通过下列文献资料的学习，希望各位战友展开深入讨论，对硬膜下腔阻滞有个新的认识。 —— YCDY1 作者: ycdy1 时间: 2009-3-17 17:53
1Anasthesiol Intensivmed Notfallmed Schmerzther. 1999 Aug;34 :510-2.
[Horner's syndrome following lumbar epidural anaesthesia--subdural block?]
[Article in German]
Brudny P, Leben J, Schregel W, Neuhaus W.
Abteilung Anasthesie und Intensivmedizin, St. Josefshopital Uerdingen.
A 28 year old primipara (37th gestational week) was scheduled to undergo delivery by caesarean section under epidural anaesthesia. An epidural catheter was easily inserted in the L3/L4 interspace. After a negative aspiration test 5 ml of bupivacaine 0.25% plus adrenaline 1:200,000 were injected and five minutes later 2 x 5 ml of bupivacaine 0.5% plus fentanyl 0.005 mg/ml were given. Ten minutes after the test dose the patient reported warmth and paraesthesia in the right leg and pelvis and numbness in the right periorbital region. The catheter was drawn back 1.5 centimeters and the operation could be performed under regional anaesthesia with supplemental doses of bupivacaine. Sensory level at the end of the operation was Th 4 which decreased continuously in the following two hours. Ocular symptoms (miosis, ptosis, right-sided numbness) as well as numbness in the right hand and leg persisted four hours longer. The most probable explanation for this peripheral Horner's syndrome is a subdural blockade caused by the first bupivacaine doses. The only known prophylaxis is a fractioned epidural injection of local anaesthetics.
题目：腰段硬膜外腔麻醉引起“霍纳氏征候群”——“硬膜下腔阻滞”？
出处：Anasthesiol Intensivmed Notfallmed Schmerzther. 1999 Aug;34 :510-2.
作者：Brudny P, Leben J, Schregel W, Neuhaus W. （德国，圣约瑟医院麻醉科）
摘要：
28岁初产妇，孕期37周，在硬膜外麻醉下施行剖宫产手术。经L3－4穿刺，置管顺利。抽吸试验阴性后，注入试验量0.25％布比卡因（含1:20万肾上腺素）5ml。5min后，继以2次各注入0.5％布比卡因5ml＋芬太尼（0.005mg/ml）。试验量注入10min后，产妇主诉右腿和骨盆部温暖、感觉异常，同时右眼窝周围区麻木。随即抽出导管1.5cm。手术可以进行。术毕测阻滞平面为T4，随后2h内阻滞平面继续下降；而眼部征像（瞳孔缩小、上睑下垂、右向麻痹）以及右手和右腿麻木持续长达4h。这种霍纳氏征候群的表现，最可能的原因是：首次量布比卡因引起了“硬膜下腔阻滞”。仅知的预防方法是硬膜外腔分次分量注射局麻药。（译者注：本例未经CT检查证实。）
2Reg Anesth. 1995 Mar-Apr;20(2):159-62.
Unintentional subdural block during labor epidural in a parturient with prior Harrington rod insertion for scoliosis. Case report.
Lee YS, Bundschu RH, Moffat EC.
Department of Anesthesiology, Jackson Memorial Hospital, Miami, Florida 33136, USA.
BACKGROUND AND OBJECTIVES. The authors report a case of unintentional subdural block in a parturient with prior Harrington rod insertion. METHODS. The epidural technique was performed successfully at the L5-S1 interspace using the loss-of-resistance technique after two failed attempts at the L3-4 interspace. RESULTS. Twenty to 30 minutes after total initial dose of 9 mL 0.25% bupivacaine with 1/200,000 epinephrine, the patient developed hypotension and a high sensory block involving the trigeminal nerve. The patient also complained of difficulties in swallowing and breathing. Signs and symptoms strongly suggested an unintentional subdural block. After careful monitoring and reassurance, the patient's sensory level receded and she could breathe and swallow comfortably. Intubation was not required. The epidural catheter was maintained in the same space. The amount of 0.25% bupivacaine was reduced to 2 mL for subsequent top-ups. Adequate analgesia was provided throughout the course of her labor and delivery without other complications. CONCLUSIONS. Lumbar epidural anesthesia is not always an easily performed technique and is known to be associated with a higher incidence of complications in patients with prior Harrington rod insertion. Prompt recognition and proper management of subdurally placed needle and catheter avoided more serious complications.
摘要：
报告一例临产妇，曾接受脊柱侧弯哈里氏棒矫形手术，发生硬膜外导管意外地误入“硬膜下腔”的经过。取L5－S1间隙采用阻力骤失法硬膜外腔穿刺，经两次穿刺失败后，换L3－4间隙穿刺置管成功。首次总量注入0.25％布比卡因（伴1:20万肾上腺素）9ml，20～30min后产妇出现低血压，上界感觉阻滞平面高达三叉神经部位，同时产妇主诉吞咽和呼吸困难。根据所表现的征像，提示导管已经意外地误入“硬膜下腔”。经过密切监测和安慰产妇后，感觉阻滞平面逐渐下退，产妇自觉呼吸和吞咽困难症状消失，不需要气管内插管。之后仍然保留硬膜下腔导管，并继续用药，但剂量减少至0.25％布比卡因 2 ml / 次。整个产程和娩出过程的镇痛满意。结论：腰段硬膜外腔穿刺置管一般并无困难，但对已接受哈里氏棒矫形术后的病人，并发症发生率明显增高，迅速辨识导管误入硬膜下腔，可避免严重并发症的发生。
（译者注：本例未经X线追查证实）
3Can J Anaesth. 1989 Nov;36 :708-12.
[Accidental catheterization of the subdural space: a complication of continuous spinal anesthesia and continuous peridural anesthesia]
[Article in French]
Mocan M, Gamulin Z, Klopfenstein CE, Forster A.
Departement d'Anesthesiologie, Hopital Cantonal Universitaire, Geneve, Suisse.
Two cases of subdural catheter placement following continuous spinal and continuous epidural anaesthesia are presented. In the first, despite an easy reflux of clear cerebrospinal fluid through the catheter, the injection of 4 ml bupivacaine 0.5 per cent with epinephrine 1:200,000 followed by 3 ml tetracaine 0.5 per cent showed a failure of spinal anesthesia. In the second, the administration through the catheter of 20 ml lidocaine 2.0 per cent CO2 plus epinephrine 1:200,000 and of ten ml bupivacaine 0.5 per cent lead to an insufficient, patchy and asymmetrical analgesia. The clinical signs observed in these two cases are compared with previous publications. The importance of an x-ray contrast study to confirm the diagnosis of subdural catheter insertion is stressed.
题目：[Accidental catheterization of the subdural space: a complication of continuous spinal anesthesia and continuous peridural anesthesia]
摘要：
报告2例腰－硬联合麻醉中，导管意外地误入硬膜下腔的麻醉经过。第1例：发现导管内有清晰的脑脊液外流，但仍然注入0.5％布比卡因（含1:20万肾上腺素）4ml，结果无腰麻效果，继以注入0.5％邦妥卡因（地卡因）3ml，腰麻仍归无效。第2例：经导管注入2％利多卡因20ml（含CO2和1:20万肾上腺素），以及追注0.5％布比卡因10ml，仅出现不完全的、节段性的、不对称的阻滞现象。根据此两例的临床表现，参考早先发表的书刊报道，强调为明确导管是否在硬膜下腔的诊断，需要采用经导管注入X线造影剂检查进行鉴别，具有重要意义。
（译者注：本例未经X线检查证实）
4Rev Chir Oncol Radiol O R L Oftalmol Stomatol Chir. 1989 Mar-Apr;38(2):151-4.
[Extra-arachnoid subdural injection, an accident of peridural anesthesia]
[Article in Romanian]
Cardan E, Azzam A, Simu M.
Two cases are presented, with accidents of peridural anesthesia, Anesthesia of the entire brain stem, paralysis of the intercostal muscles, and of the upper limbs, apnoea and miosis that developed later indicate an extension of the anesthetic effects far higher that it could have been expected considering the technical details of the procedure. On the other hand the absence of any durable coma, of extreme mydriasis, and of severe arterial hypotension, as well as the relatively rapid retrocession of the additional effects of the administration of an anesthetic exclude the possibility of total rachianesthesia, and it can be concluded that there was an accidental injection of anesthetic in the extra-arachnoid subdural space.
题目：硬膜外腔麻醉的意外：蛛网膜下腔外－硬膜下腔注药.
