Under the therapeutic drug blockade understand the introduction into the tissues of the body of a number of medicinal substances that cause temporary "pharmacological neurotomy" within a certain reflex arc, interrupting the connection of the periphery with the center [Kuzmenko V.V. et al., 1996]. Breaking the vicious circle of reflexes, blockades contribute to the elimination of pain, muscle-tonic and microcirculatory disorders.
Blockades are used in rehabilitation for therapeutic and prophylactic purposes. The therapeutic effect of drug blockades is based on their analgesic, muscle relaxant, tropostimulating, resorption or other effect determined by the nature of the blockade and the drug administered with its help. About the preventive effect of blockades it comes when it is necessary to prevent possible complications of injury or disease (neurodystrophic syndromes, etc.), since the timely use of blockades with an adequate selection of administered drugs helps to prevent the development of dystrophic processes in aseptically inflammatory tissues.
Depending on the localization of the impact on the nervous and tissue structures, the following types of blockades are distinguished [Kogan O.G. et al., 1988]:
- tissue (in aseptic-inflammatory altered, dystrophic altered, sclerosed tissues);
- receptor (intradermal, biologically active points, subcutaneous, intramuscular, intra-ligamentous, perivascular);
- preterminal (in the motor points of the muscles);
- conductive (peri - and paraneural, peri - and epidural, paravascular);
- ganglionic (intervertebral-ganglionic, trunkusnogan glionic).
Blockades can be one-component (novocaine, trimecaine, lidocaine, hydrocortisone, papain, rumalon, etc.) and multicomponent (novocaine + vitamin B12 + ATP; novocaine + lidase + hydrocortisone; novocaine + platifillin; alcohol + novocaine, etc.). Both single and course (daily, extra-day, etc.) blockades are used, in some cases - with the use of prolongators, depot preparations).
Contraindications to drug blockades can be general (drug intolerance; severe neurotic and psychopathic reactions of the patient to the blockade; concomitant diseases that limit the use of drugs) and local (purulent skin diseases; inflammatory tissue changes at the injection site; impossibility of technical implementation of the blockade due to developmental anomalies, deformities of the musculoskeletal system).
When carrying out blockades, the following complications can be observed:
- purulent (local and general) due to violations of asepsis and antiseptics;
- toxic-allergic (due to drug intolerance or penetration into other cavities, spaces, etc.);
- traumatic (injury to the nerve trunks, puncture of the pleura, puncture of the vessel with the formation of a hematoma);
- reflex (angiospasm of cerebral, spinal, peripheral vessels, muscle spasms, innervationally associated with the blockade area);
- compression (with the rapid introduction of a large amount of solution).
It must be remembered that drug blockade is a medical procedure that is equated to minor surgical interventions; when they are carried out, it is mandatory to comply with the rules of asepsis and antisepsis.
Private methods of drug blockades are most detailed in the monographs of V.V. Kuzmenko et al. and OG Kogan et al. ... Below we present those techniques that are most often used in the rehabilitation of patients with pathology of the musculoskeletal system, conditionally dividing the blockade into three groups according to the leading mechanism of their therapeutic effect.
1. Analgesic blockade, or blockade with the introduction of local anesthetics.
It is used to eliminate persistent pain syndromes, especially in the presence of concomitant vascular and neurotrophic disorders.
The analgesic effect is achieved by blocking specific nerves, or vegetative nodes, or muscles, the reflex tension of which causes compression of the underlying neurovascular bundle. Thus, analgesic blockades are usually receptor, conductive, or ganglionic.
Novocaine, which has a neurotropic effect, is most often used as a basic local anesthetic: it normalizes the permeability of nerve tissue membranes, helps to restore the function of nerves and spinal ganglia, normalizes the reactivity of neuroreceptor zones, while not causing a direct break in the nerve pathways. The formation of para-aminobenzoic acid in the process of decomposition of novocaine, which binds to novocaine, explains the antihistamine and desensitizing effect of the drug. The highest single dose for adults with the introduction of a 0.25% solution is 1.25 g (that is, you can enter no more than 500 ml), 0.5% - 0.75 g (150 ml), when using a 2% solution at the same time no more than 20-25 ml, 5% - 2-3 ml can be injected. The higher the concentration of the solution, the longer the blockade effect (the volume of the injected solution, according to V.V. Kuzmenko, does not affect the duration of anesthesia).
Before carrying out novocaine blockade, it is necessary to test for sensitivity to novocaine. To do this, a tampon moistened with novocaine is placed on the inner surface of the shoulder, covered with waxed paper and bandaged for a day; with increased sensitivity, the phenomena of dermatitis occur. Another way is intramuscular injection of 2 ml of 2% solution.
Lidocaine, which has a higher local anesthetic effect, but also a higher relative toxicity, is also used as a basic anesthetic; trimecaine; sovkain.
In mixtures with basic anesthetics, they are often used additional funds: in order to enhance the tropho-stimulating effect of the blockade, vitamin B12 is added to the solution (single dose of 200-400 μg); to improve microcirculation and achieve an angiospasmolytic effect - anticholinergic drugs (platifillin hydrotartrate in a dose not exceeding 1 ml of a 0.2% solution; gangleron in a dose not exceeding 4 ml of a 1.5% solution); to enhance the antihistamine effect - diphenhydramine (1-5 ml of a 1% solution), etc.
Here is an example of the formulation of a mixture for intramuscular receptor blockade [OG Kogan, 1988]:
novocaine 0.5% - 10 ml analgin 50% - 2 ml diphenhydramine 0.05 g vitamin B12 500 mcg
Let us briefly consider the technique of performing the most common anesthetic blockades.
Suprascapular nerve block (paraneural nerve block) - is used for suprascapular notch syndrome with suprascapular nerve neuropathy.
a) Method of A.Ya. Grishko, A.F. Grabovoi. The position of the patient is lying on his stomach (it is possible on a healthy side). An imaginary line is drawn along the upper edge of the spine of the scapula (from the inner edge of the scapula to the outer edge of the acromion). The injection point is between the middle and outer third of this line, perpendicular to the frontal plane (Figure 3.1). The needle is inserted at an angle of 45 °, open cranially, until it touches the bone (suprascapular fossa). After that, they look for the trunk of the suprascapular nerve, fan-like moving the needle until paresthesia in the shoulder joint is obtained. The needle moves in a fan-like manner along the ostiloblade in the lateral or medial direction. Enter 5 ml of anesthetic solution (1% novocaine solution).
b) Method of F.Ya. Grishko, V.A.Rodichkin. The position of the patient is any. Through the apex of the coracoid process of the scapula, a dyeing anesthetic draws a line posteriorly in a strictly sagittal plane. The point of injection of the needle directly behind the clavicle (at the intersection of this line with the posterior edge of the clavicle). The needle is inserted parallel to the longitudinal axis of the patient's body in any position until the needle stops in the supraspinatus fossa near the notch of the scapula, where the nerve passes through a large trunk 4.5-6.0 mm in diameter. For anesthesia, 5 ml of a 2% solution of novocaine is injected with the addition of 1 ml of a 0.2% solution

platyphylline and vitamin B group. When anesthetic is administered without paresthesia, the blockade effect is sharply reduced. With a correctly implemented block, pain relief occurs in 1-2 minutes.
c) Method I.A. Vitiugov, V.A. Lanshakova. The injection site is located on the bisector of the angle formed by the spine of the scapula and the clavicle, 3.5 cm from its apex. At the target point, a "lemon crust" is formed. Then the needle is passed through the tissue of the supraspinatus fossa. If at the same time the patient has a feeling of "lumbago" or blow electric shock, 15-20 ml of a 1% solution of novocaine (or 20-30 ml of a 0.5% solution) are injected. Correctly performed anesthesia is accompanied by a decrease in pain and an increase in the range of motion 5-10 minutes after anesthesia.
Axillary nerve blockade (conductive, paraneural) - is used for the syndrome of humeral-scapular periarthrosis with signs of axillary nerve neuropathy.
a) Method A. Ya. Grishko, A. F. Grabovoi. The position of the patient is sitting. The outer-lower edge of the acromial process of the scapula is palpated. From this point, a line is drawn to the beginning of the axillary fold. From the middle of this line, the perpendicular is restored outward to the intersection with the axis of the shoulder. At this point, the needle is inserted ventrally up to the humerus. For the appearance of parasthesia, the needle is fan-shaped in the sagittal plane. Enter 10-15 ml of a 0.5% solution of novocaine.
b) The needle is inserted at a distance of 1-1.5 times the diameter of the fingers downward from the place of transition of the scapular spine into the acromion (according to V.G. Weinstein), or at a distance of 5-6 cm downward vertically from the posterior corner of the acromion (according to V.V. Kotenko , V. Alanshakov).
Anterior blockade scalene muscle(receptor, intramuscular, Fig. 3.2). It is indicated for the syndrome of the anterior scalene muscle. The position of the patient is sitting with his head tilted to the sore side. The doctor pushes the outer edge of the sternocleidomastoid of the invisible muscle inward with the index or middle finger of his left hand (depending on the side of the blockade). Then the patient should take a deep breath, hold his breath and turn his head to the healthy side. At this point, the doctor continues to push the sternocleidomastoid muscle inward, deepening the index and middle fingers down to the anterior scalene muscle, which is well contoured, as tense and painful. Right hand inject

a thin, short needle between the fingers of the left hand into the thickness of the muscle to a depth of 0.5-0.75 cm and 2 ml of 2% novocaine solution is injected.
Blockade of the stellate ganglion (ganglionic) - indicated for shoulder-hand syndromes. Departing from the upper edge of the spinous process of the seventh cervical vertebra in the horizontal plane by 3.5-4 cm, a puncture of the skin, back muscles is made until it stops in the transverse process of the first thoracic vertebra. With the tip of the needle, the transverse process should be bypassed from above and the needle should be advanced 5 mm forward. Enter 10-20 ml of 0.5% novocaine solution. With a correctly performed blockade, after 10 minutes warming of the hand, face and Horner's syndrome on the side of the blockade occurs.
Paravertebral blockade at the cervical level (receptor, intramuscular). It is indicated for pain in the cervical spine. At the level of the affected vertebra along the upper edge of the spinous process, retreating outward by 2.5-3 cm, a puncture of the skin, fiber, muscles is made all the way into articular processes... Anesthetic (0.5% novocaine solution) is injected into muscles and periarticular tissues in an amount of 2-5 ml.
Small blockade pectoral muscle(receptor, intramuscular) - used for pectoralis minor syndrome. The patient lies on his back. On the skin of the chest with iodine, a projection of the pectoralis minor muscle is drawn. From the corner, which is located above the coracoid process, the bisector descends (Fig. 3.3). It is divided into three parts. A needle between the outer and middle parts of the bisector makes a puncture of the skin, fiber, muscle tissue of the pectoralis major muscle. Then the needle is advanced 5 mm forward, reaching the pectoralis minor muscle, and 10-15 ml of 0.5% novocaine solution is injected.
Blockade of the muscle that lifts the scapula (receptor, intramuscular, in tendon tissue) is indicated for scapular-rib syndrome. The position of the patient is lying on his stomach. Having felt the upper inner corner of the scapula with a needle, the doctor makes a puncture of the skin, fiber, trapezius muscle until it stops in the corner of the scapula, 3-5 ml of a 0.5% solution of novocaine is injected.
Pavavertebral block at the thoracic and lumbar levels (receptor, intramuscular). It is indicated for vertebral back and lower back pain. The injection is made at a distance of 3 cm outward from the spinous processes at the level of the affected segment. The needle is held in depth until it stops in the transverse process. A solution is introduced in the amount of 10-20 ml.
Paravertebral intradermal blockade according to M.I. Astvatsaturov (intradermal) - is used for pain in the spine. The stratum corneum is pierced and an anesthetic is injected intradermally, with each subsequent

the injection is made in the edge of the infiltrated area. 20-50 ml of 0.25% solution of novocaine is injected.
Blockade in the region of the sacroiliac joint (receptor, tissue). It is used for iliosacral periarthrosis. The patient lies on his stomach. The distance between the posterior superior and posterior inferior spines is halved. In the middle of it, an injection is made at an angle of 30 degrees to the sagittal plane until it stops in the ligaments. A solution is introduced in the amount of 5-8 ml.
Rice. 3.4. Blockade of the piriformis muscle (the “X” marks the place where the needle is punctured) According to OG Kogan et al., 1988.
Blockade of the piriformis muscle (receptor, intramuscular). .Indicated in piriformis syndrome. The patient lies on his stomach. Iodine marks the upper posterior spine, the apex of the greater trochanter, the ischial tubercle. The bisector descends from the corner in the region of the posterior superior spine (Fig. 3.4). On the border of its middle and lower tre-

A puncture of the skin and gluteal muscles is made until resistance is felt. The needle is retracted 1 cm back, tilted at an angle of 60 degrees, to the vertical and advanced cranially by 1 cm. 10 ml of solution is injected.
2. Anti-inflammatory blockade with the introduction of glucocorticosteroids - blockade, the basic drugs for which are glucocorticosteroid hormones, or glucocorticoids. Isolation of this group of blockages from analgesic ones is rather arbitrary, since hormones also have an analgesic effect; in addition, small doses of hormones are often added to a solution of local anesthetics to provide a prolonged effect of the analgesic blockades discussed above, and the blockade technique does not change at all. However, due to the existence of additional features of blockades when using hormones in them, a separate consideration of this issue is necessary.
When applied topically, glucocorticosteroid hormones have anti-inflammatory, anti-edematous, anti-allergic, analgesic effects due to antihypoxic and antihistamine effects. Corticosteroids inhibit the development of connective tissue, retard synthesis and accelerate the breakdown of denatured protein, which causes their resorption effect when injected into dystrophic altered connective tissue. At the same time, it should be borne in mind that normally (in healthy people) corticosteroids inhibit the synthesis of the cartilage matrix, therefore, in case of arthrosis, it is recommended to use hormones only with the severity of the inflammatory component. With already developed degenerative disorders (without an inflammatory component), glucocorticosteroids can aggravate the symptoms of arthrosis.
The anti-inflammatory effect of corticosteroids is manifested precisely in small doses. Hydrocortisone (hydrocortisone acetate drug) is used at a dose of 25-50 mg 1 time in 5-7 days (according to R.A.Zulkarneev, with periarthricular blockade of the hip joint, the dose of hydrocortisone acetate can be up to 75 mg, knee - 50, shoulder - 25 -50, elbow, wrist and ankle - 25, small joints of the hands and feet - 6.25-12.5 mg). Hydrocortisone can be administered without dilution with other solutions or in physiological solution or in a small amount of novocaine solution (the introduction of an excessive amount of novocaine can provoke an increase in the pain reaction). According to several authors, the combination of corticosteroids with anesthetics can make it difficult to find the exact injection site. RA Zulkarneev recommends combining corticosteroids not with novocaine, but with proteolytic enzymes (trypsin, chymotrypsin, lidase, ribonuclease, superoxidismugase; for example, 10 ml of 1% novocaine solution, 12.5-25 mg hydrocortisone, 16-64 units of lidase), however, the expediency of combining hormones and enzymes in one blockade is not accepted by everyone. In rheumatoid arthritis, it is recommended to combine intra-articular administration of corticosteroids with injections of gold preparations, cytostatics such as clafen, cyclophosphamide, endoxan, or with 1% osmic acid, orgoteine. With deforming arthrosis of large joints, a combination of corticosteroids with chondroprotectors (rumalon, arteparone, glycosamine-glycans) gives a good effect. It is inappropriate to combine corticosteroids with vitamin B12.
It must be remembered that ppococorticoid drugs differ in activity and duration of exposure (Table 3.1). For example, dexamethasone is 35 times more active than cortisone and 7 times more active than prednisone; for one blockade, no more than 2-4 mg of dexamethasone is administered.

