本文選題：神經(jīng)型胸廓出口綜合征 + 阻滯��； 參考：《吉林大學(xué)》2017年碩士論文

【摘要】：目的:神經(jīng)型胸廓出口綜合征(Neurogenic Thoracic Outlet Syndrome,NTOS)是臂叢神經(jīng)在胸廓出口區(qū)域內(nèi)受到結(jié)構(gòu)和/或體位性卡壓所引起的一組癥候群。由于其復(fù)雜多變的癥狀和體征、缺乏特異敏感的輔助檢查、以及多種相關(guān)疾病的混淆,NTOS一直被認(rèn)為是外科領(lǐng)域診斷最困難的疾病之一。作為NTOS的一種診斷性試驗(yàn),診斷性局部阻滯封閉技術(shù)成為臨床上可以選擇的一項(xiàng)診斷指標(biāo)。本文通過(guò)對(duì)“第四頸椎橫突阻滯”與“前、中斜角肌阻滯”兩種不同的診斷性阻滯方法的比較,觀察研究其優(yōu)、缺點(diǎn),為NTOS的診斷尋找更科學(xué)、更可靠的診斷性阻滯方法。方法:選取2016年1月—2016年9月就診于吉林大學(xué)中日聯(lián)誼醫(yī)院的診斷為NTOS的60例患者,入選患者均滿足NTOS的篩選標(biāo)準(zhǔn),均有頸、肩、上肢不同程度的疼痛、麻木。年齡在36-59歲之間,體重在50-75kg之間,計(jì)劃行保守治療。將本研究的60例患者隨機(jī)分成兩組(n=30):第四頸椎橫突阻滯組(T)和前、中斜角肌阻滯組(S)。T組患者均行第四頸椎橫突阻滯,S組患者均在超聲引導(dǎo)下行前、中斜角肌阻滯。阻滯所用藥物為包括1%羅哌卡因2m L、0.9%生理鹽水1m L、含碘造影劑1m L的混合液。注射后所有患者均在30分鐘內(nèi)行X線熒光透視檢查,阻滯后行診斷效果、不良反應(yīng)的記錄。結(jié)果:兩組患者一般狀態(tài)無(wú)顯著性差異(P0.05)。(1)通過(guò)X線熒光透視檢查分析頸部顯影的肌肉群。兩組前、中斜角肌均顯影,無(wú)顯著性差異。與S組相比,T組中可見(jiàn)頭長(zhǎng)肌明顯顯影。(2)T組患者聲音嘶啞的發(fā)生率明顯高于S組(30%VS 6.6%);T組患者霍納氏綜合征(30%VS 6.6%)、窒息感(13.3%VS 6.6%)、頸部麻木感(40%VS 3.3%)的發(fā)生率均高于S組,有統(tǒng)計(jì)學(xué)意義。同時(shí),與S組相比,T組患者上肢麻木(6.7%VS 16.7%)的發(fā)生率明顯降低,有統(tǒng)計(jì)學(xué)意義。(3)阻滯后癥狀緩解率T組為93.3%、S組為83.3%。即S組較T組效果不佳率更高(16.7%VS 6.7%),對(duì)于阻滯效果:優(yōu)、良、可、差的比例,兩組之間無(wú)顯著性差異。結(jié)論:1.第四頸椎橫突阻滯,藥物擴(kuò)散途徑復(fù)雜、擴(kuò)散劑量隨機(jī)不可控。藥物除局部浸潤(rùn)至前、中斜角肌外,還可擴(kuò)散至頭長(zhǎng)肌、椎前筋膜相關(guān)的頸叢、頸交感干、迷走神經(jīng)/喉返神經(jīng)、隔神經(jīng)等。癥狀緩解與多途徑作用相關(guān),不能精準(zhǔn)的反應(yīng)前、中斜角肌緊張程度與神經(jīng)癥狀的相關(guān)性。2.超聲引導(dǎo)下的前、中斜角肌阻滯,藥物能夠準(zhǔn)確注射入前、中斜角肌,并可在超聲引導(dǎo)下定點(diǎn)定量注入預(yù)定部位。通過(guò)調(diào)整注射部位,能夠有效避免因藥物局部浸潤(rùn)而出現(xiàn)的神經(jīng)阻滯。癥狀緩解與前、中斜角肌緊張程度密切相關(guān)。3.超聲引導(dǎo)下的前、中斜角肌阻滯對(duì)NTOS的診斷更準(zhǔn)確可靠。
[Abstract]:Objective: neurogenic Thoracic outlet SyndromeNTOS (NTOS) is a group of syndromes caused by structural and / or postural compression of brachial plexus nerve in thoracic outlet region. Because of its complex and changeable symptoms and signs, the lack of specific and sensitive adjuvant examination, and the confusion of many related diseases, NTOS has been considered as one of the most difficult diseases in the field of surgery. As a diagnostic test of NTOS, diagnostic local block blocking technique has become a clinical diagnostic index. By comparing the two different diagnostic block methods of "fourth cervical vertebra transverse process block" and "anterior and middle scalene block", the authors observed their advantages and disadvantages, and found a more scientific and reliable diagnostic block method for the diagnosis of NTOS. Methods: sixty patients who were diagnosed as NTOS from January 2016 to September 2016 were selected. All the patients met the screening criteria of NTOS. All patients had pain and numbness in neck, shoulder and upper limb. Aged 36-59 years, weight between 50-75kg and planned conservative treatment. 