出处：Rev Chir Oncol Radiol O R L Oftalmol Stomatol Chir. 1989
作者：Cardan E, Azzam A, Simu M.（罗马尼亚）
摘要：
报道二例硬膜外腔麻醉的事故，病人表现脑干完全麻醉，肋间肌和上肢肌麻痹，呼吸暂停和瞳孔缩小，其进展与预期的麻醉结果相差甚远，考虑与麻醉技术操作中的细节有关。另一方面，病人无意识消失，无瞳孔散大，无明显的动脉血压下降，异常情况的消褪相对迅速，可以排除全脊髓麻醉。此两例意外可以推断为导管意外置入蛛网膜下腔外的硬膜下腔所致。
5Anaesthesia. 1993 Jan;48(1):46-9.
Development of a subdural motor blockade.
Asato F, Nakatani K, Matayoshi Y, Katekawa Y, Chinen K.
Department of Anaesthesia, Okinawa Chubu Hospital, Japan.
We report an unusual development of motor blockade following the subdural injection of local anaesthetic during attempted continuous lumbar epidural anaesthesia. Four characteristic features of subdural block, extensive spread, segmental distribution, delayed onset, and short duration of motor blockade were all features of the case. The patient had gradual development of complete motor blockade in the left upper extremity, incomplete in the right upper extremity, but absence of motor blockade in the lower extremities. The duration of complete motor blockade was 10 min in the hand and 35 min in the arm. The spread of contrast medium in the subdural space revealed the extent and degree of motor blockade.
题目：硬膜下腔运动阻滞的展示。
出处：Anaesthesia. 1993 Jan;48(1):46-9.
作者：Asato F, Nakatani K, Matayoshi Y, Katekawa Y, Chinen K.（日本）
[ 本帖最后由 ycdy1 于 2009-3-17 17:55 编辑 ]作者: ycdy1 时间: 2009-3-17 23:07
6
Minerva Anestesiol. 1989 May;55(5):245-8.
[Accidental catheterization of the subdural space. Description of 2 cases]
[Article in Italian]
Visentin M, Merlo F, Bernardi L.
Two cases of accidental subdural catheterisation, occurred in cancer patients during pain treatment, are presented and radiographically confirmed. The possible mechanisms that can cause such malposition, the X-ray picture and the effect of subdurally injected morphine are discussed.
题目：意外的硬膜下腔置管（二例报道）
出处：Minerva Anestesiol. 1989 May;55(5):245-8.
作者：Visentin M, Merlo F, Bernardi L. （意大利）
摘要：
为癌性疼痛，施行硬膜外腔置管镇痛治疗，意外地发生2例硬膜下腔置管，均经X线摄片确诊。讨论了导管移位置管的可能机制、X线读片以及吗啡注入硬膜下腔效果等问题。
7
Masui. 1993 Mar;42(3):427-30.
[Accidental subdural catheterization discovered after postoperative respiratory depression]
[Article in Japanese]
Okuyama A, Makise N, Kemmotsu O.
Department of Anesthesiology, Hokkaido University, School of Medicine, Sapporo.
A 65-year-old man scheduled for gastrectomy was anesthetized with nitrous oxide combined with continuous epidural lidocaine. At the end of the operation, morphine 2 mg diluted in 0.25% bupivacaine 5 ml was injected through the epidural catheter. Seventy minutes later, the patient developed life-threatening respiratory depression which was antagonized by naloxone. The patient requested no analgesic during the first 26 postoperative hours. The respiratory depression in this patient was assumed to be caused by epidural morphine. Then subdural catheterization was confirmed radiologically. This was discovered to have resulted from migration of the epidural catheter into the subdural space. Subdural injection of morphine may have resulted in higher cerebrospinal fluid levels than the levels obtained after epidural injection. Subdural catheterization is a complication of epidural anesthesia that probably occurs more frequently than previously recognized. In postoperative patients receiving epidural morphine, their respiratory status should be monitored closely for hours.
题目：意外硬膜下腔置管发现于术后呼吸抑制
出处：Masui. 1993 Mar;42(3):427-30.
作者：Okuyama A, Makise N, Kemmotsu O. Hokkaido Univ, School of Med, 麻醉科.
摘要：
一例65岁老人在N2O复合连续硬膜外腔利多卡因阻滞麻醉下施行胃切除术。术毕时，经硬膜外腔导管注入0.25％布比卡因 5ml内含吗啡 2mg。70min以后病人出现了致命性呼吸抑制，随即用纳咯酮拮抗治疗。在术后最初26小时期间病人无止痛效果，病人的呼吸抑制考虑是由吗啡引起。随后经X线学检查，证实导管已存在于硬膜下腔，发现导管系从硬膜外腔移往硬膜下腔间隙所致。硬膜下腔注射吗啡所致的脑脊液吗啡浓度，较硬膜外腔注射吗啡者高。硬膜下腔置管是硬膜外麻醉的一种并发症，当前对其发生的认识已比以往的认识为高。对术后接受硬膜外腔吗啡镇痛治疗的病人，应做到每小时监测一次呼吸状况。
8
Reg Anesth. 1995 May-Jun;20(3):249-51.
Unintentional combined epidural and subdural block. Case report.
Chauhan S, Gaur A, Tripathi M, Kaushik S.
Department of Anaesthesiology and Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
BACKGROUND AND OBJECTIVES. Unintentional subdural block, while attempting an epidural anesthetic, is a rare but known complication. The authors describe a radiologically confirmed case of an unintentional combined epidural and subdural block while attempting to perform an epidural block for transurethral resection of prostate in a middle-aged man. METHODS. Loss of resistance to air injection was used for identifying the epidural space prior to catheter placement. Following the epidural injection of 20 mL of a 1.5% lidocaine and 0.5% bupivacaine mixture, the patient developed rapid, intense, prolonged, and extensive bilateral motor block up to C2 level. RESULTS. The patient had aphonia and respiratory paralysis requiring endotracheal intubation and controlled ventilation for 3 hours. CONCLUSIONS. Postoperative radiologic examination revealed the spread of the dye in both epidural and subdural spaces, causing the extensive sensory and motor block.
题目：非特意的硬膜外腔和硬膜下腔联合阻滞（个案报告）
出处：Reg Anesth. 1995 May-Jun;20(3):249-51.
作者：Chauhan S, Gaur A, Tripathi M, Kaushik S.（麻醉科和危重医学中心，印度）
摘要：
硬膜外腔麻醉实施中发生意外的硬膜下腔阻滞，已是人们已认知的少见并发症。作者对1例经尿道前列腺切除术的中年病人，在施行硬膜外腔麻醉中，经X线放射学检查证实，意外地发生了硬膜外腔与硬膜下腔联合阻滞。采用阻力骤失及注气法穿刺硬膜外腔并置管，继以注入1.5％利多卡因和0.5％布比卡因混合液20 ml，随即病人出现自C2平面以下迅速、强力而持久的双侧运动阻滞，同时失语和呼吸麻痹，需气管内插管施行控制呼吸3小时。本例于术后进行X线检查证实，造影剂同时分布于硬膜外腔和硬膜下腔，从而引起了广泛的感觉和运动阻滞。
9
Masui. 1990 Jun;39:778-81.
[Repeated inadvertent subdural catheterization: a case report]
[Article in Japanese]
Nonaka A, Nakano S, Kumazawa T.
Department of Anesthesia, Yamanashi Medical College.
We had a patient who had repeated inadvertent subdural catheterization. Eighty-two year old woman with post herpetic neuralgia had a continuous epidural anesthesia for the relief of pain. An epidural catheter was inserted at the Th 5-6 interspace using a paramedian approach. Fifteen minutes after 4 ml test dose of 1% lidocaine injection, she developed circulatory depressions and massive sensory block. The exact position of the catheter and the distribution of the local anesthetic agent were confirmed by radiographic contrast material. The catheter was observed in the subdural space. Anesthesia was therefore continued with an injection of 1.5 ml mepivacaine. After one month, epidural catheterization was done in the same patient. The catheter was inserted in subdural space again. The subdural injection has been implicated in a case in whom there has been extensive spread of an epidural block. The diagnosis of subdural block can be made by a subsequent injection of contrast medium, since an unusual clinical course might be seen. Subdural space has a poor blood supply, and injected medium may stay in this space for considerable period of time. Subdural catheterization in epidural anesthesia probably occurs more frequently than previously recognized.
题目：硬膜下腔意外地重复2次置管（1例报道）
出处：Masui. 1990 Jun;39:778-81.