Table 3.1
Comparative characteristics of glucocorticoid drugs (according to L. Axelrod, 1993)

Due to the slow absorption, the overall effect of glucocorticoids when administered locally (intramuscularly, into connective tissues) is very insignificant; the general effect is more often manifested with articular administration of drugs due to the large absorption surface. Nevertheless, even with topical application of corticosteroids, it is necessary to remember about the possible complications of hormone therapy and about contraindications to it.
The incidence of complications with the introduction of corticosteroids, according to different authors, is extremely variable and ranges from 0.013 to 1.0%. A number of authors believe that the propene of complications with the introduction of these drugs is not higher than with the introduction of any other drugs. The highest complication rate (2-5% or more) is observed with intra-articular administration. Complications can be general and local:
- general: bleeding, perforation of a stomach ulcer, exacerbation of a sluggish inflammatory process, abscesses, hypertension, edema, diabetes mellitus, dyspepsia, steroid glaucoma, myopathy, pseudo-rheumatism, an increase in the frequency of fractures, osteoporosis, arthropathy;
- local: local arthrolathy, post-injection inflammation of the joint (after intra-articular injection), tendon rupture, skin changes.
In addition, with the introduction of corticosteroids, side effects such as fever, nausea, pain in the heart, and dyspepsia can be observed. The painful reaction observed in 20% of patients is a natural tissue reaction.
Contraindications to the use of corticosteroids:
- absolute (peptic ulcer, hypertension II-III, active tuberculosis, psychosis, keratitis, diabetes mellitus with symptoms of decompensation;
- relative (thrombophlebitic disease or a tendency to thrombosis, hypertension in the stage of compensation, general infections, pregnancy and postpartum conditions, fractures of long bones, epilepsy, tuberculosis in the stage of compensation.
The introduction of glucocorticosteroids is undesirable in the presence of abscesses, with increased bleeding, the presence of purulent complications in the anamnesis.
It is necessary to avoid the introduction of corticosteroids under the periosteum, into the thickness of the tendons. When injecting large doses into the joints lower limbs within 2-3 weeks, a large load on the joint should be eliminated ^ especially along the axis of the limb.
The frequency of administration is no more than 3-5 injections per course. The repeated course is carried out not earlier than in 4-6 months (preferably not earlier than 12 months). The exception is rheumatoid arthritis, in which a maintenance dose can be administered in 3-7 days without interruption in treatment. More frequent administration contributes to the rapid development of destructive changes in the joint.
The technique of blockade with the introduction of corticosteroids, as already mentioned, does not differ from the technique of analgesic blockade. Hormones are injected into the interspinous ligaments, into the intervertebral joints, paravertebrally, into the anterior scalene muscle, into the area of ​​the carpal and obturator canals; corticosteroids are widely used for ruptures of ligaments, tendons, bursitis, synovitis, tendovaginitis; in the postoperative period (in order to reduce the recovery time of the joint function and prevent the formation of adhesions).
Subdeltoid blockade (receptor, in the tissue of the tendon-periarticular complex). It is used for humeroscapular periarthrosis. In the middle of the groove between the clavicular and acromial portions of the deltoid muscle, a skin puncture is made (Fig. 3.5), the needle is inserted under the deltoid muscle towards the large tubercle of the humerus. Enter 10-15 mg of kenalog in 2-5 ml of 0.5-1% novocaine solution.

Blockade of the subacromial bursa (tissue, in dystrophically altered tissues). Indications - humeroscapular periarthrosis stage II-III. The acromial process of the scapula is palpated, 1 cm recede from it, and a puncture of the skin, subcutaneous tissue and deltoid muscle is made until a characteristic crackling sensation is felt (then the needle is not inserted in order to avoid getting into the joint cavity). Inject 2-3 ml of the solution.
Blockade in the area of ​​muscle attachment to the internal or external epicondyle of the humerus (receptor, tendon tissue). It is indicated for elbow periarthrosis syndrome. Feel the apex of the epiploon, retreat from it by 0.5-1 cm distal. Make a puncture of the skin and underlying tissues all the way to the bone. 12.5-25 mg of hydrocortisone is introduced into 2-3 ml of novocaine solution.
Blockade in the area of ​​the carpal tunnel (conduction, receptor, tissue). It is used for carpal tunnel syndrome with symptoms of median nerve neuropathy. The injection is made at the level of the distal transverse skin fold of the wrist. The needle is inserted 1-1.5 cm outward from the center of the pisiform bone at an angle of 35-45 ° to the plane of the forearm until the ligament is punctured, after which the needle is advanced another 5 mm. 12.5-15 mg of hydrocortisone is administered.
Blockade in the canal of the tendon of the head of the peroneal longus muscle (conduction, receptor, tissue). It is used for the syndrome of the tendon canal of the head of the long peroneal muscle with symptoms of neuropathy of the peroneal nerve. The patient lies on a healthy side. Feel the head of the fibula and retreat from it 1.5-2 cm distally. A puncture of the skin, subcutaneous tissue and tendon of the peroneus longus muscle is made. Add up to 10 ml of solution.
Blockade in the area of ​​the tarsal canal (receptor, tissue, conduction). It is used for tarsal canal syndrome with symptoms of neuropathy of the plantar branches of the tibial nerve. Having retreated from the posterior edge of the inner ankle by 1 cm, a puncture is made in the skin, subcutaneous tissue and the flexor tendon retainer (Fig. 3.6). Inject 2-3 ml of the solution.

3. Muscle relaxant blockade.
Used to reduce pathologically increased muscle tone with spastic paresis (with the consequences of a stroke, craniocerebral or spinal trauma, with infantile cerebral palsy, multiple sclerosis, etc.). According to the localization of the impact, these are preterminal and conduction blockades, the mechanism of action is based on pharmacological interruption of the flow of nerve impulses to the muscle. As topically administered drugs, you can use an alcohol-novocaine mixture, botulinum toxin.
According to M.O. Friedland, who successfully applied the method of closed perimuscular alcoholization to relieve spastic tension
muscles, alcohol-novocaine mixture is prepared according to the following recipe: Novocaini 1.0 (2.0) Aq.destillatae 20.0 Spiritum vini rectiflcati 95% 80.0 According to the recommendations of the above author, the solution is injected under the fascia of the muscle in doses not exceeding 30 ml solution per session for the lower limb and 20 ml for the upper limb in adults and, respectively, 15 and 10 ml in children. Muscle relaxation occurs in a few minutes and lasts from several hours to several days. If the effect is insufficient, the blockade is repeated after 5-10 days.
There are other modifications of the introduction of an alcohol-novo-kain mixture. So, according to the method of G. Jardine, J. Hariga, a spirtonovocaine mixture (0.25% solution of novocaine and 45% ethanol solution in equal parts) is injected in an amount of 1-2 ml into the motor points of the muscles, 1-2 times a week, for a course from 3 to 15 procedures; the effect of blockages is associated with the selective blocking of fibers of hyperactive gamma-motor neurons [Demidenko ETC, 1989] Blockades are necessarily combined with corrective gymnastics [Goldblat YV, 1973].
The main disadvantage of alcohol-novocaine blockades, in addition to the painfulness of the procedure, is the short duration of the muscle relaxation effect.
Phenol is also used abroad for chemical neurolysis of peripheral nerves. The main disadvantages of blockades with phenol include the frequent occurrence of dysesthesias after blockade and the patient's tolerance.
Since the 1980s, local injections of botulinum toxin type A have been used to reduce increased muscle tone. Botulinum toxin type A is one of eight types of toxins (proteins) produced by Clostridium botulinum that inhibit the release of acetylcholine at neuromuscular synapses. It is currently available as Botox (USA) and Dysport (UK). The content of toxin in these two preparations is different: botox contains 0.4 ng of toxin in 1 unit, dysport - 0.025 ng (one unit corresponds to LDS0 FOR female - Swiss-Webster mice weighing 18-20 g). Toxicity (LDS0) for monkeys is 39 U / kg when administered intramuscularly, and 40 U / kg when administered intravenously.
The drug is injected into a tense muscle (at two or three points, according to the projections of motor points), preferably under the control of a needle EMG for more accurate localization of the injection. The muscles recommended for injections and the corresponding relaxing doses of Dysport are shown in Table 3.2. The effect appears in 4-14 days and lasts 2-6 months.
Avoid prescribing more than 250-300 units in one injection session. To date, no serious side effects botulinum toxin preparations

Scheme for increasing muscle tone	Muscle	Doses of the drug Dysport (in units) per muscle
Upper limb
Adduction and internal rotation of the shoulder	Pectoralis major	350
Elbow flexion	Biceps brachii Brachioradialis Brachialis	500
Pronation of the forearm	Pronators	200
Flexion of the hand	Flexor carpi radialis Flexor carpi ulnaris	300
Flexion of the fingers	Flexor digitorum superf. Flexor digitorum prof.	250
First finger adduction	Opponens pollicis	125
Lower limb
Hip adduction	Adductors	500
Knee flexion	Hamstrings	400
Knee extension	Quadriceps femoris	1000
Plantar flexion of the foot	Gastrocnemius	1000
Flexion of the toes	Flexor digitorum longus	200

when applied in recommended doses. Excessive muscle weakness may occur, but muscle strength recovers over time. There may also be secondary resistance to the drug, for the prevention of which it is recommended to make an interval between injections of at least 12 weeks. The effect of interaction between botulinum toxin and oral muscle relaxants such as baclofen was also not revealed.
Scheme 3.1
The widespread use of botulinum toxin is limited by the high cost of drugs produced on its basis. For a more reasonable prescription of the drug O "Brien recommends adhering to the algorithm presented in diagram 3.3.

The pectoralis minor is located in the second layer of the chest muscles, below the pectoralis major muscle. It starts from the III-V ribs near their osteochondral articulation and is attached by a short tendon to the coracoid process of the scapula. Topographically, the subclavian artery, vein and brachial plexus pass between the coracoid process and the pectoralis minor muscle.

The pectoralis minor syndrome occurs as a result of overload and chronic microtraumatization in athletes (weightlifters, gymnasts, basketball players) and construction workers (plasterers, painters). Manifested by local soreness at the level of III-IV ribs with irradiation to the shoulder joint. With the development of enthesopathy in the area of ​​the attachment of the tendon to the coracoid process, there may be paresthesias in the upper limb of the radicular type, caused by compression of the neurovascular bundle.

An important diagnostic criterion is reproduction and increased pain when trying to move the upper limb from the position of dorsal abduction to the position of sagittal adduction, when resistance to movement is provided.

TECHNIQUE. The blockade is performed in the supine position of the patient. After treatment of the skin with solutions of anti-septic tanks with iodine or brilliant green, the projection of the pectoralis minor muscle is marked. The places of its attachment are connected with straight lines, forming a triangle. From the corner of the triangle, located in the region of the coracoid process, the bisector is lowered, which is divided into three equal parts. At the point between the upper and middle parts of the bisector, the skin and subcutaneous fat are infiltrated with 0.25-0.5% anesthetic solution. Then, with a thin long needle, continuing to infiltrate, they pass through the anterior fascial leaf of the pectoralis major muscle, its muscle tissue and the posterior fascial leaf. The needle is advanced 5-7 mm forward, directing towards the shoulder joint, at an angle of 30-40 "relative to the skin surface, and 10-15 ml of a 0.5% solution of anesthetic or therapeutic mixture is injected. Considering the complexity of reproducing the projection of the pectoralis minor muscle on the front surface of the chest, we have proposed a simpler method.

Rice. 51. Blockade of the pectoralis minor muscle: A - topographic and anatomical landmarks; B - determination of the point of introduction of the needle; B - our version of determining the point of introduction of the needle

with a solution of antiseptics with iodine or brilliant green, draw a straight line connecting the beak-like process of the scapula with the xiphoid process of the sternum, which is divided into 4 equal segments. A blockade is performed at the point between the 1st and 2nd segments.

At present, it is difficult to imagine the treatment of patients with degenerative-dystrophic lesions of the spine and joints, soft tissues and ligamentous apparatus without local administration of drugs. Local administration of drugs, which often leads to immediate positive results, is firmly established in the clinical practice of manual therapy.

Of the drugs for antinociceptive therapy, the most widespread is novocaine, which is an ester of para-aminobenzoic acid, more precisely, a hydrochloric diethylaminoethanol ester of para-aminobenzoic acid. White crystalline powder of bitter taste, odorless, readily soluble in water and alcohol. In blood, biological media, in the presence of fresh blood serum, novocaine is hydrolyzed to para-aminobeisoic acid and diethylaminoethanol with a pronounced local anesthetic effect. The low toxicity of novocaine is associated with the instability of its molecule.

Novocaine is selectively absorbed by the nervous tissue, cells and fibers of the sympathetic nervous system are especially sensitive to it; a break with novocaine of the vasomotor impulses passing through these fibers is manifested by a vasodilating effect. Under the influence of novocaine, they consistently turn off different kinds sensitivity. First of all, the feeling of cold is lost, then successively heat, pain and pressure. For anesthesia, we usually inject 3.0-5.0 ml into tonically strained muscles. 2% novocaine solution.

