三叉神经阻滞法

三叉神经阻滞
三叉神经为脑神经中粗大者,主由感觉纤维构成,只一小部分由运动纤维构成。此神经广泛的分布于面、头部,发生神经痛率高。
三叉神经阻滞分为末梢支阻滞及半月状神经节阻滞。前者又分为第一支阻滞包括眶上神经和滑车上神经阻滞,第二支阻滞包括眶下神经和上颌神经阻滞,第三支阻滞包括颏神经和下颌神经阻滞。

一、 眶上神经阻滞
(一) 解剖标志
眶上孔多位于眼或上缘中、内1/3交界眶中点附近,其形态及位置个体差异较大:约60%为单切迹、仅21%是单骨孔,余为2-3个骨孔或切迹,切迹一般可由表皮摸到,但骨孔却不能触到,后者常位于眶上缘1-4mm处。
(二) 操作步骤

患者平卧位,头向前视,在患侧眶上缘内1/3处或在眉中间可触及眶上切迹,或用手指或圆珠笔尖诱发出疼痛板机点作为穿刺点。
常规消毒后,用针长2.5cm的6~7号短针垂直刺入切迹,用针尖刺探可向额部的放射痛,如有骨孔,可将针头插入少许,回抽无血,先注入2%利多卡因0.5-1ml。如果先碰到骨质无异感,针的方向应轻轻做扇形移动,寻找异常感觉或诱发出疼痛板机点,穿刺到位后即可注射1%利多卡因0.5~1ml。此时用左手食指、拇指捏压住注药部位的皮肤,使药液横向扩散1cm左右,此操作目的是使眶上神经及滑车上神经得到阻滞,及使药液不向眼睑的软组织扩散。注入局麻药5分钟后检查额部感觉缺失,即可注入无水乙醇0.5ml。拔针后为了防止出血,用纱布压迫刺入点5分钟。如果上述方法未能阻滞眶上神经,可以沿眶上缘向眶内进针0.5cm注射药液也可以阻滞该神经。

(三) 适用范围
三叉神经第一支疼痛,眼部痛;带状疱疹后疼痛;此部位的继发性神经痛。
(四) 注意事项
并发症有眼睑水肿、肿胀。因于同名动脉相并行,刺破后可出血血肿,或药液引起的水肿,为了避免上眼睑水肿,可在注药时压住上眼睑。因药物阻滞了动眼神经上支,可引起眼睑下垂,需数日至数周得到改善。消毒液过多,进入眼内造成角膜化学性损伤。穿刺时术者左手食指应该一直注意保护患者眼球,避免穿刺针误伤眼球。穿刺针一旦刺进眶上孔后,进针深度不应超过0.5cm。治疗当天不要洗脸,避免针眼感染。
二、 滑车上神经阻滞
操作步骤与眶上神经阻滞相似,只是注入点在眶上切迹内侧0.5-1.0cm处。眶上神经于滑车上神经常不分别阻滞,在一处注药后,即可扩散而阻滞此两个神经。
平卧,取头正中位消毒后用5号短针距鼻正中线外侧1.5-2cm处刺入鼻根背部与眉弓交汇点,注入1%利多卡因2ml注射药液后拔针,轻压3~5min
三、 眶下神经阻滞
(一) 解剖标志
眶下孔位于上颌骨的前面,是眶下管的外口,其内口在眶底面与眶下沟相连接,眶下神经即通过此管及眶下孔而达表面。眶下孔呈半月形,凸边朝外上方,少数呈圆形或卵圆形,个别亦可呈缝隙状。其孔口开向前、下、内方,周围是浅凹,即犬齿窝,一般从皮表可以摸到。此孔距眶下缘约0.5-0.8cm,距鼻中线约2.5-3.0cm,多于眶下缘的颧颌缝处在一个纵切面上。眶下管的轴向,多由眶下孔起向上、后、外方,约与矢状面成40°-45°角向外、上、后方进针,而且深度不宜超过1cm,以防将药物注入眼眶内,引起不良后果。
(二)操作步骤