作者：Nonaka A, Nakano S, Kumazawa T.（大学麻醉科，日本）
摘要：
我们曾遇到1例意外地重复发生2次硬膜下腔置管的病例。患者82岁，女性，因带状疱疹疼痛给予施行持续硬膜外腔阻滞镇痛治疗。经T5－6间隙，取旁正中法硬膜外腔穿刺置管。注入试验量1％利多卡因4ml 15min后，病人出现循环抑制和大范围的感觉阻滞。经注入造影剂X线摄片，观察到导管的位置和局麻药的分布情况，证实导管位于硬膜下腔。继以经导管注入美匹维卡因1.5ml施行镇痛。事隔1个月后，病人再次就诊镇痛，经硬膜外腔穿刺置管后，又一次被证实导管位于硬膜下腔。讨论：硬膜下腔注药意味着将出现局麻药的广泛扩散，继以注入造影剂可明确硬膜下腔置管的诊断，在临床上可发生不寻常的过程。硬膜下腔的血供较差，造影剂可以在其中潴留相当长的时间。在硬膜外腔麻醉中发生硬膜下腔置管的现象可能比以往的想像要常见。
10
Reg Anaesth. 1989 Sep;12(5):102-5.
[Subdural location of a catheter. A complication of peridural anesthesia]
[Article in German]
Bredtmann R, Scholz A.
Anaesthesieabteilung, Allgemeines Krankenhaus Altona, Hamburg.
A case of an involuntarily placed subdural catheter (between arachnoid and dura) is described. The catheter was thought to be in the epidural space. It was placed at T9/10 in order to achieve postoperative epidural analgesia in a patient with colonic surgery. Administration of 4 ml bupivacaine 0.5% was followed by segmental analgesia (left: C7 to T9, right: T2 to T8) 10 min later. The systolic blood pressure fell from 85 to 50 mmHg. No motor block was detectable. After 150 min remission of analgesia was complete. All effects were reproducible. Using 1.3 ml of a radiopaque fluid, a spinal X-ray film showed a typical subdural picture with radiopacity detectable on the left from C8 to T8 and on the right from T1 to T7. An additional 2.7 ml did not visualize the lumbar subdural space as well. No radiopaque fluid entered the epidural or intrathecal space. It may be that accidental subdural catheter placement in regional anesthesia is not as rare as it was thought to be a few years ago. There is at present no available epidural technique that guarantees the avoidance of this complication. In addition, the symptoms of 'subdural analgesia' vary to a great extent. Therefore, the diagnosis can only be verified by X-ray examination. If patients with epidural analgesia are supervised with care and uncommon dose responses are recognized, subdural catheter placement will not lead to a severe and dangerous situation for the patient.
[ 本帖最后由 ycdy1 于 2009-3-17 23:16 编辑 ]作者: ycdy1 时间: 2009-3-18 22:50
11
Masui. 1995 Oct;44(10):1373-6.
[Subdural catheterization uncovered by severe hypotension during epidural plus general anesthesia]
[Article in Japanese]
Okuyama A, Saito Y, Amenomori H, Okuyama M, Kobayashi S, Kemmotsu O.
Department of Anesthesia, Asahikawa Kosei Hospital.
We experienced three cases of accidental subdural catheterization during epidural combined with general anesthesia. In each case, epidural catheterization was performed before induction of general anesthesia. Aspiration through the catheter and a response to a test dose were negative. Then anesthesia was induced with thiamylal IV and the trachea was intubated with vecuronium IV. Hypotension, which was not easily treated by vasopressors and volume load, occurred after administration of 3 to 8 ml mepivacaine with 1: 200,000 epinephrine through the catheter. We examined position of the catheter by injecting iohexol 240 and confirmed subdural catheterization after surgery. It is often difficult to identify subdural placement of an epidural catheter under general anesthesia since signs of massive sensory blockade are masked by general anesthesia. In each case, we suspected malpositioning of the catheter by severe hypotension due to sympatholysis which was difficult to treat. Subdural catheterization is a complication of epidural anesthesia that probably occurs more frequently than previously recognized and is usually unpredictable during general anesthesia.
题目：硬膜外结合全麻期间被忽略的硬膜下腔置管所致的严重低血压
出处：Masui. 1995 Oct;44(10):1373-6.
作者：Okuyama A, Saito Y, Amenomori H, Okuyama M, Kobayashi S, Kemmotsu O. (医院麻醉科，日本）
硬膜下腔置管是硬膜外麻醉的并发症，其发生的可能性远比我们以往的想象要普遍得多，但是在全麻期间通常是无法预知的。
12
Anesth Analg. 1988 Feb;67(2):175-9.
Inadvertent subdural injection: a complication of an epidural block.
Lubenow T, Keh-Wong E, Kristof K, Ivankovich O, Ivankovich AD.
Department of Anesthesiology, Rush Presbyterian St. Luke's Medical Center, Chicago, Illinois.
Twenty-one hundred eighty two consecutive lumbar epidural injections were studied to determine the incidence of inadvertent subdural block retrospectively. A subdural block is defined as an extensive neural block in the absence of subarachnoid puncture, that is out of proportion to the amount of local anesthetic injected. Subdural injection is a complication of epidural block that probably occurs more frequently than previously recognized. An earlier report has estimated the incidence of subdural block to be 0.1%. This study, however, reports an incidence of 0.82% from a sample size of 2182 patients. Cadaveric dissection was also performed, further clarifying the presence and anatomic position of the subdural space.
题目：意外的硬膜下腔置管：硬膜外腔麻醉的并发症
出处：Anesth Analg. 1988 Feb;67(2):175-9.
作者：Lubenow T, Keh-Wong E, Kristof K, Ivankovich O, Ivankovich AD. （芝加哥 医学中心麻醉科，美国）
硬膜下腔的存在，及其解剖学位置，已被尸解结果所进一步澄清。
13
Br J Anaesth. 1993 Apr;70(4):462-5.
Comment in: Br J Anaesth. 1993 Oct;71(4):607.
A continuous subdural block.
Collier CB, Gatt SP, Lockley SM.
Department of Anaesthesia, Royal Hospital for Women, Paddington, N.S.W., Australia.
We describe a case of accidental subdural block, after attempted extradural puncture for Caesarean section. Fractionation of the local anaesthetic dose led to avoidance of more serious complications. Subdural fentanyl and a continuous low-dose subdural infusion were used satisfactorily for intraoperative management and postoperative analgesia. As little as 0.5 ml of bupivacaine, hourly, provided satisfactory analgesia over a 15-h period.
14
South Med J. 1995 Apr;88(4):467-9.
Subdural injection of a local anesthetic with steroids: complication of epidural anesthesia.
Lehmann LJ, Pallares VS.
Department of Anesthesiology, University of Miami/Jackson Memorial Medical Center, Fla, USA.
We describe the unintentional injection of a small amount of local anesthetic with steroids into the subdural space during an attempted lumbar epidural injection for low back pain. When small volumes of local anesthetic are injected into the subdural space, a patchy and unilateral block of greater magnitude than expected will result. When larger volumes of local anesthetic are injected, a massive motor and sensory block can occur due to the small confines of this space. Accidental subdural injection must be recognized early and treated appropriately to avoid serious complications, especially in an outpatient setting.
题目：硬膜下腔注射局麻药激素：硬膜外腔麻醉并发症
出处：South Med J. 1995 Apr;88(4):467-9.
作者：Lehmann LJ, Pallares VS. （美国 福罗里达 某大学医疗中心麻醉科）
15
Rev Esp Anestesiol Reanim. 2002 Feb;49(2):108-11.
[Cardiorespiratory arrest: a rare complication of subdural block]
[Article in Spanish]
Silva Costa-Gomes T, Montes A, Sanchez JC, Bermejo S, Escolano F.
Servicio de Anestesiologia y Reanimacion Hospital Universitario del Mar Paseo Maritimo, 25-29 08003 Barcelona.
We report a case of accidental subdural block after epidural anesthesia that manifested as cardiac arrest due to extensive spinal blockade 20 minutes after administration of 50 mg of 0.5% bupivacaine. The event resolved without sequelae. Subdural placement of the catheter was verified by computed axial tomography contrast medium. Clinical signs of subdural block are highly variable, extensive neural block being among the possible rare presentations, with latency ranging from a few minutes to as long as 30. Recent electron microscope observations with new methods for fixing and preparing tissues suggest that the dubdural space does not exist naturally, but rather forms artificially within a low-resistance cell plane composed of neurothelial cells, as a result of trauma or the injection of a local anesthetic. The characteristics of the space depend, therefore, on factors that come together at the site. These data explain the great variability in the clinical manifestations of a subdural block. The case of cardiopulmonary arrest we report is rare in the literature.
题目：心跳呼吸骤停：一例罕见的硬膜下腔阻滞并发症
出处：Rev Esp Anestesiol Reanim. 2002 Feb;49(2):108-11.
