Nội dung

1 NOTICE Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with the new or infrequently used drugs. 2 3 Copyright © 2018 by McGraw-Hill Education. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of the publisher. ISBN: 978-0-07-178935-6 MHID: 0-07-178935-9 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07178934-9, MHID: 0-07-178934-0. eBook conversion by codeMantraVersion 1.0 All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs. To contact a representative, please visit the Contact Us page at www.mhprofessional.com. TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause 4 whatsoever whether such claim or cause arises in contract, tort or otherwise. 5 CONTENTS Preface Acknowledgments 1. Basics of Musculoskeletal and Doppler Ultrasound Imaging for Regional Anesthesia and Pain Medicine 2. Sonoanatomy Relevant for Ultrasound-Guided Upper Extremity Nerve Blocks 3. Sonoanatomy Relevant for Ultrasound-Guided Lower Extremity Nerve Blocks 4. Sonoanatomy Relevant for Ultrasound-Guided Abdominal Wall Nerve Blocks 5. Ultrasound Imaging of the Spine: Basic Considerations 6. Sonoanatomy Relevant for Ultrasound-Guided Injections of the Cervical Spine 7. Ultrasound of the Thoracic Spine for Thoracic Epidural Injections 8. Ultrasound Imaging of the Lumbar Spine for Central Neuraxial Blocks 9. Ultrasound Imaging of Sacrum and Lumbosacral Junction for Central Neuraxial Blocks 10. Sonoanatomy Relevant for Thoracic Interfascial Nerve Blocks: Pectoral Nerve Block and Serratus Plane Block 11. Sonoanatomy Relevant for Ultrasound-Guided Thoracic Paravertebral Block 12. Sonoanatomy Relevant for Ultrasound-Guided Lumbar Plexus Block Index 6 PREFACE This Atlas is intended to illustrate the aspects of sonoanatomy that are important in the performance of ultrasound guided nerve blocks for acute and chronic pain medicine. The use of ultrasound has increased exponentially in the area of regional anesthesia and pain medicine in the last decade. During this time of evolution, learning sonoanatomy was hampered with the need to refer to various resources for the technical aspects of machine optimization, correlating sonoanatomy with gross anatomy and other imaging modalities and discovering the ergonomic aspects of imaging and intervention. For regional anesthesia, transitioning from landmark based techniques for nerve blocks to real time ultrasound image guided nerve blocks required the development of the ability to visualize and understand the cross sectional anatomy of the area of interest outside the traditional transverse, sagittal and coronal axis views presented by current modalities such as computed tomography and magnetic resonance imaging. For pain medicine, transitioning from fluoroscopy guided interventions to real time ultrasound image guided or assisted interventions required the development of new points of reference for interventions and a move away from traditional fluoroscopic guided endpoints for intervention. This book is divided into chapters that present the sonoanatomy specific for interventions in the area of interest. With a total of 768 illustrations this book is designed to be the complete resource for gross anatomy, CT, MR and sonoanatomy of the specific area of interest for easy cross-reference between gross anatomy and the various modalities allowing users to better understand the sonoanatomy. These cross-referenced images are presented with the relevant anatomy in the same cross sectional plane of the ultrasound image. Within each area of interest, users are guided to acquire the ideal ultrasound image for targeted intervention with attention to the required ergonomics for operator safety and comfort. Each approach to the relevant sonoanatomy is accompanied by clinical pearls to aid readers acquire ultrasound images of the area of interest with ease, provide guidance for successful intervention and avoid pitfalls. This Atlas has been written both as an introduction for new users to ultrasonography and as a review and instruction aid for users familiar with the subject. It is our sincere hope that the users of this book will develop an appreciation of the ease and usefulness of ultrasonography and the beauty of sonoanatomy. 7 ACKNOWLEDGMENTS We would like to express our deepest gratitude to Philips Medical for their assistance, with special appreciation to – Inainee binte Abu Bakar, Lynette Barss, Cheong Yew Keong, Doxie Davis, Nicolaas Delfos, Cellinjit Kaur, William Kok, Nah Lee Tang and Wayne Spittle. And, of course, our families for their support and encouragement. The anatomic images are courtesy of the Visible Human Server at Ecole Polytechnique Fédérale de Lausanne, Visible Human Visualization Software (http://visiblehuman.epfl.ch), and Gold Standard Multimedia www.gsm.org. All figures and illustrations in this book are reproduced with the kind permission from www.aic.cuhk.edu.hk/usgraweb of the Department of Anesthesia and Intensive care of The Chinese University of Hong Kong. Manoj K. Karmakar, MD, FRCA, DA(UK), FHKCA, FHKAM Edmund Soh, MD Victor Chee, MD Kenneth Sheah, MD 8 CHAPTER 1 Basics of Musculoskeletal and Doppler Ultrasound Imaging for Regional Anesthesia and Pain Medicine A sound knowledge of the basic concepts of musculoskeletal ultrasound is essential to obtain optimal images during ultrasound-guided regional anesthesia (USGRA). This chapter briefly summarizes the ultrasound principles that the operator should be aware of when performing USGRA. Ultrasound Transducer Frequency Spatial resolution is the ability to distinguish two closely situated objects as separate. Spatial resolution includes axial resolution (the ability to distinguish two objects at different depths along the path of the ultrasound beam) and lateral resolution (the ability to distinguish two objects that are side by side perpendicular to the ultrasound beam). Higher transducer frequencies increase spatial resolution but penetrate poorly into the tissues. Lower transducer frequencies penetrate deeper into the tissues at the expense of lower spatial resolution. Spatial resolution and beam penetration have to be balanced when choosing the transducer frequency. Examples: A high-frequency (6–13 MHz) ultrasound transducer is used to image superficial structures such as the brachial plexus in the interscalene groove or supraclavicular fossa. A lower-frequency transducer (5–10 MHz) is suitable for slightly deeper structures such as the brachial plexus in the infraclavicular fossa, and a low-frequency transducer (2–5 MHz) is used to image deep structures such as the lumbar paravertebral region or the sciatic nerve. High-frequency (6–13 MHz) linear transducers with a small footprint (25–26 mm) are particularly suited for regional blocks in young children. Scanning Plane Scans can be performed in the transverse (axial) or longitudinal plane. During a transverse scan, the transducer is oriented at right angles to the long axis of the target, producing a cross-sectional display of the structures (Fig. 1-1A). During a longitudinal (sagittal) scan, the transducer is oriented parallel to the long axis of the target (eg, a blood vessel or nerve) (Fig. 1-1B). During USGRA, ultrasound scans are most commonly performed in the transverse plane in order to easily visualize the nerves, the adjacent structures, and the circumferential spread of the local anesthetic. 9 FIGURE 1-1 Axis of scan. Transducer and Image Orientation The ultrasound image must be correctly oriented in order to accurately identify the anatomical relationships of the various structures on the display monitor. Ultrasound transducers have an orientation marker (eg, a groove or a ridge) on one side of the transducer, which corresponds to a marker on the monitor (eg, a dot or logo) (Fig. 1-2). There are no accepted standards on how to orient a transducer, but it is common to have the orientation marker on the transducer directed cephalad when performing a longitudinal scan, and directed towards the right side of the patient when performing a transverse scan (Fig. 1-3). In this way, the monitor “marker” should be at the upper-left corner of the screen representing the cephalad end during a longitudinal scan, or the right side of the patient during a transverse scan (Fig. 1-3). The top of the monitor represents superficial structures, and the bottom of the monitor deep structures. 10