超声引导下的骶骨竖脊肌阻滞的临床应用进展
Clinical Application Progress of Ultrasound-Guided Sacral Erector Spinae Plane Block
DOI: 10.12677/acm.2025.153747, PDF, HTML, XML,   
作者: 谭伟臻, 陈欣悦, 臧梦璇:青岛大学附属医院麻醉科,山东 青岛;宋海成, 任悦义*:青岛大学附属妇女儿童医院心脏中心,山东 青岛
关键词: 神经肌肉阻滞术后镇痛临床应用Neuromuscular Blockade Postoperative Analgesia Clinical Application
摘要: 骶骨竖脊肌阻滞(SESPB)将局麻药注射于骶骨与多裂肌之间,通过药物扩散实现对骶神经、腰神经等的阻滞作用,有学者根据解剖提出应称之为骶骨多裂肌阻滞。目前,SESPB在骨科、泌尿外科、肛肠外科等表现出良好的镇痛效果。本文总结了SESPB在解剖基础、作用机制、常用药物、临床应用等方面的研究进展,旨在为临床应用提供参考。
Abstract: Sacral erector spinae plane block (SESPB) injects local anesthetic between sacrum and multifidus muscle, realizing the blocking effect on sacral nerve, lumbar nerve and so on through drug diffusion, and some scholars propose that it should be called sacral multifidus block according to anatomy. At present, SESPB shows good analgesic effects in orthopedics, urology, anal surgery and so on. This paper summarizes the research progress of SESPB in terms of anatomical basis, mechanism of action, commonly used drugs, clinical application, etc., aiming to provide a reference for clinical application.
文章引用:谭伟臻, 陈欣悦, 臧梦璇, 宋海成, 任悦义. 超声引导下的骶骨竖脊肌阻滞的临床应用进展[J]. 临床医学进展, 2025, 15(3): 1338-1346. https://doi.org/10.12677/acm.2025.153747

1. 背景

竖脊肌平面阻滞(ESPB)由Forero等于2016年首次描述,最初用来为胸背部神经病理性疼痛提供镇痛[1]。之后,Tulgar等描述了ESPB在骶骨区域的应用,通过阻断骶神经的后支为骶旁区域提供感觉阻滞[2]。由于其操作方式由ESPB衍生而来,目前研究多称之为“骶骨竖脊肌阻滞(sacral erector spinae plane block, SESPB)”,但根据其解剖结构,“骶骨多裂肌阻滞”是更合适的命名[3],本文暂统一使用骶骨竖脊肌阻滞(SESPB)描述。目前研究已证实其适用于肛肠外科、骨科、泌尿外科等众多外科手术类型,可为患者提供有效镇痛。本文从解剖及作用机制、操作方法、药物选择、不同手术类型中的应用以及相关并发症等方面对SESPB进行详细讨论,旨在展望该技术的未来发展方向。

2. 解剖基础

骶骨由5块骶椎融合而成,呈倒三角形。骶骨盆面正中线前方左右各4个骶前孔,骶神经前支由此发出;后面从中线至外侧分别为骶正中嵴、中间嵴、外侧嵴,中间嵴和外侧嵴中有4个骶后孔,骶神经后支在此经过。竖脊肌纵向走行于背部,上起枕骨后方,下至髂嵴、骶骨和腰椎棘突的后部,其覆盖并填充于脊柱后表面。竖脊肌并非单一肌肉,而是一组肌群,其在脊柱整个轴线上呈现不同变化。当竖脊肌延伸至骶骨区域时,竖脊肌形成肌腱,附着于多裂肌,多裂肌成为骶骨主要附着肌肉,所以临床操作时局麻药实际注射于骶骨与多裂肌间。虽然已发表的研究大都称之为骶骨竖脊肌阻滞(SESPB),但Hamilton根据解剖结构首次提出“骶骨多裂肌阻滞”概念,Piraccini和Taddei等学者也认为这是更正确的称呼[3] [4]

