选择性腰骶神经后根切断治疗痉挛性脑瘫

选择性腰骶神经后根切断治疗痉挛性脑瘫武警山东总队医院毕复海,颜国际（济南２５０１０１）１９９２年１２月～１９９４年４月,我院应用多功能方波脉冲治疗仪的电刺激,选择性地行腰骶神经后根切断术治疗８２例下肢痉挛性脑瘫患者,取得较好效果,现报告如下。１临床资...     

选择性脊神经前根选切治疗痉挛性脑瘫

近年来我们在总结前人利用脊髓半横断、脊髓纵切、脊神经后根选切、脊神经切断、周围神经切断等方法的基础上[1] ,在脊神经前根选切治疗痉挛性脑瘫方面做了些探索 ,以求避开感觉问题、保护站立肌功能。1　临床资料1.1　一般资料 :本组 8例 ,男 3例 ,女 5例 ;年龄 6～ 18岁 ,平均 10岁。全部确诊为 :痉挛性脑瘫 ,四肢型 5例 ,双肢型 3例。其中双下肢 6例 ,单侧下肢 2例 (左右各 1例 )。术前均未行软组织手术。能独立步行者 7例 ,双侧搀扶行走者 1例。智力尚可 7例 ,差 1例。随访 6个月～ 2年。平均 14个月。1.2　手术方法 :全麻插管 ,俯卧位…     

膈神经与副神经移位种植治疗臂丛撕脱伤

用３６只ＳＤ大鼠，对膈神经移位，副神经移位经腓肠神经移植种植于肱二头肌治疗臂丛撕脱伤进行比较研究。术后２、４、６月分别进行电生理学，组织学，功能测定。结果提示潜伏期，最大诱发电位，远端有髓纤维通过率，远端有髓纤维截面积，肌重，肌细胞截面积，肌肉功能测定，膈神经组优于副神经组（Ｐ〈０．０５）。实验结果表明，动力神经移位肌肉内种植是一种有一定疗效的手术方法，膈神经移位种植优于副神经移位种植。     

木丹颗粒联合中药外洗治疗糖尿病周围神经病变临床观察

目的观察木丹颗粒联合中药外洗治疗糖尿病周围神经病变的临床疗效。方法将入选的80例2型糖尿病周围神经病变患者按1：1随机分为治疗组和对照组各40例。对照组在糖尿病常规治疗基础上给予依帕司他片1：2服,3次/日,治疗组在对照组基础上给予木丹颗粒7g,3次/日,加用中药外洗治疗,2周后观察患者的神经传导速度、血液流变学及I临床症状改善情况。结果治疗组总有效率为90．0％,对照组t临床总有效率为82．5％。两组比较差异有显著性意义（P〈0．05）,治疗组优于对照组;神经传导速度、血液流变学两组比较,差异有显著性意义（P〈0．05）。结论木丹颗粒联合中药外洗治疗可以改善糖尿病周围神经病变能明显改善神经传导速度及血黏度,I临床用于治疗糖尿病周围神经病变有较好疗效。     

痉挛性脑瘫脊神经后根改变与临床研究

目的探讨痉挛性脑瘫的更佳治疗方法。方法对４７例痉挛性脑瘫病人施行高选择性脊神经后根切断术（Ｓｅｌｅｃｔｉｖｅｐｏｓｔｅｒｉｏｒｒｈｉｚｏｔｏｍｙ，ＳＰＲ），采用方波脉冲器测定仪法测定和电镜下观察脊神经后根超微结构。结果电镜观察结果，表明ＳＰＲ手术切断Ｈｚ低组为未受损脊神经后根，而未切断保留的Ｈｚ高组为受损脊神经后根。结论说明ＳＰＲ手术求得受损与未受损脊神经锥体外系神经及肌力均衡，协调了肢体平衡，促进痉挛性脑瘫病人步态恢复正常或基本正常     