60 patients in this study were randomly divided into two groups: the fourth cervical transverse process block group (T3) and the anterior scalene muscle block group (S group). All the patients in the fourth cervical vertebrae transverse process block group (S group) were treated with anterior and middle scalene muscle block under the guidance of ultrasound. The mixture of 1% ropivacaine 2m L, 0.9% normal saline 1m L and iodine contrast agent 1m L were used in the block. X-ray fluoroscopy was performed within 30 minutes after injection, diagnostic effect and adverse reaction were recorded after block. Results: there was no significant difference in general state between the two groups. There was no significant difference in the development of the middle scalene muscle between the two groups. Compared with group S, the incidence of hoarseness in group T was significantly higher than that in group S (30 vs 6.6), the incidence of asphyxia was 13.3VS 6.6 and the incidence of numbness in neck was higher than that in group S (P < 0.05). There was significant difference in the incidence of hoarseness between group A and group S (P < 0.05). The incidence of hoarseness in group T was significantly higher than that in group S (P < 0.05), and the incidence of hoarseness in group T was significantly higher than that in group S (P < 0.05). The incidence of hoarseness in group T was significantly higher than that in group S. At the same time, compared with S group, the incidence of upper limb numbness in T group was significantly lower than that in S group (P < 0.05). That is to say, the bad rate of group S was higher than that of group T, and there was no significant difference between the two groups in the effect of block: excellent, good, fair and poor. Conclusion 1. The fourth cervical vertebra transverse process block, the drug diffusion path is complex, the diffusion dose is not controlled at random. In addition to local infiltration to the anterior and middle scalene muscles, the drug can also spread to the head long muscle, the cervical plexus associated with the prevertebral fascia, the cervical sympathetic trunk, the vagus / recurrent laryngeal nerve, the septal nerve, and so on. Symptom relief is related to multiple pathways, and the correlation between the degree of tension of the middle scalene muscle and the neurological symptoms before the accurate response. 2. Ultrasound-guided anterior and middle scalene block, drugs can be accurately injected into the anterior and middle scalene muscles, and under the guidance of ultrasound fixed point quantitative injection of the predetermined site. By adjusting the injection site, the nerve block caused by local drug infiltration can be effectively avoided. Symptom relief was closely related to the degree of tension in the anterior and middle scalene muscles. Anterior scalene block guided by ultrasound is more accurate and reliable in the diagnosis of NTOS.
【學(xué)位授予單位】：吉林大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R688

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