骶骨内走行的骶神经,对下肢、骨盆、会阴部、臀部等的感觉和功能起重要支配作用,SESPB将局麻药注射于骶骨与多裂肌之间,可直接对骶后孔穿出的骶神经后支发挥阻滞作用。而Diwan等的研究中还发现,通过连续输注染色剂,在腹侧甚至硬膜外腔中可观察到染色剂,同时指出导管的插入和较高的注射压力可能促进注射液的腹侧扩散[5]。且一名接受开腹子宫切除术的患者接受SESPB后,术后未使用任何镇痛药物,证明SESPB可能不仅仅局限于骶神经后支,通过药物扩散其对于骶神经前支或交感神经可能均起到作用[6]。SESPB因骶骨而无法直接向腹侧扩散,骶骨前、后孔的存在可能是其背侧局麻药向腹侧以及硬膜外腔扩散的潜在通道。但部分研究对于腹侧扩散存在一定争议,如Nanda等的一项尸体研究中在S3水平的多裂肌下注射20 ml溶液,未发现染料可扩散到骶骨的腹侧或外侧部分[7]。一项尸体研究在S2注射染料,后在L2/3椎间水平的竖脊肌中观察到染料扩散[8],同时已发表的研究显示腰椎手术中行SESPB可产生良好镇痛,证明了局麻药通过竖脊肌前部的深筋膜向颅骨端扩散另可实现对腰丛的阻滞[9]。目前SESPB作用机制更多的属于推断,一是筋膜间平面阻滞药物扩散的不确定性,二是SESPB作用机制相关研究较少,目前更多的证据依赖于临床效果,未来仍需大量研究深入探讨。

3. 操作方法

SESPB操作时患者应采取俯卧位或侧卧位,对于卧床困难者亦可实施站立位操作[10]。为满足不同的手术要求,可选择不同的骶椎水平进针。根据已有文献,SESPB可通过正中入路、中间入路两种方式实施。两者进针多采用平面内技术,自颅尾方向进针,待触及骶骨后轻微退针,注射生理盐水确认位置,回抽无血、气体等,注射局麻药观察到竖脊肌、多裂肌向上运动,呈现与骶骨分离状态证明注药成功。由于成人和小儿在解剖结构上的差异,如肌肉、筋膜和皮肤下的结缔组织等在小儿中通常更薄且硬度更低[11],面对小儿患者应注意退针距离以及误入其他筋膜层等问题。

3.1. 中间入路定位方式

中间入路由Tulgar等于2019年首次描述[2]。首先纵向放置超声探头,在矢状面上定位第五腰椎的棘突。然后将探头向尾部移动,观察到骶正中嵴,后将探头向两侧移动至骶中间嵴。中间入路的优势在于涉及单侧肢体手术时,可选择单侧注射,减少局麻药用量。如有需要可双侧注射实现双侧阻滞,双重注射的优点是沿双颅尾方向扩散,可同时阻滞骶神经和腰丛神经分支[12]

3.2. 正中入路定位方式

在一例小儿行尿道下裂修复的个案报道中,Aksu等首次提出正中入路即纵向中线入路操作方式[13]。纵向放置超声探头确认第五腰椎棘突,之后向尾端移动探头确定骶正中嵴,或直接将探头纵向放置在骶骨正上方的中线处。正中入路的优势在于定位简单、操作方便。同时,Keleş等的研究发现,正中入路可以观察到注射液通过骶孔渗透至骶骨前端[8],这或许有利于对从骶孔前端穿出的骶神经前支、臀下神经等实现阻滞。

4. 药物选择

SESPB研究中,推荐使用浓度范围为0.2%~0.375%的罗哌卡因,成人单侧注射量常为30 ml,双侧阻滞每边各20 ml。布比卡因最常用浓度为0.25%,成人注射量常为20~30 ml。儿童多是按照0.5~1 ml/kg计算注射量。用药尚无金标准,临床应用应尽量低于药物最大安全剂量,儿童用量应较成人酌减。在选择局麻药时,也应密切关注最新研究进展。部分新药物在镇痛效果、安全性及作用时间等方面或有更出色的表现。例如,Voulgarelis等的研究发现,在竖脊肌阻滞中,相较于普通布比卡因,脂质体布比卡因的镇痛效果显著延长[14]。同时现有研究表明,局麻药中混合佐剂可延长阻滞作用时间并增强镇痛效果[15],常用佐剂包括地塞米松、右美托咪定、肾上腺素等。亦可通过留置导管持续给药的方式,延长镇痛时间。筋膜间平面阻滞药物扩散范围的不确定性是此类技术的共同缺陷,且目前无单独研究探讨SESPB不同注射量与扩散范围的关系,未来需要加大研究填补此处空缺,为临床应用提供帮助。