病人取仰卧位,用手可摸到眶下孔,有压痛。刺入点在鼻翼旁0.5cm。穿刺时用左手食指触在眶下孔,以指引针尖方向,约刺至1.5-2.0cm深度时,即达眶下孔边缘,刺及眶下神经时,病人产生由鼻翼向上唇的放散痛,然后再向外、上后方成40°-45°角进针0.5cm,充分抽吸无血后,先注入2%利多卡因0.5-1ml,待眶下神经分布麻木后,再缓慢注入无水乙醇0.5ml。
(三)应用范围
适用于三叉神经第二支痛,或其他情况引起的下眼睑、鼻旁、上唇或上颌中切牙、尖牙等部位的疼痛者。
(四)注意事项
应注意下列并发症:
1、皮下出血:
因眶下神经与眶下动静脉在眶下孔并行可以损伤出血,遇血肿可用手指压迫穿刺点数分钟。动脉性出血可波及眼睑不能睁眼,不需特殊处理,2-3日可恢复。
2、局部水肿
术后一般都可发生,不必做特殊处理,5-7日后可自行消退,以刺入部位为中心出现水肿、肿胀,尤其无水乙醇注入皮下组织时,水肿严重或出现乙醇神经炎,应早期施行星状神经节阻滞治疗。
3、视力障碍
因外眼肌损伤所致,或针尖刺入眶下管过深,使药液渗入眶内,或在眶下管内刺破血管后出血,使眶内压升高,出现复视、眼球突出、视力障碍及眼球疼痛等症状。
4、眼球损伤
注入局麻药后,须注意观察眼球活动情况。
为了预防副损伤,在未触到眶下孔或未得到放散痛时,虽可注入局麻药,但不可注入神经破坏药。

四、上颌神经阻滞
(一)解剖标志

一般躯体感觉神经,经圆孔出颅,进入翼腭窝,再经眶下裂入眶,续为眶下神经。穿刺圆孔即难又宜发生严重并发症,故上颌神经阻滞常在翼腭窝处进行。
翼腭窝位于颅底下面,眼眶之后,颞下窝的内侧。此窝是一个宽0.3-0.4cm,深约1cm的裂隙,呈漏斗状,尖端朝下。

(1)眶下神经:上颌神经的终支,通过眶下沟、眶下管、出眶下孔至面部,分为数支分布于下睑、鼻翼和上唇的皮肤。

(2) 颧神经:在翼腭窝内发出,经眶下裂入眶,穿眶外侧壁至面部,分支分布于颧、颞部皮肤。颧神经在行程中发出由副交感节后神经纤维组成的小支与泪腺神经吻合,此支进入泪腺,控制泪腺分泌。

(3) 上牙槽神经:分为上牙槽前、中、后支。后支有2~3支,在翼腭窝内自上颌神经发出后,穿上颌骨体后面进入骨质。上牙槽前、中支从眶下神经分出,三支在上颌牙槽骨质内吻合,形成上牙丛,分支分布于上颌窦,上颌各牙和牙龈。