2型糖尿病伴周围神经病变胫神经的超声特征

目的：探讨2型糖尿病伴周围神经病变患者跗管处胫神经的超声特征,为病情评估及治疗提供依据。资料与方法54例2型糖尿病患者分为周围神经病变组31例和无周围神经病变组23例,并选择同期22例非糖尿病患者作为对照,所有受检者内踝水平的胫神经行超声检查,比较各组胫神经的左右径、前后内径、截面积和血流情况。结果糖尿病周围神经病变组较无周围神经病变组胫神经双侧左右径及内径增大,且均较对照组增大（P<0.01）。糖尿病周围神经病变组胫神经超声主要表现为神经束回声减低、筛网状结构模糊和神经外膜增厚、不平整,与毗邻组织分界不清。糖尿病周围神经病变组、无周围神经病变组及对照组胫神经血流信号比较,差异无统计学意义（P>0.05）。结论糖尿病伴周围神经病变患者跗管处胫神经的超声特征为神经束回声减低、筛网状结构模糊和神经外膜增厚、不平整,与毗邻组织分界不清,为评估患者的周围神经病变程度以及治疗方案的选择提供形态学依据。     

突发强声刺激下神经肌肉反应时间优势的研究

目的对突发强声刺激下神经肌肉活动潜伏期及其较之意识反应的时间优势进行研究,探讨刺激强度变化对该优势的影响。方法实验一:以110 dB强声低调纯音刺激诱发神经肌肉活动,通过表面肌电技术考察突发性强刺激下神经肌肉活动相对于意识反应的潜伏期及其时间优势;实验二:在实验一结果的基础上,测定不同强声刺激(90 dB,100 dB,110 dB)对诱发神经肌肉活动影响的变化。结果 1)当背景刺激为55～60 dB,诱发刺激为110 dB时,突发强声刺激条件下神经肌肉的反应潜伏期显著快于意识反应活动,时间优势可达1178 ms。2)90 dB组、100 dB组、110 dB组下产生惊跳反射的受试者人数存在显著差异(P<0.01),但3组间的反应潜伏期、最大振幅及时间优势效应、干扰效应没有显著差异(P>0.01)。结论 1)突发刺激下神经肌肉活动具有显著时间优势,且会对当前的任务造成干扰;2)突发强声刺激对机体意识反应活动的干扰效应有随刺激强度增强而增大的趋势,但神经肌肉反应的时间优势效应量以及神经肌肉反应的幅度不受刺激强度的影响。     

SPR治疗脊髓损伤后肢体痉挛及神经根的组织化学研究

探讨选择性脊神经后切断术（SPR）治疗脊髓损伤后肢体痉挛的效果并对其腰骶神经根进行组织学和组织化学研究，采用L2－S1双侧节段开窗式部分椎板切除，保留棘突和棘间，棘上韧带，显露双侧L2－S1神经根出口处，将前后根分开，分束，测定各后根束阈值，阈值较低的后根小束切断，。对切取的神经束进行冰冻切片，染色，固定和组织化学处理，结果发现，临床应用29例，随访3年疗效满意，痉挛解除率为90％，功能改善率为80％，切除的神经后根纤维Ache反应阳性，后根同感觉支传入纤维相混合，说明采用选择性脊神经后根切断术能有效治疗脊髓损伤后肢体痉挛，在选择性脊神经后根切断术中电刺激选择是必要的。     

通心络胶囊联合依帕司他治疗糖尿病周围神经病变45例临床观察

目的观察通心络胶囊联合依帕司他治疗糖尿病周围神经病变（DPN）的疗效。方法选取2型糖尿病周围神经病变患者90例,随机分为对照组及治疗组各45例,两组患者在糖尿病病程、周围神经病变程度、HbA1c、降糖措施及营养神经等基础治疗方面具有可比性。对照组服用依帕司他（50mg,3次/日）,治疗组在对照组基础上加服通心络胶囊（3粒,3次/日）,3个月为1疗程。比较两组治疗前后临床疗效及正中神经、腓总神经运动神经传导速度（MCV）及感觉神经传导速度（SCV）变化情况。结果治疗组与对照组总有效率比较有统计学意义（P〈0.05）,治疗组治疗前后正中神经及腓总神经MCV及SCV比较有统计学意义（P〈0.05）,对照组治疗前后正中神经MCV及SCV比较有统计学意义（P〈0.05）,对照组治疗前后MCV及SCV比较无统计学意义（P〉0.05）。结论通心络胶囊联合依帕司他治疗糖尿病周围神经病变可提高疗效,尤其在改善下肢周围神经病变方面意义显著,联合用药未增加不良反应。     

