1～14岁正常儿童胫后神经体感诱发电位正常值及其特点

目的：探讨正常儿童胫后神经（PTN）体感诱发电位（SEP）的特点及正常值。方法：对121名正常儿童进行PTN—SEP检测,分析各波的特点及各波参数随年龄变化规律。结果：PTN—SEP随年龄增长,波幅增高,使波容易辨认,波幅在个体问变异较大。左右双侧对应波的潜伏期（PL）和峰间期（IPL）比较差异无显著意义（P〉0．05）,各组男女间PL和IPL无性别差异（P〉0．05）。外周神经电位的腰髓电位（LP）、马尾电位（cE）、胭窝电位（PF）等3个波的潜伏期随年龄增长PI。延长,而P40和N45等皮层电位的PL在8岁前变化则不明显（相邻组间P〉0．05）,8岁后延长明显。PF-T12的IPL也随年龄增长而延长（相邻组间P〈0．05）;而T12-P40IPL3岁组较1岁组延长,但差异不明显,以后随年龄增长而缩短,6岁组达成人值。结论：儿童PTN—SEP的正常值按年龄组划分是完全必要的。由于各波PL受身长的影响大,因此绝对PL不宜作为PTN—SEP的异常标准。PTNSEP是评价小儿躯体感觉通路、脊髓、脑干和大脑功能的客观指标,具有较大的临床实用价值。     

Change in Tinnitus after Treatment of Vestibular Schwannoma: Microsurgery vs. Gamma Knife Radiosurgery

Purpose

Tinnitus is a very common symptom of vestibular schwannoma, present in 45 to 80% of patients. We evaluated changes in tinnitus after translabyrinthine microsurgery (TLM) or gamma knife radiosurgery (GKS).

Materials and Methods

Among 78 patients with vestibular schwannoma who underwent TLM or GKS at Severance Hospital from 2009-2012, 46 patients with pre- or postoperative tinnitus who agreed to participate were enrolled. Pure tone audiometry, tinnitus handicap inventory (THI), visual analogue scale (VAS) scores for loudness, awareness, and annoyance were measured before and after treatment. Changes of THI and VAS were analysed and compared according to treatment modality, tumour volume, and preoperative residual hearing.

Results

In the TLM group (n=27), vestibulocochlear nerves were definitely cut. There was a higher rate of tinnitus improvement in TLM group (52%) than GKS group (16%, p=0.016). The GKS group had a significantly higher rate of tinnitus worsening (74%) than TLM group (11%, p<0.001). Mean scores of THI and VAS scores significantly decreased in the TLM group in contrast to significant increases in the GKS group. Tumor volume and preoperative hearing did not affect the changes in THI or VAS.

Conclusion

GKS can save vestibulocochlear nerve continuity but may damage the cochlea, cochlear nerve and can cause worsening tinnitus. In cases where hearing preservation is not intended, microsurgery with vestibulocochlear neurectomy during tumor removal can sometimes relieve or prevent tinnitus.     

舌神经至不同下颌磨牙牙龈缘距离的关系分析

目的探讨舌神经至不同下颌磨牙牙龈缘的距离,为患者进行相关手术治疗提供可靠临床依据,尽量避免患者术后发生舌神经损伤情况,提高患者生活质量。方法在本院2000年至2012年之间所收集的成人头部标本中随机选取20例进行解剖,所有标本均已进行防腐固定措施,使用专用测量工具对标本左侧舌神经、右侧舌神经与下颌第1、2、3磨牙牙龈缘距离分别进行测量,记录测量结果并进行统计学分析,得出结论。结果左侧舌神经与右侧舌神经相距下颌第1、2、3磨牙牙龈缘水平距离、垂直距离以及45度角距离相近,且P>0.05,左侧舌神经与右侧舌神经相距下颌第1磨牙牙龈缘距离无统计学意义。结论在对患者进行下颌磨牙舌侧骨嵴修整术或阻生智齿拔除术治疗时,应根据人体舌神经解剖学知识,以及舌神经至不同下颌磨牙的牙龈缘距离范围,尽量避免对患者舌神经造成伤害,从而有效预防患者术后发生暂时性或永久性舍感觉丧失并发症,提高患者生活质量。     

