發(fā)布時間：2018-05-19 06:07

  本文選題：臂前群肌 + 胸上肢肌��； 參考：《遵義醫(yī)學院》2017年碩士論文

【摘要】：目的:借助骨性標志和螺旋CT掃描,準確地定位臂前群肌和胸上肢肌神經入肌點(N點)和肌內神經密集區(qū)中心(CINDR)這些靶點在體表的位置和穿刺深度,為治療這兩群肌肌痙攣的肌外化學神經溶解術和肌內化學神經阻滯術提供形態(tài)學指導。方法:1.無神經肌肉疾病史、上肢與胸部關節(jié)變形的中國成年尸體22具(男,16;女,6),其中10具教學使用過尸體用于大體觀察,收集的12具尸體用于靶點定位。仰臥,保持解剖學體位。2.臂前群肌肌外及肌內神經阻滯靶點定位的參考線設計:設計經皮膚連接肩峰至頸靜脈切跡最下點間的曲線為喙肱肌靶點的橫向參考線(H1),肱骨外上髁至內上髁間的曲線為肱二頭肌和肱肌支靶點的橫向參考線(H2);肩峰至肱骨外上髁間的曲線為縱向參考線(L)。3.胸上肢肌肌外及肌內神經阻滯靶點定位的參考線設計:緊貼皮膚連接頸靜脈切跡最下點到劍胸結合處的曲線為胸上肢肌阻滯靶點的L線,連接肩峰至頸靜脈切跡最下點的曲線為胸大肌和胸小肌靶點的橫向參考線(H1);經N點連接腋前線與腋后線的曲線為前鋸肌靶點的橫向參考線(H2)。4.Sihler’s染色法顯示肌內神經末梢密集區(qū)(INDR)和CINDR。5.解剖暴露N點并確定對側肌塊的CINDR,涂抹硫酸鋇,螺旋CT掃描,三維重建。N點和CINDR在體表上的投影點定為P,P點通過N點或CINDR后投射至肢體相反側體表上的點為P'。將經P的垂線與H線、經P的水平線與L線的交點分別記為PH和PL。Syngo系統下測量與確定PH和PL在H和L線上的百分位置及靶點的深度。6.統計學處理。結果:1.大體解剖發(fā)現:臂前群各肌常有1個N點。胸上肢肌中,胸大肌的胸外側神經支常有2個N點,但彼此靠近,胸內側神經支僅1個N點;胸小肌有1個N點;胸長神經主干末端從第5肋間隙入肌。這些肌的肌門處均有血管伴行。2.Sihler’s肌內神經染色所示的INDR:喙肱肌、肱二頭肌、肱肌、胸大肌、胸小肌內的INDR個數分別為3、2、2、2和1,前鋸肌各肌齒內均有1個INDR。3.臂前群肌各N點在體表的位置與深度:肌皮神經喙肱肌支N點的PH位于其H1線的(18.38%±1.78)%處。肱二頭肌短頭支、長頭支和肱肌支N點的PH分別位于其H2線的(56.85%±4.41)%、(52.81%±4.36)%和(57.52%±4.22)%處。它們的PL分別位于其L線的(24.86%±4.52)%、(50.20%±4.89)%、(55.91%±3.89)%和(64.31%±4.32)%處。它們的穿刺深度分別位于其PP'線的(23.16%±2.73)%、(24.68%±2.55)%、(26.32%±3.20)%和(38.19%±3.36)%處;4.胸上肢肌各N點在體表的位置與深度:胸外側神經胸大肌支、胸內側神經胸大肌支和胸內側神經胸小肌支N點的PH分別位于其H1線的(47.83±1.75%)、(32.31±4.18)%(男性)和(34.31±3.03)%處;胸長神經前鋸肌支N點的PH位于其H2線的(63.77±3.33)%處。它們的PL分別位于其L線的(-9.84±1.62)%、(36.16±4.51)%(男性)、(2.44±1.16)%和(73.84±2.36)%處。胸外側神經胸大肌支、胸內側神經胸大肌支和胸內側神經胸小肌支N點的深度分別位于其PP'線的(17.76±2.84)%、(17.53±3.14)%(男性)和(25.51±2.31)%處。胸長神經前鋸肌支N點的深度為(1.63±0.24)cm。5.臂前群肌各CINDR在體表的位置與深度:喙肱肌CINDR1、2和3的PH位于H1線的(24.22±1.49)%、(18.89±1.49)%和(8.15±1.14)%處,PL分別位于其L線的(21.37±2.48)%、(31.78±2.32)%和(30.07±1.12)%處,穿刺深度分別位于其PP'線的(22.81±1.59)%、(26.76±1.32)%和(27.99±2.04)%處。肱二頭肌CINDR1和2的PH分別位于其H2線的(49.68±2.03)%和(40.28±2.58)%處,L線的(56.60±3.35)%和(67.63±3.29)%處,穿刺深度分別位于其PP'線的(14.79±1.35)%和(17.45±1.28)%處。肱肌CINDR1和2的PL分別位于其H2線的(48.34±3.25)%和(52.45±3.47)%處,L線的(71.30±3.06)%和(81.62±4.70)%處。穿刺深度分別位于PP'線的(34.03±1.10)%和(30.26±3.14)%處。6.胸上肢肌各CINDR在體表的位置與深度:胸大肌CINDR1和2的PH分別位于其H1線的(41.95±2.72)%和(55.88±2.06)%處,PL分別位于其L線的(-3.87±0.92)%和(25.29±2.73)%處。穿刺深度分別位于PP'線的(5.23±0.94)%和(6.75±0.98)%處。胸小肌CINDR的PH位于其H1線的(32.58±3.77)%處,PL位于L線的(-7.13±0.99)%處,穿刺深度位于PP'線的(13.73±2.27)%處。前鋸肌第七肌齒CINDR的PH位于H2線的(84.08±1.77)%處,PL位于L線的(100±1.86)%處,穿刺深度為(1.86±0.35)cm。結論:1.同一塊肌的肌外神經入肌點的體表位置和穿刺深度與肌內神經密集區(qū)中心不同;2.這些神經入肌點和肌內神經密集區(qū)的準確定位可提高臂前群肌和胸上肢肌痙攣肌外神經溶解術和肌內化學神經阻滯術的效率與療效;3.以神經入肌點為靶點治療女性患者胸大肌痙攣時,宜阻滯胸外側神經支入肌點。4.除前鋸肌優(yōu)先選擇肌外神經入肌點外,其它肌可任意選擇肌外或肌內靶點阻滯。
[Abstract]:Objective: with the help of bone markers and spiral CT scan, the location and depth of the target points on the body surface and the depth of the center of the intramuscular nerve dense area (N) and the intramuscular nerve dense area (CINDR) are accurately located in the two groups of muscle spasticity and intramuscular chemical nerve block for the treatment of these groups of muscle spasms. Methods: 1. the 22 Chinese adult cadavers (male, 16; female, 6) of the history of the deformity of the upper and chest joints (male, 16, female, 6) were used in 10 teaching, and 12 corpses were used for target location. Supine, the reference line was designed to maintain the location of the target location of the.2. arm anterior group muscle and the intramuscular nerve