昆山杜克大学研究生，昆山杜克大学研究生申请条件
翻译：王清峰 徐州医科大学2021级麻醉学研究生
审校：赵林林 徐州医科大学附属医院麻醉科
The interscalene brachial plexus block is a technique that’s been used by anesthesiologists for 50 years. There was a time when even if you only knew two to three blocks and the interscalene was probably one of them. We still use it routinely for shoulder and upper limb surgery. And in this video, we’ll discuss the technique and some key safety points to keep you out of trouble.
肌间沟臂丛神经阻滞是一种被麻醉医生使用了50年的技术。曾经有一段时间，如果你只知道两三种神经阻滞，而肌间沟臂丛神经阻滞很可能是其中之一。我们仍经常使用肌间沟臂丛神经阻滞进行肩部和上肢手术。在这段视频中，我们将讨论臂丛神经阻滞和一些让您远离麻烦的关键安全要点。
The goal of the interscalene block is to place local anesthetic right next to the brachial plexus sheath at the level of the C5 and C6 nerve roots. These roots come together to form the superior trunk and whether you do the block where they’re single roots or one trunk doesn’t seem to influence the clinical effect much.
肌间沟臂丛阻滞的目的是将局部麻醉药置于C5和C6神经根水平的臂丛神经鞘附近。这些C5、C6神经根聚集在一起形成上干，无论你阻滞单个神经根还是神经干似乎都不会对临床效果产生太大影响。
Here’s an ultrasound image showing the brachial plexus contained within its sheath and a puddle of local anesthetic right beside it. This is the image you’re aiming for at the end of the procedure.
这是超声图像，显示了鞘内的臂丛神经和它周围的局麻药。这是你在神经阻滞结束时的目标图像。
The interscalene block anesthetizes the C5 and C6 roots. And so this is well suited to procedures of the shoulder and upper arm including the clavicle, proximal humerus and the scapula.
肌间沟臂丛神经阻滞麻醉了C5和C6神经根。因此这非常适合于肩部和上臂的手术，包括锁骨、近端肱骨和肩胛骨的手术。
In the old days with larger volumes, we used interscalene for procedures as distal as the elbow or proximal forearm. But with the targeted technique we use now, it’s primarily proximal arm and shoulder.
在过去使用大容量局麻药的时代，我们在肘关节远端或前臂近端应用肌间沟臂丛神经阻滞。但是我们现在使用的定位技术主要用于胳膊近端和肩膀。
There are other ways to anesthetize parts of the shoulder and surrounding structures. But if you want to do wide awake shoulder surgery, interscalene is what you want, because it fully anesthetizes the relevant skin, muscle, fascia and bone of the whole shoulder girdle.
还有其他方法来麻醉肩部和周围结构。但是，如果你想做完全清醒的肩部手术，肌间沟臂丛神经阻滞是你所需要的，因为它会完全麻醉整个肩带的相关皮肤、肌肉、筋膜和骨骼。
For positioning, you want to have good exposure to your working area. Turning the patient’s head away and placing a bump under the ipsilateral shoulder can help turning the patient on their side, is also a great way to give yourself lots of room, especially when replacing catheters.
为了定位，你需要充分地暴露你的工作区域。将患者的头转向对侧并在同侧肩部下方放置一个垫子可以帮助患者偏向一侧，这也是一种给自己很多操作空间的好方法，特别是在植入导管时。
Placing an ultrasound transducer on the anterior lateral neck one to two centimeters north of the clavicle should get you an image like this. You can see the posterior aspect of the sternocleidomastoid muscle, the anterior and middle scalene muscles, and the string of black pearls that is the interscalene brachial plexus nestled between the scalenes.
将超声探头放在颈部前外侧锁骨上1-2厘米处可以让你得到这样的图像。你可以看到胸锁乳突肌的后缘，前、中斜角肌，以及位于前中斜角肌之间的串珠样的臂丛神经。
Sometimes these roots can be hard to pick out of a static image and for that reason we recommend doing some dynamic scanning. Slide the transducer down to the clavicle until you see the subclavian artery and honeycomb of plexus and anterolateral to it. The artery makes a great landmark. Then it’s an easier job to scan up the plexus until you see the C5 and C6 roots distinctly. We see the C7 root here too although you may not always.
有时这些神经根很难从静态图像中分辨出来，因此我们建议进行一些动态扫描。将探头向下滑动到锁骨，直到看到锁骨下动脉以及它前外侧的蜂窝状的神经丛。锁骨下动脉是一个明显的标志，然后就更容易扫描神经丛，直到你清楚地看到C5和C6神经根。我们在这里也看到了C7神经根，尽管你不可能总是看到它。
It’s not important for our purposes and we’re not going to target it now. That your probe is in the right position, the needle can be lined up and advanced from the lateral aspect.
C7对我们的操作目的并不重要，我们现在也不会对准它。当你的探头在正确的位置时，针可以放在侧面然后推进。
Okay, so let’s look at this in real time. Here we see the anterior and middle scalene muscles and the C5 and C6 roots between them. The needle is coming across the screen from the lateral side. Note the space between the C5 and C6, this is a useful target to aim for.
