超声引导三叉神经阻滞用于带状疱疹痛治疗一例

2020-05-26 曹雪芹 梅伟 临床外科杂志

病人,男,77岁。左侧面部、颞顶部疼痛伴起疹1个月余。入院诊断为带状疱疹后神经痛,拟行三叉神经阻滞术。取仰卧位,口含纱布卷,保持张口姿势,头稍偏向对侧(图1)。

病人,男,77岁。左侧面部、颞顶部疼痛伴起疹1个月余。入院诊断为带状疱疹后神经痛,拟行三叉神经阻滞术。取仰卧位,口含纱布卷,保持张口姿势,头稍偏向对侧(图1)。


图1 病人体位及超声探头放置位置

将高频超声探头(GE Healthcare,6~13MHz)放置于颧弓下缘,下颌骨上方,显示翼突外侧板(lateral pterygoid plate,LPP),探头向头端滑动,确定LPP顶部,其前端即为翼腭窝开口翼突上颌裂(pterygomaxillary fissue,PMF)。利用彩色多普勒协助辨认翼腭窝内上颌动脉,亦可以此为标志,采用由前向后的平面内穿刺技术将18G穿刺针穿经翼外肌(lateral pterygoid muscle,LPM)进入翼腭窝、上颌动脉下方(图2),注射地塞米松1mg+1%利多卡因混合液3ml阻滞上颌神经。


图2 超声引导上颌神经阻滞。红色箭头显示穿刺针方向Ant:前,Post:后,LPP:翼突外侧板,LPM:翼外肌,MT:上颌结节,TM:颞肌

穿刺针退至皮下,改变穿刺针方向,采用由前向后的平面内穿刺技术穿透LPM进入LPP顶端后缘,注射地塞米松1mg+1%利多卡因混合液3ml阻滞下颌神经(图3)。


图3 超声引导下颌神经阻滞。黄色箭头显示穿刺针方向Ant:前,Post:后,LPP:翼突外侧板,LPM:翼外肌,MT:上颌结节,TM:temporalismuscle颞肌

5分钟后观察镇痛效果,病人诉疼痛症状缓解70%~80%,利多卡因诊断实验阳性,遂运用同样方法分别于两点注射0.375%罗哌卡因2.5ml。阻滞后即刻病人疼痛缓解率达80%。术后第2天随访,病人左侧颞部及面部疼痛明显减轻,疼痛缓解率90%左右,无其他不适,继续口服药物治疗。术后1周随访,病人诉疼痛较术后稍加重,但仍较术前明显缓解,缓解率约为50%~60%;术后1个随访,病人诉疼痛缓解率仍为50%~60%。嘱再次入院巩固治疗。

讨论

三叉神经阻滞是三叉神经痛常用的微创治疗方法。既往常用X线透视和CT引导定位三叉神经,但费用高、不能实时调针,操作人员需暴露于放射线。超声检查除了实时、可视化引导穿刺外,还可清晰显示周围神经、血管、骨质、肌肉等关键解剖结构,更有利于判断神经的解剖定位,设计安全的穿刺路径;同时便携、避免放射线暴露亦是其优点。超声引导下经翼腭窝三叉神经阻滞方法目前国内外虽有零星报道,但均为于翼腭窝内单次注射局麻药阻滞上颌神经。

三叉神经上颌支经由圆孔出中颅窝,穿经翼腭窝(pterygopalatine fossa,PPF)后分成多个分支,包括上腭神经、颧神经、上牙槽神经等。下颌神经经卵圆孔出中颅窝进入颞下窝,走行于LPP后缘分出多个分支,包括耳颞神经、舌神经、下牙槽神经等。从上述解剖结构可知,单纯通过注射局麻药至翼腭窝肯定会存在下颌神经阻滞不全的情况,因此对于下颌神经病变严重的病人,同时行下颌神经阻滞很有必要。

Nader等最早报道在临床上以翼外肌和上颌动脉为解剖标志行翼腭窝三叉神经阻滞,可成功阻滞三叉神经的三个分支。在操作过程中,Nader等采用从后往前穿刺路径。但该穿刺路径穿刺针有可能进入腮腺,面神经损伤风险较高。并且由于口未张开,PPF会被下颌骨冠状突隐盖,增加超声显示难度,针尖不能准确进入翼腭窝,从而影响阻滞效果。Kampitak等在尸体解剖上发现,运用Nader等提出的方法,穿刺针针尖多位于LPP上的脂肪组织,局麻药很难完全浸入PPF。同时,Kampitak等运用本报道的方法在尸体上注入美蓝发现上颌神经、翼腭神经节、上腭神经大小支、上牙槽神经中后支均被染色。证明此方法阻滞上颌神经效果确切。

本报道中,穿刺针由前往后进针,避免穿经腮腺,使面神经损伤风险降低。本方法中清楚显示LPP是关键,为避免LPP被下颌骨冠状突所隐盖,操作过程中病人需始终保持张口姿势,这给病人带来明显不适。在本操作中,病人含纱布卷,这样既可使病人保持张口姿势,又可以减轻病人的不适感。由解剖可知,在上颌神经进入翼腭窝之前,下颌神经已经分出,但其进入颞下窝,走行于LPP后缘,这是我们采用一针穿刺两点注药的方法,同时阻滞上颌神经和下颌神经的解剖基础。

Kampitak等尸体解剖证明通过LPP途径进行下颌神经阻滞具有较高的准确性和可行性。本文所报道的技术应用于临床经验有限,目前国内外均未见大样本研究报道。今后应进行大样本研究,以确定本方法的优越性。虽然超声下可较好显示神经周围结构、骨质LPP及PPF等关键结构,但上颌神经及下颌神经并不能显示。因此,该操作须由有一定经验的医师完成,同时需全程显示针尖,避免造成严重后果。

原始出处:

曹雪芹,梅伟.超声引导三叉神经阻滞用于带状疱疹痛治疗一例[J].临床外科杂志,2019,27(06):468-469.

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