5. 超声引导下的SESPB的临床应用

5.1. 在肛肠外科手术中的应用

藏毛窦为一种在年轻男性中高发病率的骶尾部软组织感染性疾病[16]。其会导致局部的肿胀、疼痛,不及时干预会有炎症加重、窦道形成及癌变风险。一例接受藏毛窦手术患者,术后在S2水平行SESPB,患者术后NRS评分均小于3,未给予额外镇痛药[2]。Elghamry等的研究中,70例藏毛窦患者随机分配至全麻组和SESPB组,SESPB延长了首次补救镇痛时间,同时术中芬太尼用量减少[17]。SESPB通过阻滞骶神经后支,可为肛周手术提供有效镇痛,减少镇痛药物用量,即使是面对臀部重建等复杂手术亦得到满意效果[18]。在一项痔切除术中的研究中还指出,SESPB具有改善患者术后恢复质量的优点[19]。Kay等报道了对两例行肛瘘切除术患者使用SESPB作为唯一的麻醉技术,整个围术期血流动力学保持平稳,术后无并发症,且术后4 h便出院[20]。这为门诊手术提供了一个新的选择,可减少全麻或脊髓麻醉带来的术后恶心呕吐、尿潴留等,并缩短术后观察时间,提高门诊手术周转率。对于广泛腹腔手术,单一阻滞技术可能无法完全覆盖,在涉及直肠肛周镇痛时,SESPB可作为多模式镇痛的重要辅助手段。Chao等在一例广泛腹部手术中通过双侧胸部ESPB联合单个中线SESPB,为腹部、脐部和会阴切口提供了持久的镇痛,患者术后R-FLACC评分均≤1,未再使用阿片类药物[21]。SESPB对骶神经后支的确切阻滞作用,使得其有望成为肛肠外科的重要辅助镇痛措施。

5.2. 在骨科手术中的应用

5.2.1. 脊柱手术

2019年,Tulgar等首次行SESPB,1 h后行针刺实验发现,患者后3根腰神经后支支配区也出现感觉阻滞,证明SESPB有在腰神经支配区内应用的希望。Gupta等首次在腰椎手术中应用SESPB,5例接受经椎间孔腰椎融合术患者,仅有2例需要术中额外追加芬太尼,术后仅有1例患者刚入恢复室时追加补救镇痛,其余节点均未再使用镇痛药物[9]。另一项行椎间盘切除术的病例报道中显示,患者术后48 h NRS评分均<4分[22],证明SESPB是一种有效的腰椎手术镇痛技术,可减少患者术后疼痛。一项腰椎间盘切除术随机对照研究还指出,SESPB可减少患者术后恶心呕吐的发生率,提高患者的满意度[23]。对于椎间盘突出的患者,即使行非手术治疗,亦可通过SESPB对骶神经和腰丛神经分支的阻滞作用减轻患者腰疼症状[24]。目前研究多集中于下腰椎手术,如L4/5、L5/S1等,主要受限于局麻药颅骨端扩散能力,如若加大局麻药用量则又会增加异常广泛阻滞风险。但若涉及多节段脊柱手术,SESPB可作为下段重要辅助镇痛。

骶椎手术是一种相对罕见的脊柱手术,可导致严重疼痛。Mistry等的病例报道中,一例行骶椎手术的患者,术前接受双侧SESPB,患者术后24 h内无需额外镇痛[25]。考虑SESPB作用机制,相较于腰椎,SESPB更适用于骶椎手术。SESPB通过对背支的内侧支和外侧支的阻滞作用,还可减轻手术切口导致的皮肤、肌肉痛。但目前研究多集中于病例报道,未来仍需更多的对照研究给予验证。

5.2.2. 下肢手术

根据ERAS协会建议,对于下肢骨科手术患者,推荐使用少阿片类药物的多模式镇痛[26],神经阻滞对有效的多模式镇痛起着至关重要的作用。一项病例报道显示,一名股骨近端骨折的患者,采用SESPB作为主要麻醉技术,整个术中血流动力学平稳且未追加任何镇痛药物[12]。Gupta等报道了两名接受髋部和大腿下肢手术的儿童在S2水平使用单侧SESPB,其明显减少阿片类药物用量、降低术后FLACC评分[27]。Kilicaslan等的病例报道中,患者接受SESPB后T12至S3皮节之间存在感觉阻滞,这提示SESPB足以满足绝大多数下肢手术的需求[28]。除对骶神经的作用外,SESPB向颅骨端扩散产生对腰丛的阻滞以及可能存在的硬膜腔扩散均是其在下肢手术中起作用的关键。

髋关节手术是下肢手术另一常见类型,Mostafa等对比了SESPB和髋关节囊周围神经(PENG)阻滞对髋关节手术患者的镇痛效果,SESPB术后首次补救镇痛时间更长,吗啡总消耗量更低[29]。目前SESPB在髋关节手术中表现出良好的镇痛作用,但由于髋关节的神经支配来源于腰神经根和骶神经根(L2-S1) [30],我们仍要考虑部分患者可能存在高位腰神经阻滞不全的问题。但竖脊肌阻滞是一个可多节点注射的操作,我们可于纵向多点注射预防以及解决此类问题,如Marrone等通过腰椎和骶部竖脊肌阻滞联合应用得到了理想的镇痛效果[31]

