Möglichkeiten und Grenzen der interskalenären Blockade

 

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Zusammenfassung

Regionalverfahren haben in den letzten Jahren zunehmend an Bedeutung gewonnen. Voraussetzung für eine erfolgreiche Regionalanästhesie der Schulterregion ist die exakte Kenntnis der anatomisch relevanten Strukturen. Die gebräuchlichsten Techniken der interskalenären Blockade sind das Verfahren nach Winnie, seine Modifikationen nach Meier und Borgeat sowie der posteriore Zugang nach Pippa. Insbesondere die Techniken nach Meier und Borgeat zeichnen sich durch geringe Komplikationsraten aus. Sie sind für fast alle Eingriffe an der Schulter geeignet und bieten – vor allem als Kathetertechniken –sowohl eine wichtige Ergänzung bzw. Alternative zur Allgemeinanästhesie als auch eine unentbehrliche Option für die postoperative Schmerztherapie.

Abstract

Regional anaesthesia has gained increasing importance during the last decades. Successful regional anaesthesia for shoulder surgery requires a detailed knowledge of the relevant anatomy. Interscalene nerve blocks are most frequently used to anaesthetize the shoulder and among them the techniques according to Winnie, Meier, Pippa and Borgeat are the most popular. The techniques described by Meier and Borgeat are characterized by low complication rates. They are efficient for the majority of surgical procedures and therefore offer an interesting supplementation or an alternative to general anaesthesia. When carried out as a catheter–technique they provide a high quality postoperative pain therapy.

Kernaussagen

• Operative Eingriffe am Schultergelenk sind sehr schmerzhaft. Oft besteht eine große Diskrepanz zwischen mäßigen Ruheschmerzen und erheblichen bewegungsabhängigen Schmerzen.

• Regionalverfahren bieten eine gegenüber anderen Verfahren überlegene Analgesiequalität.

• Genaue Kenntnisse der Anatomie des Plexus brachialis sind für eine erfolgreiche Blockadetechnik notwendig.

• Auch bei „lege artis” durchgeführten Blockaden können Teilbereiche des Operationsgebietes von der Blockade ausgespart bleiben.

• Hohe Erfolgsraten bieten die interskalenären Blockaden, z. B. die Techniken nach Meier oder Borgeat.

• Die Komplikationsraten dieser Techniken sind gering; bleibende neurologische Defizite sind nur in Einzelfällen beschrieben.

• Wird die Blockade als singuläres Verfahren eingesetzt, können neben den blockadetechnischen Komplikationen auch die Auslösung des Bezhold–Jarisch–Reflexes und Atemwegsverlegungen durch periartikuläre Flüssigkeitseinschwemmung bei Arthroskopien Probleme bereiten.

• Eine Single–Shot–Blockade sollte nur bei kurzen Eingriffen ohne Eröffnung der Gelenkkapsel durchgeführt werden. In allen anderen Fällen bietet sich der interskalenäre Katheter als sichere und längerfristig wirksame Alternative an.

• Ob Regionalverfahren zu verbesserten Rehabilitationsergebnissen nach Schulterchirurgie führen, ist derzeit unklar.

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Dr. med. Klaus Hofmann–Kiefer
PD Dr. med. Matthias Jacob
PD Dr. med. Markus Rehm
Dr. med. Philip Lang

Email: Klaus.Hofmann-Kiefer@med.uni-muenchen.de

Email: matthias.jacob@med.uni-muenchen.de

Email: markus.rehm@med.uni-muenchen.de

Email: philip.lang@med.uni-muenchen.de

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