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硬膜外麻醉致导管椎管内断裂一例

2019-03-26 李洋 魏智彬 云利兵 临床误诊误治

女,43岁。因急性阑尾炎入甲医院,拟急诊行持续硬膜外麻醉阑尾切除术。术前检查脊柱及四肢无畸形,活动自如,腰椎无压痛。术中患者取右侧屈膝位,穿刺点为胸11~12,常规消毒、铺巾后经旁路穿刺,到达硬膜外腔后向上置管,退出穿刺针调整硬膜外置管过程中导管突然断裂,遂急诊切开皮肤约3 cm,组织钳依次钝性分离皮下组织,寻找硬膜外导管残端未果,立即请邻近上级医院麻醉科会诊,亦未找到硬膜外导管残端,后缝合切口。

1.病例资料
 
女,43岁。因急性阑尾炎入甲医院,拟急诊行持续硬膜外麻醉阑尾切除术。术前检查脊柱及四肢无畸形,活动自如,腰椎无压痛。术中患者取右侧屈膝位,穿刺点为胸11~12,常规消毒、铺巾后经旁路穿刺,到达硬膜外腔后向上置管,退出穿刺针调整硬膜外置管过程中导管突然断裂,遂急诊切开皮肤约3 cm,组织钳依次钝性分离皮下组织,寻找硬膜外导管残端未果,立即请邻近上级医院麻醉科会诊,亦未找到硬膜外导管残端,后缝合切口。
 
由于患者病情须立即手术治疗,征求患者同意后继续在气管插管全身麻醉下顺利完成手术。术后予止血、护、抗感染、补液等对症支持治疗,查体:生命体征平稳,双肺呼吸音清,律齐,腹软,四肢活动自如。术后10 d在上级医院行MRI示:腰背部皮下脂肪水肿,腰椎生理曲度存在,椎体退行性变,脊髓信号未见异常。
 
为进一步诊治,术后15 d患者于乙医院行胸部CT示:胸7~12层面椎管右侧见管条状稍高密度影,在胸12平面似可见该异常密度影伸出体外,胸12棘突后缘软组织肿胀,胸腰椎退行性变。神经系统检查未见明显异常,故于术后22 d在乙医院行椎管内异物取出术。
 
术中见背部皮肤有一直径约0.5 cm的痂壳,周围轻微红肿,沿胸12~腰1平面取后正中直切口约6 cm,分层切开皮肤、皮下、肌肉,显露腰1椎板,磨钻打孔,韧带及硬脊膜未见钙化,咬除腰1右侧半椎板后见一破裂孔,有清亮脑脊液流出,见一直径约0.3 cm、长约15 cm的导管,顺利取出后修补硬脊膜,骨窗周围止血,无活动性出血后逐层缝合筋膜、肌肉、皮下及皮肤,无菌敷料覆盖切口,术后恢复良好出院。患方认为甲医院术前持续硬膜外麻醉操作不当致硬膜外腔导管遗留及硬脊膜破裂,由此引发医疗纠纷。
 
法医检查见:腰背部后正中见一约8 cm×(0.1~0.2)cm的纵行瘢痕,其左侧旁下有一约4 cm×(0.2~0.3)cm的纵行瘢痕;双侧腹股沟内侧、髂前上棘平面以下及会阴区浅感觉明显减退,肛周反射减弱,双下肢浅感觉减退。复阅术后10 d腰椎MRI示:腰椎序列如常,生理曲度存在,椎体边缘骨质增生、变尖,腰4~5、腰5~骶1椎间盘向外膨出约0.5 cm,压迫硬膜囊伴腰5~骶1后方纤维环撕裂,其双侧椎间孔、侧隐窝变窄,脊髓信号未见明显异常,腰背部皮下脂肪水肿;术后15 d胸部CT示:胸7~12层面椎管右侧见管条状稍高密度影,胸12似可见该异常密度影伸出体外,胸12棘突后缘软组织肿胀,胸腰椎退行性变。法医鉴定结论为甲医院在硬膜外穿刺、置管前后对患者一般情况评估不够全面,未严格执行硬膜外麻醉操作规范等,诊疗行为存在一定过错,且与患者不良后果存在一定因果关系。
 
2.讨论
 
2.1本案责任认定
 
甲医院在操作置管前未综合考虑患者年龄、职业、硬膜外穿刺置管前紧张度等因素,穿刺后未见关于进针过程及难易程度、测量皮肤至硬膜外腔的距离、判断穿刺针是否到达硬膜外腔等记录,退针前无已置入体内的硬膜外导管长度、断裂并滞留体内的硬膜外导管长度、如何退针调整硬膜外置管及难易程度的相关记录,提示甲医院硬膜外穿刺置管前后的诊疗操作不符合临床规范,导管断裂滞留体内亦未立即行相关检查以确定硬膜外导管滞留位置(椎管内或椎管外)及是否产生相应的神经症状等,说明甲医院对导管断裂处置欠合理。
 
