星状神经节阻滞

一、适应证
1、偏头痛、丛集性头痛
2、头面、胸背及上肢带状疱疹和疱疹后遗神经痛
3、复杂性局部痛综合征
4、幻肢痛
5、急性血管栓塞、雷诺氏病、硬皮病。
6、急性或慢性心绞痛
7、脑血管痉挛等心血管疾病
8、更年期妇女不定陈述综合症
9、过敏性鼻炎、突发性耳聋等
二、解剖

颈部交感神经节位于颈血管鞘的后方,颈椎横突的前方。每侧有三个: 颈上神经节、颈中神经节、颈下神经节。颈下交感神经节也称星状神经节或颈胸交感神经节;其形状不规则,呈卵圆形,放射状,长约2cm,宽约lcm;大于颈中神经节;位于第7颈椎横突基部和第1肋骨颈之间的前方,椎动脉的后方,斜角肌群的内侧;肺尖在其下方;下界位于胸膜后方,被疏松的蜂窝组织及脂肪组织所包裹。发出的灰交通支连接第7、第8颈神经和第1胸神经,还发出分支围绕锁骨下动脉及其分支组成丛,随该动脉到达腋动脉第1段。 一些分支分别围绕椎动脉组成椎动脉丛,进入颅腔,围绕椎动脉及基底动脉,直到大脑后动脉,和起自颈内动脉的神经丛会合。发出的心下神经沿锁骨下动脉后方,气管的前方下降,加入心丛而参与支配心脏的活动。
三、生理功能
主要表现为交感肾上腺系统的兴奋而产生的交感神经系统反应,如心肌收缩力增加、传导功能加速、心率加快。扩张支气管。扩瞳、松弛睫状肌。促进肝糖原分解、升高血糖、肾上腺髓质激素分泌增加等。
四、操作方法

仰卧,肩下垫枕,口微张开,放松颈前肌肉。
用左手食指和中指将胸锁乳突肌和颈总动脉推向外侧。
在食管旁和胸锁乳突肌前缘胸锁关节上方约两横指(环状软骨平面相当于第6颈椎横突)处与皮肤垂直进针。触到骨质,退针少许,回吸无血即可注入局麻药液3-5ml.阻滞成功的标志为注药侧出现霍纳氏综合征。穿刺针触及交感神经节时并无异感。
1、注射期间令患者睁眼,观察注射反应,注射后令患者坐位,2~3min后患者出现同侧霍纳(Horner’s)氏征,则表明阻滞成功。
2、普通患者针进入约2cm左右,针尖触及到横突时患者不出现异感。
3、对肥胖和颈短粗患者,可能深到2.5~3cm左右。如果发现进针比这更深,则有可能针尖刺进两个横突之间。应立即将针退出,再调整针尖向头侧或尾侧方向穿刺,直至针尖触及到横突骨性感觉。
五、并发症
1、喉返神经阻滞。
2、膈神经和臂丛神经阻滞。
3、气胸。
4、硬膜外或蛛网膜下腔阻滞。
5、误注入椎动脉或颈动脉。
6、误注入食管和气管壁或腔内。
六、注意事项:
1、穿刺过深误将局麻药误注入椎动脉内,而引起患者中枢神经性抽搐和呼吸心跳停止。
2、误注入蛛网膜下腔,产生全脊麻导致呼吸抑制、心跳停止。
3、注射药物过浅或接近气管-食管沟,阻滞喉返神经,可导致声音嘶哑。
4、穿刺部位过高或局麻药量过大,可以阻滞膈神经,出现腹式呼吸减弱或因膈神经受刺激而出现呃逆。
应特别提醒术者,在进行本操作过程中,必须边回吸,边进针。甚至一滴或二滴局麻药误入到椎动脉,即可以引起患者抽搐。
穿刺针过于朝向尾侧,容易刺伤胸膜顶或肺尖引发气胸。反复穿刺损伤血管引起出血、血肿和感染。近年有人提出,在颈6和颈7部位穿刺对星状神经节的阻滞效果相似,而前者发生并发症明显少于后者。因此坚持穿刺针尖深度不触及横突根部骨性感不能注药的原则以策安全。
七、霍纳(Horner’s)氏征:、
1.瞳孔缩小。
2.眼睑下垂及眼裂狭小。
3.眼球内陷。
4.患侧额部无汗。

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