B型超声辅助定位L5-S1间隙用于老年髋部骨折患者椎管内麻醉  

Application of type-B ultrasonic assisted localization of the L5-S1 interspace for intrathecal anesthesia in elderly patients with hip fractures

作　　者：袁嫕 朱丰 张文超 陈廷露 田晓威 黄佳颖 李庭 杨明辉 王瑞 高兴帅 王庚 YUAN Yi;ZHU Feng;ZHANG Wenchao;CHEN Tinglu;TIAN Xiaowei;HUANG Jiaying;LI Ting;YANG Minghui;WANG Rui;GAO Xingshuai;WANG Geng(Department of Anesthesiology,Beijing Jishuitan Hospital,Capital Medical University,Beijing 100035;Department of Anesthesiology,Zhongshan Orthopedics Hospital,Beijing Jishuitan Hospital Zhongshan Orthopedics Hospital,Zhongshan 528400,Guangdong;Department of Trauma Surgery,Beijing Jishuitan Hospital,Capital Medical University,Beijing 100035;Department of Orthopedics,Zhongshan Orthopedics Hospital,Beijing Jishuitan Hospital Zhongshan Orthopedics Hospital,Zhongshan 528400,Guangdong,China)

机构地区：[1]首都医科大学附属北京积水潭医院麻醉科,北京100035 [2]中山市骨科医院(北京积水潭中山骨科医院)麻醉科,广东中山528400 [3]首都医科大学附属北京积水潭医院创伤外科,北京100035 [4]中山市骨科医院(北京积水潭中山骨科医院)综合骨科,广东中山528400

出　　处：《中华骨与关节外科杂志》2023年第11期1015-1020,共6页Chinese Journal of Bone and Joint Surgery

基　　金：北京积水潭医院院级科研基金(ZR-202108);北京市属医院科研培育项目(PX2021019)。

摘　　要：目的:探讨应用B型超声辅助定位L5-S1间隙能否提高老年髋部骨折患者椎管内麻醉一次穿刺成功率。方法:前瞻性选取2021年6月至2022年6月采用椎管内麻醉实施髋部骨折手术的老年患者(年龄>65岁)100例,随机分成辅助定位组及传统定位组。辅助定位组应用低频(2~5 MHz)凸阵超声探头采用旁正中矢状位及横轴水平位扫查L5-S1间隙后定位穿刺点;传统定位组由主治医师根据间隙的清晰度确定穿刺间隙的优先顺序,在间隙处用记号笔标注,作为正中入路的进针点。两组穿刺均采用正中穿刺入路。主要观察指标为一次穿刺成功率,即通过1个皮肤穿刺点到达蛛网膜下腔的比例。次要观察指标包括穿刺次数、调整穿刺针方向的次数、定位时间、穿刺时间、操作时间、操作相关不良反应、麻醉平面,并记录L5-S1穿刺点与双侧髂后上棘连线中点的距离。结果:共93例患者完成椎管内麻醉,7例穿刺失败(传统定位组6例,辅助定位组1例)。传统定位组一次穿刺成功率为33.3%,辅助定位组一次穿刺成功率为67.7%(χ^(2)=22.257,P<0.001)。传统定位组皮肤穿刺次数和调整穿刺针方向的次数分别为2(2,3)、5(4,6)次,辅助定位组分别为1(1,1)、1(0,2)次(Z=-4.232,P<0.001;Z=-5.281,P<0.001)。两组的定位时间、穿刺时间、操作时间分别为[(3.24±0.95)min vs.(1.26±0.41)min,P<0.001],[(2.83±0.67)min vs.(4.80±0.59)min,P<0.001],[(6.98±1.01)min vs.(7.28±0.80)min,P=0.196]。L5-S1间隙穿刺点与双侧髂后上棘连线中点的距离男性为(2.01±0.63)cm,女性为(1.89±0.45)cm,该间隙的B型超声图像质量优于L3-L4或L2-L3间隙。结论:B型超声辅助定位正中入路L5-S1间隙可提高老年髋部骨折患者椎管内麻醉一次穿刺的成功率,缩短穿刺时间,临床实用性强。Objective:To investigate whether type-B ultrasonic assisted localization of the L5-S1 interspace increases the first-attempt success rate of intrathecal anesthesia in elderly patients with hip fractures.Methods:A prospective study was conducted from June 2021 to June 2022,including 100 elderly patients(age>65 years)undergoing hip fracture surgery with intrathecal anesthesia.The patients were randomly divided into the ultrasound-assisted localization group and the conventional localization group.In the ultrasoundassisted localization group,a low-frequency(2-5 MHz)convex-array ultrasound probe was used to scan the L5-S1 interspace from the paramedian sagittal and transverse section before localization of the puncture point.Patients in the conventional localization group were performed by the physician who determined the priority order of the puncture site according to the clarity of the interspace and marked it with a pen as the midline entry point.Spinal anesthesia was processed via the midline approach in both groups.The primary outcome was the rate of successful access to subarachnoid space on the first needle insertion attempt.Secondary outcomes included the number of needle insertion attempts,needle redirection times,time taken to establish landmarks,puncture time,procedure time,adverse events during the procedure,anesthesia level,and the distance between the L5-S1 puncture site and the midpoint of the bilateral posterior superior iliac spines.Results:A total of 93 patients successfully received intrathecal anesthesia,and 7 patients failed(6 patients in the conventional localization group and 1 in the ultrasound-assisted localization group).The first-attempt success rate was 33.3%in conventional localization group and 67.7%in the ultrasound-assisted localization group(χ^(2)=22.257,P<0.001).The conventional localization group had a skin puncture count and needle direction adjustments of 2(2,3)and 5(4,6)times,respectively,while the ultrasound-assisted localization group had 1(1,1)and 1(0,2)times,respectively(Z=

关 键 词：B型超声 椎管内麻醉 髋部骨折 加速康复外科 

分 类 号：R683.4[医药卫生—骨科学]