| Objectives:This study intends to explore a new method of lumbosacral plexus block,ultrasound-guided anterior lumbosacral plexus block,by means of autopsy,in vivo imaging(CT and ultrasound)measurement and clinical validation,and to observe the feasibility,safety and effectiveness of its clinical application.It is intended to be anesthesia for patients undergoing clinical hip surgery.And provide a new way of thinking for postoperative analgesia.Methods:Part one:Five formalin-fixed cadavers provided by the Department of Medical Sciences of Soochow University were selected as subjects in the first part.(1)The specimens 1,2 and 3 were dissected locally on the pelvis and abdomen,and the specimens were dissected layer by layer on the upper 4～5 cm of the left and right anterior superior iliac spine and the inner edge of the iliac crest in the order of outward and inward.The anatomical morphology of the three compartments of RC,RPSC and PPC as well as the distribution and course of the internal nerves were observed.(2)According to the preset anterior LPB method;Methylene blue was injected into the compartment of RPSC on the right side of specimens 4 and 5.The infiltration of methylene blue along the nerve was traced and the diffusion of methylene blue into the RPSC compartment was observed.Methylene blue was injected into the PPC compartment on the left side of specimens 4 and 5.The infiltration of methylene blue along the nerve was traced and the diffusion of methylene blue into the PPC compartment was observed.Part two:Randomly retrospectively selected 100 patients who underwent enhanced CT examination in our hospital from January 2019 to June 2019.All patients who met the inclusion criteria received enhanced CT scanning results in supine position.According to the preset anterior LPB method,the horizontal CT images of sacral promontory were selected to observe and measure the bilateral pseudo-puncture paths:(1)Mark measuring points and make measuring lines on the pseudo-puncture paths.(2)Observe whether there is intestinal or vascular obstruction on the route of puncture.(3)Record the measurement line(A’line,B’line)of the patients without intestinal or vascular obstruction.(4)Analyze the relationship between the safety path and BMI size of the patients.Part three:100 adult volunteers were randomly selected as the research object.The intestinal canal and blood vessels were identified under ultrasound.The measurement plane was determined by ultrasound scanning.The ultrasound images at the level of sacral promontory were selected to observe and measure the bilateral pseudo-puncture paths:(1)(2)(3)Observation and measurement methods were the same as those of CT scan measurement part.(4)Measure the vertical distance(C line)between the center line of the ultrasound probe and the level of the anterior superior iliac spine.(5)Analyze the relationship between the safety path and the abdominal circumference and BMI of volunteers.Part four:Randomly selected 30 patients with unilateral selective THA for ultrasound-guided anterior LPB technique.According to the aforementioned ultrasound scanning method,the ultrasound low-frequency convex array probe was scanned on short-axis cross-section until the level of sacral promontory appeared under ultrasound.The puncture needle was inserted at the lateral edge of the probe and the medial edge of the iliac bone.The puncture needle was inserted into the RPSC compartment by in-plane technique,and 20 ml of local anesthetics was injected into the PPC compartment,and 30 ml of local anesthetics was injected into the compartment.MAIN OUTCOME MEASURES:(1)After 30 minutes of operation,the blocking effect of the incision area of buttock operation was detected.(2)After 30 minutes of operation,the range of lower limb block was measured and the effect was evaluated.(3)Record the types and doses of intravenous adjuvant drugs during operation.(4)Evaluate the RVAS score at rest 2 hours after operation.(5)Complications were recorded during anesthesia and within 24 hours after operation.Results:Part one:(1)observed that the RC compartment was located between the parietal peritoneum and the transverse peritoneal fascia,mainly filled with adipose tissue,and did not contain the main peripheral nerves of the lumbosacral plexus.The RPSC compartment is a triangular groove extending between the psoas major muscle and the iliac muscle.The compartment contains the lateral segment of the psoas major muscle of the femoral nerve and the lateral femoral cutaneous nerve.The posterior part of PPC compartment is sacrum,the medial part is sacral promontory and the anterolateral part is psoas major muscle to form an anatomical space.The compartment contains anterior ramus of spinal nerve L4-S1,lumbosacral trunk and obturator nerve.