术后22 d于乙医院行椎管内异物取出术,证实硬膜外腔遗留长15 cm的导管(胸7~12层面)及胸腰段右侧硬脊膜破裂伴腩脊液流出,提示甲医院术前硬膜外穿刺置管操作不当致硬膜外导管断裂遗留椎管内并硬脊膜破裂,说明甲医院诊疗行为存在过错,且与患者硬膜外导管残留并胸腰段硬脊膜破裂存在一定的因果关系。
 
2.2导管断裂原因
 
硬膜外导管断裂既可发生在穿刺置管时,亦可见于术后拔管时。临床导管断裂的原因复杂,多与麻醉科医师操作、穿刺区病理或生理改变及导管因素有关。置管时导管断裂的主要原因与导管置入过深(>5 cm)、置管遇及阻力时过度用力、退管(调节)操作Tuohy针未配合移动、Tuohy针在硬膜外间隙位置不当、导管位于针尖与骨面间或卡入椎间关节或骨缝等有关;拔管时导管断裂的原因与拔管遇及阻力时过度用力及反复尝试拔出已打结或与周围组织缠绕的导管等有关。
 
此外,患者自身存在脊柱狭窄、骨质增生、妊娠、硬膜外间隙结缔组织增生、体位改变等病理(生理)因素亦是硬膜外导管置入或拔出过程中发生断裂的重要原因?。其他少见原因还有硬膜外导管的材质及型号等。有文献报道尼龙或聚氨酯导管较特氟隆或聚乙烯导管更坚固,而19G导管有在尖端附近固定位置断裂的倾向。
 
本例为中年女性,术后MRI证实存在胸腰椎退行性变、双侧椎间孔及侧隐窝变窄等脊柱病变,提示患者存在影响导管置入的病理因素;患者穿刺置管前过度紧张(甲医院未行心理疏导或药物缓解)提示其存在穿刺置管时体位移动的风险;甲医院穿刺置管过程中麻醉科医师未采取相应措施以判断穿刺针是否已进入硬膜外间隙,亦未拔出针芯观察是否有脑脊液或血液流出以判断穿刺针是否置入蛛网膜下腔或血管;导管断裂后甲医院探查术区椎管外阴性,而乙医院术中见硬膜外问隙遗留长15 cm的导管及相应CT征象提示导管置入过深(纵贯胸7~12椎体,深度>5 cm),且不能排除麻醉科医师在患者脊柱存在阻力的基础上不当用力或违规操作等导致硬膜外导管断裂并遗留椎管内。
 
本例后续探查未见感染征象,导管断裂后至取出前无明显神经系统阳性体征及脊髓异常信号改变,说明胸腰段右侧硬脊膜破裂为后续探查取管前(时)系断裂硬膜外导管残端损伤硬脊膜所致;术后遗留双侧髂前上棘以下浅感觉减退,说明遗留神经系统症状较轻,考虑患者存在胸腰椎基础病理改变,其双侧髂前上棘以下浅感觉减退系断裂导管在体内较长时间遗留、移动损伤脊神经或导管纤维结缔组织包裹后压迫相应节段神经及既往基础疾病共同所致。
 
2.3导管断裂处理
 
硬膜外导管断裂遗留体内应予体外残余导管及影像学检查,进行针对性查体,以了解体内遗留导管长度并最大可能评估导管确切位置(椎管内/外)和预后,对鼓励无症状的患者密切规律随访和临床资料收集大有裨益。Mitra等报道CT平扫对硬膜外断管的定位较x线透视分辨率高,若CT检查无法立即进行,x线透视可作为临床首选。Singh等。认为影像学检查对遗留导管的定位作用不大,其原因可能与硬膜外导管厚度小、周围组织密度高有关。有学者建议改进导管材料可提高硬膜外导管影像学可视化程度。
 
若初步评估断裂导管位于椎管外,可选择局部切开探查并尽可能取出导管;若断裂导管位于椎管内,术者必须仔细权衡取管利弊及所面临的风险。目前,学术界对椎管内导管是否进行外科干预尚存在争议,因多数椎管内断裂导管常于3周后被硬膜外间隙的纤维组织包裹,但部分学者仍建议率先考虑外科手术取管,其对合并神经系统后遗症或断裂导管并发症者进行及早外科干预的意见相一致。
 
