
==== Front
Zhong Nan Da Xue Xue Bao Yi Xue Ban
Zhong Nan Da Xue Xue Bao Yi Xue Ban
zndx
Journal of Central South University Medical Sciences
1672-7347
中南大学出版社 湖南省长沙市湘雅路110号湘雅医学院

39311796
1672-7347(2024)06-0998-07
10.11817/j.issn.1672-7347.2024.230511
230511
Case Analyses
椎管内麻醉后颅内积气1例
Intracranial air following spinal anesthesia: A case reporthttp://orcid.org/0000-0002-5917-1504
罗 柳 LUO Liu 1
唐 林 TANG Lin 1
谭 米多 TAN Miduo 2
http://orcid.org/0009-0005-1864-5370
付 卫东 FU Weidong 1
1 中南大学湘雅医学院附属株洲医院麻醉科,湖南 株洲 412000
1 Department of Anesthesiology, Zhuzhou Hospital Affiliated to Xiangya Medical College, Central South University Zhuzhou Hunan 412000
2 中南大学湘雅医学院附属株洲医院乳腺外科,湖南 株洲 412000
2 Department of Breast Surgery, Zhuzhou Hospital Affiliated to Xiangya Medical College, Central South University Zhuzhou Hunan 412000 China
田 朴 executive-editor
付卫东，Email: forward314@qq.com, ORCID: 0009-0005-1864-5370
罗柳，Email: luoliu_0312@163.com, ORCID: 0000-0002-5917-1504

28 6 2024
49 6 9981004
13 11 2023
©Journal of Central South University (Medical Science). All rights reserved.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ 开放获取(Open access)：本文遵循知识共享许可协议，允许第三方用户按照署名-非商业性使用-禁止演绎4.0(CC BY-NC-ND 4.0)的方式，在任何媒介以任何形式复制、传播本作品(https://creativecommons.org/licenses/by-nc-nd/4.0/)。
椎管内麻醉后出现颅内积气是一种少见的并发症，相关文献报道的椎管内或颅内积气多与麻醉过程中采用空气阻力消失法相关，生理盐水阻力消失法罕见。本文报告1例采用生理盐水阻力消失法实施椎管内麻醉手术后发生颅内积气的患者资料。患者为38岁女性，无明显诱因肛周肿痛1周，择期椎管内麻醉下行“肛周脓肿切开排脓+肛瘘切除内扣挂线+混合痔外剥内扎+肛乳头瘤电灼术”。术后第2天出现头痛、头晕，以及颈部、后背剧烈疼痛，伴手臂麻木且无法触碰及活动，平卧位休息后无好转，头部CT发现颅内散在多发积气，总量约3 mL。经多学科会诊，采取卧床休息、补液、吸氧、消炎止痛等对症支持治疗，病情好转出院，半年后随访无不适。目前采用生理盐水阻力消失法实施椎管内麻醉后颅内积气的病理生理机制、诊断、治疗、预防尚不明确，仍需进一步研究。

Intraspinal air is a rare complication of intraspinal anesthesia. Reported cases of intraspinal or intracranial air are mostly associated with the air insufflation resistance test, while those associated with the normal saline resistance test are rare. This article presents a case of intracranial air following intraspinal anesthesia performed using the normal saline resistance method. The patient was a 38-year-old female who underwent elective intraspinal anesthesia for 1 week without obvious cause of perianal swelling and pain. The procedure included incision and drainage of perianal abscess, excision of anal fistula with internal thread insertion, mixed hemorrhoid exfoliation and internal ligation, and electrocautery of anal papilloma. On the second postoperative day, she experienced headaches, dizziness, severe neck and back pain, along with numbness in the arms and inability to touch or move them. Resting in a supine position did not alleviate the symptoms. Head CT revealed scattered multiple air collections in the cranial cavity, with a total volume of approximately 3 mL. After a multidisciplinary consultation, symptomatic supportive treatment including bed rest, fluid supplementation, oxygen therapy, and anti-inflammatory and analgesic treatment was administered, leading to improvement and discharge. Follow-up at 6 months showed no discomfort. Currently, intracranial air is mostly associated with the air insufflation resistance test, while cases following the normal saline resistance method are rare, with unclear pathophysiological mechanisms, diagnosis, treatment, and prevention, necessitating further research.