block. The transverse reference line (H1) for the target of the beak brachial muscle was designed by the curve of the skin connecting the shoulder peak to the jugular vein. The curve between the epicondyle and the inner condyle of the humerus was the lateral reference line (H2) of the biceps and brachial branches. The curve between the shoulder and the outer condyle of the humerus was the longitudinal reference line (L).3. outside of the upper limb of the chest and the intramuscular nerve resistance. The design of the reference line of the stagnation target location: the L line that closely connects the lower point of the jugular vein incisor to the combination of the sword chest is the target of the thoracic upper limb muscle block. The curve connecting the acromion to the jugular notch is the lateral reference line (H1) for the pectoralis major and the pectoralis minor targets. The curve of the front and the rear lines of the axillary front and the axillary line via N points is the target of the anterior sawing muscle. The point of the transverse reference line (H2).4.Sihler 's staining showed that the intramuscular nerve end dense area (INDR) and the CINDR.5. anatomy exposed N points and determined the CINDR of the contralateral muscle mass, smear barium sulfate, spiral CT scan, the three-dimensional reconstruction of.N points and CINDR on the body surface, the projection point was determined to be P, P points passed the dots or projected to the opposite side of the body surface. The intersection of the P's vertical line and the H line, the intersection of the horizontal line of P and the L line as the PH and PL.Syngo system, respectively, to measure and determine the depth of the percentile and target depth of the PH and PL on the H and L lines. Results: 1. gross anatomy found that there are 1 N points in the muscles of the anterior arm group. In the chest upper limbs, the thoracic lateral nerve branches of the pectoralis major muscle often have 2 points, But close to each other, the nerve branches of the medial chest were only 1 N points; the pectoralis minor muscle had 1 N points; the end of the trunk of the thoracic nerve was from the fifth rib space into the muscle. There were the INDR: beak brachial muscles, the biceps brachii, the brachii muscle, the pectoralis major and the pectoralis minor muscle, respectively, 3,2,2,2 and 1, and the anterior sasawing muscles. The position and depth of each N point in the body surface of 1 INDR.3. arm anterior group muscles in the teeth: the PH of the N point of the brachial muscle branch of the musculocutaneous nerve beak is located at (18.38% + 1.78)% of its H1 line. The PH of the biceps brachii muscle, the long head and the N point of the brachial muscle is located at (56.85% + 4.41)%, (52.81% + 4.36)% and (57.52% + 4.22)% at its H2 line, respectively. Their PL is located on its L line, respectively. (24.86% + 4.52)%, (50.20% + 4.89)%, (55.91% + 3.89)% and (64.31% + 4.32)%. Their puncture depth was located (23.16% + 2.73)%, (24.68% + 2.55)%, (24.68% + 2.55)%, (26.32% +)% and (55.91%)%, respectively. The position and depth of each N point in the upper limb muscles of the chest: the lateral thoracic pectoralis major muscle branch, the pectoralis pectoralis major muscle branch