作者：Silva Costa-Gomes T, Montes A, Sanchez JC, Bermejo S, Escolano F. （西班牙，巴塞罗那某大学医院麻醉科）
最近对组织块采用新的固定和准备方法，在电子显微镜下进行观察，设想硬膜下间隙原本是不存在的，但是当一层由神经上皮细胞组成的低阻力细胞层，在遇到穿刺损伤或注入局麻药时，就可能人为地形成了硬膜下间隙。因此，硬膜下间隙的特性取决于当时众多因素的综合结果。这些资料可以解说硬膜下腔阻滞的临床表现存在着巨大的变异性。本文所报道的一例心跳骤停，在文献中是罕见的。
丁香园网友YSDA作者: ycdy1 时间: 2009-3-20 23:11
16
Reg Anaesth. 1990 May;13(3):88-90.
[Subdural spread of a local anesthetic following installation of a peridural catheter]
[Article in German]
Zentrale Abteilung fur Anaesthesie, Christian-Albrechts-Universitat, Kiel.
We report 4 cases of inadvertent subdural injection of local anesthetics among 640 patients receiving epidural anesthesia. In contrast to subarachnoid injection a typical sign was the development of patchy anesthesia in cervical segments and with late onset of symptoms. The case of a 63 year old woman scheduled for aortofemoral bypass surgery in epidural anesthesia is reported. She developed paresthesia, paresis and signs of sympatholysis in both arms 30 min after the injection of 10 ml bupivacaine 0.5% at T10-11. These symptoms lasted for 7 h. Subdural injection was documented using radiopaque dye. Two other cases of probable subdural injection leading to paresthesia and paresis in cervical segments after lumbar injection of 50 or 75 mg bupivacaine are reported. The symptoms began 15-30 min after injection and lasted for 60 min. The fourth case was that of a 26-year-old woman scheduled for cesarean section under epidural anesthesia. Following the injection of 75 mg bupivacaine 0.5% patchy anesthesia extending to T10 developed. By 10 min after an additional injection of 25 mg bupivacaine 0.5% she had paresis and paresthesia in both arms and was unable to cough. Her trachea was therefore intubated; 30 min later the level of anesthesia was below T5 and she could be extubated. Uneventful cesarean section was then performed. These cases demonstrate that as well as subarachnoid injection, inadvertent subdural injection of local anesthetic agents is a potential hazard of epidural anesthesia, not only in patients in an advanced state of pregnancy but also in nonpregnant patients.
题目：硬膜外腔导管注射局麻药后进入了硬膜下腔[Subdural spread of a local anesthetic following installation of a peridural catheter]
出处：Reg Anaesth. 1990 May;13(3):88-90.
作者：Maier C, Schele HA, Haverlach T. （德国 某大学麻醉科）
这些病例提示，如同蛛网膜下腔注射一样，可发生局麻药硬膜下腔注射的意外，这是硬膜外腔麻醉的一种潜在危险，不仅可发生在姙娠病人，非姙娠病人也同样可以发生。
17
15：Can J Anaesth. 1996 Oct;43(10):1068-71.
Surgical anaesthesia for Caesarean section with a subdural catheter.
Gershon RY.
Department of Obstetric Anesthesiology, Grady Health System, Emory University School of Medicine, Atlanta, Georgia 30303, USA. [email protected]
PURPOSE: This case report describes a radiologically proven subdural catheter placed in a term parturient, which consistently performed as an epidural catheter for both labour analgesia as well as surgical anaesthesia. CLINICAL FEATURES: The patient was a 26-yr-old, 52.7 kg. 140 cm healthy woman with a 39 wk intrauterine pregnancy. At initiation of epidural blockade, and for many hours throughout labour, an appropriate volume and concentration of local anaesthetic achieved an appropriate analgesic sensory level (10 ml bupivacaine 0.25%, bilateral T10 sensory level). However, for Caesarean section, while an appropriate volume and concentration of local anaesthetic achieved an appropriate surgical anaesthetic sensory level (15 ml bupivacaine 0.5%, bilateral T4 sensory level), there was no demonstrable motor blockade (0 on the Bromage scale). The Caesarean section was performed without incident, and without the need for supplemental intravenous opioids or anxiolytics. CONCLUSION: We report the case to question the commonly held beliefs of subdural catheter presentation. We questioned the catheter position, and proved its subdural placement, only after larger volumes of higher concentration local anaesthetic did not achieve expected goals. It is possible that a high percentage of epidural catheters may be subdural, unbeknownst to the practitioner.
题目：剖宫产麻醉中的硬膜下腔导管
出处：Can J Anaesth. 1996 Oct;43(10):1068-71.
作者：Gershon RY. （加拿大 某大学妇产麻醉科）
18
16：Rev Esp Anestesiol Reanim. 1999 Mar;46(3):126-9.
[Accidental catheterization of the subdural space. Confirmation by radiological study]
[Article in Spanish]
Tornero Tornero JC, Vila Senante M, Comallonga Comallonga N, Aren Frontera JJ.
Servicio de Anestesiologia y Reanimacion, Hospital General de Granollers, Barcelona.
We report two cases of accidental subdural blockade after peridural anesthesia. The blockade was detected postoperatively in both cases, two hours after start of continuous perfusion in one patient and eight hours afterwards in the other. Subdural diffusion was confirmed after injection of a radiopaque contrast medium. Subdural blockade usually manifests as an extensive neural block that is disproportionate to the amount of anesthetic injected. We discuss the need for frequent monitoring of metameric, sensory and motor levels to detect possible catheter misplacement, in addition to routine monitoring of heart rate, arterial pressure and oxygen saturation. When subdural blockade is suspected, epidural perfusion should be discontinued in order to prevent extensive sensory and motor blocks. A firm diagnosis can only be made by X-ray. A simple radiograph may adequately demonstrate subdural placement in some cases, although computed axial tomography should be performed when doubt arises.
题目：导管意外进入硬膜下腔（经X线影像学证实）
出处：Rev Esp Anestesiol Reanim. 1999 Mar;46(3):126-9.
作者：Tornero Tornero JC, Vila Senante M, Comallonga Comallonga N, Aren Frontera JJ. （西班牙 巴塞罗那 某医院麻醉科。）
19
17：Masui. 1995 Feb;44(2):252-5.
[Diagnosis of accidental subdural block]
[Article in Japanese]
Saitoh K, Kasuda H, Hirabayashi Y, Fukuda H, Mitsuhata H, Shimizu R.
Department of Anesthesiology, Jichi Medical School, Tochigi.
Accidental subdural block occurred in a 47-year-old man who underwent gastrectomy under nitrous oxide-sevoflurane anesthesia combined with continuous epidural block. The development of subdural block was suspected from unexpectedly severe hypotension with small doses of mepivacaine during operation and was confirmed by a characteristic X-ray photograph after operation. The subdural block should be suspected from abnormal changes in vital signs and by careful observation of X-ray photographs, because it is not always easy to determine the presence of contrast media either in the subdural space or in the epidural space.
摘要：
1例47岁男性病人在N2O-七氟醚吸入麻醉复合连续硬膜外腔麻醉兄施行胃切除术。术中当注入小剂量美哌维卡因后出现意外的严重低血压，此时怀疑发生了意外的硬膜下腔阻滞。术后经X线摄片得到了证实。当生命体征出现异常改变时，应怀疑发生硬膜下腔阻滞，此时应仔细观察X线摄片，辨别造影剂是在硬膜下腔还是硬膜外腔。
20
Br J Anaesth. 1986 Oct;58(10):1194-7.
[Migration of an extradural catheter into the subdural space. A case report.]
Abouleish E, Goldstein M.
After repeated, successful extradural injections in a parturient, the extradural catheter migrated into the subdural space. The injection of 3% chloroprocaine 10 ml resulted in an extensive block, which extended to the cranial nerves and paralysed the respiratory muscles. The position of the catheter tip was confirmed by fluoroscopy. Subdural injection should always be suspected when tests for subarachnoid injection are negative, but an extensive block occurs gradually within 15-20 min. Respiration and circulation should be supported until the block regresses.
题目：硬膜外腔导管移入硬膜下腔。1例报告.
出处：Br J Anaesth. 1986 Oct;58(10):1194-7.
作者：Abouleish E, Goldstein M.（英国）
摘要：
一例产妇，经仔细辨别明确是硬膜外腔置管，结果导管恰移入了硬膜下腔。本例系在硬膜外腔注入3％氯普鲁卡因10ml后，发生了广泛的阻滞高达颅神经，同时呼吸肌麻痹而被发现的，经X线检查证实导管已移入至硬膜下腔。此时首先应排除蛛网膜下腔，然后应怀疑硬膜下腔置管，广泛的阻滞系在注药后15～20min内逐渐出现，此时应对呼吸和循环功能给予全面支持。
丁香园网友YSDA作者: ycdy1 时间: 2009-3-23 11:12
21
Acta Anaesthesiol Sin. 2003 Mar;41(1):37-41.
