Zusammenfassung:
Einleitung: Die elektrische Nervenstimulation ist ein etabliertes Standardverfahren zur Nervenlokalisation bei der Durchführung peripherer Nervenblockaden. Neurologische Defizite nach peripheren Regionalanästhesien lassen sich jedoch trotz Berücksichtigung vermeintlich nervenschonender Techniken bisher nicht vollends vermeiden und stellen ein klinisch relevantes Problem dar. Als häufige Ursache wird die Nervenverletzung während der Kanülenplatzierung diskutiert. Nadel-Nerv-Kontakte gelten als gesicherter Risikofaktor für Nervenschäden. Die verfügbaren Designs isolierter Stimulationskanülen unterscheiden sich zum Teil beträchtlich in der Größe ihrer Stromemissionsfläche. Bisher liegen keine vergleichenden Daten zur Inzidenz von Nadel-Nerv-Kontakten in Abhängigkeit von der Emissionsfläche vor.
Material und Methoden: An sechs anästhesierten Schweinen wurde am offenen Plexus brachialis eine Nadel-Nerv-Distanzmessung bei minimaler Reizantwort unter Anwendung eines Schwellenstroms von 0,3 bis 0,8 mA durchgeführt. Es wurden drei Kanülentypen untersucht: Stimuplex® A (Standardkanüle mit mittlerer Emissionsfläche, n = 2025), Stimuplex® D (kleine Emissionsfläche, n = 1800) und eine Tuohy-Kanüle (StimucathTM, große Emissionsfläche, n = 2025). Die relativen Häufigkeiten für Nadel-Nerv-Kontakte wurden mittels Fishers Exact Test verglichen. Unterschiede zwischen den Nadel-Nerv-Abständen wurden mittels Friedman-Test und anschließendem Paarvergleich ermittelt.
Ergebnisse: Insgesamt wurden 5850 Stimulationsversuche durchgeführt. Im Intervall 0,3 - 0,5 mA fand sich eine hohe Anzahl an unerwünschten Nadel-Nerv-Kontakten. Im Niedrigstrombereich traten zudem Nadel-Nerv-Kontakte ohne begleitende Stimulationsantwort auf. Die höchste Stimulationsversagerrate wies die Tuohy-Kanüle auf, gefolgt von der Stimuplex® D und der Stimuplex® A. Der Unterschied zwischen den untersuchten Nadeltypen war signifikant (p < 0,0001 für 0,3 mA). Im Intervall 0,6 - 0,8 mA wies die Stimuplex® A die geringste Inzidenz von Nadel-Nerv-Kontakten auf und unterschied sich signifikant von den beiden anderen Kanülen (Stimuplex® A vs. Stimuplex® D p < 0,005 für 0,6 mA, p < 0,0001 für 0,7 mA, p < 0,005 für 0,8 mA, Stimuplex® A vs. Tuohy p < 0,0001 für 0,6 mA bis 0,8 mA). Für die Tuohy-Nadel zeigte sich im Vergleich zur Stimuplex® D eine höhere Inzidenz von Nadel-Nerv-Kontakten.
Schlussfolgerung: Beim Einsatz von Stimulationskanülen mit kleinen Emissionsflächen treten Nadel-Nerv-Kontakte nicht seltener auf als bei der Verwendung von Kanülen mit großen Emissionsflächen. Dennoch implizieren die signifikanten Unterschiede in der Inzidenz von Nadel-Nerv-Kontakten mit und ohne Stimulationserfolg differente Stimulationseigenschaften der unterschiedlichen Kanülenmodelle. Das Tuohy-Design scheint besonders anfällig für Nadel-Nerv-Kontakte und das Ausbleiben einer Reizantwort bei unmittelbarer Berührung des Zielnerven. Bei Stimulation mit Strömen oberhalb von 0,5 mA ist im Vergleich zu niedrigeren Schwellenwerten unabhängig vom Kanülendesign von einer größeren Sicherheit durch seltenere Nadel-Nerv-Kontakte bei vergleichbarer Nähe der Stimulationsnadel zum Nerv auszugehen. Darüber hinaus variiert der optimale Stimulationsstrom in Abhängigkeit vom verwendeten Kanülentyp.
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