and the chest inside the chest The PH of the N point of the lateral nerve branch of the lateral nerve was located at its H1 line (47.83 + 1.75%), (32.31 + 4.18)% (male) and (34.31 + 3.03)%; the PH of the N point of the anterior sawing muscle of the thoracic long nerve was located at (63.77 + 3.33)% of its H2 line. Their PL was located (-9.84 + 1.62)% (36.16 + 4.51)% (36.16 +%), and (2.44 + 1.16)% and (73.84 +)%)%. The depth of the N points of the pectoralis major branch, the pectoralis major pectoralis major branch and the medial pectoralis minor muscle branch at the PP'line (17.76 + 2.84)%, (17.53 + 3.14)% (male) and (25.51 + 2.31)%. The depth of the N point of the anterior segment of the thoracic long nerve was (1.63 + 0.24) the position and depth of CINDR in the body surface of the anterior group of the cm.5. arm: CINDR1,2 of the beak brachial muscle and the PH position of 3. At the H1 line (24.22 + 1.49)%, (18.89 + 1.49)% and (8.15 + 1.14)%, PL was located at (21.37 + 2.48)%, (31.78 + 2.32)% and (30.07 + 1.12)% respectively at its L line, and the puncture depth was located at the PP'line (22.81 +%)% and (1.14%)% respectively. The CINDR1 and PH of the biceps brachii were located on the H2 line respectively. ) at% (56.60 + 3.35)% and (67.63 + 3.29)% of the L line, the puncture depth is located at (14.79 + 1.35)% and (17.45 + 1.28)% of the PP'line respectively. The CINDR1 and 2 of the brachial muscle are located at (48.34 + 3.25)% and (52.45 + 3.47)% of the H2 line respectively, and the L line is located at the PP' line, respectively. .14) the position and depth of CINDR in the upper limb muscle of.6. in the body surface: the CINDR1 and 2 PH of the pectoralis major muscle were located at (41.95 + 2.72)% and (55.88 + 2.06)% of the H1 line respectively. The PL was located at (-3.87 + 0.92)% and (25.29 + 2.73)% respectively in its L line. The puncture depth was located at (5.23 + 0.94)% and 6.75 0.98)% respectively. The CINDR PH of the pectoralis minor muscle was located on its thread. At (32.58 + 3.77)%, PL was located at (-7.13 + 0.99)% of the L line, the puncture depth was located at (13.73 + 2.27)% of the PP'line. The PH of the anterior sawing muscle CINDR was located at (84.08 + 1.77)% of the H2 line, PL was located at (100 + 1.86)% of the L line, and the puncture depth was (1.86 + 0.35) cm. conclusion: the body surface position and puncture depth of the extricardial nerve into the muscle of the same muscle. The center of intramuscular nerve is different from the center of intramuscular nerve; 2. the accurate localization of these nerve entry points and intramuscular nerve dense areas can improve the efficiency and effect of the extricardiac and intramuscular nerve blockade of the anterior arm and upper limb muscle spasm, and 3. the lateral deity should be blocked in the treatment of the female patients with the pectoralis major spasm with the nerve entry point as the target. Through insertion of.4. into the muscle, apart from the anterior serratus muscle to select the extra muscular nerve entry point, the other muscles can selectively choose out of muscle or intramuscular target block.
【學位授予單位】：遵義醫(yī)學院
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R741

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