尺神经单纯原位松解术和皮下前置术治疗肘管综合征的疗效比较

[摘要] 目的 比较尺神经原位松解术和皮下前置术两种手术方法治疗肘管综合征的疗效，为临床选择适当的治疗术式提供理论依据。方法2009年3 月~2012 年10月收治64例肘管综合征患者，其中32例采用尺神经原位松解术（原位松解组），32例采用尺神经皮下前置（皮下前置组）。两组患者性别、年龄、手术侧、病程及临床分型等一般资料比较，差异均无统计学意义（P>0.05），具有可比性。测量手术前后两组患者手部第一背侧骨间肌肌力、小指展肌肌力以及小指末节指腹皮肤测量两点辨别觉，肘上5cm~肘下5cm尺神经传导速度和术后并发症，进行比较。结果 两组患者术后切口均Ⅰ期愈合。患者均获随访，随访时间24~32个月，平均27个月。末次随访时，二组患者手部第一背侧骨间肌肌力、小指展肌肌力及小指末节两点辨别觉，神经传导速度比较，差异均无统计学意义（P>0.05）；但均较术前显著改善，差异有统计学意义（P? 0.05）。但尺神经原位松解组并发症的发生率6.25%明显低于皮下松解前置组25%，差异有统计学意义（P?0.05）。结论 尺神经单纯松解及皮下前置两种方法治疗肘管综合征均可达到良好疗效，其中尺神经原位松解法并发症较少。     

肌电图在肘管综合征中的诊断阳性率与鉴别诊断

目的:探讨肌电图在肘管综合征诊断及与相关疾病鉴别中的意义。方法:对23例27侧肢体经临床初步诊断为肘管综合征的患者进行神经肌电图检测及分析。结果:23例27侧肢体,尺神经运动CMAP波幅下降17条、未引出7条,尺神经肘段MCV减慢15条、未引出9条,前臂段MCV减慢3条、未引出9条,尺神经SNAP波幅下降17条、未引出7条。小指感觉SCV减慢11条、未引出11条,针极检测27侧肢体尺神经支配的小指展肌和第1骨间肌共40块出现自发电活动,尺侧腕屈肌3块出现自发电活动。募集相小指展肌减弱19块、未引出3块。第1骨间肌募集相减弱18块、未引出3块。结论:神经肌电图检查是诊断肘管综合征的可靠手段,可早期确诊及准确定位受损部位及损伤程度、判断愈后,从而指导临床治疗。     

肘管综合征的临床和电生理分析

目的：探讨肘管综合征（CUTS）患者的临床和电生理特点,并分析可能的病因。方法：回顾性分析69例CuTS患者（共73侧肢体）的临床和电生理资料。神经传导检测时,采用表面电极刺激和记录。分别于腕部、肘下5cm、肘上5cm刺激尺神经,记录小指展肌复合肌肉动作电位（CMAP）。腕部刺激尺神经,于小指逆向记录感觉神经动作电位（SNAP）。测量不同节段尺神经的运动传导速度（MCV）和感觉传导速度（SCV）。针电极肌电图观察尺神经所支配肌肉静息状态下的异常自发电活动。结果：①前臂尺侧、小指及无名指尺侧半麻木48例（70％）,上肢麻木及力弱19例（28％）,肘部疼痛或活动受限5例（7％）;第一骨间背侧肌萎缩28例（41％）,小鱼际肌萎缩15例（22％）,爪形手6例（9％）;②CuTS原因不明者53例（77％）;长期、频繁操作电脑所致者8例（12％）;③尺神经肘上-肘下节段MCV减慢[（29．91±5．09）m／s],肘下一腕段正常[（50．88±4．63）m／s]。小指展肌CMAP波幅降低,4只上肢未引出CMAP波形;尺神经腕一小指节段SCV正常[（47．43±7．27）m／s],SNAP波幅降低,36只上肢未引出SNAP波形;肌电图显示异常自发活动者,小指展肌和第一骨间背侧肌73肢,尺侧腕屈肌29肢。结论：CuTS临床表现以前臂尺侧、小指及无名指尺侧半麻木为主,伴力弱、疼痛及尺神经支配肌肉萎缩;电生理表现以尺神经肘上、下段MCV减慢为主,伴感觉纤维受损;病因以特发性占多数,长期、频繁操作电脑为另一重要因素;神经电生理检测为诊断CuTS的可靠手段,能明确神经受损受压的部位和程度。     

