阴部神经的观测及其临床意义

本文用经过福尔马林固定的成人尸体60侧(男34,女26)。测量分析了阴部神经出盆腔后在梨状肌下孔处、坐骨小孔处、分支前及三个分支始部横径,男女性间作了统计学处理,其中阴茎(蒂)背神经始部横径男性为1.36±0.05 mm,女性为1.22±0.03mm,t=2`23,P<0.05,男女性间有显著性差异。观察分析了阴部神经在坐骨小孔内和阴部管内与血管的排列情况,测量了阴部神经在阴部管内离坐骨结节下缘上方的距离,对阴部神经阻滞麻醉的位置进行了探讨。     

第九、十、十一肋间神经和肋下神经与阴部神经吻接术治疗截瘫的应用解剖

在供研究用的20具(男13女7)成人尸体上,对40侧九、十、十一肋间神经和肋下神经进行了应用解剖研究。可取长度平均值分别为111.11mm。100.88mm,81.28mm,和64.20mm,分支处的宽、厚度平均值分别为2.59和1.12mm,2.58和0.08mm,2.89和0.10mm,3.49和1.04mm。游离切断各肋间神经远侧端,在肩胛线上垂直下拉,观察了其末端与腰椎棘突的对应关系,并测量了其与阴部神经出盆处之间的距离。阴部神经长度及出盆处的宽、厚度平均值分別为31.35mm,4.87mm和1.59mm。本文认为用带血管蒂的腓肠神经作为供体桥接下位肋间神经与阴部神经,为截瘫病人的外科治疗提供了一种新的方法。     

男性尿道膜部括约肌支配神经的应用解剖

目的:为根治性膀胱前列腺切除手术中保护尿道控尿神经提供解剖学依据。方法:对15例成年男性尸体盆腔标本进行解剖,观察支配尿道膜部括约肌神经的组成、形态及毗邻关系。结果:尿道膜部括约肌接受下腹下丛和阴部神经盆内盆外分支支配,其中盆神经起源于下腹下丛远端盆内脏神经分支,沿肛提肌表面到达尿道膜部5点和7点位;40%的标本中阴部神经存在盆内分支,此分支自阴部管内的阴部神经主干穿肛提肌进入盆内,与盆神经一起支配尿道膜部括约肌,其进入尿道膜部的位置距离前列腺尖部(5.3±1.8)mm。在53.3%的标本中阴茎背神经发出分支到达尿道膜部,此分支进入尿道膜部的位置距离前列腺尖部(4.2±1.1)mm。结论:根治性膀胱前列腺切除术中对控尿神经的保护是多方面的,术中对精囊和前列腺尖部的操作最易损伤控尿神经。     

小趾展肌神经与神经源性跟痛症关系的解剖学基础

目的　探讨小趾展肌神经的局部解剖特点及其与神经源性跟痛症的关系,为临床诊断治疗提供解剖学依据。 方法　32侧防腐成人尸体下肢标本,解剖观察小趾展肌神经的起源、分支、走行和分布特点。 结果　小趾展肌神经81.25%起源于足底外侧神经,起点59.38%位于后上象限;起点与参考线的垂直深度,左侧（10.81±0.96）mm,右侧（10.24±1.10）mm;小趾展肌神经发出1～3支骨膜支到达跟骨结节内侧突的骨膜;小趾展肌神经与跟骨结节内侧突该的水平距离左侧（19.95±1.82）mm,右侧（20.89±2.48）　mm 。 结论　小趾展肌神经行经　展肌和足底方肌内侧头之间,跟骨结节内侧突前可能被卡压,卡压或病变（特别是骨膜支）可能与足底腱膜炎发生有关;跟骨骨刺不一定会造成神经源性跟痛症。     

肩胛上神经卡压机制的临床解剖学研究

目的　探讨肩胛上神经卡压症的解剖学机制,为临床诊断和治疗提供解剖学依据。 方法　22具(男13具,女9具)44侧成尸标本,解剖观测肩胛上切迹,冈盂切迹的形态特点以及肩胛上神经走行、分支及分布的解剖学特点,所测数据统计学处理。 结果　肩胛上切迹类型：U型占40.91%（18侧）,浅U型占22.73%（10侧）,大弧型占27.27%（12侧）,方形占9.01%（4侧）四种。肩胛上切迹的厚度为（1.55±0.36）mm。肩胛上神经主干与冈上肌支所成角为(86.04±1.28)°。冈下肌支的入肌点,有22.73%在该肌的起点处,77.27%在中或外1/3处。冈盂切迹的厚度在（6.82±1.21）mm 。肩胛上神经自肩胛上孔穿出点至肩胛冈基底部的高度为（11.13±0.21）mm;至冈盂切迹的水平距离为（14.03±0.64）mm 。肩胛上神经转折角为（49.65±1.63）°。 结论　肩胛上切迹的类型、肩胛上切迹和冈盂切迹的厚度,肩胛上神经转折角的大小、神经主干与冈上肌支的角度以及冈下肌支的入肌点等均是肩胛上神经卡压的危险因素。     