(4) 翼腭神经:神经节支,为2~3条神经分支,从上颌神经主干行经翼腭窝上方的一段发出,向下连于翼腭神经节,后分布于腭部和鼻腔的粘膜以及腭扁桃体。

(二)操作步骤

1、侧入路法:
病人取仰卧位,头稍转向健侧。穿刺点在外耳孔前方3cm,颧弓下缘中点,由侧方看下颌的髁状突和喙突之中间点。穿刺针长8cm,7号针。由刺入点向上前方眼窝尖部刺入约4-5cm达蝶骨的翼突外侧板,此时将标志置于距皮肤1cm处,将针拔至皮下,而将针的方向改为向前方1cm、上方1cm处刺入,使针尖进入翼腭窝,此时上唇及齿龈、颊部皆出现放散痛,在充分回吸无血时,注入2%利多卡因0.5-1ml。充分观察镇痛效果、触觉消失及有无并发症,15-20分钟即无痛后再注入无水乙醇0.5ml。
2、侧前入路法:
体位同前。穿刺点由侧面看下颌骨喙突与颧骨下缘交点,针长8cm、7号针。由刺入点向上前方眼窝尖部刺入约4-5cm深度,针尖可触到上颌骨后面(针尖过于向前方)或触到蝶骨的翼突外侧板根部(针尖过于向后方),经过几次试验使针尖对准两者的中间点,约5-5.5cm的深度可达上颌神经而出现其区域的放散痛。充分抽吸后注入局麻药0.5ml后,再如侧入法观察15-20分钟后可注入神经破坏药0.5ml。
要注意针刺入超过6cm时,可能刺入眶内或鼻腔中。
(三)适用范围
1、三叉神经第二支痛或癌性痛,尤其痛点较广泛及经眶下神经阻滞失效者。
2、蝶腭神经痛
3、继发性神经痛,如:该部位带状疱疹或带状疱疹后遗神经痛,创伤继发性或放疗后疼痛
4、上颌、齿部手术
(四)注意事项
1、出血、血肿:较其他阻滞易刺破血管,翼腭窝是围以骨的狭小间隙,出血时易向阻力小的下方及颊部扩散,一般1周内吸收。
2、视力障碍
3、复视
4、面神经麻痹:在刺入点浸润麻药时,可阻滞面神经的颞支,使病人不能闭眼。
5、三叉神经全阻滞:针刺过深后局麻药用量过多,药液由圆孔进入颅内的蛛网膜下腔并引起三叉神经全支阻滞及其他脑神经阻滞,呼吸停止、意识丧失。
6、乙醇神经炎:虽触觉丧失,但仍有持续痛,对此施行星状神经节阻滞。
禁忌证:
1、注射部位感染
2、患者不能合作
3、有严重出血倾向者

五、 后上牙槽神经阻滞
(一)解剖标志
上颌骨的后侧即颞下面最突出部分是上颌结节,后上牙槽孔即位于此结节上。该孔是后上牙槽神经进入上颌骨而达磨牙的通道,其数目不定,大多数是单孔,少数为2-3个,亦有缺如者,后上牙槽孔距离上颌骨颧突与牙槽嵴的交角大约是2-2.5cm。
(二)操作步骤
病人取坐位或仰卧位,头转向健侧。穿刺点在颧骨下缘与牙槽嵴成角处,及相当于过眼外缘的垂线与颧骨下缘相交点。局部消毒后,先用左手手指将附近皮肤向下方拉紧,这样有利于下一步针尖朝内侧倾斜,继之以5cm长针头自穿刺点稍向后、上、内方刺入,直达牙槽嵴的后侧骨面,然后轻贴骨面,缓慢深入2-5cm,即达后上牙槽孔附近。回吸无血,先注入2%利多卡因2ml,待磨牙麻木后,再注入无水乙醇0.5-1ml。
(三)应用范围
三叉神经第二支痛,主要发生于上磨牙及其外侧粘膜者。