With poor tolerance of novocaine, there may be pallor of the face and mucous membranes, dizziness, general weakness, cold sweat, nausea, vomiting, rapid and weak pulse, rapid breathing, drop in blood pressure, collapse. The reaction of the central nervous system is manifested in convulsions, convulsions, motor excitement, a sense of fear, hallucinations. In case of signs of intoxication, it is necessary to introduce ephedrine, calcium chloride, caffeine, barbiturates; intravenous isotonic sodium chloride solution.

For local injection therapy, 0.025 g prednisolone hemisuccinate, 0.025 g hydrocortisone hemisuccinate, kenalog-40 and diprospan were used.

Diprospan is a prolonged dosage form of betamethasone, a fluorinated derivative of methyl-prednisolone. It is produced in ampoules of 1 ml, which contains 2 mg of betamethasone disodium phosphate and 5 mg of betamethasone dipropionate. The first component (highly soluble, rapidly absorbed ether) provides a fast onset of the effect, and the second (poorly soluble, slowly absorbing depofraction) provides a prolonged effect. Thanks to this combination, the effect of diprospan begins within 2-4 hours after intra-articular injection and lasts up to 3 weeks. Another important advantage of the drug is that the crystals of the suspension are micronized. as a result, extra-articular injections are practically painless and are not accompanied by complications. This allows diprospan to be used without anesthetic.

Kenalog-40 is an aqueous crystalline suspension of a synthetic fluorinated glucocorticosteroid - triamcinolone acetonide. Available in ampoules of 1 and 5 ml at a concentration of 40 mg / ml. The anti-inflammatory effect appears 1-3 days after intra-articular injection and lasts on average up to 1 month.

Glucocorticosteroids are dissolved in water for injection or in 0.5% novocaine solution. For better breeding the solution must be warm (above room temperature). The introduction of the drug is carried out in a stream and slowly. The dosage of glucocorticosteroids is calculated so that no more than 1.0 ml of the drug is obtained for 1 injection. Repeated injections are carried out not earlier than in 7-14 days. 3-5 injections are used for the course, intervals between courses are at least 6 months. If after the course the effect is not achieved, then the drug is canceled.

The skin is treated with a 5% alcohol solution of iodine, then with 70% alcohol once, immediately before the injection, the point of injection is wiped again. At the end of the manipulation, the injection site is pressed with a swab moistened with alcohol, which is fixed with a tight bandage for two hours. When injecting into the joints of the foot, the patient was warned to thoroughly wash his foot and put on a clean sock the day before. Unlike other areas, the injection site on the foot is treated with an alcoholic solution of iodine and alcohol twice. As an antiseptic for treating the skin, a 0.5% aqueous-alcoholic solution of chlorhexidine bigluconate was also used.

The main requirement for local injection therapy is the strictest adherence to asepsis. Use only disposable syringes and needles. Use ampouled drugs in the dosage required for a single injection, do not open sterile packages of needles and syringes until the moment of use. The doctor's hands should be thoroughly washed (as for surgical procedures) and dry. It is better to carry out manipulations with sterile gloves. Never touch the needle with your finger.

After injection into the joint, the drug partially spreads along the lymphatic pathways up to the regional lymph nodes. This leakage of the drug from the joint cavity slows down significantly when the joint is at rest for 2-3 hours and, conversely, increases with active movements in the joint, physical activity... Therefore, it is necessary to limit the movement in the joint as much as possible after the injection. Some clinicians are of the opinion that after insertion into the small joints of the fingers, a splint should be applied to them for 24 hours. Experience shows that this is not necessary. It is enough to exclude repetitive or vigorous movements in the joint for a specified time.

When blocking the inferior oblique muscle of the head with iodine, a line is drawn connecting the spinous process of CII with the apex of the mastoid process. At a distance of 2.5 cm along this line from the spinous process, a puncture of the skin is made with a needle, which is further directed at an angle of 15 ° to the midline and 20 ° to the horizontal plane until it stops at the base of the spinous process. The tip of the needle is pulled back 1-2 mm and the drug is injected. The volume of the injected drug is 2.0 ml.

When blocking a painful point of the vertebral artery with iodine, a line is drawn connecting the spinous process of CII and the apex of the mastoid process. On the border of the outer and middle third of this line is the point of the vertebral artery. A needle directed perpendicular to the surface of the skin sequentially punctures the skin, adipose tissue, belt and inferior oblique muscles of the head, to the adipose tissue surrounding the vertebral artery, where the drug is injected. The volume of the injected substance is 2.0 ml.

Paravertebral blockade in the cervical spine is performed as follows. Along the upper edge of the spinous process, retreating outward by 2.5-3 cm, a needle is used to puncture the skin, subcutaneous tissue and muscles until it stops in the articular processes. The drug is injected into the muscles and periarticular tissues. The volume of the injected solution is 2.0-5.0 ml.

The superior cervical sympathetic node lies on the anterior surface of the transverse processes of the III-IV cervical vertebrae. Anteriorly is the carotid artery, surrounded by the perivascular plexus, and the internal jugular vein. The vagus nerve is located in the groove between the posterior surface of the internal jugular vein and those located medial first to the internal carotid and then to the common carotid arteries. All of them are enclosed in a common connective tissue vagina, forming the neurovascular bundle of the neck. Anteriorly and medially - the esophagus and trachea, outward - the long muscle of the head and the scalene muscles. Anterior to the scalene is the sternoclavicular muscle. The blockade is carried out in the supine position of the patient. A small roller is placed under the thoracic region so that the neck is slightly unbent. The head is turned in the opposite direction. The index finger of one hand of the doctor is located at the outer edge of the sternocleidomastoid muscle, displacing it inward and inward of the neck. The needle is inserted in the middle of the muscle at an angle of 70 ° to the horizontal plane and is pushed inward to the stop in the transverse process, then it is withdrawn from it by 5 mm and the solution is injected. The volume of the injected solution is from 30.0 to 50.0 ml. With a correctly performed blockade, after 10-15 minutes. Horner's symptom appears.

The stellate node is located on the anterior surface of the transverse process of the VII cervical vertebra and the head of the transverse rib. Behind the transverse processes of the VII cervical and I thoracic vertebrae lie the intertransverse, transverse spine, belt, multifidus neck muscles and the tendon of the trapezius muscle. Departing from the upper edge of the spinous process of the VII cervical vertebra to the outside by 3.3-4 cm, the needle punctures the skin, subcutaneous tissue, back muscles until it stops in the transverse process of the I thoracic vertebra. With the tip of the needle, the transverse process is bypassed from above and the needle is advanced 5 mm forward. The volume of the injected solution is 10.0-20.0 ml. If the blockade is performed correctly, after 10 minutes. there is a warming of the hand, face and Horner's syndrome on the side of the blockade.

The blockade of the temporomandibular joint is carried out in the sitting position of the patient, his head is slightly thrown back and rests on the headrest. It is necessary to weed the condyle lower jaw by asking the patient to move the jaw in a horizontal plane. The joint line is marked with iodine. After treating the skin in the joint area with an antiseptic, an injection is performed with a thin needle, which is directed slightly upward. Unobstructed administration of the drug mixture indicates that the tip of the needle is in the joint cavity. The volume of the injected drug is 1.0 ml.

The Kylenkampf brachial plexus blockade is performed in the patient's supine position, with the head rotated as much as possible in the opposite direction. The arm on the side of the blockade hangs down freely. The pulsation of the subclavian artery is determined by palpation above the clavicle in the region of its middle. Branches of the brachial plexus are located outside and posterior to it. The needle without a syringe is inserted 1 cm above the middle of the clavicle, outward from the pulsating artery, perpendicular to the skin in the direction of the spinous processes of the I and II thoracic vertebrae. The needle should be advanced all the way into the I rib, then, pushing the needle back a little, guide it up and, sliding along the upper edge of the I rib, reach the branches of the brachial plexus. When the end of the needle meets one of the nerve trunks, the patient experiences an unpleasant sensation in the form of “shooting pain” along the course of the hand, reaching the fingertips. After making sure that blood does not flow out of the needle, the drug is injected. The volume of the injected substance is 20.0-30.0 ml.

The blockade of the anterior scalene muscle is carried out in the sitting position of the patient. With the index and middle fingers of the hand, the doctor pushes the sternocleidomastoid muscle outward, for which the patient slightly tilts his head towards the tense muscle. Then the patient is asked to turn his head in the opposite direction and take a deep breath. The anterior scalene muscle, contracting during inhalation, as if slightly “enters” between the index and middle fingers of the doctor's hand. With the other hand with a needle perpendicular to the surface, a puncture of the skin, subcutaneous tissue, anterior fascial leaf, anterior scalene muscle is made to a depth of 0.9 cm. The volume of the injected solution is 1.0-2.0 ml.

The blockade of the subclavian muscle is carried out in the sitting or lying position of the patient. The collarbone is mentally divided into three parts. Between the outer and middle parts along the lower edge of the clavicle, a needle is made perpendicular to the frontal plane with a depth of 0.5 to 1.0 cm (depending on the thickness of the layer of subcutaneous fat) until the tip of the needle touches the edge of the clavicle. Then the tip of the needle is turned upward at an angle of 45 ° and advanced deeper by another 0.5 cm. The volume of the injected substance is up to 3.0 ml.

The blockade of the sterno-arm joint is performed with the patient lying or sitting. The doctor palpates the joint line and marks it with iodine, the needle is inserted perpendicularly. The volume of the injected substance is 0.2-0.3 ml.

The blockade of the sternoclavicular joint is carried out in the sitting or lying position of the patient. The needle is directed perpendicular to the surface of the chest to a depth of no more than 1 cm.The volume of the injected substance is 0.3 cm.

The blockade of the pectoralis minor muscle is carried out in the position of the patient on the back. The doctor palpates the attachment points of the pectoralis minor muscle (the coracoid process of the scapula and II-V ribs in the place of their transition from the cartilaginous part to the bone part) and draw its projection on the patient with iodine. The attachment points of the pectoralis minor muscle are connected by straight lines. From the angle located above the coracoid process of the scapula, the bisector descends, which is divided into three parts. Between the outer and middle parts of the bisector, a needle is used to puncture the skin, subcutaneous fat, the anterior fascial leaf, muscle tissue and the posterior fascial leaf of the pectoralis major muscle. Then the doctor advances the needle 5 mm forward, reaching the pectoralis minor muscle. The volume of the injected substance is 3.0-5.0 ml.

The blockade of the pectoralis major muscle is carried out in the sitting or lying position of the patient. On palpation, the most painful points are determined and an injection is made into each of them. The volume of the injected substance for each zone is 0.5-1.0 ml.

The blockade of the clavicular-acromial joint is carried out in the sitting position of the patient, facing the doctor. The doctor palpates the line of the joint and marks it with iodine. The needle is inserted perpendicularly, in front of the center of the joint. The volume of the injected substance is 0.3-0.5 ml.

The blockade of the shoulder joint is carried out in the sitting position of the patient. For lateral access, the acromion serves as a reference point. The doctor finds its most convex part and, since the head of the humerus is located directly under it, the needle directs under the acromion, passing it between it and the head of the humerus. At the beginning of the injection, the patient's hand is pressed against his body. After the needle penetrates deeply and passes the deltoid muscle, the hand is slightly raised up and returned a little downward. Continuing to press on the needle, the doctor feels how it passes through the obstacle, consisting of a dense joint capsule, and enters the joint cavity. When performing an anterior blockade, the doctor rotates the patient's shoulder inward, placing the forearm of his hand on his stomach. The doctor palpates the coracoid process and tries to determine the line of the joint by moderate rotation of the shoulder. The doctor performs the injection from the side towards the joint space. When carrying out a blockade, the base of the acromion serves as a reference point. Find it and determine the area located slightly lower, where there is a small dimple formed by the posterior edge of the deltoid muscle and the tendon of the infraspinatus muscle. It is in this place that a puncture is performed with a needle, which is directed perpendicular to the joint. The bursa is pierced after the needle penetrates to a depth of 4 ~ 5 cm. Penetration of the needle into the joint cavity is felt quite clearly. The volume of the injected substance is 5.0-10.0 ml.

The blockade of the muscle lifting the scapula is carried out with the patient lying on his stomach. The muscle that lifts the scapula is covered from above by the trapezius muscle. Trigger zones of the muscle that lifts the scapula are found most often in the upper inner corner of the scapula. Having felt the upper inner corner of the scapula, the doctor makes a puncture of the skin, subcutaneous fatty tissue and trapezius muscle all the way to the corner of the scapula. By pulling the needle back a little, the doctor injects the drug. The volume of the injected substance is 3.0-5.0 ml.

Suprascapular nerve blockade is performed with the patient lying on his stomach. The doctor palpates the spine of the scapula and draws a line along it with iodine. Then he divides this line into three parts. Between the outer and middle third at an angle of 45 ° to the line from the inside to the outside, the doctor makes a puncture of the skin, subcutaneous fat, trapezius and supraspinatus muscles with a needle, pushing it all the way to the edge of the scapula notch. By pushing the needle back 5 mm, the doctor injects the drug. The volume of the injected substance is 1.0-2.0 ml.

The blockade of intercostal nerves is carried out in the sitting position of the patient. The doctor draws two parallel lines on the back of the patient with iodine: one along the spinous processes, the other along the inner edge of the scapula. Having found the middle of this line, the doctor makes a puncture of the skin in the area of ​​the outer surface of the rib at its lower edge. Then the doctor pulls the needle back a little and directs its end downward, while displacing soft tissue... Sliding off the rib, with slight forward movement, the needle enters the tissue next to the intercostal neurovascular bundle, where the drug is injected. The volume of the injected substance is 3.0 ml.

The blockade of the elbow joint is carried out in the sitting position of the patient. When carrying out a blockade with a posterior approach, the patient's arm is bent at an angle of 90 °. The doctor uses palpation to locate a midline depression on the back of the elbow between the two tendons of the triceps muscle. The needle is inserted above the olecranon into the elbow joint perpendicularly up to 2 cm deep. When injecting using the lateral approach, the elbow is also fixed at a right angle. The doctor gropes the head of the radial bone at the brachioradial part of the joint using thumb hands of one hand, while the other hand rotates the patient's forearm. It is necessary to determine exactly where the joint line is, mark it with iodine and, after treating the skin with an antiseptic, insert the needle into the joint to a depth of 2 cm. The volume of the injected substance is up to 0.5 ml.