椎管内麻醉
阻力消失法
并发症
颅内积气
intraspinal anesthesia
resistance disappearance method
complications
intracranial air
株洲市创新型城市建设专项社会化出资项目株科办〔2023〕4号┫。This work was supported by the Zhuzhou City Innovative City Construction Special Socialized Investment Project Guidance Plan Item China (Zhuke Ban [2023] No.4).
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pmc椎管内麻醉并发症是指椎管内注射麻醉药及相关药物所引起的生理反应、毒性作用以及椎管内穿刺与置管给机体带来的不良影响[1]。常见的不良影响有呼吸、心血管系统影响，全脊髓麻醉，异常广泛脊髓神经阻滞，恶心呕吐，尿潴留以及椎管内穿刺与置管相关并发症(如椎管内血肿、感染、硬脊膜穿破后头痛、神经机械性损伤、脊髓缺血性损伤和脊髓前动脉综合征、导管折断或打结，严重者可出现呼吸心跳骤停等)。临床表现因并发症类型而异，椎管内麻醉后颅内积气非常罕见，症状可轻可重，轻者出现恶心呕吐等类似低颅压症状，重者可出现呼吸心跳骤停。诊断需与低颅压相鉴别，少量积气可自行吸收，无需特殊治疗，但大量积气需外科干预。笔者报告1例椎管内麻醉后颅内积气的临床表现及诊疗经过，旨在探讨椎管内麻醉后颅内积气的机制、预防、诊断和治疗方法。

1 病例资料

患者，女，38岁，肛周肿痛1周，自诉1周前无明显诱因出现肛周肿胀疼痛，肛周可触及一蚕豆大小痛性包块，自觉症状加重，间断口服抗炎药后症状无明显缓解。2022年7月16日于中南大学湘雅医学院附属株洲医院就诊。体格检查及专科检查：身高159 cm，体重56 kg，体重指数22.13 kg/m2，体温37.8 ℃，心率124 次/min，呼吸20 次/min，脉搏71 次/min，血压 123/62 mmHg(1 mmHg=0.133 kPa)，双肺未闻及干湿啰音，心律齐；指检肛门9点方向可触及约2 cm×2 cm大小，质稍软的痛性肿块，无波动感及表面破溃。心电图、X线胸片、输血前四项、三大常规、凝血功能均正常，既往史无特殊。诊断为“肛周脓肿，肛瘘”。于2022年7月18日腰硬联合麻醉下行“肛周脓肿切开排脓+肛瘘切除内扣挂线+混合痔外剥内扎+肛乳头瘤电灼术”。

患者入手术室后行心电监护，建立静脉通路，用生理盐水阻力消失法行椎管内麻醉，穿刺过程详见图1。术中患者因紧张频繁抬头，但生命体征平稳，输液500 mL；手术结束后拔除硬膜外置管，详细告知术后注意事项安全送回病房。

图1 椎管内麻醉具体操作过程

Figure 1 Specific operation process of intraspinal anesthesia

术后6 h患者突然诉腰背部疼痛明显，麻醉科会诊进行体格检查，以穿刺点为圆心约10 cm圆形区域为疼痛区，无肢体麻木、疼痛等不适，考虑为穿刺引起，予抗炎镇痛(曲马多、双氯芬酸钠静脉注射)后明显好转。术后第2天(2022年7月20日)，患者外出散步回病房后突感头晕、头痛并呕吐2次，颈部及后背剧烈疼痛，无法触碰及活动，手臂有麻木感，平卧位休息后无明显好转，组织多学科紧急会诊。头部CT可见颅内脑室散在积气影，脑实质密度未见异常征象，余无异常(图2)。根据症状及影像学结果，考虑到患者随体位改变的头晕、头痛为低颅压综合征表现，不排除颅内积气导致目前症状，予卧床休息、止痛、吸氧、补液(每日2 000~3 000 mL)等对症支持治疗。2周后复查头部CT(2022年8月3日)，示颅内未见积气影，脑实质密度未见异常征象(图3)。颈腰部MRI示颈椎退行性病变(图4)。继续治疗1周后(2022年8月10日)患者病情好转并出院，当天自诉偶感耳鸣，头晕头痛已缓解，余无不适。随访半年，无头痛、腰痛等相关异常神经症状。

图2 MDT紧急会诊后头部CT影像资料

Figure 2 Head CT imaging data after MDT emergency consultation

A (bone window) and B (brain window): Low-density air shadow in the anterior horn of the right lateral ventricle is visible in the bean nucleus-corpus callosum plane (arrow), no abnormalities are observed in the brain parenchyma. C (bone window) and D (brain window): Brain low-density air shadow is seen in the plane of the bridge-four ventricle (arrow), with no obvious abnormalities in the brain parenchyma. MDT: Multidisciplinary diagnosis and treatment.

