在新鲜尸体收肌管注射后注射液在筋膜中的扩散
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Interfascial Spread of Injectate After Adductor Canal Injection in Fresh Human Cadavers
背景与目的
内收管阻滞已成为膝关节置换术患者常见的镇痛技术。内收管外局部麻醉药通过筋膜层扩散，阻滞支配膝关节的小神经，能增强内收管阻滞的镇痛效果。我们研究了在新鲜尸体收肌管注射混合染料的局部麻醉剂后的扩散。研究的所有8条腿，都是在与腘窝相接触的坐骨神经和/或腘血管发现注射液。发现了筋膜间扩散模式。虽然收肌管阻滞已成为膝关节术后镇痛的常用方法，但其作用机制是有争议的。收肌管始于股三角顶点，止于内收肌裂孔，即股动脉移行为腘动脉的位置。该肌间隙横截面是三角形，位于缝匠肌后，可作为从股三角到腘窝之间的神经血管束的通道，成为这两个结构在解剖上的连续。根据标准，这个通道可能包含股动脉、股静脉、隐神经和支配股内侧肌的分支以及后闭孔神经和内侧韧带神经（腓总神经的一个分支）的分支。这是可能的，注射液由筋膜扩散到内收肌管以外的支配膝关节的小神经可以增增强至少可以部分增强内收管阻滞对膝关节成形术患者的镇痛治疗效果。例如，已有报道在股内侧肌前表面注射液就近扩散可引起意想不到的股神经阻滞。局部麻醉药注射入收肌管也可能扩散到腘窝。 在本次研究中，我们描述了在新鲜尸体收肌管注射混合有染料的局部麻醉药后的扩散模式。
方 法
由科克克里大学伦理委员会批准后，选用8个无明显病理特点的新鲜尸体肢体进行研究，保存于4°C环境下。 为了便于识别股动脉，在腹股沟水平置入一个取栓导管（爱德华兹生命科学公司、尔湾、洛杉矶）到股动脉管腔，在内收肌管水平之上。内收管在大腿远端三分之一用超声成像。在后内侧向外侧方向置入导管（平面）绕动脉进入收肌管后，紧靠股动脉用针尖注射20毫升0.2%罗哌卡因与0.01%亚甲蓝。在动脉改变走行向腘窝后方的水平上方注射。手持注射器注射给药，注射速度约为20毫升/分钟，像在临床实践中一样。所有尸体被注入局麻药后，它们被放置于俯卧位，解剖腘窝。仔细解剖组织鞘，大收肌以及股骨和内收肌间的裂孔，观察含亚甲基蓝溶液在筋膜间的扩撒。尸体被保存在室温下。对数据进行描述性分析。
结 果
由科克克里大学伦理委员会批准后，选用8个无明显病理特点的新鲜尸体肢体进行研究，保存于4°C环境下。 为了便于识别股动脉，在腹股沟水平置入一个取栓导管（爱德华兹生命科学公司、尔湾、洛杉矶）到股动脉管腔，在内收肌管水平之上。内收管在大腿远端三分之一用超声成像。在后内侧向外侧方向置入导管（平面）绕动脉进入收肌管后，紧靠股动脉用针尖注射20毫升0.2%罗哌卡因与0.01%亚甲蓝。在动脉改变走行向腘窝后方的水平上方注射。手持注射器注射给药，注射速度约为20毫升/分钟，像在临床实践中一样。所有尸体被注入局麻药后，它们被放置于俯卧位，解剖腘窝。仔细解剖组织鞘，大收肌以及股骨和内收肌间的裂孔，观察含亚甲基蓝溶液在筋膜间的扩撒。尸体被保存在室温下。对数据进行描述性分析。
结 论
我们对新鲜尸体的研究表明在收肌管注射可能导致注射液在收肌管外沿筋膜向腘窝扩散。注射液从内收肌管到腘窝的大幅蔓延可能会阻滞组织鞘内的各种神经，可以帮助解释报道在患者内收管阻滞的镇痛效果。这些结果与我们以前的报告一致，即在CT图像上发现注射液在腘窝，在坐骨神经附近，造成了腘窝坐骨神经阻滞。未来的研究将进一步指出膝盖手术病人内收肌管神经阻滞的程度和模式。总之，在新鲜尸体收肌管注射局部麻醉药，结果通过筋膜间隙蔓延到腘窝。注射液通过这些筋膜扩散可能为膝关节手术镇痛机制提供新思路。
原始文献摘要
Pierre Goffin ；Interfascial Spread of Injectate After Adductor Canal Injection in Fresh Human Cadavers；Anesthesia & Analgesia ；2016.8
Background
The adductor canal block has become a common analgesic technique in patients undergoing knee arthroplasty. Dispersion of local anesthetic outside the adductor canal through interfascial layers and blockade of smaller nerves that confer innervation to the knee could contribute to the analgesic efficacy of the adductor canal block. We studied the diffusion of local anesthetic mixed with dye after injection into the adductor canal in fresh human cadavers. In all 8 legs, injectate was found in the popliteal fossa in contact with the sciatic nerve and/or popliteal blood vessels. Interfascial spread patterns were identified.
