枕大、小神经阻滞

一、适应证
颈源性偏头痛。
其它原因引起的偏头痛。
该部位带状疱疹和疱疹后遗神经痛。
枕部后、枕上1/3的头皮麻醉。
二、解剖
枕大神经(1)枕大神经为C2神经后支的内侧支,出椎管后呈弧形绕过头下斜肌下缘,向上内行走,与矢状面约呈70°角,冠状面呈60°角,穿行于头半棘肌和头最长肌之间。
(2)枕大神经起始点约位于C2棘突上2.0cm,后正中线旁开2.5cm处。在C2棘突上方约2.2cm,后正中线旁开约2.0cm处穿出肌肉,在斜方肌和胸锁乳突肌腱性止点纤维深面,紧贴项筋膜,于筋膜水平位,斜形走向外上,开始段与后正中线约呈30°~40°角,邻近上项线处增至55°~70°角,走行距离约5cm,在上项线距枕外隆突约3.5cm处,浅出皮下,该处为斜方肌腱性索带与枕骨之间形成一纤维骨性孔道,直径约2mm。浅出皮下后,与枕动脉伴行,分成2~5支,支配枕部皮肤,皮支最远可解剖到冠状缝。
枕小神经由第2颈神经前支通过颈浅丛分出, 绕过胸锁乳突肌后缘上行。
颧弓以上的头皮后部, 为第3枕神经(第3颈神经)及枕大神经(第2颈神经),侧面向前, 依次为枕小神经(第2颈神经)、耳颞神经、颧颞神经、颧面神经、泪腺神经、眶上神经及滑车上神经。
枕大神经与眶上神经分布区的分界线为两耳间冠状平面。耳大神经分布在耳垂下方的一部分颈部皮肤、耳廓下半的前后面。耳后乳突部上下及耳后上部的头皮, 皆由枕小神经分布。
三、枕大神经阻滞操作方法与程序
患者面对治疗床,头稍前屈,双肘部支撑在床上,长发患者用治疗巾从后向前包住枕后头发,让患者双手自己固定治疗巾同时用手掌托住前额,患者下颊尽量接近自己前胸。
确定乳突与寰枢关节连线或颈2棘突与乳突后缘连线中点向上1cm,在此点可能触及枕动脉。
无需注射局麻皮丘,用3.5cm长,7号短针垂直进针,直至触及枕骨。此时病人有可能会出现异感,表明触及枕大神经,但多数患者可以没有异感。充分回吸无血后即可于帽状腱膜上、下注射局麻药或除痛液5~6ml,轻压3~5min后不再出血即可。
注意事项:
注药前坚持回吸,避免将局麻药误注入枕动脉内。
通常只要沿枕后骨板注药,罕有并发症出现。
四、枕大神经阻滞操作方法与程序
治疗体位同枕大神经阻滞术。
在枕大神经阻滞点外侧2cm为枕小神经穿刺点。注射1%利多卡因或除痛液2~3ml,轻压3~5min不出血即可。
五、枕大、小神经阻滞法
坐位,头前曲(前额抵于枕上),确定乳突与枕骨粗隆,在其连线上均分三等份的两点,内侧点为枕大神经穿刺点,外侧为枕小神经穿刺点。在枕大神经穿刺点用5号针头垂直进针直达枕骨,充分回吸无血后注射0.6-1%利多卡因5-6ml+曲安奈德5mg。

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