포진후 신경통

朴澳 대한의학협회 1995 대한의학협회지 Vol.38 No.6

全脊髓 및 硬膜外遮斷으로 鞭打性 損傷의 痛症治驗 : 4例 報告 Report of Four Cases

朴澳,玉時英,宋厚彬 순천향대학교 1986 논문집 Vol.9 No.1

For the relief of pain in 3 cases of whiplash syndromes (case Ⅰ, Ⅱ and Ⅳ) and in one of reflex sympathetic dystrophy (case Ⅲ), we have carried out six intentional total spinal blocks (TSB) which attempted two times in case Ⅰ, three in case Ⅱ and one in case Ⅲ whose various symptoms were chronically unresponsive to the usual conservative treatments, and a time of cervical epidural and right suprascapular nerve block in case Ⅳ whose acute symptom lasted 4 days following the cervical injury (see tables from 1 to 9). During the TSB, we have observed clinically the sequential changes of respiration, lid and pupil reflexes, body motion and consciousness. And checked the blood pressure, pulse rate and arterial Pco2. The effectiveness of those blocks has been assessed by using the Visual Analog Scale which is designed to measure the patient´s subjective intensity of pain and also we have found out the sequelae following those blocks. The methods of the blocks were as the following: 1. Under the N.P.O. for 8∼10 hours, the preparations of immediate cardiopulmonary resuscitation and premedication with atropine 0.5mg at thirty minutes before the TSB, it was performed by injecting the mixture of 2 % mepivacaine 10 or 15ml and normal saline 10 or 5ml through No. 23 G. spinal needle into the subarachnoid space of C7-T1 interspinous region with fully flexed neck on the lateral posture. Immediately after the injection of the local anesthetic in the lateral position, the patient´s were hasten to change Trendelenburg´s position in order to act the drugs cephalad and to make easy controlled respiration with oxygen. 2. The cervical epidural block was done by injecting the mixture of 0.5% bupivacaine 4ml, normal saline 4ml and triamcinolone 15mg through No.18G Tuohy needle into the epidural space on the same region and posture as the above without premedication. The suprascapular nerve block was done by injecting of 0.5% bupivacaine 3ml only into the right suprascapular fossa on the sitting posture. The results were as the following: 1. The cessation of respiration was seen within 5 minutes following the subarachnoidal injection of the above 20ml mixture in 2 to 3 minutes and then soon the consciousness began to disappear. The loss of lid and pupil reflexes noted between 5 to 10 minutes and the size of the dilated pupil was equal between 5 to 20 minutes, but the pupil of the dependant side on the lateral position was dilated 1 to 3 minutes earlier than that of the independent. The patients had never responded to any stimulations during the TSB except their heart funtion. 2. The recovery of the TSB was as the following, firstly the ankle and lower limb of the independent side began to move slightly with in 34 to 75 minutes after the injection and then that of the dependent. Secondly the neck and upper limb moved 6 to 15 minutes later than the lower limb. Thirdly the self respiration began to appear between 40 to 80 minutes from the block. The lid and pupil reacted to touch and light respectively between 40 to 80 minutes but the pupil of the independent side responded earlier than that of the dependent. Lastly the consciousness recovered completely between 80 to 125 minutes from the block. 3. In the cardiopulmonary function during the TSB, the blood pressure were stable except the 210/130 torr at the 2nd block of case 1. There were bradycardias between 65 to 85 minutes in case Ⅰ and Ⅱ but no arrythmia on the EKG. The level of the arterial Pco2 was maintained to 43∼45 torr during the TSB. 4. The effectiveness of the above blocks was no pain(0%) in case Ⅳ,and light(10∼20%) in case Ⅰ and Ⅱ but no improvement in case Ⅲ. 5. The right arm weakness has been complicated as to be injected accidently the "COLD" local anesthetic at the 2nd block of case Ⅰ.

上肢 外轉位에서 施行한 鎖骨上 上腕神經叢遮斷

田溶愛,朴澳,金晟烈 순천향대학교 1981 논문집 Vol.4 No.1

With the arm in hyperabduction, we have carried out 525 procedures of supraclavicular Brachial plexus block from Aug. 1976 to June 1980, whereas block with the arm in adduction has been customarily performed by other authors4,27,28). The anesthetic procedure is as follows: 1) The patient lies in the dorsal recumbent position without a pillow under his head or shoulder. His arm is hyperabducted more than a 90 degree angle from his side. and his head is turned to the side opposite from that to be blocked. 2) An "X" is marked at a point 1cm above the midclavicle, immediately lateral to the edge of the anterior scalene muscle. and on the pa1pab1e portion of the subclavian artery. The area is aseptically prepared and draped. 3) A 22 gauge 3. 5cm needle attached to a syringe filled with 2% lidocaine (7-8mg/kg of body weight) and epineprine (1 :200,000) is inserted caudally toward the second portion of the artery where it crosses the first rib and parallel with the lateral border of the muscle until a paresthesia is obtained. 4) Paresthesia is usually elicited while inserting the needle tip about 1∼2cm in depth. If so, the local anesthetic solution is injected after careful aspiration. 5) If no paresthesia is elicited. the needle is withdrawn and redirected in an attempt to elicit paresthesia. 6) If, after several attempts, no paresthesia is obtained, the local anesthetic solution is injected into the perivascular sheath after confirming that the artery is not punctured. 7) Immediately after starting surgery. Valium is injected for sedation by the intravenous route in almost all cases. The age distribution of the cases was from 11 to 80 years. Sex distribution was 476 males and 49 females (Table 1) . Operative procedures consisted of 103 open reductions, 114 skin grafts combined with spinal anesthesia in 14, 87 debridements, 75 repairs, i.e. tendon(41), nerve(32), and artery (2), 58 corrections of abnormalities, 27 amputations above the elbow (5). below the elbow (3) and fingers (17). 20 primary closures, 18 incisions and curettages, 2 replantations of cut fingers respectively (Table 2). Pareathesia was obtained in all cases. Onset of analgesia occured within 5 minutes, starting in the deltoid legion in almost all cases. Complete anesthesia of the entire arm appeared within 10 minutes but was delayed 15 to 20 minutes in 5 cases and failed in one case. Thus, our success rate was nearly 100%. The duration of anesthesia after a single injection ranged from ?? to ?? hoers in 94% of the cases. The operative time ranged from 0.5 to 4 hours in 92.4% of the cases(Table 3). Repeat b1ocks were carried out in 33 cases when operative times which were more than 4 hours in 22 cases and the others were completed within 4 hours (Table 4). Two patients of the 33 cases, who received microvasular surgery were injected twice with 2 % lidocaine 20 ml, for a total of ?? hours. The 157 patients who received surgery on the forearms or hands had pneumatic tourni-quets (250 torrs) applied without tourniquet pain. There was no pneumothorax, hematoma or phrenic nerve paralysis in any of the unila- teral and 27 bilateral blocks, but there was hoarseness in two, Horner's syndrome in 11 and shivering in 7 cases. No general seizures or other side effects were observed. By 20m1 of 60% urografin study, we confirmed the position of the needle tip to be in a safer position when the arm is in hyperabduction than when it is in adduction. And also that the humeral head caused some obstruction of the distal flow of the dye, indicating that less local anesthetic solution would be needed for satisfactory anesthesia. (Fig.3.4)