Accidental subdural catheterization due to complication of epidural anesthesia--a case report.
Huang HW, Ho WM, Shih ER, Lee SC, Shen CH.
Department of Anesthesiology, Taichung Veterans General Hospital, Taichung 40705, Taiwan, R.O.C.
Although accidental subdural injection is a well-recognized complication of epidural block, only a mere handful cases have been substantially proven by radiological evidence. Here we report a case of subdural catheterization during the attempt of epidural anesthesia for a gynecological procedure. Its clinical course and radiological findings are compared with those of the cases previously reported in literature. Whenever there is the occurrence of widespread of sensory block together with respiratory distress and hemodynamic unstability following epidural injection of local anesthetic, a subdural injection should be considered in spite of a negative confirmation. Repeated subdural injection of a local anesthetic at the same site may predispose patients to serious morbidity. Therefore, we recommend that when a subdural injection is evident or suspected, reinsertion of the catheter in the epidural space via another entry or contemplation of a switch to another anesthetic technique is mandatory.
题目：意外硬膜下腔置管－硬膜外麻醉并发症1例报告。
出处：Acta Anaesthesiol Sin. 2003 Mar;41(1):37-41.
作者：Huang HW, Ho WM, Shih ER, Lee SC, Shen CH. （台湾荣军总医院 麻醉科）
摘要：
尽管人们已经熟知意外硬膜下腔置管是硬膜外麻醉的一个并发症，但得到X线确切证实的病例毕竟还是少数。本文报告1例产科病人在硬膜外麻醉期间发生了硬膜下腔置管，其临床表现和X线造影检查均符合以往的文献报道。随着硬膜外腔注入局麻药，出现了广泛感觉阻滞，伴以呼吸困难和血流动力学不稳定。此时应该想到存在硬膜下腔注药，如果再次注入局麻药，就可能导致病人严重危险。因此，我们建议，一旦发生或怀疑硬膜下腔置管时，必须改换间隙另做硬膜外腔穿刺置管，或者改用其它麻醉方法。
22
Paediatr Anaesth. 1999;9:543-8.
Unintentional paediatric subdural catheter with oculomotor and abducens nerve palsies.
Haughton AJ, Chalkiadis GA.
Department of Anaesthesia, Royal Children's Hospital, Parkville, Australia.
A 13-year-old female with a past history of lumbar laminectomy developed a subdural block 18 h after the commencement of an epidural infusion of bupivacaine 0.125% and fentanyl 2 micrograms.ml-1. Signs at presentation included bilateral abducens nerve palsies in the absence of headache and a previously unreported unilateral third cranial nerve palsy. An epidurogram displayed subdural placement.
23
Afr Med J. 1992 Mar 21;81:325-6.
Inadvertent extra-arachnoid (subdural) injection of a local anaesthetic agent during epidural anaesthesia. A case report.
Boezaart AP, Kadieva VS.
Department of Anaesthesia, Johannesburg Hospital.
Profound hypotension occurring in a patient 2 hours after initiation of combined general and epidural anaesthesia for a myocutaneous free-flap graft was found to be attributable to subdural/extra-arachnoid injection of 0.5% bupivacaine. The initial diagnosis was based on a negative aspiration test, a delayed widespread sensory and sympathetic block, and the absence of any other obvious cause for the hypotension. This was confirmed by myelography, which demonstrated an extension of the contrast medium predominantly posteriorly in the spinal canal with excessive spread along the nerve roots. Posture and coughing did not affect the spread.
题目：硬膜外麻醉局麻药误注入硬膜下腔1例报告。
出处：Afr Med J. 1992 Mar 21;81:325-6.
作者：Boezaart AP, Kadieva VS. （南非 某医院麻醉科）
摘要：
在全麻复合硬膜外麻醉施行皮肌游离皮瓣手术，开始2小时后病人出现了深度低血压，发现系0.5％布比卡因系误注入硬膜下腔所致。硬膜外麻醉之初抽吸试验阴性，注药后也未见任何明显的低血压。广泛的感觉和交感阻滞属迟发性，经X线造影证实，造影剂在椎管的后侧及沿神经根呈广泛扩散分布，且不受体位和咳嗽所影响。
24
J Clin Anesth. 1999 Mar;11(2):129-31.
Subdural cannulation and local anesthetic injection as a complication of an intended epidural anesthetic.
Orbegozo M, Sheikh T, Slogoff S.
Department of Anesthesiology, Stritch School of Medicine, Chicago, IL, USA.
We report a 52-year-old woman scheduled for laparotomy with combined epidural-general anesthesia who experienced abnormal responses to local anesthetic injections administered via the epidural catheter. The catheter subsequently was found to be in the subdural space. A review of the literature is provided.
题目：硬膜下腔置管和注入局麻药是硬膜外麻醉的并发症。
出处：J Clin Anesth. 1999 Mar;11(2):129-31.
作者：Orbegozo M, Sheikh T, Slogoff S. （美国，芝加哥某医学院医院麻醉科）
摘要：
报告1例54岁妇女在硬膜外麻醉联合全麻下施行剖腹手术。局麻药注入硬膜外腔后发生了异常反应，随后证实导管被误置入硬膜下腔。文章对文献资料进行了复习。
25
Acta Anaesthesiol Scand. 1992 Oct;36(7):707-9.
Failure of anaesthesia after accidental subdural catheter placement.
van der Maaten JM, van Kleef JW.
Department of Anaesthesiology, Leiden University Hospital, The Netherlands.
A case is described where an epidural anaesthetic was complicated by dural puncture, following which attempted conversion to a continuous subarachnoid infusion technique resulted in failure of anaesthesia. Accidental subdural catheter placement was confirmed radiologically, subdural spread of solution being demonstrated; however, only minimal anaesthetic effects were produced.
题目：导管误置硬膜下腔后的麻醉失败
出处：Acta Anaesthesiol Scand. 1992 Oct;36(7):707-9.
作者：van der Maaten JM, van Kleef JW. （荷兰 某大学医院麻醉科）
Anaesth Intensive Care. 2003 Oct;31(5):570-2.
Comment in: Anaesth Intensive Care. 2004 Feb;32(1):145-6.
Inadvertent subdural spread complicating cervical epidural steroid injection with local anaesthetic agent.
Bansal S, Turtle MJ.
Anaesthetic Department, Walsgrave Hospital, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, United Kingdom.
Although cervical epidural steroid injection with local anaesthetic is considered a safe technique and widely practiced, complications may occur. We report a patient experiencing unexpected delayed high block, moderate hypotension and unconsciousness eight to ten minutes after an apparently normal cervical epidural steroid injection. The most probable diagnosis was a subdural block. Anatomical peculiarities of the epidural and subdural space in the cervical region increase the risk of subdural spread during cervical epidural injection. Fluoroscopic guidance is important during cervical epidural injection to increase certainty of correct needle placement, thus minimizing the risk of complications.
Anaesthesist. 2002 Nov;51(11):918-21.
[Delayed occurrence of subdural malposition of epidural catheter]
[Article in German]
Gaus P, Eich C, Hildebrandt J.
Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Georg-August-Universitat Gottingen, Germany.
We describe a case of postoperative subdural dislocation (between dura and arachnoidea spinalis) of an epidural catheter. After 24 h of normal functioning of the catheter, the injection of 5 ml lidocaine caused an extensive unilateral sensory block including the cranial nerves. X-ray control excluded an epidural or intrathecal position of the catheter. A delayed dislocation of the epidural catheter into the subdural space can occur but this complication only usually becomes evident after injection of a normal dose of local anaesthetic into the catheter and can have catastrophic consequences. The safety of patients can only be guaranteed if epidural catheters are managed solely by professional anaesthesiological personnel. Anatomy, mechanisms of complications and clinical differential diagnosis are discussed.
本文描述1例正常硬膜外腔麻醉术后24h时，出现导管误入硬膜下腔意外。经导管注射利多卡因5ml后出现广泛的单侧感觉阻滞，包括颅神经阻滞。这种导管延迟性误入硬膜下腔的并发症，偶尔可在注入正常量局麻药后得到证实，但恰是非常危险。为保证病人的安全性，硬膜外腔穿刺置管的操作应由专职麻醉科医生来执行。讨论了解剖学、并发症发生机制和鉴别诊断。
28
South Med J. 1989 Jan;82(1):87-9.
Subdural injection of local anesthetics and morphine: a complication of attempted epidural anesthesia.
Miller DC, Choi WW, Chestnut DH.
Department of Anesthesia, University of Iowa College of Medicine, Iowa City 52242.
