硬膜外分娩镇痛相关肩胛间疼痛的管理

介绍

肩胛间疼痛是硬膜外分娩镇痛的常见并发症，但很少被讨论，确切机制尚不清楚。

一些假说认为，硬膜外腔快速输注，可能会牵拉脑膜而引起疼痛；而另一些假说则认为，硬膜外腔进入空气，可能会导致不适。

本文介绍一种处理这种并发症的技术，并回顾其在9例受影响产妇中的治疗有效性。

方法

1.椎管内分娩镇痛穿刺成功后，所有产妇开始进行患者自控硬膜外镇痛(PCEA)输注。

含2mcg/ml芬太尼的0.0625%布比卡因标准溶液，以12ml/h的速度注射，补救剂量为6ml，锁定时间为10mins。

2.当产妇出现肩胛间疼痛时，麻醉小组立即对其进行评估。如果症状与硬膜外分娩镇痛相关肩胛间疼痛一致，则开始新的PCEA输注策略。

含4mcg/ml芬太尼的0.0625%布比卡因溶液。设置调整为6ml/h的速度注射，补救剂量为3ml，锁定间隔为10mins。

3.调整输注策略后，持续对产妇进行评估，观察肩胛间疼痛的改善情况以及子宫收缩疼痛的变化情况。

结果

表(1)列举了9例确诊为硬膜外分娩镇痛相关肩胛间疼痛的产妇的BMI、分娩镇痛技术和疼痛评分。

8例产妇在调整输液后2小时肩胛间疼痛完全缓解，但其中2例产妇宫缩痛加重。

1例产妇调整后无明显改善，肩胛间疼痛和宫缩痛加重。

本病例系列描述了与硬膜外分娩镇痛输注相关的肩胛间疼痛的处理方法。通过此治疗方案，减少注入硬膜外腔的药液容量，可能导致硬膜外腔内压力的减少，从而改善肩胛间疼痛。

而此方案的一个局限性是，麻醉药液容量的减少，可能导致宫缩痛的镇痛不足，正如表中两个患者。

鉴于缺乏硬膜外分娩镇痛相关肩胛间疼痛管理的医学文献，我们希望这个病例系列可以帮助遇到同样状况的麻醉医生。

个人疑惑--特提出三个问题

1.硬膜刺破后头痛PDPH的治疗方案中，血补丁理论是硬膜受刺激收缩引起的头痛缓解，容积一般在20ml以下。硬膜外分娩镇痛相关肩胛区疼痛的输注量大于血补丁，单纯靠容量牵拉硬膜导致疼痛？

2.硬膜外腔输注可导致硬膜牵拉，会不会改变椎管内动静脉畸形血管的跨壁压，导致畸形团破裂，压迫脊髓？

3.体位改变会不会引起椎管内压力的改变，脊髓空洞症进展会不会与此相关，如果有可能，改变椎管内压力的操作是不是都有风险？

原文在此

Management of Epidural-Associated Interscapular Pain

Presenting Author: Christine Chen, MD

Presenting Author's Institution: Mount Sinai West

Co-Authors: Michael S. Balot, DO - Mount Sinai West

Ghislaine C. Echevarria, MD, M.S. - Mount Sinai West

Brian Taussig, MD - Mount Sinai West

Introduction

Interscapular pain is a common yet infrequently discussed complication of epidural analgesia. The exact etiology of epidural-associated interscapular pain is unknown. Some postulate that rapid epidural infusion of fluid may cause pain by stretching the meninges, while others suggest epidural air entrapment may lead to the discomfort. Here we present our institution’s technique for managing this complication and review its effectiveness in the setting of 9 affected parturients.

Methods

After placement of neuraxial anesthesia, all laboring parturients are started on a patient controlled epidural analgesia (PCEA) infusion. A standard solution of bupivacaine 0.0625% with fentanyl 2 mcg/mL is infused at a rate of 12 mL/hr with a demand dose of 6 mL and a 10-minute lockout interval. When parturients endorse interscapular pain, they are immediately evaluated by the anesthesia team. If the symptoms are consistent with epidural-associated interscapular pain, a new PCEA infusion is started consisting of bupivacaine 0.0625% with fentanyl 4 mcg/mL. The PCEA settings are adjusted to an infusion rate of 6 mL/hr, demand dose of 3 mL, and a lockout interval of 10 minutes. Following infusion adjustment, parturients are continually reevaluated for improvement in interscapular pain as well as any changes to their uterine contraction pain.

Results

Table 1 depicts the BMI, neuraxial technique, and pain scores of the 9 parturients identified as having epidural-associated interscapular pain. Eight parturients had complete resolution of their interscapular pain 2 hours after infusion adjustment, however two of these parturients endorsed worsening labor contraction pain. One parturient had no improvement and developed worsening interscapular and contraction pain after the adjustment.

Discussion

This case series describes the management of interscapular pain associated with an epidural infusion. By utilizing our treatment method, the volume that is infused into the epidural space is decreased. This decrease in volume may lead to a reduction in pressure within the epidural space resulting in an improvement in interscapular pain. A limitation of our technique is the possibility that the decrease in the volume of anesthetic delivered may lead to an inadequate analgesic level for uterine contractions, as demonstrated in two of our patients. Given the lack of medical literature regarding the management of this topic, we hope that our case series can help guide providers who encounter this problem.

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