舌下神经断层解剖与MRI

目的：研究舌下神经在不同断面上的位置、毗邻、走行及识别标志,为舌下神经病变的影像学诊断和外科手术提供形态学依据。方法：取用国人成年尸体头部标本69例,以冷冻切片法切制成连续横断层标本36例、矢状断层标本18例和冠状断层标本15例;招募成年志愿者10名,利用3．0TMRI扫描仪,以3D—CISS序列扫描,获取横、矢状、冠状断层图像;在上述断层标本对照下,于MR图像上观察舌下神经在断面上的形态、位置、毗邻和识别标志等。结果：在横断面上,可见枕骨基底部两侧呈倒“八”字形的舌下神经管,管内走行着舌下神经;在矢状断面上,舌下神经管呈椭圆形,位于小脑前下方,岩下窦与寰枕关节之间;在经舌下神经管外口的冠状断面上,舌下神经管外口位于寰枕关节外上方、颈内静脉内侧,其间容纳舌下神经;在经舌下神经管内口的冠状断面上,呈“鸟喙”状的舌下神经管内口居枕骨侧部内,其内侧为延髓,外侧为颈内静脉,上方为颈静脉孔,下方为寰枕关节。结论：在横、矢状和冠状断面上,均可清晰显示舌下神经的位置及毗邻结构,但以横断面和冠状面为佳。     

舌咽神经、迷走神经和副神经断层解剖与MRI

目的：探讨舌咽神经、迷走神经和副神经的走行和毗邻关系,为影像学诊断及临床开展该区手术提供形态学依据。方法：利用36例成尸头部连续横断层标本和15例成尸头部连续冠状断层标本,并与10例志愿者的3D—CISS序列MR图像进行对照,观察舌咽神经、迷走神经和副神经在颅内的走行规律及其与周围结构的位置关系。结果：舌咽、迷走和副神经由上而下从延髓的橄榄后沟发出,跨过延池,穿颈静脉孔出颅。根据走行,可分其为延髓内段、脑池段和颈静脉孔段。在脑池段,舌咽神经走行在上方,迷走神经和副神经在下方且结合紧密;在颈静脉孔段,这3对脑神经及其与颈内静脉和颈内动脉的关系是：颈内动脉位于最前方,颈内静脉位于最外侧,舌咽神经走行在前内上方,有单独的硬脊膜包绕,迷走神经和副神经位于其后外下方,形成迷走、副神经复合体。结论：在标本的连续断面和对应的MR图像上能够清楚地显示舌咽、迷走和副神经的走行和毗邻关系。     

面神经和前庭蜗神经断层解剖与MRI

目的：探讨面神经及前庭蜗神经颅内段、内耳道段的断层解剖学特征,为相关疾病的影像学诊断和外科治疗提供解剖学依据。方法：在69例成人尸体头部的连续断层标本（横断层标本36例、冠状断层标本15例、矢状断层标本18例）上分别探讨面神经、前庭蜗神经颅内段及内耳道段在断面上的走行规律及毗邻关系,并与10例活体成人头部MR扫描图像的相应层面进行对照分析。结果：面神经与前庭蜗神经自发出后相互伴行向外水平走行,穿过脑桥小脑角池后进人内耳道;内耳道是断面上识别面神经与前庭蜗神经的重要标志性结构,小脑绒球在横断层上也有助于对二者的识别。结论：横断面及冠状断面均可清晰显示面神经及前庭蜗神经颅内段,矢状断面则对二者在内耳道内走行的显示最佳。     

