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目的:对膈神经阻滞入路相关结构及其毗邻关系进行了解剖观测,为膈神经阻滞入路和预防并发症的发生提供解剖学基础。方法:实验于2003-12/2004-12在郧阳医学院解剖学教研室完成。由郧阳医学院解剖学教研室提供24具尸体,男20具,女4具。对48侧尸体头、颈、胸部的标本与膈神经穿刺入路相关结构及其毗邻关系进行了解剖观测。结果:①膈神经进针的深度:皮肤至膈神经(胸锁乳突肌外侧缘上距其锁骨头25～30mm头侧为进针点)为26.0±0.3(21～30)mm。②膈神经与胸膜顶,肺尖、胸导管等结构毗邻的关系:胸膜顶的体表投影,胸膜顶的内侧界距胸骨柄上缘中点两侧均为10～19(14.2±0.3)mm。胸膜顶的外侧界与胸锁关节之间的距离左侧为43～70(55.3±0.6)mm。右侧为51～80(57.5±0.6)mm。胸膜顶的最凸点与锁骨之间的距离左侧为11～29(21.6±0.4)mm,右侧为11～39(26.5±0.5)mm。左侧锁骨上缘点位于胸锁关节外侧为19～28(22.5±0.3)mm,右侧为13～29(23.0±0.4)mm。胸膜顶的外侧界距颈正中线两侧均为50～90(72.1±0.8)mm,肺尖与颈正中线两侧均为31～52(38.1±0.4)mm。胸导管在颈动脉鞘后方,椎动脉、椎静脉及膈神经前方弓形入静脉角,胸导管末端的弓高平均为5.2～12.5mm。③膈神经与副膈神经、颈交感干联系的观测结果:颈交感干与膈神经和副膈神经联系的出现率为43.6%,主要与膈神经相联系,与副膈神经则较少。它们与颈下神经节联系最多为60.4%,其次与颈中神经节为17.5%。此外也有与椎动脉神经节、锁骨下袢、颈中、下神经节之间相联系,于此可见膈神经在颈部与交感干有广泛的联系。结论:为膈神经穿刺的入路进针深度和预防并发症的发生提供了解剖学参考依据。
OBJECTIVE: To anatomize the related structures of phrenic nerve block and its adjacent relationship and to provide anatomical basis for the pathogenesis of phrenic nerve block and prevention of complications. Methods: The experiment was performed in Department of Anatomy, Yunyang Medical College from December 2003 to December 2004. By Yunyang Medical College Department of Anatomy provide 24 bodies, 20 men and 4 women. The anatomical observation was performed on the structures and their adjacent relations of the specimens of 48 sides of the head, neck and chest with the phrenic nerve puncture. Results: ① The depth of phrenic nerve needle insertion: 26.0 ± 0.3 (21-30) mm from the skin to the phrenic nerve (25-30 mm head side of the sternocleidomastoid muscle). ② phrenic nerve and the top of the pleura, apical, thoracic duct and other structures adjacent to the relationship: the top of the pleural surface projection, the medial pleural crest of the upper edge of the midpoint of the sternum are 10 ~ 19 (14.2 ± 0.3) mm . The distance between the lateral border of the pleural top and the sternoclavicular joint was 43-70 (55.3 ± 0.6) mm on the left. The right side is 51 to 80 (57.5 ± 0.6) mm. The distance between the most protruding point of the pleural crest and the collarbone was 11-29 (21.6 +/- 0.4) mm on the left and 11-39 (26.5 +/- 0.5) mm on the right. The upper margin of the left clavicle is located at the outer side of the sternoclavicular joint at 19-28 (22.5 ± 0.3) mm and the right side at 13-29 (23.0 ± 0.4) mm. The lateral margin of the pleural top was 50 to 90 (72.1 ± 0.8) mm from both sides of the median line of the neck, and 31 to 52 (38.1 ± 0.4) mm on either side of the midline between the apical and the neck. Thoracic duct in the carotid sheath, vertebral artery, vertebral vein and phrenic anterior arch arcuate venous angle, the average height of the end of the thoracic duct arch 5.2 ~ 12.5mm. ③ The relationship between phrenic nerve and phrenic nerve and cervical sympathetic trunk: The incidence of cervical sympathetic trunk-phrenic nerve and phrenic nerve was 43.6%, which was mainly associated with phrenic nerve and less with phrenic nerve. They were associated with the inferior ganglion at most 60.4%, followed by the middle of the ganglion at 17.5%. In addition, there are also associated with the vertebral artery ganglion, the subclavian, the neck, the lower ganglion between the visible phrenic nerve in the neck and sympathetic have a wide range of contacts. Conclusion: This study provides an anatomic reference for the depth of phrenic nerve puncture and the prevention of complications.