With medial epicondylosis, the injection is carried out into the painful area found on palpation slightly distal to the medial epicondyle. As with lateral epicondylosis, injection is performed under significant pressure. It should be remembered that the ulnar nerve is located in the groove behind the medial epicondyle. To avoid injury, the needle must be inserted under the control of a finger. The volume of the injected substance is 1.0-3.0 ml.

The blockade of the wrist joint is carried out in the position of the patient sitting at the table so that the edge of the table fixes the proximal part of the wrist joint, and the hypotenar hangs freely to the floor. The doctor stands facing the patient, fixing his hand with one hand. With the index finger of the other hand, the doctor palpates the T-shaped gap between the end of the radius and the wrist and marks the line of the joint with iodine. The doctor places the needle at an angle of 60 ° to the patient's hand. Fixing the patient's hand with one hand and pulling it towards himself, the doctor administers an injection with the other hand. The volume of the injected substance is up to 0.5 ml.

The blockade of the radioulnar joint is carried out in the position of the patient and the doctor sitting at a table opposite each other. The doctor takes the patient's radial joint between the thumb and forefinger and supines and pierces the patient's forearm until the joint line is felt. The needle is inserted at an angle of 15-20 ° in relation to the dorsal surface of the patient's hand, almost under the basal ligaments. The volume of the injected substance is 2.0 ml.

The blockade of the metacarpal-carpal joint is carried out in the same position of the doctor and the patient. Before the blockade of the metacarpal-carpal joint of the first finger, the doctor palpates the joint space. The most suitable place for introduction is the base of the metacarpal bone of the 1st finger from the lateral side. During the injection, it is necessary to withdraw the 1st finger in order to stretch the joint capsule. It is important that the patient does not strain the tendons of the first finger, because this makes it difficult to carry out the blockade. The injection is performed at an angle of 60 ° to the patient's forearm. The volume of the injected substance is 1.0 ml.

Injections into the small joints of the hand are very painful and usually difficult for patients to tolerate. The doctor and the patient sit at a table facing each other. The doctor, resting the elbows of both hands on the table, palpates the line of the joint. Stretching the patient's finger distally bent index and thumb with one hand, with the other hand, the doctor injects into the metacarpophalangeal or phalangeal-phalangeal joint. The volume of the injected substance is not more than 1.0 ml.

The blockade of the thoracic part of the border sympathetic trunk, located approximately at the level of the heads of the ribs, is carried out in the position of the patient lying on the couch on his stomach. At the level of the lower edge of the spinous process of the affected motor segment of the thoracic spine, stepping back 3-3.5 cm, the doctor pierces the skin, subcutaneous tissue and back muscles with a needle perpendicularly to the end of the transverse process,

which bypasses from above, advances the needle forward another 0.5 cm and injects the drug. The volume of the injected substance is 10, -20.0 ml.

The blockade in the thoracic and lumbar spine of Lyushka's sinuvertebral nerve, which innervates the tissues of the spinal canal, is carried out in the position of the patient on his stomach. Stepping back 3 cm outward from the upper edge of the spinous vertebra of the affected motor segment of the thoracic or lumbar spine, the doctor perpendicularly pierces the skin, subcutaneous fatty tissue and muscles all the way into the transverse process. The doctor bypasses the transverse process from above, turns the needle inward at an angle of 45 ° to the horizontal plane, and slowly, paying attention to the patient's sensations, moves it all the way to the edge of the intervertebral foramen. By pushing the needle back 5 mm, the doctor injects the drug. The volume of the injected substance is 10.0-20.0 ml.

Parasacral blockade is carried out in the position of the patient on his side with the legs bent at the knee and hip joints as much as possible. The doctor pierces the skin on the side of the coccyx with a long needle (10-15 cm) and advances it to the anterior surface of the sacrum until it stops against the bone obstacle at the level of the second, third or fourth sacral leads. Then the doctor pulls the needle back a little and lowers its front end downward. With further advancement of the needle, its tip abuts against the upper edge of the first, second or third sacral holes. After making sure of this, the doctor injects a medicinal substance. The volume of the injected substance is 10.0 ml.

It is safest to perform an epidural block in the lumbar spine, since the spinal cord ends at the LI-LII level and the epidural space is widest at this level.

The epidural space begins at the occipital foramen and continues to the foramen of the sacral canal. The inner border is defined by the dura mater, ending at the level of the second sacral segment; outer - the outer layer of the dura mater. The ligamentum flavum fills the space between the vertebral arches. It starts from the inner surface of the arch of the overlying vertebra and attaches to the outer surface of the underlying vertebra. In the midline, the yellow ligament is about 5 mm thick, and laterally - 2 mm. The intervertebral foramen, through which the neurovascular bundles pass, connect the epidural space with the paravertebral one. The epidural space contains adipose tissue, connective tissue and venous vessels, which form numerous plexuses. Arteries are represented by branches that supply blood to the spinal nerves. In the lumbar spine, the spinal space has a cross-section in the shape of a triangle, one of the corners of which is directed dorsally. A greater distance to the dura mater is noted along the midline posteriorly (approximately 5 mm). Between the arches of the adjacent vertebrae there is an intervertebral cleft, which is bounded on the sides by the articular processes. In the upper lumbar region, the intervertebral fissure has an ovoid shape, it flattens caudally and expands laterally.

When the needle is inserted into the epidural space along the midline, it passes through the skin, subcutaneous fatty tissue, the supraspinous ligament covering the spinous processes, the interspinous ligament located between the spinous processes, the yellow ligament, after which the end of the needle is located at a depth of about 4.5 cm and there is a drop in resistance. There is a space between the interspinous and the ligamentum flavum, the passage of which can be regarded as a "failure" of the needle, however, when the interspinous ligament passes, the loss of resistance is not as pronounced as after passing the ligamentum flavum.

The drug enters the spinal nerves through the intervertebral foramen and causes para-vertebral blockade and blocks the spinal nerve. Myelin-free sympathetic fibers are blocked first, thicker motor and propriocetive myelin fibers are turned off later. The spread of the drug in the epidural space occurs both in the caudal and cranial directions from the injection site. At the age of 16-20 years, the leakage of the solution through the intervertebral foramen and by absorption into the circulatory system is especially great. With increasing age of patients, it decreases due to the compaction of loose tissue and sclerotic changes in blood vessels. This also leads to a decrease in the epidural space. The latter also decreases in pregnant women due to increased venous pressure in the lower trunk.

The epidural blockade is carried out in the position of the patient sitting across the couch with the legs bent at the knee and hip joints, located on a support, with the patient's back bent. With a median approach in the lumbar spine, the doctor pierces the skin with a needle perpendicularly along the midline directly under the overlying spinous process with its further deviation, as it moves inward, caudal by 5-7 °. Entry into the epidural space is felt by the physician as a “sinking feeling” or “loss of resistance”. After making sure by pulling the piston that there is no blood or cerebrospinal fluid flow, the doctor injects a drug. The volume of the injected substance is 20.0-30.0 ml.

In older people, the interspinous ligament may be calcified, making it difficult to median needle insertion. In these cases, it is possible to apply the approach, stepping back 1-1.5 cm from the midline and introducing the needle medially to the midline at an angle of 15-20 °.

Peridural block with lateral access is carried out in the position of the patient lying on his stomach across the couch, with freely hanging lower limbs. Departing from the spinous process of the affected motor segment of the lumbar spine by 7-8 cm, the doctor pierces the skin with a needle and directs it slowly to the spine at an angle of 30-35 ° to the body surface until it stops against the bone. By pulling the needle back a little, the doctor injects the drug. The volume of the injected substance is 20.0-30.0 ml.

Epidural blockade is carried out in the position of the patient lying on the "sick" side with the lower limbs bent at the knee and hip joints as much as possible and the pelvis protruding above the edge of the table. The anal area is limited to sterile swabs and a towel. The outlet of the sacral canal is formed by non-fused arches of the V sacral vertebra, which are located on its sides, and have the shape of an inverted Latin letter V. In every twentieth person, it is underdeveloped and has a diameter of 2-3 mm. The entrance to the opening is covered by the sacrococcygeal ligament. The sacral canal is an extension of the vertebral canal and is about 10 cm long. In adults, the dural sac ends at the level of the II sacral vertebra. The dorsal and ventral branches of the sacral nerves exit through the sacral canal, blood and lymph vessels, and adipose tissue are located.

The main difficulty in implementing an epidural block is finding the sacral foramen and correctly inserting a needle into it. Finding the entrance to the sacral canal is extremely difficult in obese people with an abundant layer of subcutaneous fat, therefore, in some cases, the epidural blockade has to be abandoned.

To find the sacral opening, the doctor probes the sacral horns (cornua sacralis), between which the sacral opening is directly located. If the sacral horns are not pronounced, then the sacral foramen is located at a distance of 5-6 cm from the coccyx up the midline. You can find the entrance to the sacral canal by palpating down the median ridge of the sacrum, reaching the end of the ridge and resting on the sacral opening closed by the membrane. Using all these techniques, we almost always find the entrance to the sacral canal. To find the sacral entrance, you can connect the upper-posterior ridges of the iliac bones of one side with the ischial tubercles of the other with conventional lines; the point of intersection of these lines will correspond to the location of the sacral foramen.

The doctor draws a line between the posterior superior spines of the iliac bones, and parallel to it, at a distance of 1 cm from the caudal side, a second line ("the line of prohibition").

The needle should be sharp enough, but with a short cut, so as not to injure the venous plexus of the epidural space and not to lose the sensation of a puncture when it is passed through the membrane of the sacral foramen. The doctor pierces the skin with a needle with a mandarin and introduces it at first almost perpendicular to the membrane that closes the entrance to the sacral canal. cm, so as not to damage the dura mater After putting on a syringe, the doctor conducts an aspiration test. The absence of cerebrospinal fluid or blood in the needle convinces that the tip of the needle has not penetrated into the subarachnoid space or venous plexus. Then the doctor slowly, in portions of 20.0 ml for 2-3 minutes, injects the drug.

Sometimes the inserted needle rests against the wall (upper or lower) of the sacral canal; then, accordingly, it is retracted a little more or rises up to the sensation of "falling through". When blood appears in the needle, it is necessary to pull the needle back a little, do a second test suction, and only then inject the medicinal solution. The appearance of blood in the needle is not a contraindication for further epidural injection.

The correct penetration of the needle and solution into the epidural space can be judged by the fact that no infiltrate is formed above the sacrum (in the area of ​​injection) and soon after the start of the injection, the patient experiences a feeling of "bursting" in the sacrum, a feeling of the solution rising and often the appearance of paresthesias along the sciatic nerve on the sore side.

After the end of the administration of the medicinal substance, the patient must be allowed to lie on the table in the same position. Then he is offered to stand up carefully, while the patient needs help, since after the blockade, sometimes weakness in the legs can occur and without support he can fall. The volume of injected medicinal substance with epidural block is 40.0-60.0 ml.

The blockade of the sacroiliac joint is carried out in the position of the patient lying on a couch on his stomach. The doctor palpates the posterior superior and posterior inferior iliac spine and divides this distance in half. In the middle, the doctor pierces the skin with a needle at an angle of 30 ° to the midline of the patient's torso, pushes it all the way into the ligaments and injects the drug. The volume of the injected solution is 5.0-8.0 ml.

The blockade of the piriformis muscle is carried out in the position of the patient lying on his stomach across the couch with the lower limbs hanging freely. The doctor palpates the posterior superior iliac spine, the apex of the greater trochanter and the sciatic tubercle, connecting the lines with iodine, resulting in a triangle. From the angle of the posterior superior iliac spine, the doctor lowers the bisector, which is divided into three equal parts. At the border of the lower and middle parts, the doctor pierces the skin, subcutaneous fatty tissue, large and medium gluteus muscle to a feeling of elastic resistance, which indicates the achievement of the sacrospinous ligament. The needle is retracted 1 cm back, tilted 60 ° caudally and moved forward 1 cm. The doctor then injects the drug. The volume of the injected substance is 10.0 ml.

The blockade of the hip joint is carried out in the position of the patient lying on his back with the hip joint slightly bent and rotated inward. The doctor palpates the anterior superior iliac spine, pubic tubercle, greater trochanter, and femoral artery. The doctor marks the position of the femoral artery with iodine.

In the anterior approach, the block is performed lateral to the femoral artery, 2 cm below the inguinal ligament. The doctor pierces the skin with a needle, directing it lateral to the femoral neck, focusing on the position of the greater trochanter, all the way to the bone. Having touched the bone, the doctor pulls it back a little and at a lower angle pushes it forward again so that it passes through the capsule and synovial membrane, after which the drug is injected.

With a lateral approach, the doctor pierces the skin with a needle more laterally, at the level of the lower edge of the greater trochanter, directing it inward, medially and upward along the line of the femoral neck until it stops in the bone. Having touched the bone, the doctor pulls it back a little and re-pushes it forward at a smaller angle of inclination so that it passes through the capsule and synovial membrane, after which the drug is injected. The volume of the injected drug substance is 10.0-15.0 ml.

The blockade of the muscle straining the wide fascia of the thigh is carried out in the position of the patient lying on the couch on the “healthy” side. The doctor palpates the leg abducted 30 ° upwards, determines the most tense part of it and injects a drug into the abdomen, which strains the wide fascia of the thigh. The volume of the injected substance is 10.0 ml.

The blockade of the triceps muscle of the leg is carried out in the patient's standing position. The doctor palpates the most elevated part of the abdomen of the tonically strained gastrocnemius muscle and injects the drug into the abdomen with a needle. The volume of the injected substance is 10.0 ml.

The blockade of the knee joint is carried out in the position of the patient lying on his back with a straightened knee joint. The doctor palpates the patella of the knee joint, marks its length with iodine on the side and divides it into three equal parts. The border between the upper and middle third of the line is the injection site. With the hand of one hand, the doctor shifts the patella to the medial side, with the index finger of the other hand, palpates the gap between the patella and the femur. Then the doctor, holding the displacement of the patella with one hand to the medial side, with the other hand injects into the gap between the patella and the femur, directing the needle under the patella and slightly upward, injecting the drug. One mistake is usually made - pushing the needle too far. In this case, you can get into the fatty tissue behind the patella. To make sure that the needle has entered the joint cavity exactly, it is necessary to try to aspirate its contents. For the knee joint, this is always possible. The volume of the injected drug substance is 5.0-10.0 ml.

