邱柳基 侯芝琦▲ 羅德興 孫來保
1.廣東省惠州市中心人民醫(yī)院麻醉科,廣東惠州516001;2.中山大學(xué)附屬第一醫(yī)院麻醉科,廣東廣州510080
胸椎旁神經(jīng)阻滯在疼痛治療中的應(yīng)用進(jìn)展
邱柳基1侯芝琦1▲羅德興1孫來保2
1.廣東省惠州市中心人民醫(yī)院麻醉科,廣東惠州516001;2.中山大學(xué)附屬第一醫(yī)院麻醉科,廣東廣州510080
胸椎旁神經(jīng)阻滯(TPVB)是指將局麻藥注射到胸椎體兩側(cè)、出椎間孔的脊神經(jīng)根附近,即胸椎旁間隙,達(dá)到阻滯胸椎旁脊神經(jīng)的目的。該技術(shù)可引起同側(cè)軀體神經(jīng)和交感神經(jīng)阻滯,是單側(cè)條帶狀的節(jié)段性阻滯,所產(chǎn)生的麻醉和鎮(zhèn)痛效果類似于單側(cè)硬膜外阻滯。在所需阻滯平面的較高或較低水平進(jìn)行TPVB可獲得單側(cè)條帶狀的節(jié)段性阻滯,而且不會(huì)引起劇烈的血流動(dòng)力學(xué)改變。最近的Meta分析結(jié)果也表明,相對(duì)于其他鎮(zhèn)痛方法,TPVB能夠提供更好的圍術(shù)期鎮(zhèn)痛且不良反應(yīng)較少。因此,TPVB已經(jīng)成為臨床胸部、乳腺等手術(shù)圍術(shù)期鎮(zhèn)痛的重要方法,且應(yīng)用范圍越來越廣泛。
胸椎旁神經(jīng)阻滯;胸椎旁間隙;脊神經(jīng);圍術(shù)期鎮(zhèn)痛
自1979年Easo等[1]提出胸椎旁神經(jīng)阻滯(TPVB)的概念,TPVB已不僅被用于胸部手術(shù)麻醉,還被用于乳腺手術(shù)、肋骨骨折手術(shù)及上腹部手術(shù)的圍術(shù)期鎮(zhèn)痛、急慢性疼痛管理、良惡性神經(jīng)痛、急性帶狀皰疹后遺神經(jīng)痛等[2]。近年來神經(jīng)刺激儀及超聲技術(shù)的不斷進(jìn)步,使得TPVB技術(shù)得以迅速發(fā)展,使操作變得淺顯而簡(jiǎn)單,成功率大大提高,阻滯效果進(jìn)一步完善,不良反應(yīng)發(fā)生率明顯降低。本文就TPVB在疼痛治療中的應(yīng)用進(jìn)展作一綜述。
TPVB是一種將局麻藥注射到椎旁間隙的技術(shù),此間隙在胸段脊神經(jīng)穿出椎間孔的位置,脊神經(jīng)根出椎間孔后在椎旁間隙內(nèi)走行于胸椎橫突的前下方,因此胸椎橫突是進(jìn)行TPVB的重要骨性標(biāo)志。因?yàn)樾刈蹬蚤g隙(TPVS)與外側(cè)的肋間隙、內(nèi)側(cè)的硬膜外腔以及對(duì)側(cè)的椎旁間隙通過椎前筋膜相延續(xù);所以局麻藥可以向頭側(cè)或尾側(cè)縱向擴(kuò)散,通過對(duì)脊神經(jīng)的直接作用、向外擴(kuò)散對(duì)肋間神經(jīng)的作用及向內(nèi)擴(kuò)散經(jīng)椎間孔進(jìn)入硬外腔起效。
1.1 穿刺方法
1.1.1 阻力消失法阻力消失法為經(jīng)典的椎旁間隙穿刺方法之一,患者取坐位或側(cè)臥位,首先在皮膚上標(biāo)記出棘突的頂端,然后在正中線外側(cè)2.5 cm處畫出脊柱旁矢狀面的標(biāo)示線,常規(guī)消毒后用一根8~10 cm Quincke型針或18G Tuohy型硬膜外針,在相應(yīng)棘突上緣垂直于皮膚進(jìn)針。略從內(nèi)向外的方向進(jìn)針并時(shí)刻注意進(jìn)針的深度,可避免氣胸和誤入椎管內(nèi)的發(fā)生。通常進(jìn)針3~6 cm時(shí)可觸到橫突,觸及橫突后,記錄下皮膚與橫突的距離,然后退針至皮膚并向頭側(cè)或尾側(cè)傾斜,越過橫突后再進(jìn)針1 cm,穿過上位肋橫突外側(cè)韌帶后即有阻力消失的感覺,此即意味著針尖進(jìn)入椎旁間隙[1,3]。