双侧尺神经肘部走行异常1例

患者,男性,25岁,左手肌肉萎缩并环小指麻木半年就诊,查体:左环指尺侧半及左小指皮肤感觉减退,左手小鱼际肌,骨间肌萎缩,环小指呈爪状畸形,夹纸试验阳性,左肘尺神经沟处Tinel征阳性,左前臂内侧皮肤感觉无异常.诊断为"左肘管综合征(重度)[1]",入院拟行尺神经探查松解及前置术,术中探查见尺神经并未在尺神经沟内,而是在肱骨内侧髁的前侧走行,与尺侧上副动脉伴行(图1).神经沟的浅面未见明显的筋膜和韧带覆盖,而是被肌肉组织充填,尺神经在肱骨内侧髁近侧和远侧分别被增厚的腱膜(来源不明)和尺侧屈腕肌的筋膜压迫,卡压段神经变细,中间段神经水肿增粗,切开筋膜,松解神经外膜,然后切开内侧髁前面的深筋膜,将尺神经移位其内,缝合筋膜数针予以固定.     

尺神经松解前置术治疗肘管综合征的临床疗效及预后的影响因素分析

目的探究尺神经松解前置术治疗肘管综合征的临床疗效及患者预后的影响因素。方法选取我院109例中重度肘管综合征患者,均行尺神经松解前置术治疗。术后随访18个月,比较治疗前后患者的上肢功能情况和相关临床资料,并进行单因素和多因素回归分析,构建Nomogram预测模型。结果术后手内肌萎缩、Tinel征阳性、夹纸试验阳性、Froment征阳性患者比例减少,手部握力、尺神经运动神经传导速度(MNCV)、潜伏期、波幅、两点分辨觉(2-PD)、上肢功能测定(DASH)评分等结果均有改善,差异有统计学意义(P 0.05)。多因素分析结果显示,年龄≥50岁、男性、病程≥6个月、长期屈肘工作、尺神经MNCV 35 m·s-1、2-PD≥6 mm和DASH评分≥55分为肘管综合征患者预后不良的独立影响因素(P 0.05)。将以上因素纳入Nomogram预测模型,校正曲线显示该模型预测值与实际值有较高的一致性。结论尺神经松解前置术治疗中重度肘管综合征疗效显著,年龄、性别、病程、工作是否长时间屈肘、尺神经MNCV、2-PD、DASH评分是患者预后的独立影响因素。     

带血供尺神经松解前置术治疗肘管综合征

目的：探讨带血管蒂尺神经松解前置术治疗肘管综合征的临床效果。方法：对16例肘管综合征患者施行带血供尺神经显微松解前置术，术中观察尺神经肘管段的血供分支分布特点，术后观察其疗效。结果：14例临床症状全部消失，功能恢复正常；2例感觉功能完全恢复，运动功能大部恢复。无并发症。结论：带血供尺神经松解前置术是治疗肘管综合征的一种有效方法。     

肩胛上神经卡压综合征的电生理诊断

目的：探讨肩胛上神经卡压综合征电生理诊断方法。方法：对10例肩胛上神经卡压综合征的病人应用肌电图（EMG）观察自发电位,检测肩胛上神经支配肌冈上肌、冈下肌;腋神经支配肌三角肌;肩胛背神经支配肌提肩胛肌的复合肌肉动作电位（CMAP）,观察指标为潜伏期、波幅的变化。结果：10例病人冈上肌均见自发电位,募集反应减弱,CMAP潜伏期延长,波幅降低,且波形离散。结论：电生理是诊断和鉴别诊断肩胛上神经卡压综合征的重要辅助手段。     