Ankle block is performed with the patient supine, with plantar flexion of the foot to cause stretching of the anterior tibial tendon. The doctor palpates the outer space of the tendon between the tibia and talus, marking the site of the iodine injection. The doctor then pierces the skin and advances the needle anteroposteriorly. Approximately at a depth of 2 cm, there is a sensation of an obstacle - the needle has reached the joint capsule. The doctor slowly begins to inject the drug, while simultaneously advancing the needle deeper by another 1-1.5 cm.When the needle is correctly inserted into the joint cavity, it should penetrate to a depth of 3.5-4 cm (the needle enters the joint tangentially to the curvature of the talus) ... The volume of the injected substance is 2.0 ml.

The blockade of the metatarsophalangeal joints is carried out with the patient in the supine position. After palpation of the joint line by passive finger movements, the doctor inserts the needle obliquely from the outside so that its tip passes under the extensor tendon. Feeling the lack of resistance to the needle, the doctor injects the drug. The volume of the injected substance is 0.5 ml.

Blockade of the I metatarsophalangeal joint is carried out in the position of the patient on the back. After palpation of the joint line along passive finger movements, the doctor inserts the needle from the medial side tangentially to the joint so that its tip is directed under the extensor tendon. Feeling the lack of resistance to the needle, the doctor injects the drug. The volume of the injected substance is 2.0 ml.

The blockade with bursitis of the Achilles tendon is carried out in the patient's standing position. The doctor performs the blockade from the outer side of the heel slightly above the tubercle of the calcaneus, departing from the midline of the Achilles tendon by 1-1.5 cm. By directing the needle medially and downward, the doctor pierces the skin, penetrates into the bag and injects the drug. If the injection site is not chosen correctly, then the needle collides with the bone or dense tissue of the Achilles tendon. The result of the blockade is usually satisfactory. The patient feels a decrease in pain and swelling. The volume of the injected substance is 1-1.5 ml.

The blockade of the heel spur is carried out in the position of the patient on his side, with the upper leg bent at the knee and hip joints. The doctor marks the place of maximum pain with iodine. The doctor inserts the needle from the inside parallel to the surface of the foot so that its tip reaches the level of the iodine mark on the heel. If, at the time of insertion, the needle hits a bone, the doctor partially removes it, and then re-inserts it, bypassing the bone. Having reached the level of the painful point on the heel with the tip of the needle, the doctor very slowly, since the stretching of the tissues from the injection causes a sharp painful reaction in the patient, injects the drug. The volume of the injected substance is 0.5-1.0 ml.

Since the development of manual therapy as a medical specialty, drug blockade has been an integral part of it. Every chiropractor should be proficient in the technique of medication blockades. Local administration of a drug often allows for significant positive dynamics in the clinical therapy of diseases of the spine and joints, which is subsequently consolidated by the use of manual therapy. The technique of drug blockade is included in the professional and job requirements of a chiropractor.

Zhuleva N.M., Badzgaradze Yu.D., Zhuleva S.N.

When carrying out LMB, it is necessary to strictly focus on the topographic and anatomical features of the area where the blockade is carried out. It is important to adhere to the blockade technique in order to prevent complications. The number of blockages depends on the goal set for the doctor (analgesic, muscle-spasmolytic, anhidistonic effects, etc.).

It can range from 2-3 to 10-15. Blockades with hormonal drugs are recommended to be carried out no more than 10, in order to avoid bones and general disharmonious disorders. The blockade is carried out once every 3-4 days. With radiculo- and x, as infiltration anesthesia, it is often necessary to carry out intramuscular anesthesia.

To do this, it is necessary to localize the painful focus by palpation, to determine the epicenter of the pathological focus, which is characterized by special sensitivity and sometimes by the density of muscle tissue. Infiltration of anesthetic 1.2 ml should be carried out directly into the pain point.

LMB of the lower oblique muscle of the head

The inferior oblique muscle of the head (1) is located on the second layer of the neck muscles. It starts from the spinous process (4) of the second cervical vertebra, goes up and outward and attaches to the transverse process of the first cervical vertebra (6). (Fig. 1) Anterior to the muscle there is a neural reserve loop of the vertebral artery (2). The fascia that fits the muscle has close contact with a number of nerve formations. In the middle of the length of the muscle, at the anterior surface of the fascial layer, there is the second intervertebral ganglion (3), from which the posterior branch of the greater occipital nerve departs, as if enclosing the muscle in a loop. In this case, the occipital nerve is located between the muscle and the arch of the second cervical vertebra, and the reserve loop of the vertebral artery is between the muscle and the capsule of the atlanto-axial joint.

Blockade technique: With iodine we draw a line connecting the spinous process C2 with the mastoid process 5. At a distance of 2.5 cm from the spinous process along this line towards the mastoid process, a puncture of the skin is made with a needle No. 0625. The needle is directed at an angle of 45 ° to the sagittal plane and 20 ° to horizontal until it stops at the base of the spinous process. The tip of the needle is pulled back 1 to 2 cm and the drug is injected. The volume of the injected drug is 2.0 ml.

LMB to the point of the vertebral artery

The vertebral artery (1) passes through an opening in the transverse processes of the cervical vertebrae. Between the transverse processes C I-II, it bends, forming the first reserve loop. In front of the artery are the transverse and other muscles of the neck. Behind it is covered by the inferior oblique muscle of the head (2) and the belt muscle (Fig. 2).

The technique of drug administration. With iodine, draw a line connecting the apex of the mastoid process (3) with the spinous process of the second cervical vertebra (4). On the border of the outer and middle third of this line is the point of the vertebral artery. Needle No. 0625, directed perpendicular to the surface of the skin, sequentially punctures the skin, adipose tissue, belt and lower oblique muscles of the head. The needle enters the fatty tissue around the vertebral artery, where the drug is injected. The volume of the injected solution is 2.0 ml.

Perivascular LMB of the vertebral artery

The vertebral artery, as a rule, enters the opening of the transverse process of the sixth cervical vertebra and goes up in the canal of the same name, formed by the openings in the transverse processes of the cervical vertebrae. The intertransverse muscles are located anteriorly, the carotid artery passes between the long neck muscle and the anterior scalene muscle, the esophagus and trachea are located somewhat inside.

Blockade technique: The patient is in the supine position. A small pillow is placed under the shoulder blades. The neck is unbent. The head is turned in the direction opposite to the blockade site. The index finger between the trachea, esophagus, carotid artery and anterior scalene muscle palpates the carotid tubercle (2) of the transverse process of the sixth cervical vertebra. At the tip of the finger, a needle # 0840 is punctured into the skin and fascia of the neck until it stops in the transverse process (3). The needle is then carefully advanced to the upper edge of the transverse process. Before injecting the solution, it is checked whether the tip of the needle is in the vessel. The volume of the injected solution is 3.0 ml. At correct execution LMB after 15-20 minutes, occipital pains, tinnitus decrease, vision becomes clearer.

Paravertebral LMB of the cervical level

At the cervical level, the trapezius muscle is most superficially located. In the middle layer - the belt muscle, long muscles of the head and neck. In the deep layer - interspinous, transverse spinous and intertransverse.

Blockade technique: At the level of the affected vertebra, along the upper edge of the spinous process, retreating outward by 2.5-3 cm, a needle # 0860 makes a puncture of the skin, subcutaneous tissue, muscles until it stops in the articular processes. The drug is injected into the muscles and periarticular tissues. The volume of the injected solution is 2.0-5 ml.

LMB of the anterior scalene muscle

The scalene anterior muscle (1) is located in the second layer of the neck muscles. At one end, it attaches to the Lisfranc tubercle of the first rib, the other to the transverse processes of the III-VI cervical vertebrae. Behind it is the middle scalene muscle (2), which, like the anterior, is attached to the transverse processes of the cervical vertebrae and to the first rib lateral to the attachment of the anterior scalene muscle. Between the scalene muscles and the first rib, a triangular gap is formed through which all the primary bundles of the brachial plexus and the subclavian artery pass. Between the first rib and the anterior scalene muscle passes the connecting artery and the lower primary bundle of the brachial plexus. The deep layer of the neck muscles is located medially. In the superficial layer, covering the interstellar fissure, lies the sternocleidomastoid muscle (3). Between it and the anterior scalene muscle, the subclavian vein passes, into which the jugular vein flows, and the thoracic lymphatic duct flows into the confluence of the veins.

Blockade technique: The index and middle fingers of the left hand move the lateral leg of the sternocleidomastoid muscle, for which the patient slightly tilts his head towards the tense muscle. Then the patient is asked to turn his head in the opposite direction and take a deep breath. The anterior scalene muscle, contracting during inhalation, as if itself "enters" between the index and middle fingers of the left hand. The right hand in the horizontal plane with a needle # 0625 makes a puncture of the skin, subcutaneous tissue, anterior fascial leaf, anterior scalene muscle to a depth of 0.9 cm. The volume of the injected solution is 1.0-2.0 ml.

LMB subclavian muscle

A costoclavicular gap is formed between the scapula, the I rib and the clavicle, into which all the secondary bundles of the brachial plexus, the subclavian artery and the vein pass (1). This gap is lined in front by the subclavian (2), behind by the subscapularis, and inside by the intercostal muscles. When one of them is stressed, most often the subclavian, narrowing of the costoclavicular gap may occur.

Blockade technique: The collarbone is mentally divided into three equal parts. Between the outer and middle parts of it, along the lower edge of the clavicle, a needle No. 0810 is made perpendicular to the frontal plane, a puncture with a depth of 5 to 10 cm (depending on the thickness of the subcutaneous fat layer) until the tip of the needle touches the edge of the clavicle. Then the tip of the needle is rotated upward at an angle of 45 ° and moves inward even to 0,

5 cm. The volume of the injected substance is up to 3.0 ml.

LMB pectoralis minor

The pectoralis minor (1) lies in the second layer of the chest muscles. At one end, it attaches to the II-V ribs at the transition of their cartilaginous part to the bone (2), the other to the coracoid process of the scapula (3) (Fig. 1). The subclavian artery, vein and brachial plexus are located between the coracoid process and the tendon of the pectoralis minor muscle.

Blockade technique: The patient lies on his back. On the skin of the chest with iodine, a projection of the pectoralis minor muscle is drawn. Its attachment points are connected by straight lines. From the corner, which is located above the coracoid process, the bisector descends. It is divided into three parts. Needle # 0840 between the outer and middle parts of the bisector makes a puncture of the skin, subcutaneous fatty tissue, the anterior fascial leaf of the pectoralis major muscle. Then the needle is advanced 5 mm forward, reaching the pectoralis minor. The volume of the injected substance is 10.0-15.0 ml.

LMB pectoralis major muscle

The pectoralis major muscle is located in the superficial layer. At one end, it attaches to the crest of the large tubercle of the humerus. The other end, the clavicle part (1), is attached to the inner half of the clavicle; sternocostal part (2) - to the sternum and cartilage of the second-seventh ribs; the abdominal part (3) - to the anterior wall of the sheath of the rectus abdominis muscle (Fig. 2). On palpation, painful muscle nodules are often found in it at the point of transition of the muscle part to the tendon and soreness at the places of muscle attachment. Especially often pain points, dystrophic nodules and trigger zones are found in the clavicular and sternocostal parts of the pectoralis major muscle.

Blockade technique: The most painful areas are felt in various parts of the pectoralis major muscle. At each of these points, a No. 0625 needle is injected so as to get into the trigger zone or nodule. An indicator of a needle hitting a trigger point is a spilled, burning or breaking radiating pain. The volume of injected substance for each trigger zone is 0.5-1.0 ml. At the same time, LMB is carried out in four to five zones.

Intercostal nerve block

It is used for intercostal neuralgia, chest pain and pain along the intercostal nerves with ganglioneuritis (shingles). In the position of the patient on the side, the skin is anesthetized and the needle is inserted until it touches the outer surface of the lower edge of the rib at the place of its attachment to the vertebra. Then the needle is slightly pulled back and its end is directed downward. Sliding off the edge of the rib

Being the supraclavicular part of the brachial plexus, the suprascapular nerve goes down to the lower abdomen of the scapular-hyoid muscle and, accompanied by the suprascapular artery, follows to the superior transverse ligament of the scapula. It passes under it through the notch of the scapula into the supraspinatus fossa, where branches extend from it to the supraspinatus muscle. Then the nerve bends around the neck of the scapula and, passing under the inferior transverse ligament of the scapula, enters the infraspinatus fossa, giving off branches to the infraspinatus muscle and the posterior surface of the articular capsule of the shoulder joint. The axillary nerve is located at the apex of the axillary fossa, behind the axillary artery, on the surface of the suprascapularis tendon. Heading downward, outward and posteriorly, the nerve passes, accompanied by the posterior artery that bends around the humerus, through the quadrangular opening and, going around the back of the surgical neck of the humerus, is located between it and deltoid muscle giving away muscle branches.

Technique of blockade of the suprascapular and axillary nerve according to I.A.Vityugov(Fig. 4, a, b). In the sitting position of the patient, blockade is performed from the side of the supraspinatus fossa, where the suprascapular nerve is projected onto the bisector of the angle formed by the spine of the scapula and the clavicle, 3.5 cm from its apex. At the designated point of the skin, a "lemon crust" is formed. Then the needle is passed through the tissues of the supraspinatus fossa until it stops in the bone and 20-30 ml of 0.5% novocaine solution is injected.

With axillary nerve anesthesia, 20-30 ml of 0.5% novocaine solution is injected into the projection point located at a distance of 5-6 cm (vertically downward) from the posterior angle of the acromial process of the scapula.

The technique of blockade of the suprascapular and axillary nerves according to A.Ya. Grishko - A.F. Grabovoi(Fig. 4, c, d). The suprascapular nerve is blocked when the patient is in the prone position or on the healthy side. The spine of the scapula is marked from the inner edge of the scapula to the outer edge of the acromial process. The line is divided into three parts. The puncture point is located on the border between the middle and outer third line. The needle is inserted at an angle of 45 °, open proximally, up to the suprascapular fossa. The needle is fan-shaped to obtain paresthesia. Enter 5 ml of 1-2% solution of novocaine.

Axillary nerve blockade is performed in a sitting position. A line is drawn from the protruding part of the outer-lower edge of the acromial process of the scapula to the beginning of the axillary fold. From the middle of the line, restore the perpendicular outward to the intersection with the axis of the shoulder. At this point, the needle is inserted anteriorly up to the humerus. For the appearance of paresthesia, the needle

Rice. 4. Blockade of the suprascapular and axillary nerves.

a - external landmarks and a point for the blockade according to I.A. Vitiugov;

b - a diagram of the blockade execution technique; c - external landmarks and a point for the blockade along Grishko-Grabovoi; d - a diagram of the technique for performing the blockade (hereinafter, the dimensions in the figures are indicated in centimeters).

fan-shaped move in the sagittal plane. Then 5 ml of 1-2% novocaine solution is injected.