1.1.2 神經(jīng)刺激儀引導(dǎo)法神經(jīng)刺激器引導(dǎo)的TPVB操作簡(jiǎn)單,阻滯平面廣,成功率高,并發(fā)癥少[4-6]。操作時(shí)以神經(jīng)刺激針取代一般的Quincke型針或18G Tuohy型硬膜外針垂直于皮膚進(jìn)針,根據(jù)調(diào)整刺激器電流與肋間肌的收縮狀態(tài)來判斷針尖是否進(jìn)入椎旁間隙,當(dāng)進(jìn)入椎旁間隙時(shí)注入局麻藥。
1.1.3 超聲引導(dǎo)法與傳統(tǒng)的盲穿相比,超聲引導(dǎo)下的TPVB具有許多優(yōu)勢(shì):比如解剖結(jié)構(gòu)、針軸、針尖、導(dǎo)管及局麻藥擴(kuò)散的可視化、麻藥容量小、起效快、作用時(shí)間長(zhǎng)等,并可減少并發(fā)癥和患者的不適[2]。根據(jù)超聲探頭與脊中線的關(guān)系,分為橫向平面內(nèi)和縱向平面內(nèi)兩種超聲引導(dǎo)技術(shù)。橫向平面內(nèi)[7]超聲引導(dǎo)技術(shù)是在預(yù)穿刺間隙水平將超聲探頭垂直放置在脊中線旁,調(diào)整探頭位置至橫突、胸膜及肋間膜清晰可見,然后于探頭外側(cè)1~2 cm處平行于超聲平面向里向內(nèi)進(jìn)針,始終保持針尖、針體在超聲視"范圍內(nèi),適當(dāng)調(diào)整進(jìn)針方向,避開橫突,待針尖進(jìn)入椎旁間隙回抽無(wú)血及空氣即可注入局麻藥??v向平面內(nèi)超聲引導(dǎo)技術(shù)是在預(yù)穿刺間隙水平將超聲探頭平行放置于脊中線旁2.5 cm處,視"內(nèi)可見橫突及壁層胸膜,穿刺針于探頭下1 cm處進(jìn)針,保持整個(gè)針體在視"內(nèi),調(diào)整進(jìn)針方向,避開橫突至壁層胸膜上,刺入椎旁間隙后注藥[2]。
1.2 常用藥物
長(zhǎng)效局麻藥羅哌卡因、布比卡因和左旋布比卡因是TPVB常用的局麻藥,行單次TPVB注射,鎮(zhèn)痛作用均可長(zhǎng)達(dá)18 h[2]。但單次注射時(shí)應(yīng)注意局麻藥向頭尾側(cè)擴(kuò)散不均勻的問題。相對(duì)于穿刺咖,局麻藥向頭側(cè)及尾側(cè)擴(kuò)散的四分位數(shù)間距分別為左側(cè)1個(gè)和3(<4)個(gè)椎體,右側(cè)0.5個(gè)和3(<3.5)個(gè)椎體[8]。有研究顯示[9-10],在局麻藥中加入小劑量的阿片類鎮(zhèn)痛藥或小劑量的α2受體激動(dòng)藥鎮(zhèn)痛作用時(shí)間可以明顯延長(zhǎng)。
2.1 胸部手術(shù)后的疼痛緩解
開胸手術(shù)創(chuàng)傷大,術(shù)中應(yīng)激反應(yīng)及術(shù)后疼痛遠(yuǎn)比一般手術(shù)劇烈,TPVB主要復(fù)合全麻應(yīng)用于開胸手術(shù)。大量研究顯示[7,11-13],在開胸手術(shù)中,TPVB與硬膜外阻滯比較,鎮(zhèn)痛效果及應(yīng)激反應(yīng)(皮質(zhì)醇及血糖)抑制程度均相當(dāng),但TPVB操作簡(jiǎn)單,阻滯成功率高于硬膜外阻滯,因?yàn)樗鼉H阻滯手術(shù)側(cè)軀體椎旁神經(jīng),對(duì)機(jī)體正常的生理影響輕微,不會(huì)引起劇烈的血流動(dòng)力學(xué)改變,且尿潴留、惡心、嘔吐等副作用明顯減少,因此有學(xué)者提出胸科手術(shù)推薦鎮(zhèn)痛方式依次為連續(xù)椎旁阻滯>連續(xù)硬膜外阻滯>鞘內(nèi)注射>肋間神經(jīng)阻滯>靜脈鎮(zhèn)痛>胸膜間鎮(zhèn)痛[14]。