Although adductor canal blockade has become a common method to provide analgesia after knee surgery, its mechanism of action is somewhat con- troversial.1–3 The adductor canal begins at the apex of the femoral triangle and ends at the adductor hiatus, where the femoral artery becomes the popliteal artery. This intermus- cular tunnel is triangular in cross section, lies posterior to the sartorius muscle, and may serve as a passageway for the neurovascular bundle from the femoral triangle to the popliteal fossa, being in anatomic continuity with these 2 compartments.4 Depending on level, the canal may contain femoral artery and vein, saphenous nerve and branches to the vastus medialis muscle, and branches of the poste- rior obturator nerve and of the medial retinacular nerve (a branch of the common peroneal nerve).5 It is possible that the reported analgesic efficacy of the adductor canal block in patients undergoing knee arthroplasty could be contrib- uted, at least in part, by interfascial spread of injectate to smaller nerves outside the adductor canal that innervate the knee. For instance, proximal spread of injectate over the anterior surface of the vastus medialis muscle and unex- pected femoral nerve block have been reported.6,7 Local anesthetic injected into the adductor canal may also spread into the popliteal fossa.8 In this report, we describe the dif- fusion patterns of a dye-containing solution of local anes- thetic after injection into the adductor canal in fresh human cadavers.
METHODS
After local ethics approval by the Comité d’Ethique Hospitalo-Facultaire Université de Liège, 8 limbs of fresh cadavers, kept at 4°C and free of obvious pathology, were studied. To facilitate recognition of the femoral artery, an embolectomy catheter (Edwards Lifesciences Corp, Irvine, CA) was introduced into the lumen of the femoral artery at the groin and advanced to the level of the adductor canal. The adductor canal was imaged on traverse ultrasound view in the distal third of the thigh. After insertion of the needle (in-plane) with a posteromedial to anterolateral direction around the artery into the adductor canal, 20 mL 0.2% ropivacaine with 0.01% methylene blue was injected with the needle tip next to the femoral artery. Injections were made just above the level where the artery changed course deeper and posterior toward the popliteal fossa. The injections were administered with a hand-held syringe, and injection speed was approximately 20 mL/min, as in clinical practice. After all cadavers were injected, they were placed in the prone position, and the popliteal fossa was dissected. Careful dissection of the tissue sheaths, adduc- tor magnus, and hiatus between femoral bone and adductor muscle was performed to explore the interfascial spread of the methylene blue–containing solution. The cadavers were kept at room temperature. Data are presented descriptively.
RESULTS
Dispersion and anatomical location of dye are shown in the Table. Methylene blue was found in the popliteal fossa in contact with the sciatic nerve in all 8 legs (Figure 1). Dye was found on the anterior and posterior aspects of the adductor magnus muscle, indicating that circumferential fascial spread had occurred underneath the adductor muscle fascia and into the popliteal fossa (Figure 2). In 5 legs, the dye tracked proximally above the level at which the tibial and common peroneal nerves diverged. In 3 legs, the dye traveled through the inferior hiatus containing the popliteal vessels; and in 2 legs, the dye was found passing through the accessory hiatus between the femur and adductor magnus muscle.
DISCUSSION
Our study in fresh human cadavers demonstrated that an injection into the adductor canal may result in interfascial spread of injectate outside the adductor canal toward the popliteal fossa. Substantial spread of injectate from the adductor canal into the popliteal fossa may affect various nerves that travel in those tissue sheaths and can help to explain the reported analgesic benefits of the adductor canal block in living patients. These observations are consistent with our previous report in which injectate was found on computed tomographic images in the popliteal fossa in the vicinity of the sciatic nerve and resulted in sensory block of the popliteal sciatic nerve.8 Future studies are indicated to determine the extent and patterns of neural blockade in patients undergoing knee surgery with adductor canal block. In summary, injection of local anesthetic into the adductor canal in fresh human cadavers results in spread into the pop- liteal fossa through interfascial planes. Dispersion of injectate through these fascial planes may offer additional insight into the mechanism(s) of analgesia for knee surgery.
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