图3 对症支持治疗后头部CT影像

Figure 3 Head CT images after symptomatic support treatment

A: Bone window; B: Brain window. Patient has absorbed a small amount of air accumulation in multiple intracranial areas, and there are no abnormal signs in the rest of the brain.

图4 脊柱MRI检查影像

Figure 4 Spinal MRI examination images

A: MRI showing intervertebral disc degeneration at C2-C7, intervertebral disc herniation at C4-C5, and vertebral hyperosteogeny and lumbar degeneration at C3-C7; B: MRI showing intervertebral disc degeneration and lumbar bone hyperplasia at L4-L5. MRI: Magnetic resonance imaging.

2 讨 论

椎管内麻醉是指将麻醉药物注入椎管的蛛网膜下腔或硬膜外腔，脊神经根受到阻滞使该神经根支配的相应区域产生麻醉作用，可分为蛛网膜下腔麻醉(又称脊椎麻醉或腰椎麻醉)、硬膜外阻滞、腰硬联合麻醉、骶管阻滞麻醉，其并发症会给机体带来不良影响[1]。从1885年的动物硬膜外麻醉试验，到1891年的腰椎穿刺技术[2]，人类医学技术不断创新与进步，也为区域阻滞麻醉的发展奠定了基础，但因局部麻醉药缺乏以及会出现严重头痛、低血压等并发症，腰椎穿刺技术未被推广。随着穿刺器械与技术的改进、局部麻醉药的发展、预防治疗措施的完善，相关并发症的发生率不断下降。1939年Dogliotti[3]描述了将注射器装满生理盐水后连接穿刺针，通过突破黄韧带时注射器内压力是否锐减来判断是否进入硬膜外腔的方法——Dogliotti法(生理盐水阻力消失法)。生理盐水阻力消失法和空气阻力消失法均为椎管内麻醉的临床应用奠定基础。首例报道的椎管内麻醉后并发症为脑膜炎[4]，随后报道的椎管内麻醉相关并发症有呼吸、心血管系统疾病，全脊髓麻醉，异常广泛脊髓神经阻滞等[5-7]。生理盐水或空气阻力消失法仍为判断穿刺针进入硬膜外腔的主流方法[8]。研究[8-9]证实：采用生理盐水或空气阻力消失法对椎管内麻醉穿刺成功率及并发症的发生率并无影响。2种方法的并发症如头痛、血肿、神经机械性损伤、脊髓缺血性损伤和脊髓前动脉综合征等的机制较明确[10]；但静脉气栓、阻滞不全及椎管/颅内积气多为采用空气阻力消失法时的反复穿刺、注气引起[11]。针对硬膜外间隙识别的比较研究和系统性回顾[12]指出：相较于空气阻力消失法，液体阻力消失法降低了慢性疼痛患者硬膜穿刺后头痛(postdural puncture headache，PDPH)的发生率，但硬膜外间隙的识别方法依赖于麻醉医师的经验和熟练程度。

常见椎管内麻醉并发症主要临床表现有低血压、心动过缓、尿潴留、头晕头痛、呼吸抑制或停止、心脏骤停等，其严重程度与并发症类型相关[13]。而椎管内麻醉相关颅内积气的症状与积气量、部位有关，患者可出现肢体麻木、头痛头晕、恶心呕吐、头颈部胀痛等。少量积气多分散在额颞部蛛网膜下腔，多可自行吸收且预后良好，而大量颅内积气常在额颞顶部，易形成颅内压增高，严重时发生脑疝影响生命体征[14]。本例患者术后第2天外出后出现剧烈头痛及头晕症状，呕吐2次，颈部及后背剧烈疼痛，无法触碰及。患者豆状核-胼胝体平面右侧侧脑室前角及脑桥-四脑室平面可见低密度空气影，提示颅内多处少量积气(总量约3 mL)，但无颅内结构改变；脊柱MRI亦未发现脊柱椎管与脊髓相关损伤存在。予以加强补液、卧床休息、高浓度吸氧、止痛等对症支持治疗1周，患者症状好转，复查头部CT颅内积气已吸收完全。

因椎管麻醉相关颅内积气鲜有报道[15]，且机制及临床表现尚不明确。临床上主要依据不能解释的感觉消失、肢体麻木、头痛、头晕等症状判断颅内积气形成的可能，但需与低颅压症状进行鉴别[16]。予以头部CT或MRI检查可进行确诊。本例患者出现不可解释的剧烈头痛及头晕症状，呕吐2次，颈部及后背剧烈疼痛，头部CT检查证实存在颅内积气。椎管内麻醉目前采用的阻力消失法有空气及生理盐水2种[8]，相关椎管内/颅内积气并发症多见于空气阻力消失法，非常罕见于生理盐水阻力消失法。