胸腔鏡手術(shù)具有創(chuàng)傷小、術(shù)后恢復(fù)快的優(yōu)咖,但因肋間肌肉、神經(jīng)的機(jī)械損傷以及胸腔閉式引流管對(duì)胸膜刺激,使得胸腔鏡手術(shù)后也可達(dá)到中度至重度的疼痛[15-16],嚴(yán)重影響呼吸功能,使通氣效率下降,導(dǎo)致高碳酸血癥、肺不張、肺部感染,甚至呼吸窘迫等肺部并發(fā)癥,因此仍需要有效鎮(zhèn)痛方法減輕術(shù)后疼痛。國(guó)外多項(xiàng)研究表明[17-19],TPVB能抑制手術(shù)的應(yīng)激反應(yīng),有效阻斷手術(shù)創(chuàng)傷及術(shù)后疼痛所致的傷害性刺激,同時(shí)可以減少術(shù)中及術(shù)后阿片類鎮(zhèn)痛藥的使用量,聯(lián)合經(jīng)靜脈自控鎮(zhèn)痛(PCIA)用于胸科手術(shù)術(shù)后可以降低患者48 h內(nèi)靜息或者是咳嗽狀態(tài)下視覺模擬評(píng)分(VAS)。
2.2 多發(fā)肋骨骨折后的疼痛緩解
一項(xiàng)隨機(jī)對(duì)照試驗(yàn)[20]發(fā)現(xiàn)對(duì)多發(fā)肋骨骨折患者,用布比卡因行持續(xù)胸硬膜外和持續(xù)TPVB,兩者均可提供良好的緩解疼痛和改善呼吸功能的作用,表現(xiàn)在可以提高休息和咳嗽時(shí)的VAS評(píng)分、呼吸速率、呼氣流速峰值,但兩者沒有差異。在嗎啡的需求量、布比卡因的輸注時(shí)間、ICU時(shí)間和?。粫r(shí)間以及肺部并發(fā)癥的發(fā)生率方面也沒有差異,但TPVB低血壓的發(fā)生率較低。Ho等[21]指出對(duì)于1~2個(gè)肋骨骨折的健康患者,系統(tǒng)的鎮(zhèn)痛藥即可緩解疼痛,但對(duì)于超過3~4個(gè)的多發(fā)肋骨骨折患者,以往的研究和經(jīng)驗(yàn)再次確定了胸硬膜外、TPVB和肋間神經(jīng)阻滯的鎮(zhèn)痛優(yōu)越性,三者是多發(fā)肋骨骨折鎮(zhèn)痛首選的區(qū)域技術(shù),鎮(zhèn)痛效果相同,但綜合各有獨(dú)特的優(yōu)缺咖,作者更傾向于應(yīng)用TPVB。Buckley等[22]報(bào)道了一位45歲的麻醉醫(yī)師,因右側(cè)6~9肋骨骨折行TPVB,并在T7水平放置導(dǎo)管,在受傷18 d后,拔除導(dǎo)管,沒有任何相關(guān)并發(fā)癥。Murata等[23]報(bào)道了1例61歲多發(fā)單邊肋骨骨折患者在超聲引導(dǎo)下行持續(xù)TPVB后疼痛大為緩解,并可以做深呼吸及走動(dòng)動(dòng)作,且在觀察了15 h后出;回家。TPVB在多發(fā)肋骨骨折中的應(yīng)用日漸增多,尤其是對(duì)門診患者,操作簡(jiǎn)單、效果明顯,大大減輕了患者的疼痛,提高了生活質(zhì)量。
2.3 乳腺手術(shù)的鎮(zhèn)痛
據(jù)Naja等[5]報(bào)道,TPVB復(fù)合全身麻醉在乳腺癌根治術(shù)中能提供完善的鎮(zhèn)痛,患者術(shù)后5 d VAS評(píng)分及惡心嘔吐發(fā)生率明顯降低,鎮(zhèn)痛藥用量及住;天數(shù)也明顯減少。在非腋窩淋巴結(jié)清除的乳腺手術(shù)中單獨(dú)對(duì)T3~6行TPVB即可提供完善的鎮(zhèn)痛[24]。但最新的一份Meta分析報(bào)道指出TPVB適度降低乳腺手術(shù)患者術(shù)中及術(shù)后阿片類藥物用量,減少惡心、嘔吐的發(fā)生率,縮短??;時(shí)間,但在臨床上可能是無(wú)關(guān)緊要的程度[25]。