硫辛酸联合甲钴胺用于临床分组治疗2型糖尿病周围神经病变疗效研究

目的：分析2型糖尿病周围神经病变采用硫辛酸联合甲钴胺治疗的临床效果。方法将57例2型糖尿病周围神经病变患者根据治疗方式不同分为两组,对照组（27例）给予甲钴胺治疗,观察组（30例）给予硫辛酸联合甲钴胺治疗,对比两组治疗效果、治疗前后症状评分情况及神经传导速度变化情况。结果观察组治疗总有效率为93.3％,明显高于对照组的59.3％（ P＜0.05）;且治疗后观察组症状评分、神经传导速度较治疗前显著改善,且优于对照组,差异显著（ P＜0.05）。结论2型糖尿病周围神经病变患者采用硫辛酸联合甲钴胺治疗可显著改善麻木、感觉异常等临床症状,提升治疗效果,是一种安全、可靠的治疗方式。     

选择性腰5、骶1脊神经后根切断术加内收肌切断术治疗下肢痉挛的研究

采用选择性腰 5、骶 1脊神经后根切断术 内收肌切断术治疗成人脑外伤后、脑瘫、脊髓损伤后下肢痉挛 2 9例 ,术前术后进行步态分析。术前 3天进行步态分析 ,术中于大腿内侧将内收肌腱性部分切断松解内收肌 ,将痉挛下肢的腰 5、骶 1的脊神经后根进行分束 ,电刺激仪测阈值后将阈值较低的神经束切断。2 9例随访 3年 ,痉挛解除率 90 %,功能改善率 80 %。术后步态与术前比较有明显改善。说明选择性腰 5、骶 1脊神经后根切断术 内收肌切断术能较有效的治疗成人脑外伤后、脑瘫、脊髓损伤后肢体痉挛。     

选择性脊神经后根切断术和二期矫形手术治疗痉挛性脑瘫疗效分析

目的探讨选择性脊神经后根切断术（SPR）和二期矫形手术治疗痉挛性脑瘫的手术效果。方法回顾分析1999年6月至2008年7月外科手术治疗并得到2年以上随访的368例病例,观察术后痉挛解除情况,运动功能改变情况,伴随症状和体征改变情况。结果本组病例术前平均肌张力为3.35±0.38级,术后平均为1.24±0.21级。治疗前后比较,下肢痉挛均有明显改善,差异性非常显著（t=19.537,P〈0.001）。其运动功能明显好转,在能独立行走81例中有70例步态明显改善,介助行走155例中93例变为可独立行走,爬行117例病例中48例可独立行走,22例可介助站立或行走。伴随症状也有不同程度的改善,流涎203例中92例减轻,斜视183例中40例减轻,语言功能障碍157例中21例发音改善。82例有上肢痉挛的病例中28例上肢痉挛程度减轻。结论 SPR在解除肢体痉挛和改善功能方面效果确切,SPR和二期矫形手术相结合是外科治疗的理想方法,是痉挛性脑瘫治疗中的一个重要环节。     

Endovascular treatment of peripheral intracranial aneurysms

BACKGROUND AND PURPOSE: Distally located cerebral aneurysms are difficult to treat with preservation of the parent vessel. We report the angiographic results and clinical outcome for 27 patients with peripheral cerebral aneurysms. METHODS: From January 2000 to June 2005, 27 patients, 13 female and 14 male, presented to our institution with peripheral intracranial aneurysms and were treated endovascularly. None of these aneurysms were mycotic in origin. The age of our patients ranged from 23 to 76 years with a mean age of 53. Twenty of the 27 patients had subarachnoid and/or intracerebral hemorrhage upon presentation. In 5 patients, the aneurysm was an incidental finding. One patient with a fusiform P2 aneurysm presented with cranial nerve III palsy, and another patient with P4 aneurysm had visual disturbances. Locations of the aneurysms were as follows: posterior cerebral artery in 9 patients, superior cerebellar artery in 5 patients, anterior inferior cerebellar artery in 1 patient, posterior inferior cerebellar artery in 5 patients, middle cerebral artery (MCA) in 5 patients, and anterior cerebral artery in 2 patients. RESULTS: Seven patients were treated with selective embolization with Guglielmi detachable coils (GDCs). Nineteen patients with fusiform aneurysms underwent parent artery occlusion (PAO). Fifteen PAOs were performed with coils and 4 with glue. One patient with a MCA aneurysm was found at the time of planned embolization to have spontaneously thrombosed the aneurysm and the distal branch of the MCA, 1 day after the initial diagnostic angiogram. Five patients (5/18 or 27.7%) who underwent PAO developed neurologic deficits. Two patients (2/18 or 11.1%) had permanent neurologic deficits (a visual field defect). CONCLUSION: Our results support that distally located aneurysms can be treated with endovascular PAO in the cases in which selective occlusion of the aneurysmal sac with GDC or surgical clipping cannot be achieved.     