下肢神经支配复杂,如髋关节涉及股神经、闭孔神经和臀上神经等,因无法完全覆盖所有神经,神经阻滞的单一使用可能并非最佳麻醉方案。Marrone等的一项研究中,通过SESPB和PENG联合应用于髋关节骨折患者,患者术中及术后疼痛控制理想,甚至未使用阿片类药物,且术后无并发症[32]。另一项研究中,将收肌管阻滞(ACB)与SESPB联合应用于全膝关节置换术,患者术后72 h内NRS评分均≤4分,展示出良好的镇痛效果[33]。将针对不同目标神经的阻滞技术相结合,可以得到更完善的镇痛作用。但阻滞技术的联合应用会增加局麻药用量,无疑增加了局麻药中毒的风险。我们应尽量通过调整注射量和局麻药浓度来避免此类问题,且未来研究的重点可倾向于评估多种神经阻滞方案联用的收益和风险。

5.3. 在泌尿外科手术中的应用

现SESPB也被广泛应用于泌尿外科的疼痛控制。在尿道下裂修复术中,SESPB可减少患者术后镇痛药物用量并延长首次补救镇痛时间[34]。既往椎管内麻醉被看作是区域镇痛金标准,Bansal等将SESPB与硬膜外麻醉相对比,发现SESPB表现出不劣于硬膜外阻滞的镇痛效果,同时首次抢救镇痛表现更优[35]。泌尿外科还涉及大量导致轻、中度疼痛的门诊手术,如小儿包皮手术、鞘膜积液等。但门诊手术常面临检测设备缺乏、辅助支持不足等,此时的疼痛管理更应得到重视,避免镇痛药物过量引起的呼吸抑制等。Özen等的一项研究中,150名接受包皮环切术的患儿被随机分成两组,SESPB有效降低了患儿术后疼痛评分和术后前24 h镇痛药物消耗量,同时均未观察到副作用[36],证明SESPB可为短小手术提供一种新的镇痛选择。泌尿外科术后常需长时间留置导尿管,以缓解尿潴留和评估尿量,但这易引发导管相关膀胱不适(CRBD),其发病率为47%~90%。CRBD会导致尿急、烧灼感等症状,显著降低患者术后生活质量与满意度[37]。阴部神经由骶神经2至4腹侧分支构成,支配会阴部。SESPB通过阻滞骶神经,减弱膀胱副交感神经活动,可减少膀胱不自主收缩,降低CRBD发生率[38]。鉴于此,SESPB有望在泌尿外科术后恢复中得到推广。同时,与其他筋膜间平面阻滞方法相比,SESPB可缓解内脏痛,这将是SESPB应用于泌尿外科手术时的显著优势[39]

5.4. 在特殊群体中的应用

5.4.1. 产科

孕妇在分娩期会经历剧烈疼痛,严重干扰内分泌、免疫、循环等系统平衡。分娩期疼痛是一个多阶段过程,第一产程痛为起源于T10~L2脊神经的内脏痛为主;第二产程痛为起源于S2~S4脊神经的躯体痛为主;第三产程时因牵拉刺激减少,产妇疼痛明显减轻[40]。根据SESPB的作用机制,其更适用于第二产程镇痛。一项病例报道结果显示,一名孕妇在第二产程期间接受了SESPB,NRS评分从8降至2分,有效改善了孕妇的不适[10]。Marrone等指出,即使已接受椎管内麻醉分娩镇痛的产妇,亦可为实现更广泛镇痛在第二产程附近行SESPB [41]。既往分娩镇痛主要依靠椎管内麻醉,但有出血性疾病等原因将限制其应用,相比之下对凝血要求较低的SESPB是一种安全有效的替代措施[42]。目前SESPB主要应用于分娩镇痛,单独应用于剖宫产镇痛效果欠佳,但将SESPB联合椎管内麻醉应用可能是一种可行且有利的方案。一是与传统硬膜外麻醉相比,低剂量硬膜外麻醉可减少术后尿潴留等问题[43],基于此考虑,或许可将SESPB作为辅助镇痛措施之一,减少局麻药用量;二是骶部皮节覆盖不足是硬膜外镇痛失败的常见原因,SESPB通过阻滞骶神经可弥补此类缺陷;三是SESPB可为产妇提供一定术后镇痛作用,减少术后镇痛药物的使用。