Indications. The blockade is indicated for neurodystrophic diseases of the shoulder joint, post-traumatic pain of the shoulder joint.

Dangers. The entry of the anesthetic into the vascular bed. Violation of the blockade technique can lead to damage to the nerve trunk and, as a result, to neurological disorders.

1. BLOCKADE OF NERVES IN THE ANTERIOR LADDER MUSCLE

Anatomical features blockade zones. The anterior scalene muscle starts from the anterior tubercles C3 - C6, goes down and forward and attaches to the I rib. It is innervated by the cervical nerve. On the front surface of this muscle, and in the lower section, approaching its medial edge, the phrenic nerve passes. In the depths of the interstellar space, the bundles of the brachial plexus emerge.

Blockade technique(fig. 5). The blockade is performed in the sitting position of the patient. Having felt the lower end of the anterior scalene muscle, the sternocleidomastoid muscle is moved inward. To relax it, the neck is first tilted to the affected side, and the head is turned to the healthy side. A thin needle is inserted perpendicularly to the muscle to a depth of no more than 0.5-0.75 cm so as not to puncture the muscle. After that, 2 ml of a 2% solution of novocaine is injected.

Indications. The blockade is considered effective in cervical osteochondrosis, when pain syndrome is expressed.

Dangers. Puncture of the vessel and intravascular injection of anesthetic. With a large volume of anesthetic solution and in violation of the blockade technique, a phrenic nerve blockade is possible.

Fig 5. Blockade of nerves in the area of ​​the anterior scalene muscle according to Popelyansky.

a - position of the patient, external landmarks and point for blockade; b - cross section of the blockade area: 1 - point for blockade, 2 - anterior scalene muscle, 3 - sternocleidomastoid muscle pushed inward.

2. Blockade of the brachial plexus in the supraclavicular region

Anatomical features of the blockade zone. The brachial plexus is formed by the powerful anterior branches of the 5th, 6th, 7th, 8th cervical spinal nerves and the brachial branch of the 1st thoracic nerve. The anterior branches of the spinal nerves, forming the brachial plexus, emerge from the intervertebral foramen at the level from C6 to Th1, then pass into the interscalene space, located here behind the subclavian artery. The brachial plexus leaves the interstellar fissure with a smaller number of trunks, but already larger. The length of the brachial plexus from the interstellar space to the clavicle is 4-5 cm. The subclavian artery is located with the adducted arm 1-1.5 cm above the upper edge of the clavicle. The brachial plexus runs obliquely from top to bottom and laterally from the site of entry. There are many individual differences in the structure of the brachial plexus. The brachial plexus is enveloped throughout by a fascial sheath, which is important for the spread of the injected anesthetic. The brachial plexus has a connection with the sympathetic nervous system. Both the sympathetic trunk and the sympathetic nodes are in communication with the spinal nerves that form the brachial plexus. Therefore, the occurrence of Horner's syndrome when performing a blockade of the brachial plexus is understandable.

In relation to the clavicle, the brachial plexus is most often located in its medial middle at 0.8-1.5 cm (75% of cases). The subclavian artery is most often located medial to the brachial plexus. The exit of the brachial plexus from under the sternocleidomastoid muscle is projected onto a point located 3-4 cm above the clavicle. It is also necessary to know that the dome of the pleura extends over the I rib up to a maximum of 4 cm. In addition, there is a connection between the brachial plexus and the phrenic nerve, so this nerve can often be blocked. Given the variability in the location of the brachial plexus, we consider it necessary to reach the nerve trunk, accompanied by paresthesia.

Blockade technique(fig. 6). The blockade is performed with the patient lying down. A thin pillow is placed under the head. The head is turned to the side opposite to the place of the block. The upper limb on the side of the blockade is located on the patient's abdomen. In the supraclavicular region, the I rib is palpated, and then, retreating 1 cm medial to the middle of the clavicle and 1-1.5 cm above its upper edge, the point where the needle is inserted is determined. After anesthesia of the skin and deep-lying tissues with a needle without a syringe, an injection is made in the direction of the I rib, reaching which it is possible to move the needle relatively freely in search of nerve trunks. When paresthesia appears, the needle is slightly tightened, a syringe is attached to it and an anesthetic solution is injected. Use 20-30 ml of 1-1.5% solution of trimecaine or novocaine. The anesthetic is injected from two to three points.

Technique of supraclavicular brachial plexus block according to A.Yu. Pashchuk. The position of the patient on the back, a pillow is placed under the head and shoulder blades. Focusing on the I rib and the pulsation of the subclavian artery, a needle is inserted 1 cm above the upper edge of the clavicle. The needle is directed lateral to the artery, but in close proximity to it. A sign of the correct insertion of the needle is its oscillation in sync with the pulse. When the plexus fascial sheath is punctured, the blocker feels a click. Further movement of the needle must be careful. When paresthesia appears - an indispensable condition for the success of conduction anesthesia - 20 ml of anesthetic solution is injected by moving the needle.

The search for nerve trunks is carried out by displacing the needle 1-2 mm laterally and posteriorly from the initial injection and focusing on the I rib.

Rice. 6. Supraclavicular block of the brachial plexus.

a - the position of the patient on the table; b - diagram of the technique for performing supraclavicular blockade in our modification: 1 - point for blockade, 2 - 1 rib, 3 - sternocleidomastoid muscle, 4 - subclavian artery, 5 - clavicle; c - a diagram of the technique for performing the supraclavicular block of the brachial plexus according to A.Yu. Pashchuk; d - cross section of the blockade area: 1 - anterior scalene muscle, 2 - middle scalene muscle, 3 - bundles of the brachial plexus, 4-subclavian vein, 5 - subclavian artery.

Rice. 7. Long-term conduction block in the supraclavicular region.

a - introduction of the catheter through the needle into the projection of the bundles of the brachial plexus in the supraclavicular region; b - the needle is removed, the introduction of an anesthetic solution through the catheter.

The technique of long-term blockade of the brachial plexus in the supraclavicular region according to our method(fig. 7). The anatomical prerequisite for our technique was the presence of a fascial sheath enveloping the brachial plexus. The blockade according to our method must be performed in a hospital.

The preliminary preparation of patients is no different from the usual one. A flexible "catheter" is required for the blockade. We prefer a needle catheter.

After carrying out supraclavicular anesthesia according to the method described above, favorable conditions are created for the introduction of the catheter, since the fascial vagina is filled with anesthetic. The catheter on the needle is inserted at the same point that is used for the initial injection, or they themselves are immediately searched for the nerve trunks. If paresthesia occurs, the needle is removed, and the catheter remains in the tissues. It must be fixed to the skin with a silk ligature and covered with sterile napkins. As needed, a small amount of anesthetic is added along the catheter (10-20 ml of 0.5-1% trimecaine solution). The anesthetic is administered 3-4 times a day. The duration of the catheter is 3-5 days.

Indications. Brachial plexus conduction blocks are indicated for severe injuries upper limb, with shock, post-traumatic pain syndromes, neurotrophic diseases of the upper limb.

Dangers. The greatest and most common danger is the introduction of anesthetic into the vascular bed. Errors in technique can lead to damage to the nerve trunks, the dome of the pleura and the occurrence of pneumothorax, to the involvement of the phrenic nerve in the zone of blockade. In cases of prolonged block, it is necessary to remember about the maximum permissible doses of anesthetic and the observance of asepsis in the area of ​​the catheter.

3. Blockade of the brachial plexus in the axillary region.

Anatomical features of the blockade zone. The main neurovascular bundle is located in the axillary region along the inner edge of the coracohumeral muscle and the short head of the biceps brachii. The main reference point for determining a block in this area is the axillary artery. For the axillary block, the most convenient is the location of the main branches of the plexus behind or below the pectoralis major muscle, where three bundles of the brachial plexus are adjacent to the axillary artery. Behind the axillary artery are the posterior bundle of the brachial plexus and the subscapularis muscle, outside - the outer bundle and medially - the inner bundle of the plexus, which separates the brachial artery from the axillary artery.

The concentrated arrangement of nerve trunks around the axillary artery in the axillary fossa, the presence of a common fascial sheath for the neurovascular bundle and its connection with the supraclavicular region create favorable conditions for anesthesia in the axillary fossa, despite the significant variability in the location of the nerve trunks in this area.

Technique of the blockade of the brachial plexus in the axillary region according to our method(fig. 8). The position of the patient on the back. Upper limb placed on a stand or table in the abduction position in shoulder joint at an angle of slightly more than 90 °. The forearm is also bent at an angle of 90 ° in relation to the shoulder. The palm is rotated outward. The point of injection of the needle is determined at the apex of the axillary fossa at the site of pulsation of the axillary artery. The blocker is located on the side of the axillary fossa and palpates the artery with two fingers of the left hand. After anesthesia of the skin with a needle without a syringe, at a point located between two fingers, an injection is made perpendicular to the axis of the humerus, first outside of the artery, and then, manipulating from one injection, the needle is moved behind the artery, and then in front. When blocking, it is not necessary to achieve paresthesia. A sure sign that the anesthetic is hitting the target will be a clear pulsation of the needle in time with the artery.

From two or three points, 20-30 ml of 1-1.5% trimecaine solution is injected.

Rice. 8. Blockade of the brachial plexus in the axillary region.

a - the position of the patient on the table; b - a schematic representation of the blockade technique with external and internal landmarks: 1 - blockade point at the apex of the armpit; 2- median nerve; 3- ulnar nerve; 4- radial nerve; 5- axillary artery; c - diagram of a cross section of the blockade area: 1 - point for blockade; 2 - axillary artery; 3 - ulnar nerve; 4 - radial nerve; 5 - median nerve.

Rice. 9. Long-term conduction block in the axillary region.

a - location and fixation of the catheter in the axillary region; b - the introduction of anesthetic through the catheter.

Technique of long-term conduction blockade in the axillary region according to our method(fig. 9). The blockade according to our method is performed in a hospital. The position of the patient is the same. The injection site of the needle is determined by the pulsation of the axillary artery. A special catheter on a thin needle is used to anesthetize the skin and subcutaneous fat, and then the branches of the brachial plexus according to the method described above. After the introduction of 20-30 ml of 1-1.5% trimecaine solution, the needle with the catheter is directed in the proximal direction, parallel to the artery and nerve trunks. After making sure with the help of an aspiration test that the catheter is outside the vascular bed, the needle is removed, fixing the catheter to the skin with a silk ligature.

If necessary, 10-20 ml of anesthetic is added through the catheter 2-3 times a day.

Indications. This method is most indicated for postoperative pain relief and for neurotrophic diseases, especially the hand.

Dangers. Intravascular injection of anesthetic and damage to the nerve trunks by gross manipulations.

4. Blockade of the branches of the brachial plexus at the level of the elbow, wrist and hand

Anatomical features of the blockade zone. The greatest difficulty for blockade at the level of the elbow joint is the median and radial nerves, which run deep in the soft tissues. The radial nerve passes through the intermuscular septum above the beginning of the brachioradialis muscle 8-9 cm above the lateral epicondyle of the humerus. Then it passes in a small depression in the brachialis muscle, covered in front and outside by the brachioradialis muscle. Below the nerve is located in the interval between the brachial muscle and the long radial extensor of the wrist. An external reference point for finding the radial nerve in the upper third of the forearm is the gap between the brachial and brachioradial muscles, which is palpable 1.5-2 cm outward from the outer edge of the biceps tendon.

The median nerve at the level of the medial epicondyle of the humerus passes more often 0.5-1 cm medially from the brachial artery, less often at its inner edge and even less often 1-1.5 cm medially from the artery. On the joint line, the median nerve is located 0.5-1 cm medially from the artery. Below the medial epicondyle of the humerus, the median nerve and brachial artery run along the superior edge of the pronator round.

The ulnar nerve, above the medial epicondyle of the humerus, runs along the medial head of the triceps muscle. At the level of the medial epicondyle of the humerus, the nerve adjoins the capsule of the elbow joint between the medial epicondyle of the humerus and the tendon of the triceps brachii. Here the nerve is easily palpable.

Rice. 10. Blockade of the long branches of the brachial plexus at the level of the elbow bend.

a - a diagram of the technique for performing a blockade of the radial nerve: 1 -radial nerve; 2 - brachial artery; 3 - brachioradial muscle; 4 - proximal biceps tendon; b - a diagram of the technique for performing blockade of the median and ulnar nerves: 1 - the median nerve; 2 - brachial artery; 3 - proximal biceps tendon of the shoulder; 4 - ulnar nerve; c - a diagram of a cross section of the blockade area: 1 - the radial nerve; 2 - the median nerve; 3 - ulnar nerve.

Finding the nerve trunks at the level of the wrist joint is not particularly difficult, since the nerves are located at a shallow depth. So, the median nerve is located between the tendons of the radial flexor of the wrist and the length of the palmar muscle. Here, the nerve lies superficially and is covered in front only by the fascia of the forearm, behind and outside the median nerve, the synovial bags of the flexor tendons of the fingers are adjacent.

The ulnar nerve runs lateral to the pisiform bone. The site of ulnar nerve blockage in this area is most persistent. "Anatomical snuffbox" is convenient for blocking the branches of the radial nerve. The nerve lies superficially and for its blockade it is enough to infiltrate this area with an anesthetic.

The technique of blockade at the level of the elbow bend according to our method(fig. 10). The block can be performed with the patient supine or sitting. To block the radial nerve in the upper third of the forearm, palpate the gap between the brachial and brachioradial muscles, where a thin needle is injected perpendicular to the axis of the limb to a depth of 1.5-2 cm. Obtaining paresthesia is mandatory. For this purpose, the needle is carefully moved both along the depth of the injection and to the sides. 10 ml of anesthetic is injected.

For blockade of the median nerve at the same level, the main landmarks are determined: the pulsation of the brachial artery, the medial edge of the tendon of the biceps brachii. The initial injection of the needle is made medial to the pulsating artery by 0.5-1 cm. After passing the fascia, carefully move the needle in all directions in search of nerve trunks.

Anesthesia of the ulnar nerve is performed in the medial, ulnar groove. In this case, it is not necessary to achieve paresthesia, since it is impossible to make a mistake when finding the nerve.