Selective dorsal rhizotomy as a treatment option for children with spastic cerebral palsy

Cerebral palsy is the most common motor disorder originating in childhood and spasticity is the most frequent manifestation. The treatment strategies to reduce spasticity and thereby ameliorate the attendant gait abnormalities have included physiotherapy, orthoses, antispastic medications, orthopaedic surgery and neurosurgery. Of these, the neurosurgical procedure known as selective dorsal rhizotomy has gained widespread exposure, and indeed acceptance, over the past two decades, despite there being some controversy as to its efficacy. In this paper we review: cerebral palsy, including classification and treatment; selective dorsal rhizotomy, including historical background, patient selection, operative procedure, clinical outcome and complications; and gait analysis studies, including temporal-distance parameters, joint kinematics, normalisation for growth, and long-term follow-up. Both the short-term (1 year) and long-term (10 years) evidence has demonstrated that selective dorsal rhizotomy not only reduces spasticity but it also provides lasting functional benefits as measured by improved range of motion during gait. Rhizotomy is not a panacea for children with spastic diplegia but it is an important treatment option for the clinician to consider. Copyright 1998 Elsevier Science B.V.     

单纯运动或感觉神经损伤在骨骼肌萎缩中的致凋亡作用

目的探讨单纯运动神经或感觉神经损伤在骨骼肌萎缩中的致凋亡作用。方法健康成年SD大鼠30只,随机分为前根切断组(切断左侧L4-L6脊神经前根)、后根切断组(切断左侧L4-L6脊神经后根)和坐骨神经切断组(切断左侧坐骨神经),每组10只。10周后取左右两侧腓肠肌,应用荧光标记、电镜技术以及免疫组化方法观察单纯运动或感觉神经损伤后骨骼肌细胞的凋亡表现及Fas/FasL的表达变化。结果失神经支配10周后,骨骼肌细胞出现各种凋亡变化,细胞核凋亡形态明显,其中后根切断组、前根切断组和坐骨神经切断组的细胞核排列密集程度依次增加,Fas/FasL表达依次增强。电镜观察可见失神经支配的骨骼肌细胞未见典型的凋亡小体,但出现凋亡前期的形态改变。结论运动神经损伤对骨骼肌萎缩的影响大于感觉神经损伤,临床治疗失神经支配的骨骼肌萎缩应优先考虑重建运动神经。     

Muscle activation characteristics of stance balance control in children with spastic cerebral palsy

Two studies were conducted to investigate muscle recruitment of children with spastic cerebral palsy in response to unexpected perturbation of balance in stance. The aim of the studies was to investigate neural and non-neural mechanical contributions to muscle responses differences these children display when maintaining balance. In the first study, muscle responses of children with spastic diplegia were compared to typically developing children with similar levels of walking experience. Each child stood on a moveable platform that was displaced backward. Electromyographic recordings of posterior agonist and anterior antagonist muscles of the legs and trunk were analyzed and compared to those of normal children who had obtained a similar developmental levels of mobility. Children with spastic cerebral palsy were found to have an increase in antagonist recruitment and decreased trunk activation when compared to typically developing children at the same level of walking experience. Developmental trends were noted to be similar in all children with or without pathology. As children gained independent walking skills, they demonstrated shorter onset latencies in leg and thigh muscles. In the second study, older children with no pathology were perturbed in crouch stance, simulating the posture of their matched children with cerebral palsy. Changes in their muscle responses were observed to more clearly approximate the muscle onset latency organization of children with spastic diplegia. Results of these studies suggest that muscle recruitment differences for balance control in children with spasticity are due to CNS deficits as well as mechanical changes in posture.     