甲钴胺治疗新诊断2型糖尿病周围神经病变疗效观察

目的：了解甲钴胺对2型糖尿病周围神经病变的治疗效果。方法：收集住院的新诊断为2型糖尿病患者44例,做神经传导速度检查,与正常人30例比较。用甲钴胺治疗2周,复查神经传导速度,并与治疗前比较。统计学分析与对照组比较用独立样本t检验,治疗前后比较用配对t检验。结果：新诊断2型糖尿病患者神经传导速度较对照组明显降低（P〈0.05或0.01）;经甲钴胺治疗2周后,2型糖尿病组神经传导速度较治疗前明显增加（P〈0.05或0.01）。结论：新诊断2型糖尿病患者已经出现周围神经传导速度下降,甲钴胺治疗可以使其有所改善。     

腓肠肌外侧头纤维化钙化与膝及小腿后外侧疼痛

目的：探讨腓肠肌外侧头纤维化、钙化引起膝后及小腿后外侧疼痛的临床特点及治疗方法。方法：收集腓肠肌外侧头纤维化、钙化导致膝及小腿后外侧疼痛病例25例（28侧）,其中侧位X线片于股骨外侧髁后部可见明显的小豆骨22侧,仅见小钙化点6侧;均行钙化或纤维化组织包块切除,腓总神经探查松解术。结果：全部病例随访6-24个月,平均12个。术后静态及动态一过性足下垂及小腿下段与足背麻木症状消失,膝关节后外侧疼痛消失或明显缓解。结论：腓肠肌外侧头纤维化钙化是膝后外疼痛的重要原因,大多伴有腓总神经受损症状,目前对其认识欠缺,误诊率高,手术切除纤维化钙化包块、选择松解受累的腓总神经效果确切。     

腓总神经内囊肿3例报道及文献复习

目的：总结3例胭窝部腓总神经内囊肿患者的诊治过程,并对该病进行相关的文献复习,为该病的临床诊治提供一定的临床经验。方法：2011年8月-2012年3月,采用囊肿切开引流术治疗胭窝部腓总神经内囊肿3例,其中结扎、切除含囊肿腓总神经关节支2例。结果：手术均顺利。术后随访9～15个月,平均11．3月。3例患者术后4—10d胭窝部胀痛症状均消失,术后3个月第1、2趾间刺痛感消失。足背伸肌力恢复至4级者2例,恢复至3级者1例。患者均无囊肿复发表现。结论：胭窝部腓总神经内囊肿十分罕见。对于临床诊断明确的患者,目前多行手术切开神经外膜引流,同时随访囊肿复发情况及神经功能恢复情况。     

A novel method for lymphadenectomy along the left laryngeal recurrent nerve during thoracoscopic esophagectomy for esophageal carcinoma

Background

Due to limited space in the left upper mediastinum, complete dissection of lymph nodes (LN) along left recurrent laryngeal nerve (RLN) is difficult. We herein present a novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position for esophageal carcinoma. The method, suspension the esophagus and push aside trachea, allows en bloc lymphadenectomy along the left RLN from the below aortic arch to the thoracic inlet.

Methods

Between September 2014 and September 2015, a total of 110 consecutive patients with esophageal carcinoma were treated with thoraco-laparoscopic esophagectomy with cervical anastomosis in the semi-prone position. Outcomes between those who received surgery with the novel method and conventional surgery were compared.

Results

Fifty patients underwent the novel method and sixty received conventional surgery. The operative field around the left RLN was easier to explore with the novel method. The estimated blood loss was less (23.7±8.2 vs. 34.2±10.3 g, P=0.001), and the number of harvested LNs along the left RLN was greater (6.4±3.2 vs. 4.1±2.8 min, P=0.028) in the novel method group, while the duration of lymphadenectomy along left RLN was longer in the novel method group (28.2±3.9 vs. 20.3±2.8 min, P=0.005). The rate of hoarseness in the novel and conventional groups was 10% and 16.7%, respectively. No significant difference in postoperative morbidity related to the left RLN was noted between the groups.

Conclusions

The novel method during semi-prone esophagectomy for esophageal carcinoma is associated with better surgeon ergonomics and operative exposure.