好的，让我们来实时看看这个视频。在这里，我们可以看到前、中斜角肌，以及它们之间的C5和C6神经根，针从屏幕侧面穿过。注意C5和C6之间的空隙，这是一个有用的目标。
You don’t ever want to contact either of these sensitive nerve roots with your needle. As the needle passes through the fascial covering of the middle scalene muscle, you may feel a small give. A test injection shows the injectate spreading up and down along the side of the plexus. The needle is advanced a little more, so it’s within the puddle of local and the remainder of the dose injected.
你永远不要用你的针头去接触这些敏感的神经根。当针穿过中斜角肌的筋膜时，你可能会感到轻微的弹性。测试注射显示注射液沿着神经丛的一侧上下扩散，针头再前进一点，在刚刚注入的液体阴影里，注射剩余剂量的局麻药。
You don’t have to flood this area. 10 to 15 mils are more than enough to ensure a quick onset high quality block. The choice of local anesthetic obviously depends on your goals for onset duration and block density.
你不必过分扩展这个区域。10-15毫升的局麻药足以确保起效迅速且有高质量的阻滞效果。局麻药的选择显然取决于你对阻滞持续时间和阻滞强度的要求。
Now I want to emphasize that the brachial plexus sheath is not a diffusion barrier. In other words, local anesthetic placed outside the sheath easily diffuses across and quickly anesthetizes the nerve structures. You don’t need to actually get inside with your needle and in fact we really shouldn’t.
现在我想强调一下，臂丛神经鞘不是局麻药扩散的屏障。换句话说注射到鞘外的局麻药容易扩散并快速麻醉神经结构。你无需让针头进入神经，事实上我们应确保不这样做。
In this category study, investigators placed needles within the sheath or just outside and injected 1/10 of a mil of black ink. The cadavers were then dissected to see what the disposition of the ink was, and in the peri-plexus group outside the sheath, there was no staining of the nerve structures, which is what you’d expect.
在这类研究中，研究人员将针放在鞘内或鞘外，然后注入十分之一毫升的黑色墨水。然后解剖，观察墨水的分布情况，在鞘外组像你所期望的那样神经结构没有染色。
With that volume in the intra-plexus group, most of the ink was between the C5 and C6 roots, which is great except that they found the remaining 12% showed ink staining within a number of fascicles. Look how many of the fascicles are involved here with 1/10 of a mil and we know that local anesthetic within fascicles predisposes to chemical nerve injury, to say nothing of the potential for mechanical needle entry by getting too close. So the upshot of the study is stay outside the sheath.
在鞘内组大部分墨水位于C5和C6根之间，这很好，除了他们发现12%的臂丛神经出现了神经束内有墨水染色。看看这里有多少神经束被到1/10毫升的墨汁染色，我们知道束内的局麻药容易造成化学性神经损伤，更不用说靠得太近可能导致针刺入，所以这项研究的结果是阻滞针要留在鞘外。
There are a few other nerves in the neck and you have to be aware of the potential for phrenic nerve blockade and injury to the dorsal scapular and long thoracic nerves. We’ve known for decades that even small volumes in the interscalene groove leads to phrenic nerve blockade and hemidiaphragmatic paresis.
颈部还有一些其他神经，你必须意识到膈神经阻滞、以及肩胛背神经和胸长神经损伤的可能性。几十年来，我们早已经知道，即使肌间沟内的小剂量局麻药也会导致膈神经阻滞和横隔麻痹。
Here we see 10 mils of dye spilling up and over the scalene muscles and since the phrenic runs on the surface of the anterior scalene, it’s going to get blocked. Patient selection is important here. And in another video, we talk about alternatives to interscalene block for patients who may not tolerate a reduction in their pulmonary mechanics.
这里我们看到10毫升的染料就会溢出到斜角肌表面，由于膈神经位于前斜角肌的表面，此时膈神经将被阻滞。此时病人的选择很重要。在另一个视频中，我们讨论了替代臂丛神经阻滞的方法，以帮助那些可能无法忍受呼吸动力降低的患者。
Here we see the middle scalene muscle and the plexus medial to it, the long thoracic and dorsal scapular nerves often pass right through this muscle and if you’re not careful, they can be at risk for needle trauma. We like to keep our needle trajectory superficial in the muscle until reaching the plexus to avoid these nerves, which are usually somewhat deeper at the interscalene level. Nerve stimulation can also help identify potential needle nerve contact.
这里我们看到中斜角肌和它的内侧神经丛，胸长神经和肩胛背神经通常会直接穿过这块肌肉。如果你不小心，他们可能就会有被针刺伤的风险。我们喜欢将针的轨迹保持在肌肉的表面，以避开这些神经，直接到达臂丛，这些神经通常比臂丛水平略深一些。神经刺激器也可以帮助识别潜在的阻滞针和这些神经的接触。
In summary, the interscalene brachial plexus block is an excellent technique for upper limb surgery that has stood the test of time. It can provide standalone surgical anesthesia for shoulder and upper limb procedures, and is our go-to for post-operative analgesia and shoulder patients. As many blocks, there are some delicate structures to look out for, and the risk of neural injury can be minimized by staying outside the sheath.
综上所述，肌间沟臂丛神经阻滞是一种经得起时间考验的用于上肢手术的非常好的技术。它可以为肩部和上肢手术提供的麻醉，是术后镇痛和肩部患者的首选。正如许多阻滞一样，有一些微妙的结构要注意，通过将针头留在鞘外可以将神经损伤的风险最小化。
昆山杜克大学研究生(昆山杜克大学研究生申请条件)