We have reported a case of unintentional, roentgenographically proven cannulation of the lumbar subdural space. Injection of 13 ml of local anesthetic provided satisfactory anesthesia for cesarean section, and administration of 1 mg of morphine resulted in postcesarean analgesia for 22 hours. Subdural catheterization is a possible explanation for the occasionally irregular course of an apparent "epidural" anesthetic.
题目：硬膜下腔注射局麻药和吗啡：1例硬膜外腔麻醉的意外。
出处：South Med J. 1989 Jan;82(1):87-9.
作者：Miller DC, Choi WW, Chestnut DH. （美国爱荷华州立大学医学院麻醉科）
摘要：
报告1例腰段硬膜下腔置管注药的意外，经X线证实系硬膜下腔置管。对1例剖宫产在硬膜外腔注射局麻药13ml，麻醉效果满意，当注射吗啡1mg后恰得到了术后22h的镇痛效果。对这样一个明显为硬膜外腔麻醉正确的病例，恰发生了硬膜下腔置管意外，其可能的解说是偶发而无规律性的表现.
29
以下是台湾somnolent先生在山东麻醉论坛就Dr. Collier对于硬膜下腔解剖的描述文章的节译，转贴如下，以资共享。
Subdural Space
Clive Collier
The classic anatomical description of the subdural space is of "a potential cavity between the dura and arachnoid mater, containing a small volume of serous fluid" (1). The space runs up from the lower border of the second sacral vertebra into the cranial cavity as high as the diaphragma sellae in the floor of the third ventricle (2) but does not communicate with the subarachnoid space. It is continued onto the cranial and spinal nerves for a short distance. The space appears to be widest in the cervical region (3).
[节译]
对硬膜下空间的典型描述为:位于硬膜与蜘蛛网膜之间的潜在性空间，内含少量的浆液性液体，此空间由第二骶骨(S2)底部往上延伸到大脑的第三脑室板隔鞍，但并不与蜘蛛网腔相通，另外，会延着脑神经及脊神经延伸一小段距离，此腔室在颈椎段最宽。
Contemporary anatomists have suggested, however, that the spinal subdural space is not a "potential" space at all, but that it occurs as a result of tissue damage which creates a cleft in this area of the meninges (4). These anatomists contend that there is no natural space between the arachnoid barrier cell layer and the dural border cell layer. When tissue damage occurs, it results in a cleaving open of the dural border cell layer.
[节译]
当代的解剖学家曾暗示，硬膜下腔绝非一个"潜在性"的空间，但这须有一个组织受损的前提，造成在神经膜间的一个裂隙，他们 强调，蜘蛛膜与硬膜间没有存在天然的空间，但当组织受伤，裂缝会撑开此两层组织。
The force required to enter the subdural space or produce this cleavage is usually small. Blomberg (5) reported little difficulty in inserting an endoscope and viewing the cavity in the majority of his autopsy studies.
[节译]
要造成或进入此裂隙的力道通常很小，Blomberg就报告使用内视镜进入尸体的硬膜下腔并不困难。
Entry into the subdural space in the course of attempted epidural block appears to result from:
1. the bevel of an epidural needle perforating the dura, particularly if the bevel has been rotated in the epidural space ,
2. invasion by an epidural catheter at the time of its insertion, or
3. subsequent migration of the catheter.
[节译]
操作硬膜外阻滞而造成进入硬膜下腔通常是经由:
1.硬膜外针的前端斜面，特别是有经过旋转(180度)之后。
2.置入硬膜外导管时，
3.或后续导管移动迷入。
The subdural space is well known to radiologists as a place to go astray when attempting subarachnoid contrast injection (6, 9). This is particularly likely to occur following previous subarachnoid block, or lumbar puncture, and is recognized on fluoroscopic screening by the sluggish flow of contrast away from the injecting needle, which is little improved by tilting the patient.
[节译]
放射线科医师对硬膜下腔非常熟悉，因为在做蜘蛛网膜下腔注射时，常会误入此腔，特别在那些之前做过蜘蛛网下阻滞，腰椎穿刺的病例，当在X光透视下检查，显影剂溢出针尖的移动非常缓慢，且上下移动病人姿势并无法改善多少。
Injection of local anaesthetic into the subdural space usually results in an unexpectedly high level of sensory block - as little as 3.5 ml bupivacaine 0.5% has produced a block as high as the C5 level (7). The high sensory block is usually evident between 10 and 35 minutes following injection (Chapter 8). It may spread intracranially producing apnoea and unconsciousness. Accompanying hypotension is gradual in onset and systolic blood pressure is rarely below 60 mm Hg. .
[节译]
局麻药注入蜘蛛网膜下腔，通常会造成意想不到的高位知觉阻滞，可以少到3.5ml 0.5% bupivacaine，阻断到C5平面，时间约在注射后10~35分钟后，可以延伸到颅内造成呼吸停止以及意识丧失，伴随的低压通常渐进的发生，收缩压很少低于60 mmHg。
References:
1. GRAY'S ANATOMY. Neurology pp 1044-1102 33rd edition, Editors: Davies DV, Davies F. London,Longmans, 1964
2. Jones MD, Newton TH. Inadvertent extra-arachnoid injections in myelography. Radiology 1963 80:818-821.
3. Mehta M, Maher RM. Injection into the extra-arachnoid subdural space. Anaesthesia 1977 32:760-766.
4. Haines DE. On the question of a subdural space. The Anatomical Record 1991 230:3-21.
5. Blomberg RG. The lumbar subdural extra-arachnoid space of humans; an anatomical study using spinaloscopy in autopsy cases. Anesthesia and Analgesia 1987 66:177-180.
6. Schultz EH, Brogdon BG. The problem of subdural placement in myelography. Radiology 1962 79:91-95.
7. Brindle-Smith G, Barton FL, Watt JH. Extensive spread of local anaesthetic solution following subdural insertion of an epidural catheter during labour. Anaesthesia 1984 39:355-358.
8. Collier CB. Accidental subdural block: four more cases and a radiographic review. Anaesthesia and Intensive Care 1992 20:215-232.
9. Reynolds F and Speedy HM. The subdural space: The third place to go astray. Anaesthesia 1990: 45:120-123
29
译稿（由somnolent先生供原文，与Etomidate网友合译）
题目：探索“硬膜下腔”！
题目：Exploring the Subdural Space
来源：Regional Anesthesia and Pain Medicine, Vol 29, No 1 (January–February), 2004: pp 7–8.
作者：Craig Palmer, M.D.
单位：Department of Anesthesiology，University of Arizona Health Sciences Center. Tucson, Arizona
我们中的不少人会被告知：硬膜下腔位于硬脊膜与蛛网膜之间，后两者是围绕脊髓的两层脊膜。根据Cousins’ and Bridenbaught’ text一书描述：“….硬膜下腔是一个毛细管状的间隙，名之为“硬膜下腔”，位在硬脊膜与蛛网膜之间，其中含有极少量浆液。但硬膜下腔与蛛网膜下腔之间没有任何联络”[1]。Miller在最新版教科书中名之为“硬膜下间隙，……是位于硬脊膜与蛛网膜之间的一个潜在间隙，其中只有少量浆液…….”[2]。Cousins 和 Bridenbaugh一书进一步描述：“……硬脊膜与蛛网膜紧密粘贴，在腰穿过程中仅刺破硬脊膜而不刺破蛛网膜是不可能的”[1]。但是，在该书100页以后又明确重审：“………硬膜下腔置管系刺破硬脊膜而又没有刺透其下方的蛛网膜所致，是一种罕见的硬膜外腔置管意外，这在影像学顕影证实是较为常见的现象，发生率在1:100以上”[3]。而在当时我和我的同事都设想这是一种“奇怪的高位阻滞”。十年后的今天我和我的同事又被告知：“……….注入硬膜下腔的局麻药扩散缓慢，但十分广泛，这在大数量硬膜外止痛实践中是可能遇到的，令人莫名其妙，可能与解剖学异常有关”[4] 。25年后的今天，上述的解说看来没有很大的改变：“硬膜下腔注入局麻药，可导致意想不到的高位阻滞，但都是节段性阻滞。硬膜下腔阻滞的扩散变幻莫测，是否引起广泛扩散，取决于注入局麻药的总容量。”[5]
DR. Coolier在Regional Anesthesia and Pain Management[6]撰文提出一个令人注目的问题：“这些年来，我们对硬膜下腔的认识大概是错误的。硬膜下腔注入局麻药可能并不引起‘广泛的扩散性阻滞’，而恰恰相反，是一种‘扩散不全的局限性阻滞’。硬膜下腔注药并非想像中的那么罕见”。 Collier提出4例硬膜外腔麻醉病例，特点是局麻药未见广泛扩散、起效迟缓、需要硬膜外腔追加局麻药，阻滞方始生效。术毕该4例病人都在X线下注入造影剂证实导管已误入硬膜下腔，同时也观察到造影剂的扩散同样受到限制。这是一篇局麻药误注硬膜下腔受到“扩散限制”的首篇报道。
References
1. Bridenbaugh PO, Kennedy WF Jr. Spinal, subarachnoid neural blockade. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade. Philadelphia, PA: J.B. Lippincott Company; 1980:146-175.
