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肩胛上神经和腋神经联合阻滞治疗肩周炎的应用解剖 1

来源:医学杂志 2006-10-19 03:10:01 

   【摘 要】 目的:为神经阻滞治疗肩周炎提供解剖学基础。方法:在34侧经常规防腐处理的成人尸体标本上解剖出肩胛上神经和腋神经,观察其走行位置及分支分布,拟定穿刺点及体表定位。结果:①肩胛上神经主要分支有冈上肌支和冈下肌支。肩胛上神经在肩胛横韧带处距皮肤的距离和冈上肌支起始段距皮肤的距离均为4.0~4.5 cm,冈下肌支起始段距皮肤的距离为4.0 cm。②腋神经主要分支有前支和后支。腋神经穿四边孔处距皮肤的距离为5.0 cm,前支在四边孔中点外旁开3 cm处,距皮肤的距离为3.5~4.0 cm。后支在三角肌后缘中、下1/3交点处距皮肤的距离为3.0 cm。结论:对肩胛上神经和腋神经及其分支选择6个穿刺点进行正确的体表定位和熟练掌握穿刺阻滞的深度,可成为治疗肩周炎的有效方法。

    Applied anatomy of treating frozen shoulder by anesthetic block of suprascapular nerve and axillary nerve

    Dou Zhongxin,Mao Huaihai,Chen Xiuqing,et al.

  Department of Anatomy,Nanjing Military Medical College, the Second Military Medical University,Nanjing 210099

  Objective:To provide morphological basis for treating frozen shoulder by aneshetic block. Methods:The supracapular nerve and axillary nerve were observed and measured on 34 side adult cadavers.Results: ①Supraspinous and infraspinous branches are the main branches of the suprascapular nerve.The depth of suprascapular nerve is about 4.0~4.5 cm at the points of scapular ligament and the start part of supraspinous branch,4.0 cm at the point of the start part of infraspinous branch.②Anterior and posterior branches are the main branches of the axillary nerve.The depth of axillary nerve is 5.0 cm at the point of passing through four-side foramen.The depth of anterior branch is 3.5~4.0 cm at the point of 3.0 cm away from the center of four-side foramen.The depth of posterior branch is 3.0 cm at the point of posterior edge of deltoid.Conclusion:If the 6 points are correctly located on the body surface and the depth of puncture is well controlled,anesthetic block of suprascapular nerve and axillary nerve should be an effective method to treat frozen shoulder.

  Key words Suprascapular nerve  Axillary nerve  Block  Frozen shoulder

  肩周炎是一种长期困扰中老年人的严重疾患。虽然目前对肩周炎的治疗方法较多,如理疗、针灸及痛点注射等,但到目前为止还没有一种令人满意的治疗方法[1]。近年来有资料显示,肩胛上神经或腋神经阻滞对肩周炎的治疗有较好的效果[2~5]。但由于定位和穿刺深度不准确而影响阻滞效果或出现气胸等并发症。有关肩胛上神经和腋神经的解剖学观察虽有报道[6~8],但未见有阻滞两神经的应用解剖学资料,特别是缺少对多点穿刺进行准确定位的资料。为提高阻滞两神经的临床治疗效果,减少并发症的发生,作者对其作了进 一步观察和研究,旨在为临床有效阻滞提供形态学依据。

  1 材料和方法

  研究用34侧经甲醛常规防腐固定的成人尸体标本,分别解剖出肩胛上神经和腋神经,观察了其走行位置、分支及分布。用电子数显卡尺测量了有关数据,并经统计学处理。同时对拟定的穿刺点进行了体表定位和摹拟穿刺注射墨汁试验,找出最佳穿刺点和穿刺深度。

  2 观察结果

  2.1 肩胛上神经

  2.1.1 肩胛上神经的走行位置 肩胛上神经由臂丛上干发出以后,斜向外下经斜方肌及肩胛舌骨肌的深面至肩胛切迹处,穿肩胛横韧带下方至冈上窝,在此发出冈上肌支及关节支。其主干继续伴肩胛上动脉绕肩胛颈切迹至冈下窝,并发出冈下肌支及关节支(图1)。

                                           

                                            图1 肩胛上神经和腋神经及分支

  2.1.2 肩胛上神经的干长、外径及体表投影 肩胛上神经的干长为(4.30±0.6)cm(3.0~5.2 cm)[(±s) (min~max),下同],根部横径为(1.9±0.3)mm(1.4~2.2 mm)。冈上肌支干长为(2.7±0.4)cm(2.0~3.3 cm),根部横径为(0.8±0.2)mm(0.6~1.0 mm)。冈下肌支干长为(4.2±0.5)cm(3.4~5.5 cm),根部横径为(1.1±0.1)mm(0.8~1.4 mm)。肩胛上神经的体表投影为:自胸锁乳突肌后缘中、下1/3交点稍下划一至斜方肌前缘下端锁骨外侧端止点的连线即为其体表投影。

  2.2 腋神经

  2.2.1 腋神经的走行位置 腋神经起于臂丛的后束,于桡神经外侧和腋动脉后方之间伴旋肱后动脉穿四边孔,并绕过肱骨外科颈向后入三角肌深面,分为前后两支,分布于三角肌、小圆肌和肩部皮肤(图1)。

  2.2.2 腋神经的干长、外径和体表投影 腋神经的干长为(4.7±0.9)cm(2.6~6.7 cm),根部横径为(2.7±0.4)mm(2.1~3.3 mm)。前支干长为(4.0±0.8)cm(2.9~4.1 cm),根部横径为(1.7±0.3)mm(1.1~2.5 mm)。后支干长为(4.5±0.8)cm(2.5~5.0 cm),根部横径为(1.8±0.4)mm(1.0~2.0 mm)。腋神经的体表投影为:由肩胛骨上角划一至三角肌后缘中点向外2 cm处的连线,此线即为腋神经背部投影。

  2.3 肩胛横韧带中点和四边孔中点的定位及至皮肤

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