Zusammenfassung
Durch die Einführung des Ultraschalls in die Regionalanästhesie wurde in den letzten Jahren deutlich, dass es in der Vergangenheit wahrscheinlich erheblich häufiger als bisher angenommen zu sog. intraneuralen Punktionen bzw. Injektionen (d. h. Penetration des Epineuriums) gekommen ist. Allerdings führte dies nur selten zu bleibenden neurologischen Schäden. Die sonographische Darstellung der Nerven hat gezeigt, dass die „intraneurale Injektion“ als Oberbegriff zu betrachten ist, der unter Berücksichtigung der Morphologie der Nerven einer detaillierteren Beschreibung bedarf. Es wurde deutlich, dass der Stichkanal bei einer intraneuralen Punktion meist an den Nervenfaszikeln vorbei (intraneural-perifaszikulär) und selten durch sie hindurch (intraneural-transfaszikulär) verlief, wobei die Nadelspitze entsprechend selten im Faszikel selbst (intraneural-intrafaszikulär) zu liegen kam. Bei intraneural-extrafaszikulärer Lage kann derzeit davon ausgegangen werden, dass es wahrscheinlich zu keinen bleibenden Nervenschädigungen kommt. Werden Faszikel geschädigt, sind klinisch apparente Nervenschäden nicht auszuschließen. In einer Reihe von Studien zur Bestimmung des minimalen effektiven anästhetischen Volumens, in denen bewusst eine intraneurale Injektion vermieden wurde, konnte aber belegt werden, dass auch bei gezielter zirkumferenzieller Applikation des Lokalanästhetikums mithilfe des Ultraschalls (d. h. bei ringförmiger Verteilung um die äußerste erkennbare Nervenhülle) eine erhebliche Volumenreduktion des Lokalanästhetikums möglich ist. Diese erscheint gegenüber einer Einzelpunktinjektion außerhalb des Epineuriums (extraneurale Injektion ohne garantierte Verteilung des Lokalanästhetikums um den Nerv herum) vorteilhaft. Da die intraneural-intrafaszikuläre Applikation des Lokalanästhetikums das Risiko von z. T. lebensqualitätseinschränkenden Nervenschäden in sich birgt, sollten die Möglichkeiten des Ultraschalls im Hinblick auf die Vermeidung von intraneuralen Punktionen genutzt werden.
Abstract
Ever since the use of ultrasound guidance in regional anesthesia became more and more popular in recent years, it seemed obvious that so-called intraneural puncture and injection of local anesthetics was much more common than previously assumed. However, neurologic damage was not seen very often. The ultrasound-guided imaging of the nerves showed that intraneural injection has to be seen as an overall term. This term must be characterized in more detail in accordance with nerve anatomy and morphology. Various studies demonstrated that if intraneural puncture occured the needle usually took a path away from the fascicles (intraneural perifascicular), while intraneural transfascicular puncture seemed relatively rare and intraneural intrafascicular placement of the needle even more uncommon. As long as the needle is placed intraneurally but in an extrafascicular fashion a safe injection and the absence of neurologic damage can be assumed. However, if nerve fascicles are affected neurologic dysfunction can occur. In studies investigating the minimal effective local anesthetic volume needed for successful nerve block, a relevant reduction of injected volume was still achieved by intentionally applying the local anesthetic circumferentially around the outermost nerve layer rather than injecting it into neural structures. As an intraneural -intrafascicular injection carries the risk of nerve injury associated with a decrease in quality of life, the potential of ultrasound guidance in regional anesthesia should be considered. Circumferential administration of local anesthetic rather than creating a single point injection appears to be advantageous.
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Gorsewski, G., Dinse-Lambracht, A., Tugtekin, I. et al. Ultraschallgesteuerte periphere Regionalanästhesie. Anaesthesist 61, 711–721 (2012). https://doi.org/10.1007/s00101-012-2045-x
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DOI: https://doi.org/10.1007/s00101-012-2045-x