2.4置管注意事项
 
硬膜外导管断裂为硬膜外麻醉的少见并发症,麻醉科医师特别是基层医院或临床经验尚少的年轻医师应提高认识和警惕,术前进行风险评估,尽可能对硬膜外穿刺置管相关区域的病理、生理及患者心理状态进行预估,同时穿刺时务必严格遵守操作规范,规避可控风险,运用阻力消失法或毛细血管负压法等判断穿刺针是否进入硬膜外间隙,观察针芯是否有脑脊液或血液流出,切不可根据落空感或经验盲目穿刺。若置管遇及阻力时切忌使用蛮力,并注意与Tuohy针配合操作,且导管置入长度以4~5 cm为宜;置管后尽量避免使用缝线固定硬膜外导管,减少操作因素所致硬膜外导管断裂甚至相关并发症的发生。若导管发生断裂,准确定位遗留体内导管的位置及长度,密切随访以评估患者情况及预后尤为重要,一旦出现神经系统后遗症或断裂导管并发症,外科干预必须尽早进行。
 
原始出处:

李洋,魏智彬,云利兵,刘敏,易旭夫.硬膜外麻醉致导管椎管内断裂一例临床分析[J].临床误诊误治,2018,31(03):45-47.

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    2019-12-05 bugit
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  3. [GetPortalCommentsPageByObjectIdResponse(id=1690780, encodeId=f1f31690e804e, content=<a href='/topic/show?id=de3362880f1' target=_blank style='color:#2F92EE;'>#椎管内#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62880, encryptionId=de3362880f1, topicName=椎管内)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ae6d29130493, createdName=bugit, createdTime=Thu Dec 05 12:22:00 CST 2019, time=2019-12-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1724257, encodeId=a4581e242573b, content=<a href='/topic/show?id=71c1628e901' target=_blank style='color:#2F92EE;'>#椎管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62879, encryptionId=71c1628e901, topicName=椎管)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7d4e33593434, createdName=caobinglei8090, createdTime=Wed Jun 26 07:22:00 CST 2019, time=2019-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1937161, encodeId=0dbd193e16186, content=<a href='/topic/show?id=c06ae363256' target=_blank style='color:#2F92EE;'>#硬膜外#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=73632, encryptionId=c06ae363256, topicName=硬膜外)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3b172500206, createdName=12498ebem19暂无昵称, createdTime=Wed Jul 10 17:22:00 CST 2019, time=2019-07-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2027262, encodeId=d3d5202e26242, content=<a href='/topic/show?id=5259e36453f' target=_blank style='color:#2F92EE;'>#硬膜外麻醉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=73645, encryptionId=5259e36453f, topicName=硬膜外麻醉)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=0357291, createdName=xiaoshitou, createdTime=Tue Jun 25 06:22:00 CST 2019, time=2019-06-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363593, encodeId=32b7363593ca, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160304/IMG56D94856B1B5D6405.jpg, createdBy=27931687771, createdName=一个字-牛, createdTime=Tue Mar 26 19:14:29 CST 2019, time=2019-03-26, status=1, ipAttribution=)]
  4. [GetPortalCommentsPageByObjectIdResponse(id=1690780, encodeId=f1f31690e804e, content=<a href='/topic/show?id=de3362880f1' target=_blank style='color:#2F92EE;'>#椎管内#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62880, encryptionId=de3362880f1, topicName=椎管内)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ae6d29130493, createdName=bugit, createdTime=Thu Dec 05 12:22:00 CST 2019, time=2019-12-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1724257, encodeId=a4581e242573b, content=<a href='/topic/show?id=71c1628e901' target=_blank style='color:#2F92EE;'>#椎管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62879, encryptionId=71c1628e901, topicName=椎管)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7d4e33593434, createdName=caobinglei8090, createdTime=Wed Jun 26 07:22:00 CST 2019, time=2019-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1937161, encodeId=0dbd193e16186, content=<a href='/topic/show?id=c06ae363256' target=_blank style='color:#2F92EE;'>#硬膜外#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=73632, encryptionId=c06ae363256, topicName=硬膜外)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3b172500206, createdName=12498ebem19暂无昵称, createdTime=Wed Jul 10 17:22:00 CST 2019, time=2019-07-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2027262, encodeId=d3d5202e26242, content=<a href='/topic/show?id=5259e36453f' target=_blank style='color:#2F92EE;'>#硬膜外麻醉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=73645, encryptionId=5259e36453f, topicName=硬膜外麻醉)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=0357291, createdName=xiaoshitou, createdTime=Tue Jun 25 06:22:00 CST 2019, time=2019-06-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363593, encodeId=32b7363593ca, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160304/IMG56D94856B1B5D6405.jpg, createdBy=27931687771, createdName=一个字-牛, createdTime=Tue Mar 26 19:14:29 CST 2019, time=2019-03-26, status=1, ipAttribution=)]
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    2019-03-26 一个字-牛

    学习了谢谢分享

    0

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