能提高穿刺成功率;实时引导的旁矢状位倾斜面下的平面内椎管穿刺技术是安全可行的。鉴于此,有必要行更大样本量的随机对照研究,以验证该技术在中国老年患者硬膜外穿刺中的应用价值。
 
原始出处:

费昱达,崔旭蕾.超声引导下老年患者硬膜外穿刺二例[J].临床麻醉学杂志,2018,34(01):98-99.

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