TPVB+芬太尼可改善患者術(shù)后靜止(24、48、72 h)和運(yùn)動(dòng)(24、48、72 h)疼痛,多水平阻滯可提供更好的術(shù)后疼痛控制,但只對(duì)運(yùn)動(dòng)狀態(tài)下(24、48、72 h)有效,所以他們認(rèn)為TPVB可減輕乳腺手術(shù)患者術(shù)后疼痛,降低阿片類藥物的用量,但對(duì)患者恢復(fù)質(zhì)量只有有限的有益影響。從他們?cè)u(píng)估的所有方法中,只有加入芬太尼和執(zhí)行多水平的阻滯才對(duì)改善急性疼痛有關(guān)。
2.4 膽囊切除術(shù)和腎手術(shù)后的疼痛緩解
有研究顯示[10]在腹腔鏡膽囊切除術(shù)中,在神經(jīng)刺激器下行雙側(cè)TPVB(T5~6),注射20 mL混合麻藥,包括2%利多卡因6 mL、加1/20萬(wàn)腎上腺素的2%利多卡因6mL、0.5%布比卡因5mL、芬太尼1mL(50μg/mL)、可樂定2mL(150μg/mL)。復(fù)合全身麻醉,與單純?nèi)檫M(jìn)行相比,患者術(shù)后早期(72 h)疼痛評(píng)分及鎮(zhèn)痛藥使用量(36 h)也明顯減少,惡心、嘔吐發(fā)生率均顯著降低。Moawad等[26]發(fā)現(xiàn)在腎臟手術(shù)中TPVB術(shù)后鎮(zhèn)痛效果與硬膜外阻滯單次注射基本相當(dāng),鎮(zhèn)痛時(shí)間長(zhǎng)達(dá)24 h,術(shù)中的血流動(dòng)力學(xué)更為穩(wěn)定,因此認(rèn)為在共存循環(huán)系統(tǒng)疾病的患者更適用TPVB。
3.1 絕對(duì)禁忌證
①穿刺部位皮膚、軟組織有感染性疾??;②膿胸或者全身膿毒血癥;③對(duì)局麻藥過敏;④腫瘤占據(jù)胸椎旁間隙。
3.2 相對(duì)禁忌證
有出血傾向(如凝血障礙、正在接受抗凝治療等情況)。
TPVB操作簡(jiǎn)便,成功率高,鎮(zhèn)痛效果好,不良反應(yīng)少,是一種安全、有效、簡(jiǎn)單的鎮(zhèn)痛方法,在胸部和上腹部鎮(zhèn)痛方面發(fā)展前景廣闊。隨著神經(jīng)刺激器尤其是近年來超聲引導(dǎo)技術(shù)廣泛用于區(qū)域神經(jīng)阻滯,PTVB技術(shù)進(jìn)入可視化,變得淺顯而簡(jiǎn)單,大大提高了穿刺的準(zhǔn)確性和安全性,降低了并發(fā)癥的發(fā)生率。國(guó)內(nèi)外陸續(xù)有關(guān)于超聲引導(dǎo)TPVB的臨床應(yīng)用的報(bào)道[27-30],結(jié)果提示:超聲引導(dǎo)TPVB定位準(zhǔn)確,操作成功率高,用于開胸患者術(shù)后能有效抑制術(shù)后疼痛導(dǎo)致的強(qiáng)烈應(yīng)激反應(yīng),鎮(zhèn)痛效果好,能明顯減少術(shù)后靜脈鎮(zhèn)痛藥尤其是阿片類鎮(zhèn)痛藥的用量,降低術(shù)后各種不良反應(yīng)及并發(fā)癥的發(fā)生率。有研究顯示,TPVB對(duì)術(shù)后PCIA有增強(qiáng)作用,原因可能為TPVB的超前鎮(zhèn)痛[31]。為了提高術(shù)后鎮(zhèn)痛的質(zhì)量及術(shù)后患者的安全性和生活質(zhì)量,目前臨床越來越多的人用TPVB聯(lián)合PCIA用于胸科手術(shù)術(shù)后鎮(zhèn)痛治療。TPVB用于慢性疼痛治療方面已經(jīng)取得一定成果,但對(duì)是否可以減少術(shù)后機(jī)體免疫抑制,預(yù)防病理性疼痛,從而減少不良反應(yīng),有待進(jìn)一步臨床研究。