2. Brown DL. Spinal, epidural, and caudal anesthesia. In: Miller RD, ed. Anesthesia. 5th ed. Philadelphia, PA: Churchill Livingstone; 2000:1492-1493.
3. Cousins MJ. Epidural neural blockade. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade. Philadelphia, PA: J.B. Lippincott Company; 1980:176-274.
4. Bromage PR. Epidural Anesthesia. Philadelphia, PA: W.B. Saunders Company; 1978:20.
5. Rosen MA, Hughes SC, Levinson G. Regional anesthesia for labor and delivery. In: Hughes SC, Levinson G, Rosen MA, eds. Anesthesia for Obstetrics. 4th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2002:42.
6. Collier CB. Accidental subdural injection during attempted lumbar epidural block may present as a failed or inadequate block: Radiographic evidence. Reg Anesth Pain Med 2004;29:45-51.
7. Jones MD, Newton TH. Inadvertent extra-arachnoid injection in myelography. Radiology 1963;80:818-822.
8. Ajar AH, Rathmell JP, Mukherji SK. The subdural compartment. Reg Anesth Pain Med 2002;27:72-76.
30
J Clin Anesth. 2001 Aug;13(5):392-7. Related Articles, Links
Subdural air collection: a likely source of radicular pain after lumbar epidural.
Overdiek N, Grisales DA, Gravenstein D, Bosek V, Nishman R, Modell JH.
Department of Anesthesiology, University of Florida College of Medicine, Gainesville, 32610-0254, USA.
This case conference reports two cases of epidural anesthesia in which air was used to identify the epidural space during a loss-of-resistance placement technique. Both patients subsequently complained of severe pain and subdural air was demonstrated in case 1 by computed tomography and in case 2 by magnetic resonance imaging. The possible causes of the pain syndrome experienced by both patients are discussed.
题目：硬膜下腔气泡集结：腰段硬膜外阻滞出现根性疼痛的可能原由。
出处：J Clin Anesth. 2001 Aug;13(5):392-7.
作者：Overdiek N, Grisales DA, Gravenstein D, Bosek V, Nishman R, Modell JH.（美国福罗利达大学医学院麻醉科）
摘要：
在病例讨论会上报告2例硬膜外腔麻醉，使用阻力骤失注气法鉴定硬膜外腔。2例病人都主诉严重的疼痛，1例经CT证实硬膜下腔有气泡，另1例经MRI证实硬膜下腔有气泡。对两例病人严重疼痛症状的可能原因进行了讨论。
丁香园网友YSDA作者: ycdy1 时间: 2009-3-24 23:42
31
Reg Anesth Pain Med. 2004 Jan-Feb;29(1):45-51. Related Articles, Links
Comment in: Reg Anesth Pain Med. 2004 Jan-Feb;29(1):7-8.
Accidental subdural injection during attempted lumbar epidural block may present as a failed or inadequate block: radiographic evidence.
Collier CB.
Royal Hospital for Women, New South Wales, Australia. [email protected]
BACKGROUND AND OBJECTIVES: Until now, case reports after accidental subdural injection during attempted epidural block have usually described extensive neuraxial blocks with a delayed onset, after low doses of local anesthetic, with a characteristic radiographic appearance on contrast injection. Our radiographic investigation of atypical "epidural" blocks has revealed that subdural injection may go unrecognized clinically and may be a cause of inadequate blocks. The mechanism is explored. CASE REPORTS: A radiographic study of 35 cases of atypical or inadequate blocks for cesarean delivery has unexpectedly revealed four instances of subdural contrast injection. On imaging, only localized posterior spread of subdural contrast was detected in these 4 cases, unlike the more widespread distribution previously reported after extensive neuraxial blocks. Recent findings on the ultrastructure of the subdural space are reviewed and related to the new clinical findings, which include inadequate blocks and pain developing on postoperative reinjections. CONCLUSIONS: Accidental subdural injection may now be added to the list of causes of failed or inadequate "epidural" block. Clinicians should be aware of the diagnosis of a possible subdural injection, if a poor quality block with restricted spread and slow onset is associated with pain on postoperative reinjection of the catheter.
至今认为，硬膜外腔导管误入硬膜下腔小剂量局麻药注入后，通常都表现为广泛的阻滞，伴以起效延迟，可以通过注入造影剂得到证实。但我们的X线造影对非典型性“硬膜外腔”阻滞进行研究，证实硬膜下腔注药的阻滞不全可能尚未被临床所认识。对其原因进行了讨论。病例报告：对剖宫产硬膜外腔麻醉表现非典型性或阻滞不全的35例剖宫产病人，进行X线造影研究，出乎意料地证实有4例造影剂被注入硬膜下腔。在荧光屏下看到这4例病人的造影剂只局限分布于后侧，不像以往所描述那样发生局麻药的广泛扩散和广泛阻滞。对最近有关硬膜下腔的超微结构进行了复习，报告了我们新近的临床发现，即阻滞不全和术后再注药时出现疼痛。结论是：意外的硬膜下腔注药，可以列为硬膜外腔阻滞失败或不全的原因之一。临床工作者应对下列情况提高警惕，可能存在硬膜下腔注药，其表现特点是：阻滞质量差，扩散范围窄，起效缓慢，术后经导管注药可出现疼痛。
32
Br J Anaesth. 1975 Oct;47(10):1111-3. Related Articles, Links
Accidental subdural analgesia: A case report, possible clinical implications and relevance to "massive extradurals".
Boys JE, Norman PF.
A continuous obstetric epidural is described, in which an abnormally extensive block and hypotension resulted. The catheter was subsequently shown to enter the subdural space. As this case resembles a "massive epidural", it is suggested that subdural injection may explain the phenomenon.
题目：意外的硬膜下腔镇痛：报告1例临床认为可能是“广泛硬膜外腔阻滞”的病例。
出处：Br J Anaesth. 1975 Oct;47(10):1111-3.
作者：Boys JE, Norman PF.
摘要：
报告1例产科持续硬膜外腔麻醉，出现异常的广泛阻滞和低血压。随后证实导管已误入了硬膜下腔。此例病人看似一个“广泛的硬膜外腔阻滞”，但可以用硬膜下腔注药进行解释。
33
Br J Anaesth. 1986 Oct;58(10):1194-7. Related Articles, Links
Migration of an extradural catheter into the subdural space. A case report.
Abouleish E, Goldstein M.
After repeated, successful extradural injections in a parturient, the extradural catheter migrated into the subdural space. The injection of 3% chloroprocaine 10 ml resulted in an extensive block, which extended to the cranial nerves and paralysed the respiratory muscles. The position of the catheter tip was confirmed by fluoroscopy. Subdural injection should always be suspected when tests for subarachnoid injection are negative, but an extensive block occurs gradually within 15-20 min. Respiration and circulation should be supported until the block regresses.
题目：硬膜外腔导管迷入硬膜下腔一例报道。
出处：Br J Anaesth. 1986 Oct;58(10):1194-7.
作者：Abouleish E, Goldstein M.
34
31：Br J Anaesth. 1993 Apr;70(4):462-5. Related Articles, Links
Comment in: Br J Anaesth. 1993 Oct;71(4):607.
A continuous subdural block.
Collier CB, Gatt SP, Lockley SM.
Department of Anaesthesia, Royal Hospital for Women, Paddington, N.S.W., Australia.
We describe a case of accidental subdural block, after attempted extradural puncture for Caesarean section. Fractionation of the local anaesthetic dose led to avoidance of more serious complications. Subdural fentanyl and a continuous low-dose subdural infusion were used satisfactorily for intraoperative management and postoperative analgesia. As little as 0.5 ml of bupivacaine, hourly, provided satisfactory analgesia over a 15-h period.
本文报告一例临产妇剖宫产在硬膜外腔分次注入局麻药麻醉，结果意外地发生了硬膜下腔阻滞。在采用持续泵输注芬太尼和低浓度局麻药下，术中麻醉及术后镇痛都满意。尽管布比卡因的剂量小至0.5ml/h，但止痛效果仍然满意地持续了15h以上。
35
32：Anesth Analg. 1987 Feb;66(2):177-80.
The lumbar subdural extraarachnoid space of humans: an anatomical study using spinaloscopy in autopsy cases.
Blomberg RG.