六、 下颌神经阻滞
(一)解剖标志
混合神经,最粗大的分支。经卵圆孔出颅腔达颞下窝,立即分为许多支。卵圆孔位于蝶骨大翼的后部,大多数在蝶骨翼突外板后缘的后侧或后内侧。少数在其后外侧。孔长6mm、宽3mm,呈卵圆形,其外口多向前外方,开向后内方者少。卵圆孔的后外侧为刺孔。特殊内脏运动纤维支配咀嚼肌。一般躯体感觉纤维分布于下颌各牙、牙龈、舌前2/3和口腔底粘膜以及耳颞区和口裂以下的面部皮肤。
(1) 耳颞神经以两根起始,向后包绕脑膜中动脉后合成一干,穿入腮腺实质内,与颞浅动脉伴行,向上分支布于耳廓前面和颞区皮肤以及腮腺。
(2) 颊神经沿颊肌外面前行,穿此肌后分布于颊粘膜以及颊区直至口角的皮肤。
(3) 舌神经在下牙槽神经的前方,经翼外肌深面下行,途中有面神经的鼓索从后方加入此神经。此后越过翼内肌浅面到达下颌下腺的上方,再沿舌骨舌肌的表面行至舌尖。舌神经分支分布于口腔底和舌前2/3的粘膜,接受一般躯体感觉的刺激。
(4) 下牙槽神经为混合神经,含一般躯体感觉纤维和特殊内脏运动纤维。下牙槽神经在舌神经的后方,沿翼内肌的外侧面下行,其中的特殊内脏运动纤维分出分支,支配下颌舌骨肌和二腹肌前腹。一般躯体感觉纤维经下颌孔入下颌管。在下颌管内分支构成下牙丛,分支分布于下颌各牙和牙龈。其终支自颏孔穿出称颏神经,分布于颏部及下唇的皮肤和粘膜。
(5) 咀嚼肌神经为特殊内脏运动神经,分数支支配所有咀嚼肌。
(二)操作步骤

病人取仰卧位,取头正中位,于颧弓至下颌切迹中点下1/3处为穿刺点。
患者微张口,消毒铺巾,局麻后用7号长穿针垂直进针3.5-5cm可触及翼突外板,做距离皮肤1.25cm深度标记后,退针至皮下,再向外耳道方向或外后方重新进针达标记处,使针尖滑过翼突外板,可出现下颌或舌部电击样异感。
回吸无血,注射1%利多卡因2ml,病人出现疼痛区麻木且无其它不适后,再注射1%利多卡因5ml+曲安奈德5mg,拔针后按压穿刺点数分钟。
(三)应用范围:
1、下颌神经及其各分支神经分布区域的疼痛。
2、该区域癌痛、外伤、放疗后疼痛。
3、该部位带状疱疹和疱疹后遗神经痛。
七、下齿槽神经阻滞术
(一)应用范围:
治疗下颌神经分布区域的神经痛或癌痛
此神经支配区域手术麻醉
该部位带状疱疹和疱疹后遗神经痛
(二)操作步骤

患者仰卧、头前视位,让患者尽量将口张大。
体表定位:术者先用左手食指探入口腔内确定下颌骨支前缘,其位置高于下颌骨的最后磨牙。
常规消毒后,用10cm长,7号局麻针,在食指触及到的部位稍高处,将针刺入下颌支的内侧面与口腔粘膜之间。
当针尖触及下颌骨内侧壁后,沿着下颌支的内侧面继续向后进针约2~3cm,回吸无血,注射局麻药或除痛液5~6ml。
如果患者牙和舌的前部没有异感,也可以边退针边注射上述药液3~5ml。
可用神经定位刺激器确定靶神经位置。
(三)注意事项
1、穿刺部位神经损伤及粘膜下血肿。
2、注射后应用干棉球压迫3~5min。
3、注射神经毁损药物后,部分患者感觉舌根和面部轻度麻木。
八、颏神经阻滞术
(一)适应证
1、三叉神经第三支,颏神经痛。
2、该部位带状疱疹和疱疹后遗神经痛。
3、用于颏、下唇部手术的麻醉镇痛以及第三分支抽搐的诊断与治疗。
(二)操作步骤
患者取仰卧,头直视位。
体表定位:该神经位于第一磨牙前下方或与第二尖牙之间下方,嘴角稍下可触及颏孔。
用3.5cm长,6~7号短针穿刺。垂直进针,当针尖触及下颌骨,改变穿刺针角度与皮肤呈45°向颏联合方向进针,向前或正中方向寻找颏孔。当针尖刺进骨凹陷内,即可确认为颏孔。大多数患者出现下唇感觉异常。注入局麻药2~3ml或神经损毁药0.5ml,轻压3~5min,用创可贴粘敷。
(三)注意事项
注射神经毁损药物剂量不宜过大,避免局部肌肉萎缩。
穿刺过深,针尖进入颏管内,容易引起神经的损伤。

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  4. SpainrWex

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