尺神经血液供应神经前置的解剖分析

目的对肘部供应神经、尺神经分支、尺侧上副动脉灌注尺神经的长度、肘部前内侧深筋膜血供等情况进行解剖学分析。方法对10具正常成人新鲜尸体进行解剖,观察肘部神经分支、血液供应。通过对新鲜尸体进行模拟尺神经的手术操作过程,主要是采用尺神经松解前置的方法,将尺神经进行充分的手术,游离尸体肘部后侧神经,同时观察肘部神经供养血管,最后再进行前置,这样就能够合理地测量出尺神经能够达到的最大前置距离。深筋膜动脉采用肘动脉灌注墨汁,同时将尺神经组织切片的方法观察足侧上副动脉对尺神经内部血供营养的长度。结果尺神经的营养血供、腋部内侧肌间隔后方、尺神经沟、前臂部。通过手术测试发现动脉和神经的伴行距离分别是15.0 cm、5.0cm和5.5 cm,神经的起点距离肱骨内上髁的距离,通过测试分别是15.5 cm、6.0 cm和5.5 cm。通过对新鲜的尸体进行手术后,游离的神经可以和尺神经一起跨过内侧的上上髁向桡侧方向,前置的距离最少也可以达到7 cm。结论行尺神经深筋膜瓣下手术,至少应该保留尺侧上或是尺侧下的副动脉,从而达到手术的目的。应依据任意皮瓣原则进行深筋膜瓣的制作。     

显微外科技术在肘管综合征的临床应用

目的探讨带血管蒂尺神经松解前置术治疗肘管综合征的临床疗效。方法行带血管蒂的尺神经显微松解前置术治疗23例中重度肘管综合征，术后观察其效果。结果19例临床症状全部消失，功能恢复正常；3例感觉功能完全恢复，运动功能大部恢复。1例感觉功能完全恢复，运动功能无改善。结论带血管蒂尺神经松解前置术是治疗肘管综合征一种较好的方法。     

肘管尺神经内压测量及其临床意义

目的 为探讨尺神经卡压症的发病机制,寻找本病的最佳治疗手段,提供基础资料。方法 利用神经内探针测量成人肘管的尺神经内部压力。结果 肘管内尺神经内部压力与肘后三角韧带的形态及关节活动状态有关。尺神经内压屈肘时升高(1.89kpa),伸肘时降低(0.93kpa);切断肘后三角韧带后尺神经内压明显降低,届肘时0.88Kpa,伸肘时0.61kpa。结论 手术治疗尺神经卡压症时,宜采取切断肘后三角韧带,将尺神经前置,充分降低尺神经内部压力,解除尺神经卡压症状。     

An aberrant anatomic variation along the course of the ulnar nerve above the elbow with coexistent cubital tunnel syndrome

We report on a patient with an unusual anatomic variation along the course of ulnar nerve above the elbow who had cubital tunnel syndrome. The variation consisted of a cutaneous neural branch that was originating at a distance of approximately 40 mm proximal to the medial epicondyle, and from the radial aspect of the main trunk of ulnar nerve. The branch had a superficial course and it was passing distally, anterior to the medial epicondyle without penetrating the fascia of the flexor muscles origin. Anterior intramuscular transposition of the ulnar nerve was performed leaving the newly found branch over the fascia between the muscles and the adipose subcutaneous tissue.     

儿童肘部尺神经前置术的应用解剖

目的为临床儿童尺神经前置术提供解剖学基础。方法 10具(共20肘)福尔马林固定的6~8岁儿童尸体上肢标本,解剖尺神经沟、尺神经行径伴行血管以及尺神经前置后解剖关系。结果尺神经主要接受尺侧上副动脉血供,前臂尺神经的血供则主要由尺动脉提供,尺侧上副动脉、尺侧下副动脉及尺侧返动脉后支血管的大部分行程与尺神经紧贴伴行,在尺神经前置越过肱骨内上髁时,不会造成伴行血管过度牵拉而对尺神经血供造成影响。尺神经前置后滑动性好,有良好的组织床,同时又能解除屈肘对尺神经牵拉。结论研究结果显示:尺神经前置术不会影响神经血供,具有可行性,前置时需切断上臂内侧肌间隔,皮下前置滑动性好。     