The lumbar subdural extraarachnoid space was examined by spinaloscopy in 15 autopsy subjects. Special attention was paid to the ease with which the space opened up and also to the extent of view achieved. In ten cases the space opened up with ease, in four cases with difficulty, and in one case it was not possible to establish the subdural space at all. The bevel of an 18-gauge Tuohy needle introduced into the subdural space could be visualized in eight of 13 cases. An epidural catheter was then passed through the Tuohy needle into the subdural space in eight cases and was visualized in six of them. Although care must be exercised in drawing conclusions for clinical epidural anesthesia from autopsy cases, this study confirms the possibility of placing both the bevel of a Tuohy needle and an epidural catheter in the subdural space. The results reemphasize the need for caution suggested by other reports regarding the possibility of subdural puncture in epidural anesthesia and subsequent injection of anesthetic solution into the subdural space.
在15具尸体上应用脊椎镜（spinaloscopy）对腰段硬膜下腔进行研究，特别观察到硬膜下腔是开启着的，而且有相当的长度。在15具尸体上，10具容易看到开启着的硬膜下腔，4例观察有困难，1例无法确认硬膜下腔。在13具尸体上，有8具可看到18号杜赫氏针的斜面进入硬膜下腔；在此8具中有6具可将导管通过穿刺针置入硬膜下腔。尽管利用尸体观察的结果可以用来解释临床硬膜外麻醉的异常原因，但需持慎重态度。本研究可以确定，杜赫氏针斜面和硬膜外导管可以置入硬膜下腔。
根据此项结果再次强调，在施行硬膜外腔麻醉时，必须重视有发生硬膜下腔置管和注入局麻药的可能性。
丁香园网友YSDA作者: ycdy1 时间: 2009-3-25 23:43
36
Anasthesiol Intensivmed Notfallmed Schmerzther. 1997 Oct;32(10):638-40.
[Subdural, extra-arachnoid block as a complication of stellate ganglion block: documentation with ultrasound]
[Article in German]
Kapral S, Krafft P, Gosch M, Fridrich P, Weinstabl C.
Universitatsklinik fur Anasthesie und Allgemeine Intensivmedizin, Wien, Osterreich.
We present a patient who developed a high central neural block after stellate-ganglion-blockade. The underlying pathophysiology was assessed via sonographic imaging. Stellate ganglion block was performed in a 19-year old patient according to the standard technique. Multiple aspiration tests were negative and a test dose of 3 ml bupivacaine 0.25% was injected. After a 3 min interval another 5 ml were injected. Two minutes after the local anaesthetic administration the patient reported nausea and sensations in the upper extremity. Spontaneous respiration efforts stopped, and the patient became unconscious. Tracheal intubation was performed, and the patient was ventilated in a controlled mode for two hours. Heart rate as well as blood pressure remained within the normal range. Neurologic recovery occurred rapidly and extubation was performed about two and a half hours after the event. Our sonographic studies demonstrated a local anaesthetic depot directly at the root of C 6, with a mean diameter of 10 mm and a length of 5 to 6 cm (about a third smaller than expected). Sonographic studies and clinical symptoms of our patient are most likely to occur with a subdural extra-arachnoidal block. Ultrasonographic guided puncture enhances the patient's safety by the opportunity to directly visualise transverse process, nerval root as well as local anaesthetic depot. In case of depot formation directly at the nerval root, injection may be stopped and the needle repositioned. Furthermore, direct visualisation of the great vessels (A. vertebralis) prevents intravascular injection and haematoma formation.
通过超声成像图的指导，可直视颈椎横突、神经根和局麻药的聚积点，由此可提高病人的安全性。当局麻药直接聚积在神经根上时，提示注药应停止，需调整针尖位置，进一步还可直接看到大血管（椎间动脉），从而可避免血管内注药和血肿形成。
37
Ann Acad Med Singapore. 2002 Jul;31(4):525-7.
Subdural block--from a spinal? A case report.
Department of Anaesthesia, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
INTRODUCTION: Multicompartmental blocks are commonly described in epidurals but not spinals. We describe a case of subarachnoid block performed in an obese patient which resulted in a clinical presentation resembling that of a subdural block. CLINICAL PICTURE: A 29-year-old woman, scheduled for saucerisation of thigh carbuncle, was administered 2.1 mL of hyperbaric bupivacaine. The spinal resulted in a late onset of sensory block that extended to the neck and upper limbs. There was no sympathetic or motor blockade. TREATMENT/OUTCOME: The block receded spontaneously without causing any cardiovascular or respiratory compromise. CONCLUSIONS: The diagnosis of subdural block must be considered in patients with unusual presentations after a spinal anaesthetic. Factors affecting spread of hyperbaric bupivacaine are also highlighted.
题目：硬膜下腔阻滞——来自脊椎麻醉？一例报告
出处：Ann Acad Med Singapore. 2002 Jul;31(4):525-7.
作者：Chan SY, Ong EL。 （新加坡某综合医院麻醉科）
摘要：
硬膜外腔阻滞常有多个神经节段阻滞的报道。本文描述一例29岁肥胖女性病人，因大腿痈施行切开清创术，在施行蛛网膜下腔注入重比重布比卡因2.1ml后，出现了近似硬膜下腔阻滞的临床表现：感觉阻滞起效缓慢，平面高达颈部和上肢，但不伴有交感和运动阻滞。阻滞作用自动消退，未引起心血管和呼吸方面的变化。结论：当腰麻病人出现异常的表现时，在诊断方面必须想到有硬膜下腔注射的可能，此时诸多影响重比重布比卡因扩散的因素也不再生效。
38
Anaesthesia. 1984 Apr;39(4):355-8.
Extensive spread of local anaesthetic solution following subdural insertion of an epidural catheter during labour.
Smith GB, Barton FL, Watt JH.
A case is described where a small dose of bupivacaine was accidentally injected into the subdural, extra-arachnoid space resulting in extensive unilateral block and hypotension. The spread of solution was confirmed radiologically.
报道一例意外的硬膜下腔注射小剂量布比卡因，而出现广泛单侧阻滞和低血压的现象。经放射学检查证实局麻药液系在硬膜下腔扩散。
39
Anaesthesia. 1977 Sep;32:760-6.
Injection into the extra-arachnoid subdural space. Experience in the treatment of intractable cervical pain and in the conduct of extradural (epidural) analgesia.
Mehta M, Maher R.
The anatomy and radiological appearances of the subdural space in the cervical region are described. Recognition of this space facilitates neurolytic injections for severe cancer pain in the distribution of the cervical nerve roots. The subdural space may have significance also in explaining the extensive sensory block which follows a delayed or 'massive' lumbar extradural injection.
题目：硬膜下腔注射。应用硬膜外镇痛法治疗顽固性颈部疼痛的经历
出处：Anaesthesia. 1977 Sep;32:760-6.
作者：Mehta M, Maher R.
摘要：
描述一例颈段硬膜下腔注药的解剖学和放射学表现。本例系严重癌性疼痛，在施行颈脊神经根破坏术注药时发生。硬膜下腔注射也可解释腰段硬膜外腔注药出现延迟性广泛感觉神经阻滞的现象。
40
Eur J Anaesthesiol. 1997 Jul;14(4):455-7.
Accidental subdural injection of local anaesthetic: diagnosis by pressure measurement and response to aspiration of injectate.
Tripathi M, Bano N, Gaur A, Kaushik S.
Department of Anaesthesiology and Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
A healthy 22-year-old man received an initial injection of 12 mL of lignocaine/bupivacaine solutions (2 mL test, then 10 mL) into an epidural catheter. This produced a satisfactory regional blockade that seemed to be epidural but, when a supplementary 6 mL injection was given 1 h later, the patient developed impaired motor function as far as the upper cranial nerves, with loss of pinprick sensation to the shoulder. The emergence of fluid dribbling freely from the catheter prompted measurement of the pressure, which was 36 mmHg. The fluid was proved not to be cerebrospinal fluid (CSF) by the absence of glucose (on dextrostix), by the appearance of turbidity with added thiopentone, and later by microscopy. Slow aspiration of 7 mL of the presumed injectate reduced the pressure in the catheter to 8 mmHg, which promptly reversed the additional excessive blockade, allowing surgery to proceed uneventfully. The retrieval of injectate argues strongly that the catheter tip had found its way subdurally, and the promptness of the reversal with aspiration argues for a mechanical rather than a pharmacological cause for the extensive neurological dysfunction after the second injection. Pressure measurement and aspiration may be helpful in other similar cases.
题目：意外的局麻药硬膜下腔注射：应用测压和抽吸方法做出诊断。
出处：Eur J Anaesthesiol. 1997 Jul;14(4):455-7.
作者：Tripathi M, Bano N, Gaur A, Kaushik S.（印度，毕业后教育医学中心麻醉学与危重医学科）