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腘窝坐骨神经阻滞
腘窝坐骨神经阻滞是最常见的下肢神经阻滞之一，可以覆盖小腿除内侧以外的区域和足踝部位的感觉和运动分布。然而，即使在超声引导下行腘窝坐骨神经阻滞，仍可能出现局麻药起效慢、阻滞不完全的情况，这与腘窝处的解剖结构密不可分。本视频将介绍超声引导腘窝坐骨神经阻滞的定位、最佳穿刺靶点及穿刺针引导技术，为保证阻滞的效果提供依据。
腘窝坐骨神经阻滞（中英双语对照）
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
The sciatic nerve originates from the lumbosacral plexus and travels down the posterior thigh deep to the hamstring muscles(A). As it enters the popliteal fossa several centimeters above the popliteal crease, it separates into its two principal branches, tibial nerve and the common peroneal nerve(B). The tibial nerve lies just superficial to the popliteal artery and vein in the fossa(B). The sciatic nerve and its two branches are covered by a tough membranous sheath, this has been called the paraneural sheath or in some called the circumneural sheath(C). It's important to understand that the sheath is not part of the nerve like epineurium is (D).
坐骨神经起源于腰骶丛，沿大腿后侧走行到腘绳肌深面（A）。在腘窝皱褶上几厘米处坐骨神经进入腘窝，分成两个主要分支：胫神经和腓总神经（B）。在腘窝处，胫神经位于腘动脉及静脉的浅表(B)。坐骨神经及其两个分支被一层致密的鞘膜所覆盖，我们称之为神经旁鞘，也可称为神经周鞘（C)。神经旁鞘不同于神经外膜，它不是神经的一部分，这点很重要（D）。
Let's imagine the torso of this figure is our sciatic nerve and the legs are the two branches, the pants represent the paraneural sheath. If we image here the nerves are so close, they appear almost as one big nerve(A), it would be challenging to insert a needle into the paraneural sheath while avoiding impaling the nerve structures. Conversely, this distal location finds both branches quite separate and each branch now has its own paraneural sheath(B). Local place between them would not diffuse well across the sheath and you'd end up with a slow poor block. Right as the nerves are separating but before the sheath has split apart(C), it gives you a nice safe intrasheath target to aim for.
想象一下，人的躯干是坐骨神经，腿是其两根分支，裤子是神经旁鞘。如果在这扫描，两根神经如此接近，更像是一根粗大的神经（A），这将给针尖置入神经旁鞘的同时避免神经损伤带来挑战。相反，定位在远端，两根神经完全分开且各自存在独立的神经旁鞘（B），在两者之间的局麻药无法穿透鞘膜，造成阻滞效果差且起效缓慢。在神经开始分离而神经旁鞘未独立伴行的区域（C），是一个安全的鞘内注射靶点。
The popliteal sciatic block can be performed in several positions, we prefer lateral as it offers nice ergonomics(A). In trauma patients who can't roll on their side, we'll do this supine with the calf and ankle elevated on some blankets(B). Note that your image will look identical to the lateral approach. The probe is placed on the popliteal crease and slid proximally until you're happy with the image. Here we see the typical sonogram when the probe is placed on the popliteal fossa(C、D) . A good landmark to start with is the popliteal artery which is most shallow right at the crease. Superficial to that is the vein. Above that we see the tibial nerve, the peroneal nerve can be found more lateral and superficial than the tibial nerve(C、D).
行坐骨神经阻滞有几种体位，我们更偏好利于操作的侧卧位（A）。而对于无法侧身的创伤患者，我们选择仰卧位，并放一些毯子垫高小腿和足踝（B）。注意，仰卧位的图像与侧卧位相似。探头放置在腘窝皱褶处并向近端滑动，直到扫到满意的图像。这是将探头放置腘窝处的经典超声图像(C、D）。最靠近腘窝褶皱的腘动脉是一个好的扫描起点。在动脉表面的是静脉，两者之上是胫神经，而腓总神经比胫神经更外侧与浅表(C、D）。
Dynamic scanning is key to identifying both nerves. If you slide the probe proximally and distally along the back of the distal thigh, the nerves will appear to come together then separate(B to A).If the tibial and peroneal nerves are not well defined on the screen, dorsa flexing and plantar flexing the ankle usually makes the nerves appear to dance(C、D).These makes them easier to distinguish from the background.
动态扫描是识别这些神经的关键。如果沿大腿后侧从近端向远端滑动探头，这些神经会从汇聚到分开（如B到A）。如果不能明确超声图像上的胫神经和腓总神经，背屈和跖屈踝关节可使神经在屏幕上摆动起来（C、D）。这些使坐骨神经更容易从背景中识别。
Now the goal is to choose a location where they're just starting to peel apart, leaving a small space in between for the needle(A). A needle is advanced in plane from the lateral aspect and from about two centimeters below the screen(B). Aiming the needle between the two nerves，then we aim to put 20 to 30 mils in with one injection. We see the two nerves separating and the tibial nerve being carved out by the local anesthetic(C).After the injection is finished, scanning distally to confirm that there is indeed local filling both pant legs(D).
选择它们刚分离的位置，二者之间的小空间作为靶点（A）。采用平面内技术从外侧、距屏幕下方2cm的地方进针（B）。穿刺针朝向两根神经之间,之后在该点一次性注射20-30ml局麻药。我们看到两根神经分离，胫神经被局麻药分离出来（C）。注射完成后，向远端扫描，以确认局麻药填充两条裤腿（D）。
This block provides complete anesthesia or analgesia to the bone muscle and skin of the calf ankle and foot, with the exception of the skin and small bony contribution at the medial ankle supplied by the saphenous nerve.
除了由隐神经支配的内侧踝关节的皮肤和骨骼，该阻滞为小腿和足踝区域其余骨骼肌肉和皮肤提供完善的麻醉或镇痛。
The lateral popliteal sciatic block is one of the higher risk peripheral blocks, we do from the perspective of nerve injury. Nerve stimulation is a useful adjunct for this block that may give you an early warning of inadvertent needle nerve contact you。
就神经损伤这一并发症来说，腘窝外侧入路坐骨神经阻滞是高风险的周围神经阻滞之一。而神经电刺激是辅助神经阻滞的工具，可在误扎神经前给予警示。
翻译：张国磐（泉州市正骨医院）
校对：房丽丽
字幕剪辑：许晶晶（泉州市正骨医院）
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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。