Injection of botulinum A toxin into the gastrocnemius muscle of patients with cerebral palsy: a 3-dimensional motion analysis study

Botulinum A toxin (BOTOX^®) was injected into the gastrocnemius muscle of 26 cerebral palsy subjects with equinus gait. All subjects were equinus walkers without fixed contracture of the triceps-surae muscle. Injections were performed at 3 month intervals, if needed, as determined by the treating clinician. There were 14 subjects with spastic hemiplegia, 11 subjects with spastic diplegia and 1 subject with spastic quadriplegia. In the case of those subjects with bilateral equinus gait the dose was divided and given into both the right and left gastrocnemius muscle. Gait analysis data was collected prior to the first injection and subsequently at 3 month intervals for 1 year. Kinematic and electromyographic data was obtained. This data was analyzed to provide objective information about the outcome of treatment. Four subjects moved away and were lost to follow-up. Seven subjects left the study to have surgery. The data collected revealed statistically significant improvements in dynamic ankle dorsiflexion in both stance and swing phases, stride length, and electromyography of the tibialis anterior. There were no complications. While the results of this study are promising, additional prospective studies are needed to determine the feasibility of preventing muscle contractures over a longer time period. Furthermore, there is a need for inclusion of other muscles in future research. Future research should also compare BOTOX^® treatment with alternative methods of dealing with muscle spasticity such as: casting, orthotic devices, physical therapy, selective dorsal rhizotomy, and surgical lengthening.     

大鼠自体神经移植与外周神经挤压再生模型脊髓背角c-fos表达的比较研究

目的建立大鼠外周神经挤压神经再生模型和大鼠外周神经自体神经移植神经再生模型,观察对比各模型神经恢复过程中机械痛觉超敏的变化及脊髓背角c-fos表达的改变,探讨两种神经再生模型中神经再生与神经性疼痛的联系。方法雄性Wistar大鼠60只随机均分成3组,A组为坐骨神经挤压模型组;B组为自体神经移植模型组;C组为假手术组。分别制成模型后,术后18d起检测机械刺激阈值及c-fos表达计数。结果A、B组各项指标与C组比较有显著差异;A组各指标与B组有显著差异。结论两种模型再生神经生长进入去神经支配区域时,均出现支配区域的痛觉超敏和疼痛相关行为,神经性疼痛的发生时间、强度以及恢复均有不同,并和神经再生情况相关,提示神经性疼痛是评估神经功能恢复的一个重要的参数。     

Muscle activity in children with spastic unilateral cerebral palsy when walking with ankle-foot orthoses: an explorative study

BackgroundA hinged ankle-foot orthosis is prescribed for children with spastic unilateral cerebral palsy to improve gait function by correcting spastic equinus. However, little is known about how orthotic management relates to muscle activity during walking in this population.Research questionDoes muscle activity in medial gastrocnemius and tibialis anterior change in children with spastic unilateral cerebral palsy when walking with hinged ankle-foot orthoses featuring two different footplate designs?MethodsIn this prospective, repeated-measures trial, electromyographic activity in medial gastrocnemius and tibialis anterior was recorded from 17 children (mean age: 8.4 years ± 1.3 years) with spastic unilateral cerebral palsy walking barefoot and with two designs of hinged ankle-foot orthosis. The orthotic devices consisted of custom-made hinged ankle-foot orthoses with unmodified, flatter footplates and rectified, contoured footplates. Primary outcome measures were total muscle activity, quantified as the area under a linear envelope, and relative change in profiles of muscle activity, depicted by curves of mean difference with 95% confidence bands.ResultsNo statistical difference was found in total activity of either muscle for the ankle-foot orthosis with an unmodified footplate but a significant reduction in muscle activity of tibialis anterior was seen for the ankle-foot orthosis with a contoured footplate relative to barefoot walking. Profiles of change in muscle activity were significantly altered for both shank muscles between all walking conditions. The most pronounced differences were decreased activity in medial gastrocnemius during early stance phase and lower activity in tibialis anterior during swing phase with orthotic devices.SignificanceOrthotic management with hinged ankle-foot orthoses may mitigate spastic activation of medial gastrocnemius in children with spastic unilateral cerebral palsy but also appears to functionally inactivate tibialis anterior during gait. The hinged ankle-foot orthosis with an unmodified footplate corresponded with better performance by facilitating more functional muscle activity while impeding spastic response.