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App lication progress of thoracic paravertebral block in the treatment of pain
QIU Liuji1HOU Zhiqi1▲LUO Dexing1SUN Laibao2
1.Department of Anesthesiology,Huizhou Central People's Hospital,Guangdong Province,Huizhou 516001,China;
2.Department of Anesthesiology,the First Affiliated Hospital of Zhongshan University,Guangdong Province,Guangzhou
510080,China
Thoracic paravertebral block(TPVB)refers to the local anesthetic injection inserted on both sides of the thoracic vertebra,foramen intervertebrale near spinal nerve roots,that is thoracic paravertebral space block,so as to achieve the purpose of blocking the nerve of thoracic spinal cord.This technique can cause the block of same side somatic nerve and sympathetic nerve,which is segmental block of a single strip,the effect of anesthesia and analgesia is similar to that of unilateral epidural block.TPVB at the higher or lower level of the block plane can get the block of a single stripped segmental block,which can not cause severe hemodynamic changes.Recent Meta analysis also showed that,compared with other analgesicmethods,TPVB can provide better perioperative analgesia and less adverse reactions.Therefore,TPVB has become an importantmethod of clinical chest,breast surgery and other perioperative analgesia and it hasmore extensive range of application.
Thoracic paravertebral nerve block;Thoracic paravertebral space;Spinal nerve;Perioperative analgesia
R614.2
A
1673-7210(2016)05(c)-0064-04
2016-01-13本文編輯:張瑜杰)
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