引 言
传统的椎管内穿刺是麻醉医生的基本技能，但即使是我们当中最优秀的人，也会不断遇到具有挑战性的脊柱问题。超声能够识别脊柱的解剖结构，特别是体表解剖定位不清和骨骼畸形的患者。脊柱超声成像易于掌握，在必要的时候会是一项很好的备用技能。本视频将介绍超声辅助椎管内穿刺定位及穿刺针引导技术。
脊柱超声原理与技巧 （中英双语字幕）
翻译：张国磐 校对：房丽丽
浙江大学医学院附属第二医院麻醉手术部
图1
We need to understand how a lumbar vertebra is built. We have the body (1A), thepedicles (1B), the transverse processes (1C), the articular processes (1D), thelaminae (1E) and the spinous process (1F).
我们需要知道腰椎的构成：椎体(1A)、椎弓根(1B)、横突(1C)、关节突(1D)、椎板(1E)和棘突(1F)。
图2
The first is sagittal or parasagittal. The probe moving outward from the midlinein the sagittal orientation. The spinous processes (2A), the laminae (2B), the articular processes (2C), the transverse processes (2D).
图3
The other orientation is transverse here. We see a faint shadow of the spinous processand the laminae in cross as well as the articular processes, depending on the depthand level, you're at you may or may not see the transverse processes extendinglaterally（3A、3C). This view has a characteristic shape reminiscent of the face ofa bat with articular processes as ears and the posterior complex as the top of itshead (3B). Dark circle in the center, that's the spinal canal.Superficial to it iswhat we call the posterior complex. Deep to that is the anterior complex. And ofcourse,the space between them is the thecal sac and its contents (3D).
图4
Here’s a typical scanning sequence for ultrasound assisted neuraxial procedures. We started the sacrum in the parasagittal orientation with that slight medial tilt. The broad shelf of bone is the sacrum (A). Heading north. We see a break in the bonyline.This is the first interlaminar space of L5-S1 (B). We see the L5 lamina and thenthe L4-5 interlaminar space (C)，and then the L4 lamina and the L3/4 space and soon (D) .
图5
Once we find the space we want,we center the gap and then using a skin marker fromthe center of the ultrasound probe. Make a horizontal line corresponding to the innerspace（A) . We then turn the probe 90 degrees and search for the bat sign. Trying tostay close to our original horizontal line. Once we center the midline, we draw avertical line from the probe upward (B) . At this point, we can freeze the image anduse the electronic calipers to measure the distance from the posterior complex tothe surface. This gives us an approximation of how deep we can expect to find eitherthe epidural or the subarachnoid space (C) . The two lines we've drawn give us thecross hairs to begin our needle insertion and we know the depth from our measurement. So we're all set up for success.
图6
In some challenging cases, it does make sense to visualize that small acoustic windowand advance a needle in real time. Here we see the sacrum and the L5 lamina withan acoustic window through the posterior complex. A needle is advanced in plane fromcaudate to cephalad aiming for the complex（blue arrow). If bony contact is made, a slight redirection cephalad usually allows a needle to slide home.
在一些穿刺困难的病例中，可视化的超声窗及实时引导穿刺针技术具有重大意义。我们看到骶骨和 L5椎板及通向后复合体的超声窗，穿刺针由尾侧向头侧置入后复合体(蓝色箭头）。如果碰到骨质，重新进针时稍微向头侧倾斜直至穿刺针到达目标。
翻译：张国磐（泉州市正骨医院）
校对：房丽丽
字幕剪辑：许晶晶
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（浙大二院麻醉科超声引导神经阻滞教学）浙江大学医学院附属第二医院麻醉手术部是中华医学会麻醉学分会“一带一路”海外医师首个区域麻醉培训基地。我们高度重视区域麻醉的教学工作，探索新颖的评论类教学课程，研发神经阻滞置管模型，培养的学员多次获得浙江省工会主办的麻醉职业技能神经阻滞竞赛一等奖、中华医学会麻醉学分会主办的“百花齐放”神经阻滞视频展演比赛一等奖。未来，我们将继续努力为麻醉新手、基层麻醉医师、海外麻醉医师等提供优质高效的分层区域麻醉培训。