尺神经及其血供在肘管综合征手术中应用解剖研穷

目的观察肘部尺神经及其血供,为尺神经前移术治疗肘管综合征提供解剖学基础。方法50侧成人上肢标本观察测量肘部尺神经及其血供情况。结果肘部尺神经血供有3个来源:尺侧上副动脉(IUCA)、尺侧下副动脉(IUCA)和尺侧返动脉后支(PURA),分别与尺神经伴行长度为(15.1±2.0)cm、(5.0±1.1)cm和(6.4±1.2)cm;尺神经在肘部发出1～2支关节支,2～3支肌支。结论行尺神经前移术治疗肘管综合征时保护尺神经及其血供是完全可能的。     

Factors Influencing Outcomes after Ulnar Nerve Stability-Based Surgery for Cubital Tunnel Syndrome: A Prospective Cohort Study

PurposeSimple decompression of the ulnar nerve has outcomes similar to anterior transposition for cubital tunnel syndrome; however, there is no consensus on the proper technique for patients with an unstable ulnar nerve. We hypothesized that 1) simple decompression or anterior ulnar nerve transposition, depending on nerve stability, would be effective for cubital tunnel syndrome and that 2) there would be determining factors of the clinical outcome at two years.ResultsPreoperatively, two patients were rated as mild, another 20 as moderate, and the remaining 19 as severe according to the Dellon Scale. At 2 years after operation, mean grip/pinch strength increased significantly from 19.4/3.2 kg to 31.1/4.1 kg, respectively. Two-point discrimination improved from 6.0 mm to 3.2 mm. The DASH score improved from 31.0 to 14.5. All but one patient scored good or excellent according to the modified Bishop Scale. Correlations were found between the DASH score at two years and age, pre-operative grip strength, and two-point discrimination.ConclusionAn ulnar nerve stability-based approach to surgery selection for cubital tunnel syndrome was effective based on 2-year follow-up data. Older age, worse preoperative grip strength, and worse two-point discrimination were associated with worse outcomes at 2 years.     

The Muscular Branching Patterns of the Ulnar Nerve to the Flexor Carpi Ulnaris and Flexor Digitorum Profundus Muscles

The branching pattern of the ulnar nerve in the forearm is of great importance in anterior transposition of the ulnar nerve for decompression after neuropathy of cubital tunnel syndrom and malformations resulting from distal end fractures of the humerus. In this study, 37 formalin-fixed forearms were used to demonstrate the muscular branching patterns from the main ulnar nerve to the flexor carpi ulnaris muscle (FCU) and ulnar part of the flexor digitorum profundus muscle (FDP). Eight branching patterns were found and classified into four groups according to the number of the muscular branches leaving the main ulnar nerve. Two (Group I) and three (Group II) branches left the main ulnar nerve in 18 and 17 forearms respectively. The remaining two specimens had four (Group III) and five (Group IV) branches each. Usually one or two branches were associated with the innervation of the FCU. However, in 2 cases, three and in one, four branches to FCU were observed. The FDP received a single branch in all cases, except in four, all of which had two branches. In six forearms, a common trunk was observed arising from the ulnar nerve to supply the FCU and FDP. The distribution of the muscular branches to the revealed muscles was outlined in figures and the distance of the origin of these branches from the interepicondylar line was measured in millimeters. The first muscular branch leaving the main ulnar nerve was the FCU-branch in all specimens. The terminal muscular branch of the ulnar nerve to the forearm muscles arose at the proximal 1/3 of the forearm in all specimens. In 7 forearms, Martin-Gruber anastomosis in form of median to ulnar was observed.     