(2)The results of methylene blue injection showed that the compartments of PPC and RPSC were not interrelated.Methylene blue was injected into the compartments of PPC and RPSC respectively,and could diffuse into the corresponding nerve periphery of the compartment and stain it with infiltration.The diffusion range of methylene blue solution in PPC compartment is related to its dose.Part two:(1)In all the patients who were referred to the results of CT,there was no vascular obstruction in the bilateral puncture path,6 cases had intestinal obstruction on the right side,11 cases had left intestinal obstruction,31 cases had intestinal obstruction on both sides,intestinal obstruction was regarded as no safe path,and CT images were discarded.After screening,52 patients had bilateral safe path and 17 patients had unilateral safe path.In patients with safe path,the length of A’line was 113.89(+12.37 mm)on the right side and 114.90(+12.07 mm)on the left side.The length of B’line was 92.23(+13.19 mm)on the right side and 91.57(+12.69mm)on the left side.(2)All patients who received CT measurement were divided into two groups.The patients with safe path(bilateral or unilateral)were marked as group Y(n=69),and the patients without safe path on both sides were marked as group N(n=31).Statistical analysis showed that BMI of group Y was 25.30(+2.96 kg/m2),that of group N was 21.86(+1.92 kg/m2),and that of group Y was larger than that of group N(p<0.0001).Part three:(1)Among the 100 ultrasound scans,1 volunteer had blood vessel obstruction in bilateral pseudo-puncture pathway,1 case had left blood vessel obstruction,1 case had right blood vessel obstruction,5 cases had right intestinal tube obstruction,6 cases had left intestinal tube obstruction,50 cases had bilateral intestinal tube obstruction.After screening,39 volunteers had bilateral safe path and 11 volunteers had unilateral safe path(left 5 and right 6).Among the volunteers with safe paths,the length of A’line was 90.25(+10.82 mm)on the right side and 97.83(+11.82 mm)on the left side.The length of B’line was 64.01(+10.56 mm)on the right side and 65.16(+11.15 mm)on the left side.The length of C-line was 4.57(+0.65 cm)on the right side and 4.47(+0.68 cm)on the left side.(2)All the volunteers were divided into two groups.The volunteers with safe paths(bilateral or unilateral)were marked as group Y(n=50),and those without safe paths on both sides were marked as group N(n=50).Statistical analysis showed that the abdominal circumference of Y group was 86.77(+7.98 cm),that of N group was 78.19(+8.56 cm),that of Y group was larger than that of N group(p<0.0001),and that of Y group was 25.59(+3.27 kg/m2),that of N group was 22.53(+3.27 kg/m2),and that of Y group was larger than that of N group(p<0.0001).Part four:30 patients underwent THA selectively received ultrasound-guided anterior LPB for 30 minutes.(1)The results of skin sensory blockade in the area of incision were as follows:19 patients had complete skin blockade in the area of hip incision;8 patients had incomplete skin blockade in the area of incision;and 3 patients had no skin blockade in the area of incision.(2)The results of lower limb block range:test showed that the complete block rate of b2 in femoral nerve innervation area was 90%,that the complete block rate of c2 in lateral femoral cutaneous nerve innervation area was 93.3%,that the complete block rate of a2 in obturator nerve innervation area was 73.3%,and that the complete block rate of c4 in sciatic nerve innervation area was 60%.(3)Except for 3 patients who underwent surgery under general anesthesia,the other 27 patients underwent surgery under mask oxygen inhalation.Five patients received 0.1-0.2 mg fentanyl and three patients received 5-10 mg sufentanil.During the operation,dexmedetomidine was continuously pumped 0.2 mg/kg/h without significant fluctuations in heart rate and blood pressure.(4)The RVAS score at 2 hours after operation was 25 in mild patients,5 in moderate pain,and no in severe pain.(5)During the anesthesia and within 24 hours after surgery,all patients had no epidural spread of local anesthetic,local anesthetic poisoning,local hematoma,1 patient developed urinary incontinence,which returned to normal 24h after surgery;2 patients developed femoral nerve anomaly during puncture,but no nerve injury was found.Conclusions:Ultrasound-guided anterior lumbosacral plexus block is a new type of peripheral nerve block.It has a certain application prospect in patients with safe pathway.It can operate in the supine position,and can reduce the number of punctures,shorten the operation time of anesthesia and obtain satisfactory anesthetic effect.It provides a new choice for clinical anesthesia program of hip surgery.It has certain clinical application value. |
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