在椎管内麻醉有创操作时，颅脑封闭性腔隙的生理屏障作用被打破，导致穿刺操作将外界空气带入蛛网膜下腔，最终随脑脊液循环到达颅脑。此例椎管内麻醉采用生理盐水阻力消失法出现颅内积气的机制不明，结合穿刺操作过程、患者配合度及相关文献[12, 17-18]，可能机制有：1)注药过多致硬膜外腔压力增大剥离隐性裂口，患者麻醉恢复后运动致硬膜外腔压力增大使裂口撕裂，空气经裂口通过蛛网膜下腔入脑；2)旋转硬膜外针时划破硬膜，置入腰椎麻醉针导致破口进一步扩大，脑脊液快速流出后蛛网膜下腔压力下降，流体动力学使空气经破口及穿刺针通过蛛网膜下腔入脑；3)穿刺时呼吸或咳嗽，抬头等体动致硬膜外腔存在的负压增加，使空气经穿刺针或针孔进入；4)未及时发现硬膜外导管误入蛛网膜下腔，空气经硬导管进入蛛网膜下腔再经脑脊液循环入脑；5)针芯拔除后未迅速接注射器，空气经针道进入；6)注射器抽取脑脊液时，椎管内局部压力变化，穿刺/腰麻针间隙形成压力差，气体因液体流体动力学而进入；7)无症状低颅内压(低于大气压)，压力差使气体经针道、针孔、硬膜外导管进入。

无论是经验丰富的高年资麻醉医师，还是低年资医师甚至初学者，在行椎管内穿刺的过程中，硬膜外针穿破蛛网膜或试阻力判断硬膜外腔等操作都可能使空气经硬膜外腔/蛛网膜下腔进入颅内。目前相关文献[6-7, 10]报道多为操作原因引起颅内积气，因此不排除穿刺操作因素导致的颅内积气。回顾本例患者的相关操作，未见脑脊液流出及腰麻针穿刺有突破落空感且有脑脊液缓慢流出，确认硬膜外针未穿破蛛网膜，考虑穿刺时患者体动，致使刚好进入硬膜外腔的穿刺针划伤硬脊膜，但当时并不严重而未发现，空气经穿刺针及硬膜外导管进入蛛网膜下腔，空气缓慢伴随脑脊液循环上行，并于术后第3天导致患者出现相应头痛等症状。不排除当时硬膜外生理盐水试阻力时推注速度过快而致硬膜外腔压力剧增剥离隐性裂口，患者麻醉恢复后运动致硬膜外腔压力增大使裂口撕裂，空气经裂口通过蛛网膜下腔入脑。

综上，颅脑积气可能与硬膜外腔定位方法及麻醉医师的熟练程度存在一定关系，硬膜外腔负压、患者手术过程中身体活动、麻醉医师的穿刺操作等均为椎管内及颅内积气的危险因素。因此建议：1)术中椎管内麻醉穿刺阻力测试采用生理盐水或者玻璃管液体法。2)加强椎管内麻醉穿刺操作技术能力训练及规范操作流程，提高一次性穿刺成功率及患者的舒适感。3)患者配合不佳或者穿刺困难，勿反复粗暴多次穿刺，及时终止操作改其他麻醉方式或寻求帮助。一旦出现相关并发症尤其是颅内积气时，及时采取以下措施：1)维持呼吸道通畅，避免出现二次损伤。2)及时行CT或者MRI检查明确诊断，与低颅内压等鉴别，避免误诊漏诊。3)依据颅内积气量予以吸氧、去枕平卧、降颅内压、神经营养等对阵支持治疗，如有必要及时行高压氧治疗。4)临床工作中出现此类现象应积极对症处理并及时请示汇报或开展围术期多学科治疗。

基金资助

株洲市创新型城市建设专项社会化出资项目(株科办〔2023〕4号)。This work was supported by the Zhuzhou City Innovative City Construction Special Socialized Investment Project Guidance Plan Item, China (Zhuke Ban [2023] No.4).

利益冲突声明

作者声称无任何利益冲突。

作者贡献

罗柳 资料收集，论文构思和撰写，对文章的知识性内容作批评性审阅，研究经费支持；唐林 资料采集，论文起草和修改；谭米多 论文修改，对文章的知识性内容作批评性审阅；付卫东 研究指导，对文章的知识性内容作批评性审阅。所有作者阅读并同意最终的文本。

原文网址

http://xbyxb.csu.edu.cn/xbwk/fileup/PDF/202406998.pdf

http://dx.chinadoi.cn/
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