Anatomical basis for a technique of ulnar nerve transposition

Summary There are five major anatomical locations where the ulnar nerve may be compressed near the elbow. Multiple sites of compression are often noted clinically; in other cases, the site of compression is difficult to identify. Clinical experience and results of a series of 20 anatomical dissections suggest that local decompression or subcutaneous transfer may be performed without necessarily exposing all five locations, posing a risk of incomplete decompression. Submuscular transfer of the ulnar nerve decompresses all five locations simultaneously and thus theoretically may be more reliable. The potentially superior results predicted by this anatomical investigation have been confirmed in a clinical case review. Submuscular transposition of the ulnar nerve is reliable and safe, not only in the primary treatment of ulnar neuropathy at the elbow but also in revision of previous operations. Presented at the Second Annual Meeting of the American Association of Clinical Anatomists, Omaha, June 7 to 8, 1985     

内窥镜下微创治疗肘管综合征的相关解剖学研究

目的　为内窥镜下进行肘管尺神经减压并前移术提供临床应用解剖基础。 方法　10例新鲜尸体标本、20例临床病例传统手术中尺神经在臂部、前臂游离长度,尺神经第1肌支距离肱骨内上髁的距离、尺神经前移距离。在4例新鲜尸体标本上模拟手术。 结果　此术式尺神经前臂、臂部游离距离为（3.90±0.145）cm（3.64~4.23 cm）、（4.21±0.18）cm（3.80~4.53 cm）,前移距离（1.49±0.05）cm（1.39~1.57 cm）,尺神经第1肌支距离肱骨内上髁距离（2.18±0.38）cm（1.13~2.72cm）。此术式入路点、轴线、层面：肱骨内上髁与尺骨鹰嘴间长约2 cm纵行切口;肱骨内上髁与尺骨鹰嘴之间中点与豌豆骨连线上约7cm长的轴线,肱骨内上髁与尺骨鹰嘴之间中点与肱二头肌内侧肌间隔中点连线上长8cm的轴线;奥本斯韧带、前臂尺侧腕屈肌之间纤维弓形组织表面,臂部深筋膜表面。模拟手术成功。 结论　研究证实此术式可行,达预期效果。     

Pigmented villonodular synovitis of the elbow with rdial,median and ulnar nerve compression

Pigmented villonodular synovitis (PVNS) is a rare, idiopathic proliferative disorder of the synovium. While, PVNS of elbow is extremely rare. We report an 82-year-old female patient with 20-year-history of gradually increased PVNS in her left elbow. The multiple masses were located in anterior, medial and lateral of elbow. Her radial, median and ulnar nerves were compressed by the tumor. We resected tumor of extra-articular part piecemeally and released the compression of nerves. After the surgery, the patient gained a functional recovery. Two years after surgery she had a tumor recurrence, but without any symptoms of nerve compression syndromes. We discussed its clinical diagnosis, radiological features, MRI findings, pathophysiology, and treatment.     

两种入路治疗不同年龄患者尺骨冠状突骨折的效果对比

目的 对比前侧入路及内侧入路手术治疗在不同年龄人群尺骨冠状突骨折的临床效果。方法 回顾性分析2011年1月~2017年5月我院骨科收治的尺骨冠状突骨折患者85例,按年龄分为青壮年组（42例）和高年龄组（43例）,两组均分别采用前侧入路及内侧入路手术治疗,比较两组内前侧入路和内侧入路的手术时间、术中出血量、切口长度及术后并发症情况,组间及组内前、内侧入路术后患者MEPS评分和Broberg-Morrey评分。结果 所有患者均随访至少12个月,无伤口感染;高年龄组前侧入路1例出现正中神经损伤,内侧入路2例出现尺神经损伤,1例出现异位骨化,1例出现内固定失败;两组患者前侧入路的手术时间、术中出血量、切口长度均小于内侧入路,差异具有统计学意义（P＜0.05）;青壮年组术后MEPS评分和Broberg-Morrey评分分别为（87.74±7.42）分、（88.21±7.23）分,高于高年龄组的（74.93±9.63）分、（75.86±9.55）分,差异具有统计学意义（P＜0.05）;青壮年组中前侧入路MEPS评分、Broberg-Morrey评分与内侧入路比较,差异无统计学意义（P＞0.05）;高年龄组中前侧入路MEPS评分、Broberg-Morrey评分高于内侧入路,差异具有统计学意义（P＜0.05）。结论 年龄因素对尺骨冠状突骨折的疗效可造成一定影响,尤其是高年龄患者,更应选择创伤小、疗效更好的前侧入路进行手术。同时手术中应注意操作细节,减少手术并发症的发生。