5.4.2. 儿科

SESPB已广泛应用于各类儿科手术,但以病例报道为主。Mahajan等的报道中,2例新生儿行骶尾部畸胎瘤切除术,术前在S2/S3水平给药行SESPB,患儿术后首次抢救镇痛分别为11 h和14 h,且FLACC评分最高为4分[44]。另一篇关于小儿肛门成形术的报道中,患儿术后未使用任何镇痛药,无术后并发症,并于术后第2天顺利出院[45]。Bansal等的研究中将50名接受尿道下裂修复术的患儿随机分至SESPB组和硬膜外阻滞组,SESPB组表现出更长的首次补救镇痛时间。SESPB在小儿骨科手术中也展现出良好的镇痛效果,可明显减少髋关节骨折、股骨干骨折等下肢手术镇痛药物用量[27] [29]。儿童配合度较差,SESPB均于麻醉或镇静后进行,会影响阻滞平面的评估,但考虑SESPB镇痛效果明确、安全性高,仍推荐其作为儿童镇痛的选择之一。在儿科患者中,药物剂量需根据体重精确计算,稍有偏差即可能影响镇痛效果或产生不良反应,之后的研究应加强对药物剂量的研究,以便SESPB更安全地应用于儿科患者。

5.5. 其他应用

SESPB主要阻滞骶神经背支,但硬膜外腔、骶骨腹腔侧及颅尾端的扩散增加了其应用范围。包括变性手术、阴道痉挛治疗、骶骨和转子压疮手术等罕见手术中均有应用报道[46]-[48]。除急性疼痛外,SESPB也可用于治疗慢性疼痛,且已有病例报道其可缓解骶尾骨痛、低位腰椎疾病导致的腰疼[24] [49]。为更好地推广SESPB在疼痛治疗中的应用,需要更多随机对照试验来评估其有效性。许多患者在CT、MRI等检查期间由于疼痛而无法配合。在Bilgin等的报道中,患有严重骶骨疼痛的患者接受SESPB后疼痛完全缓解,并且无运动阻滞,顺利完成MRI检查[50]。这为腰骶部、下肢、臀部、会阴部受伤患者手术室外检查提供了一种安全、有效的镇痛选择。未来,我们可尝试增加SESPB在疼痛诊疗中的应用,并结合导管置入,发挥其对慢性疼痛等的持续治疗效果。

6. 并发症以及与其他技术对比

与椎管内阻滞、椎旁阻滞相比,SESPB的优势在于它的目标远离神经轴,因此安全性更高;无抗凝剂或抗血小板剂等药物相关禁忌症;肢体运动无力、血肿等发生率较低[51]。竖脊肌阻滞与腰方肌阻滞相比,可降低实质器官损伤的风险[52]。相较于髂筋膜阻滞、髋关节囊周围神经阻滞、收肌管阻滞,SESPB作用范围更广。超声引导下,解剖层次分明、简单,SESPB可快速执行是另一显著优点[53]。SESPB潜在的缺点便是不可预测的皮区覆盖,这需要更多药物用量与作用范围相结合的研究来克服此问题。

现有研究中SESPB表现出较高的安全性,但作为一种有创操作,仍要注意其穿刺后血肿、感染的发生。在药物使用方面,尤其是面对儿童/新生儿,要警惕局麻药中毒和异常广泛阻滞的发生,目前SESPB无相关报道,但竖脊肌阻滞在胸、腰段的应用中,已有此类并发症的发生[54] [55]。在行连续给药时涉及导管留置,要警惕导管脱落、阻塞、移位等的发生。目前无并发症相关报道,部分原因可能取决于应用较少,随着技术的推广,相关报道可能会增加。

7. 讨论

超声引导下的SESPB镇痛效果确切,已广泛应用于各类外科手术。因其操作简便、安全性高,在日间手术及检查等非传统手术场景亦展现出显著的应用潜力。但目前SESPB与其他区域性阻滞技术相对比的研究较少,未来需要更多前瞻性研究验证其优劣性。药物选择和用药剂量也是亟待解决的问题,不同手术类型和患者个体差异要求个性化的用药方案,但目前缺乏统一的标准化指南。作为一种新型的区域阻滞技术,SESPB在作用机制方面的争议是现存最大问题,因此后续需要更多高质量、专项研究,为SESPB的临床应用提供支持。此外,我们应对该技术名称进行统一,建议根据解剖结构统一采用“骶骨多裂肌阻滞”,以利于未来研究检索与统计分析。

NOTES

*通讯作者。

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