Wrist nerve block technique(fig. 11, 12). The blockade is often carried out in the sitting position of the patient. The limb is placed on a table with the palm rotated outward.

The median nerve is blocked at the medial edge of the radial flexor tendon of the wrist, which corresponds to the mid-region of the wrist joint. If the radial flexor of the hand is poorly contoured, an injection is made at the proximal fold of the wrist joint. Remembering that the nerve is superficial, paresthesias are unnecessary. Anesthetic is administered in a volume of 5-10 ml.

The ulnar nerve is blocked at the pisiform bone. The lateral edge of the pisiform bone is the point for needle insertion. 5-10 ml of anesthetic solution is injected.

The blockade of the radial nerve is performed at the base of the "anatomical snuffbox" by subcutaneous injection of 5-10 ml of anesthetic solution in the form of a subcutaneous roller.

Digital nerve block. Finger pain relief is self-explanatory. Digital nerve block is shown in Fig. 13.

Rice. 11. Blockade of the long branches of the brachial plexus at the level of the wrist joint.

a - a diagram of the technique for performing a blockade of the median and ulnar nerves: 1 - the median nerve; 2 - ulnar nerve; b - diagram of a cross section of the blockade area: 1 - median nerve; 2 - ulnar nerve.

Indications. The blockade of the branches of the brachial plexus is performed mainly for postoperative anesthesia, for low-traumatic manipulations in the dressing room and for operations on the hand and fingers on an outpatient basis.

Rice. 12. Blockade of the branches of the radial nerve in the "anatomical snuffbox".

a - a diagram of the blockade execution technique; b - diagram of a cross section of the blockade area: 1 - radial nerve; 2 - long extensor tendon of the thumb; 3 - short extensor of the thumb.

Rice. 13. Blockade of digital nerves.

1, 2, 3, 4 - options for moving the needle at the base of the finger.

Dangers. If the blockade technique is violated, nerve damage is possible. The introduction of anesthetic into the vascular bed is unlikely.

5. Intra-bin blockade according to Shkolnikov - Selivanov

Anatomical features of the blockade zone. The sacral plexus is a thick triangular plate with its apex directed to the piriform opening. The plexus lies with its smaller part on the anterior surface of the piriformis muscle, surrounded by loose connective tissue and lies under the parietal fascia of the pelvis. From the sacral plexus, short and long nerves are formed that innervate the lower extremities and the pelvis.

Blockade technique(fig. 14). The position of the patient on the back. The skin and subcutaneous adipose tissue are anesthetized with a thin needle 1 cm medially and somewhat upward from the upper anterior iliac spine. Then a needle is injected with a length of 14-15 cm on a syringe with a solution of novocaine, it is inserted under the spine from front to back, and the cut of the needle should be directed to the ilium. By introducing a solution of novocaine in front of the needle, it is advanced posteriorly to a depth of 12-14 cm. The tip of the needle must constantly rest against the bone. When the desired depth in the iliac fossa is reached, a solution of novocaine is injected. With unilateral blockade, 400-500 ml of 0.25% novocaine solution is injected, with bilateral blockade - 250-300 ml on each side. The intra-pelvic blockade can be repeated after 10-12 days.

Indications. Basically, the blockade is indicated for post-traumatic pain associated with damage to the pelvic bones. In addition, intrapelvic blockade can be performed for deep vein thrombophlebitis of the lower leg and thigh, the consequences of injuries to the great vessels of the lower extremities and severe injuries of the soft tissues of the thigh and lower leg.

Dangers. Damage to the abdominal organs and the ingress of anesthetic solution into the vascular bed. To exclude the latter, an aspiration test must be performed.

Rice. 14. Intra-bin blockade according to Shkolnikov-Selivanov.)

a - position of the patient on the table: b - schematic representation of the position of the needle and the point of injection of the anesthetic; c - a diagram of a cross section of the blockade area.

6. Blockade of the sciatic nerve

Anatomical features of the blockade zone. Sciatic nerve can be blocked at the point of exit from the pelvic cavity or along its length. The sciatic nerve passes in the piriform opening, which is bounded by the lower edge of the piriformis muscle, the sacro-tuberous ligament and the upper twin muscle... The sciatic nerve in the piriform opening occupies the most lateral position. It has an oval cross-section and is surrounded by a fascial sheath. The width of the nerve can reach 1 cm. When exiting the piriform opening, the nerve lies on the twin, internal obturator and square muscles of the thigh near the outer edge of the sciatic tuberosity and the tendons of the biceps and semimembranosus muscles.

Technique of sciatic nerve blockade according to V.F. Voino-Yasenepkom(fig. 15). The patient is lying on his stomach or on his side. The point for the initial injection of the needle is at the top right angle, formed by two lines, the first of which passes horizontally through the apex of the greater trochanter, and the second, vertical line runs along the outer edge of the ischial tuberosity. An injection is made at the intersection of the lines strictly perpendicular to a depth of 8-12 cm. If paresthesia cannot be obtained, then the needle should be moved slightly higher and outward. The blockade consumes 10-20 ml of 1-1.5% trimecaine solution.

In some cases, a large volume of anesthetic solution is consumed to search for nerve trunks. In this regard, we propose to use initially 0.25% novocaine solution for infiltration of soft tissues and search for nerve trunks, and when paresthesia is obtained, inject the main anesthetic for the blockade.

Rice. 15. Sciatic nerve block according to V.F. Voino-Yasenetsky.

a - position of the patient on the table, external landmarks: 1 - point for blockade at the intersection of lines, 2 - greater trochanter, 3 - outer edge of the ischial tuberosity; b - diagram of a cross section of the blockade area: 1 - point on the skin, 2 - sciatic nerve.

Technique of sciatic nerve blockade according to Hertel(Fig. 16, a). The position of the patient on his stomach with a pillow that lifts the gluteal region. To find the point of the initial injection of the needle, three lines are drawn: the first connects the outer edge of the ischial tubercle and the upper posterior iliac spine, the second is carried out horizontally, passing through the apex of the greater trochanter and the upper end of the gluteal cleft, the third passes through the intersection of the two previous lines and the gluteal tubercle. The intersection of the three lines is the starting point for the blockade. If paresthesia is not obtained, then the needle is moved along the third line up and laterally. Enter 10-20 ml of 1-1.5% trimecaine solution.

Technique for blockade of the sciatic nerve with external access according to V.I. Katsu(Fig. 16, b). The position of the patient on his back closer to the edge of the table. A small roller is placed under the leg. The needle is inserted in the frontal plane posteriorly from the greater trochanter towards the ischium until it stops in it. Then the needle is pulled back 1 cm and 10-20 ml of anesthetic is injected.

Rice. 16. Blockade of the sciatic nerve.

a - according to Hertel: 1 - the upper posterior iliac spine, 2 - the greater trochanter, 3 - the outer edge of the ischial tubercle, 4 - the point for the injection of the anesthetic, 5 - the upper edge of the gluteal cleft; b - lateral access according to V.I. Katsu.

Combined sciatic nerve block at the level of the lumbar and sacral plexus according to A.P. Winnie(fig. 17). The patient is placed on a healthy side, with his legs bent. The needle is inserted perpendicular to the skin at the intersection of the line connecting the iliac crests and the line drawn from the superior posterior iliac spine parallel to the longitudinal axis of the spine. If the needle hits the transverse process of the vertebra, then, displacing it somewhat distally, it is advanced inward until signs of contact with the plexus appear. To reliably block the sciatic nerve at the level of the lumbar and sacral plexus, the anesthetic must spread up and down the fascial sheath, which requires the administration of 120-150 ml of anesthetic in the form of a low concentration solution.

Rice. 17. Combined sciatic nerve blockade at the level of the lumbar and sacral plexus according to A.R. Winnie.

a - position of the patient and cutaneous landmarks; b - a diagram of the blockade execution technique and a point for its implementation; c - cross-sectional diagram of the blockade area: 1 - point for the injection of anesthetic.

Sciatic nerve block with anterior approach according to V.A. Fokin(fig. 18). In the position of the patient on the back, a straight line connects the upper anterior iliac spine with the most protruding point of the greater trochanter, from which a second line is drawn parallel to the inguinal ligament. On this line, a distance equal to the length of the first line is laid, measuring it from the large trochanter, and a point is marked, which is the place where the needle is pierced. The needle is inserted in the sagittal plane and, having reached the lesser trochanter, it is advanced 4-6 cm lower.If it is not possible to obtain paresthesia at the indicated depth, then it is necessary to return to the lesser trochanter and then advance the needle inward, giving the thigh a slight internal rotation, or reject end of the needle 5 ° medially and advance it in this position until paresthesia appears. Enter 20-30 ml of 0.5-1% trimecaine solution.

Indications. Shown as a measure of shock prevention and control in severe injuries of the lower extremities. Sciatic nerve block can also be used for sciatica, especially phantom pain, in combination with other methods.

Dangers. Damage to the nerve trunks and intravascular injection of anesthetic.

Rice. 18. Blockade of the sciatic nerve by anterior approach according to VA Fokin.

a - position of the patient on the table and internal landmarks: 1 - superior anterior iliac spine, 2 - greater trochanter, 3 - point for blockade; b - diagram of a cross section of the blockade area: 1 - point for blockade, 2 - sciatic nerve.

7. Blockade of the femoral nerve

Anatomical features of the blockade zone. The femoral nerve extends from under the inguinal ligament, located in the interval between the iliac and lumbar muscles... The depth of the nerve is different. In the upper third, the nerve passes inside the fascial sheath of the iliopsoas muscle and, at a distance of 2 cm from the inguinal fold, pierces the sheath, dividing into two groups of branches. This place is most convenient for blockade, since the femoral nerve then diverges in the form of a panicle. The main reference point for the femoral nerve conduction block is the inguinal ligament and the femoral artery.

Leuven femoral nerve block technique(Fig. 19, a). In the supine position, the blocker determines the pulsation of the femoral artery directly under the inguinal ligament. Departing from the pulsating artery by 1-1.5 cm outward, determine the point of the initial injection of the needle. The needle is directed strictly perpendicular to the frontal plane. After puncture of the fascia, which is clearly felt, from this point they go deeper by 0.5-1 cm, until paresthesia occurs. 5-10 ml of anesthetic is injected.

Indications. Postoperative pain, prevention of shock, post-traumatic pain syndrome, phantom pain, neurotrophic disorders.

Dangers. Due to the fact that the main reference point for the block is the femoral artery, there is a danger of intravascular injection of anesthetic. The risk of damage to the nerve trunks is minimal.

8. Blockade of the obturator nerve

Anatomical features of the blockade zone. The obturator nerve passes in the homonymous

channel and leaves it in two branches - anterior and posterior. The branches are more often located inward of the vessels. The anterior branch is directed into the interval between the long and short adductor muscles. Having given branches to the short and long adductor and thin muscles, it goes into the gap between the last two muscles and penetrates into the subcutaneous fatty tissue, reaching the inner surface of the knee joint. The posterior branch runs in the interval between the short and long adductor muscles, innervating them and heading downward along the front surface of the adductor major muscle. The space between the adductor longus and the comb muscles can serve as a reference point for access to the obturator neurovascular bundle.

Fig. 19. Blockade of the femoral and obturator nerves.

a - blockade of the femoral nerve according to Leuven.

b - blockade of the obturator nerve according to A.Yu. Pashchuk.

c - blockade of the obturator nerve according to our method.

d- diagram of a cross section of the blockade area

The technique of blockade of the obturator nerve according to A.Yu. Pashchuk(Fig. 19, b). In the supine position, the point of injection of the needle is 1.5 cm below the inguinal ligament on a line located 3 cm inward from the femoral artery and 3 cm outward from the pubic tubercle. The needle is inserted at an angle of 60 ° to the frontal plane until it touches the bone. Then it is slightly pulled up and directed inward at an angle of 90o to the frontal plane. Having determined the upper edge of the obturator opening with the tip of the needle, the needle is advanced in depth by 1.0-1.5 cm. When paresthesia is obtained, 10-20 ml of anesthetic is injected. If paresthesia cannot be obtained, then after tightening the tip of the needle is moved inward or laterally from the site of the initial injection.

The technique of blockade of the obturator nerve in our modification(Fig. 19, c, d). The patient is in a supine position. To determine the point of initial injection, we were guided by the research of V.I. Katz (1966), according to which the nerve in 95% of cases is projected within the medial quarter of the inguinal ligament, and the place of its entrance was 1-2 cm below the ligament. Thus, dividing the inguinal ligament into four parts, the medial part is taken as a guide. Departing from the outer edge of the medial part by 1-1.5 cm and 1-1.5 cm below the inguinal ligament, the point for the injection of the anesthetic is determined. The needle is inserted in the direction of the upper edge of the obturator opening, reaching which it is advanced 1-1.5 cm deep and 10-20 ml of anesthetic is injected fan-shaped.

Indications. Pain in the hip joint with deforming arthrosis, leading to hip contracture, deforming arthrosis of the knee joint.

Dangers. Intravascular anesthetic and nerve damage are minimal.

9. Blockade of the lateral cutaneous nerve of the thigh

Anatomical features there is no lateral cutaneous nerve in the area of ​​blockade. It is best blocked below the superior anterior iliac spine, under the inguinal ligament. The needle is injected 3-4 cm below the spine under the inguinal ligament, and after puncturing the skin and superficial fascia, 5-10 ml of anesthetic is injected. The posterior cutaneous nerve of the thigh, as a rule, falls into the zone of the sciatic nerve blockade.

Indications. Roth's disease.

Dangers. With blockade of cutaneous nerves, they are absent.

10. Blockade of nerves in the popliteal fossa

Anatomical features of the zone blockade. The popliteal fossa is diamond-shaped. The upper corner of the rhombus is formed by the contact of the biceps muscle with the semitendinosus and semimembranosus muscles, and the lower one is formed by the contacting heads of the gastrocnemius muscle.

The sciatic nerve at the upper edge of the popliteal fossa at a distance of 10-12 cm from the joint line is divided into the tibial nerve and the common peroneal nerve.

The tibial nerve runs in the tissue in the middle between the biceps and semimembranosus muscles of the thigh. Further, it passes between the heads of the gastrocnemius muscle, giving branches to them. In the upper half of the popliteal fossa, the tibial nerve is surrounded by a thick layer of fiber and is located behind and outside the popliteal vessels. At the level of the heads of the gastrocnemius muscle, the nerve comes into contact with the posterior wall of the popliteal vein and is separated from it only by a thin fascial sheet. Together with the vessels, the nerve passes into the gap between the plantar and popliteal muscles and further under the soleus muscle.

