闭孔神经分段与闭孔神经反射的相互联系

摘要

目的：探讨闭孔神经分段与在泌尿外科微创手术中发生的闭孔神经反射（ONR）及其预防的相互关系。方法：根据闭孔神经自然行走的整个路线与临床需要，把闭孔神经的全长分为五段，然后将经尿道电切除膀胱肿瘤的临床实际与对应的神经段相结合，并细化分析每段神经的结构特点与临床意义。结果：虽然椎管内麻醉可阻断包括第1段闭孔神经根部在内的相关脊神经根传导冲动至中枢，麻醉效果也达到微创手术的要求，但仍无预防作用，还必须联合其它方法才能干预ONR；在第2段闭孔神经行走的间隙内，可用3+1麻醉法预防ONR；第3段闭孔神经邻近膀胱侧壁，是遭受手术电激惹而引发ONR的源头，可从消除激惹性电流或经膀胱途径阻滞神经两方面加以预防；针对第4段神经穿过的通道，可将局部麻醉药物注入到闭膜管内或闭膜管外口处，阻滞神经干或神经分支的起始部而得到预防；针对第5段神经已分发出的前支和后支分别加以阻滞，或者通过静脉注射肌肉松弛剂，阻断神经-肌肉接头处的信息传导，均可预防 ONR。结论：将闭孔神经分段的基础知识与相关的临床实践相互链接和梳理的做法，既容易理解ONR的发生机制，又有依据选择适宜的靶点进行针对性预防。%Objective:To examine interrelation between obturator nerve division, obturator nerve reflex(ONR) and related prevention in transurethral resection of bladder tumor. Methods:Based on natural running-course of obturator nerve and relative clinical applications, whole length of the nerve was divided into five neural segments. Then the intraspinal anesthesia of surgery, mechanism and interventions of ONR were combined with corresponding segments of obturator nerve. Results: Although the first segment(root part)was blocked by performing intraspinal anesthesia, and the anesthesia also met requirements of surgery, the anesthesia still could not prevent ONR. 3-in-1 nerve block was conducted in the second segment to prohibit ONR. The third trunk segment was irritated by low frequency current, inducing ONR with resulting in bladder perforation. The solutions to problems were elimination of irritated current and intravesical block of this segment. Due to passage of obturator canal for the fourth segment, local block targeted nerve trunk within the canal, or initial part of nerve division at the canal outlet. The fifth segment gave off two branches: anterior and posterior,and the block should cover the two branches. Simultaneously, at this segment there were neural-muscular junctions, and intravenous injection of muscle relaxants could inhibit the information passage from nerve terminals to muscles. Conclusion: The above method of combining anatomical division of obturator nerve with related clinical significances is helpful for understanding ONR mechanism and selecting appropriate targets for preventing ONR.