旁正中超声实时引导在腰段硬膜外穿刺中的应用

摘要

目的 探讨旁正中超声实时引导技术在成人腰段硬膜外穿刺时的应用价值.方法 72例患者随机分为盲探穿刺组和超声实时引导组2组,每组各36例.盲探穿刺组采取传统的体表标志进针及阻力消失法确定硬膜外间隙位置,超声实时引导组采用超声采集脊柱旁正中切面超声图像,并实时引导穿刺针进行硬膜外穿刺置管.记录两组硬膜外穿刺时间、试穿次数、麻醉效果、超声测量的穿刺点皮肤到硬膜外间隙距离与实际穿刺时的进针深度;导管置入时的超声图像、注射药液时的扩散情况、术中及术后可能的并发症等.结果 两组患者均顺利完成硬膜外穿刺,麻醉效果无明显差异;超声实时引导组较盲探穿刺组操作时间延长(P<0.01),但试穿次数明显减少(P<0.05),患者的术后并发症发生率较低(P<0.05).超声实时引导组36名患者均能成功显示硬膜外腔,超声测量的皮肤与硬膜外间隙距离与实际穿刺时的进针深度相关性好(r=0.781,P<0.01);33例(91.7%)患者可见穿刺针进入硬膜外间隙实时图像;9例(25.0%)患者在穿刺后可见硬膜外腔置管实时图像;30例(83.3%)患者置管成功后注入生理盐水,可见后硬脊膜前移、硬膜外腔增宽图像.结论 旁正中切面扫描能较好地显示腰段硬膜外间隙及相关解剖结构图像,超声实时引导进行硬膜外穿刺时效果较好,可靠性及成功率更高,可减少并发症发生率,具有一定的临床应用前景.%Objective To evaluate the role of real-time ultrasound guidance for paramedian epidural space punctures in lumbar anesthesia in adults. Methods Seventy two patients who underwent lower abdomen surgery under epidural anesthesia were randomized into two groups. The sonography group ( Group B ,n = 36 ) performed the puncture procedure under real-time sonography guidance which using paramedian scan. The control group ( group A, n = 36 ) used classical methods which locates the epidural space by surface landmarks and loss-of-resistance ( LOR ) sensation. The time of operation, attempt times, the distance between skin to epidural space and the needle depth, complications and the effect of anesthesia were recorded. Results In all 72 patients, the puncture was successfully performed and anesthesia effect was adequate for surgery. The time of operation in group B was longer than group B(P＜0.0l). While the attempt times and complications were less in group B ( P ＜0. 05 ). The epidural space was successfully identified in all patients in group B. In 33( 91. 7％ ) patients the image of the needle into epidural space by real-time ultrasound guided was visible, in 30( 83. 3％ ) patients the posterior dura and widening of the posterior epidural space were shown, and in 9 ( 25. 0％ ) patients, the catheter was shown after entrance into the space. There were no inadvertent punctures, nor complications which are directly related to sonography guided paramedian epidural access. Conclusion Ultrasound can show the epidural space and adjacent structure clearly by paramedian scan before puncture procedure. Epidural space puncture by real-time ultrasound guide has higher success and reliability with less complication, and it may have a good prospect in clinical.