In the topography of the common peroneal nerve, three areas should be distinguished. In the first section, the nerve is adjacent to the posterior surface of the biceps muscle and is covered by it at a distance of 5-7 cm from its beginning. In the second section, it comes out from under the inner edge of the biceps muscle and goes in the interval between the lateral head of the gastrocnemius muscle and the tendon of the biceps. In the third section, the nerve lies between the head of the fibula and the long peroneal muscle over 4-5 cm.

Technique of nerve blockade in the popliteal fossa according to A.Ya. Grishko(fig. 20). The blockade is performed in the position of the patient on his stomach. The lower leg and foot are placed on a small roller so that the patella and the calcaneus tubercle are in the same sagittal plane. In the middle of the distance between the tendons of the muscles limiting the upper corner of the popliteal fossa, at the level of the proximal edge of the patella perpendicular to the skin, a needle is inserted 1-1.5 cm deeper than the popliteal fascia. To obtain paresthesia in the heel or sole, the needle is moved in a fan-like manner in the direction transverse to the course of the nerve. 10 ml of anesthetic solution is injected.

After blockade of the tibial nerve, the needle is pulled up and injected at an angle of 30-45 ° to the frontal plane towards the inner edge of the tendon of the biceps femoris. When the end of the common peroneal nerve needle touches, parasthesia occurs in the dorsum of the foot or toes. 5-10 ml of anesthetic is injected.

The blockade of the lateral cutaneous nerve of the leg is performed by transverse subcutaneous-subfascial infiltration from the posterior edge of the lateral femoral condyle to the tibial tuberosity. 5-10 ml of anesthetic is injected.

Indications. It is used for post-traumatic pain syndrome, neurotrophic diseases of the foot and for phantom pain and other diseases of the foot.

Dangers. Perhaps the introduction of anesthetic into the vascular bed and damage to nerve fibers during rough manipulation of the needle.

Rice. 20. Blockade of nerves in the popliteal fossa according to A.Ya. Grishko.

a - the position of the patient on the table; b - external reference points for determining the point of needle sticking (given according to A.Yu. Pashchuk); c - a diagram of the technique for performing a blockade of nerves in the popliteal fossa: 1 - point for blockade; 2 - tibial nerve; 3 - common peroneal nerve; d - diagram of a cross section of the blockade area: 1 - cutaneous point; 2 - tibial nerve; 3 - common peroneal nerve; e - blockade of the lateral cutaneous nerve of the leg.

11. Nerve block at the level of the ankle and foot

Anatomical features of the blockade zone. The tibial nerve projects onto the skin in the depression between the calcaneal (Achilles) tendon and the medial malleolus, 1 cm posterior to it.

The sural nerve is projected onto the skin along a line running from the middle of the distance between the lateral malleolus and heel tendon to the tuberosity of the V metatarsal bone. The deep peroneal nerve, when passing to the rear of the foot, passes first under the muscles of the superficial extensors, then under the muscles of the deep extensors and the tendon of the long extensor muscle of the big toe and is divided into branches: one goes to short extensors fingers, the other reaches the area of ​​the first interosseous space. The medial dorsal cutaneous nerve is a branch of the superficial peroneal nerve, follows along the fascia of the lower leg and goes to the anteromedial edge of the dorsum of the foot, giving off branches to the skin of the medial ankle, after which it is divided into two branches.

The saphenous nerve is a long branch of the femoral nerve. This nerve runs down the medial surface of the lower leg to the ankle joint, supplying the skin in this area.

There are no anatomical features of the innervation of the toes, so the anatomy and technique of anesthetizing the toes can be easily understood from Fig. 25.

The technique of blockade of nerves at the level of the ankle joint according to Barsky. For tibial nerve blockade (Fig. 21), the injection is made from a point located in the middle of the distance between the apex of the medial malleolus (its lowest point) and the calcaneal tubercle, and the needle is directed outward and forward to the bone itself and until paresthesia is obtained. 5-10 ml of anesthetic is injected.

To block the deep peroneal nerve (Fig. 22), the needle is inserted at the level of the horizontal line connecting both ankles, in the middle and in front of the ankle joint. In this place, the tendons of the anterior tibial muscle and the long extensor of the thumb are clearly visible and palpable under the skin. A needle is injected between these tendons perpendicular to the skin to a depth of 0.7-0.8 cm, and then the needle tip must be turned outward so that it is behind the long extensor tendon of the thumb, where 5-10 ml of anesthetic is injected.

For blockade of the superficial peroneal nerve from the same point as in the previous case, the needle tip is directed into the subcutaneous adipose tissue outward, where the subcutaneous injection of the anesthetic solution is performed. For this, 3-5 ml is enough.

Rice. 21. Blockade of the tibial nerve at the level of the ankle joint

a - external landmarks; b - diagram of a cross section of the blockade area: 1 - medial malleolus, 2 - tibial nerve, 3 - calcaneal tendon, 4 - point of injection of the needle.

The blockade of the saphenous nerve is performed by injecting anesthetics into the subcutaneous fatty tissue in the transverse direction along the anterointernal surface at the level of the ankle joint from the same injection from which both branches of the common peroneal nerve were blocked. Without removing the needle, its tip is turned inward from the injection, where the anesthetic is injected in the transverse direction to a width of 3-4 cm. 3-5 ml of anesthetic is used.

To block the sural nerve (Fig. 23), an anesthetic is injected subcutaneously in the transverse direction between the posterior edge of the lateral ankle and the outer edge of the calcaneal tubercle. Use 5 ml of anesthetic.

Rice. 22. Blockade of the peroneal nerve at the level of the ankle joint.

a - external landmarks; b - a diagram of a transverse section of the blockade area: 1 - peroneal nerve, 2 - the point of injection of the needle.

Rice. 23. Blockade of the sural nerve at the level of the ankle joint.

a - external landmarks: 1 - point of injection;

2 - heel tendon; 3 - tuberosity of the V metatarsal bone; 4 - sural nerve; b - diagram of a cross section of the blockade area: 1 - sural nerve; 2 - heel tendon; 3 - injection point.

Technique of nerve blockade at the level of the lower third of the leg according to A.Yu. Pashchuk(fig. 24). At a distance of 10-12 cm above the apex of one of the ankles, transverse infiltration of the fiber is made with an anesthetic solution in the form of a "bracelet". At the place of its intersection with the inner edge of the calcaneal tendon, the needle is injected to a depth of 3-4 cm in the direction of the fibula and 5-7 ml of anesthetic is injected, which blocks the tibial nerve. The injection site of the needle for deep peroneal nerve blockade is determined at the point of intersection of the "bracelet" with the outer edge of the tendon of the tibialis anterior muscle. The needle is inserted perpendicular to the tibia axis in the direction of the interosseous membrane of the tibia. 5-7 ml of anesthetic solution is injected. In total, 30-40 ml of anesthetic is consumed for anesthesia.

Indications. Nerve block at the level of the ankle joint is most indicated for small operations performed in an outpatient setting, as well as for postoperative pain relief.

Dangers. The dangers of injecting anesthetic into the vascular bed and nerve damage are minimal.

Rice. 24. Nerve block at the level of the lower third of the leg according to A.Yu. Pashchuk.

a - external landmarks for determining the point of injection of the needle: 1 - tibial nerve, 2 - inner edge of the calcaneal tendon, 3 - point of injection; b - a diagram of the blockade of the tibial nerve on the transverse section: 1 - tibial nerve, 2 - calcaneal (Achilles) tendon, 3 - point of injection of the needle; c - external landmarks of the peroneal nerve: 1 - peroneal nerve, 2 - outer edge of the tendon of the anterior tibial muscle, 3 - puncture point; d - diagram of the blockade of the peroneal nerve on the transverse section: 1 - the peroneal nerve, 2 - the outer edge of the tendon of the anterior tibial muscle, 3 - the point where the needle is punctured.

Rice. 25. Blockade of the digital nerves of the foot.

a - blockade of the digital nerves of the foot according to V.A. Shaak and L.A. Andreev; b - a diagram of blockade of the digital nerves of the foot in a transverse section.

12. Blockade of intercostal nerves

Anatomical features of the blockade zone. Each intercostal nerve (anterior branch of the pectoral nerves), located in the corresponding intercostal space, at its beginning lies inward from the external intercostal muscle. Being covered by the intrathoracic and fascia and parietal pleura, with the exception of the subcostal nerve, which does not follow in the intercostal space, but under the XII rib and is located medially from the square muscle of the lower back. Further, each intercostal nerve passes between the intercostal muscles, approaching the rib groove, accompanied by the intercostal arteries and veins lying above the nerve.

Blockade technique(fig. 26). The patient is located on a healthy side. Determine the place of the greatest pain or crepitus of fragments. The blockade can be performed, slightly stepping back from the injury site towards the spine. The needle with the syringe is inserted in the direction of the rib, reaching which the needle is moved to its lower edge to the posterior surface. The anesthetic is injected along the entire length of the passage of the needle, and the main volume - 5-10 ml of the anesthetic is injected at the lower edge of the rib.

In case of multiple fractures of the ribs, the blockade is carried out according to each damaged rib, evenly distributing the anesthetic.

Indications. Rib fractures, intercostal neuralgia.

Dangers. Damage to the intercostal vessels in both the and vascular administration of the anesthetic is not excluded. If the technique is violated, the pleura may be damaged.

13. Paravertebral block

Anatomical features of the blockade zone. Each thoracic spinal nerve, emerging from the intervertebral foramen, gives branches to the membranes spinal cord, to the sympathetic trunk, the posterior branches terminating in the skin of the back, and the anterior branches are the intercostal nerves.

The lumbar, sacral and coccygeal nerves, like all overlying spinal nerves, give off the meningeal, connecting, anterior and posterior branches. The anterior branches of the lumbar, sacral and coccygeal spinal nerves form one common lumbosacral plexus. When performing paravertebral blockade, it is necessary to take into account the anatomical features of the size of the vertebrae. So, the width of the vertebrae increases towards the lumbar region, the distance from the midline to the transverse processes changes, and the spaces between the transverse processes expand.

Rice. 26. Blockade of intercostal nerves.

A - diagram of the blockade execution technique; b - diagram of a longitudinal section of the blockade area; c - a diagram of a cross section of the blockade area.

The technique of paravertebral blockade according to V.A. Shaak and L.A. Andreev(fig. 27). The patient is placed on a healthy side, the spinous process is felt and marked. At a distance of 3 cm from the midline (with blockade of the lumbar spine, this distance can be increased to 4-5 cm), a needle is injected. In the upper part of the spine, the depth of the nerve is 3 cm, and in the lower part - 4-6 cm.At the transverse process, the needle goes in the sagittal direction, at the lower edge of the bone, the needle is deflected medially so that its outer part moves outward from the midline to 20 °, after which the needle is advanced another 1-1.5 cm and the anesthetic is injected - 15-20 ml of 0.5% novocaine solution.

With blockade in the area of ​​the thoracic vertebrae, they are guided mainly along the costal angle, in the lumbar region - along the spinous processes.

The position of the patient can also be sitting with an inclination forward. Usually, the blockade is performed on one or two sides along several vertebrae. The number of blocked vertebrae should be 1-2 segments up and down higher than the number of broken ribs or overlap the damage zone in case of soft injury

Indications. The blockade is used for chest trauma, both for fracture of the ribs and damage to soft tissues, especially with compression, as well as for osteochondrosis of the spine and segmental neuralgia.

Dangers. As a result of a violation of the blockade technique, there may be: puncture of blood vessels, needle damage to the pleura, and even lumbar puncture.

Rice. 27. Paravertebral blockade

a - position of the patient;

b-internal landmarks and blockade points

14. Chest block

Anatomical features of the blockade zone. A retrosternal block is a blockade of the nerves of the anterior mediastinum. Both phrenic nerves are located in the anterior mediastinum. The right one passes between the subclavicular artery and the vein, then goes down between the mediastinal pleura and the outer surface of the inferior vena cava, and then between the pleura and the pericardium.

The left phrenic nerve is located in front of the aortic arch. Then it goes to the left surface of the pericardium, located between it and the pleura of the mediastinum.

The thoracic part of the trachea is located in the midline and is projected onto the handle of the sternum. Bifurcation of the trachea corresponds to Th5 –Th6 and the level of attachment of the II rib to the sternum. The anterior mediastinum also contains the thymus gland, which atrophies over time, such large vessels as the brachiocephalic veins and the ascending part of the aorta, pulmonary arteries, veins, lymph nodes and, finally, the pericardium and heart.

The blockade of the retrosternal space captures the nerve plexuses of the aortic arch, the zone of nerve plexuses of the tracheal bifurcation, the upper thoracic region of both vagus trunks and the branches of the sympathetic nodes going to the heart, as well as highly sensitive nerve receptors of the pericardium and epicardium.

As you can see, this zone of blockade is the most difficult in terms of the significance of the anatomical structures passing through it.

Technique of the retrosternal blockade according to V.I.Kazansky(fig. 28). The patient lies on his back, a roller is placed under his shoulders, his head is thrown back. A puncture of the skin and subcutaneous fat is made through the jugular fossa and novocaine is injected to form a small nodule, then the end of the needle is groped for the rear edge of the sternum handle and immediately behind it, 10 ml of novocaine solution is injected into the chest cavity. With this technique, the gap between the posterior wall of the sternum and the vessels of the anterior mediastinum expands. The syringe needle is removed and a needle up to 15-18 cm long with a bent end is inserted instead. The needle freely enters the anterior mediastinum, and its end should slide along the posterior wall of the sternum and penetrate up to the aortic arch, which is clearly felt as dense tissue and the pulsation of which is transmitted to the needle. In the area of ​​the aortic arch, 40-60 ml of 0.5% novocaine solution is injected. Then the needle is deflected 1 cm to the patient's neck, while its end penetrates into the upper volvulus of the pericardium, where 10-20 ml of novocaine solution is injected.

Indications. Nerve block in the retrosternal space is indicated as a measure of prevention and control of shock in case of chest injuries. Retrosternal blockade can be performed with functional disorders of the coronary circulation, with coronary angioneurosis, occurring with symptoms of cardialgia, as well as with coronary atherosclerosis with severe coronary angioneurosis and with angina pectoris of rest and tension.

Dangers. The blockade must be performed in a hospital environment by a highly qualified specialist. When the needle deviates from the midline, anesthetic can be injected into the pleural space. In addition, the vessel can be punctured and the anesthetic then enters the vascular bed.