膝降血管髌下支蒂股骨内侧髁骨膜瓣逆行转位术的应用解剖

目的　为膝降血管髌下支蒂股骨内侧髁骨膜瓣修复膝关节面缺损提供解剖学基础。 方法　在30侧动脉内灌注红色乳胶的成人下肢标本上,以收肌结节、股骨内侧髁为观测点解剖观测膝降动脉关节支的走行、分支与分布。另在1侧新鲜标本上进行摹拟手术。 结果　膝降血管关节支在距股骨内侧髁下缘上(5.9±1.2) cm处发出两大分支：①骨膜支起始外径（1.3±0.2）mm,在股骨内侧髁面上走行距离为(4.8±1.1) cm;②髌下支起始外径为(1.3±0.2) mm,向下走行距离为(6.6±1.5)cm。 结论　可形成膝降血管髌下支-骨膜支蒂股骨内侧髁骨膜瓣逆行转位修复膝关节面缺损。     

女性尿道括约肌支配神经的应用解剖

目的:为根治性膀胱切除手术中保护尿道控尿神经提供解剖学依据。方法:通过对14例成年女性尸体盆腔标本全面的神经解剖学研究,观察女性尿道控尿神经的走向、组成、形态及其毗邻关系。结果:控尿神经是由下腹下丛和阴部神经盆内盆外分支组成,其中盆神经是下腹下丛远端盆内脏神经分支,沿肛提肌表面到达尿道5点和7点位。71.4%的标本中发现阴部神经存在盆内分支,此分支自阴部管内的阴部神经主干穿肛提肌进入盆内,大约在接近尿道括约肌时汇入盆神经共同进入尿道括约肌,其进入尿道的位置距离膀胱颈平面(12.6±1.6)m m。另外在42.9%的标本中阴蒂背神经发出分支到达尿道,此分支进入尿道的位置距离膀胱颈平面(21.6±1.9)m m。结论:女性尿道的控尿神经是由盆神经和阴部神经的盆内盆外分支组成。在根治性膀胱切除手术中,膀胱颈平面以下尿道周围的操作易损伤控尿神经。     

肌皮神经肌支的定位及临床意义

目的探讨肌皮神经肌支的分支类型及其精确的体表定位方法.方法上肢标本58侧,仔细解剖观测肌皮神经走行、分支的横径和长度等.结果(1)肌皮神经穿过喙肱肌的位置距肩峰为(5.95±1.03)cm;(2)肱二头肌支起始处距肩峰距离男(12.02±1.68)cm,女(10.35±1.88)cm,分别为肩峰-外上髁长度的(41.12±4.46)%和(36.91±6.55)%;起始点横径男(1.27±0.37)mm,女(1.43±0.42)mm.短头肌支的长男(3.66±13.7)cm,女(5.07±2.05)cm,长头肌支的长男(4.27±1.37)cm,女(5.25±1.95)cm;(3)肱肌支起始处距肩峰距离为男(15.27±2.76)cm,女(12.72±2.01)cm,分别为肩峰-外上髁长度的(52.50±9.60)%和(45.42±6.97)%.起始点横径(1.35±0.40)mm,长为(5.88±2.19)cm.结论将肱二头肌支和肱肌支在肌皮神经发出点定位表达以肩峰与外上髁距离的百分比,可避免因个体差异而对肌支起点定位产生的误差,为临床提供更为便捷、可靠、实用的解剖依据.     

臀下神经转位阴部神经的应用解剖

目的：为重建单纯脊髓圆锥或阴部神经损伤后的会阴部功能提供解剖学基础。方法：对成人尸体的臀下神经和阴部神经进行了观测。结果：臀下神经以1支(45．00％)或2支(46．67％)从盆腔穿出为多，其中85．00％穿梨状肌下孔；其穿出点的位置主要在髂后上棘与坐骨结节连线的中1／3(50．00％)或上、中1／3交界处(48．33％)。神经干的长大于3cm，与阴部神经穿出处相距仅约2cm。阴部神经出盆处主要在髂后上棘与坐骨结节连线中1／3(46．67％)或中、下1／3交界(50．00％)。结论：两神经出盆处位置接近，臀下神经的长度足以直接与阴部神经缝接，用脊髓起源节段高的臀下神经转位脊髓起源节段低的阴部神经，切实易行。     

上颌神经的解剖研究及其临床意义

目的　为翼腭窝内上颌神经手术提供解剖依据。 方法　在15个成人头颅部标本中解剖观测上颌神经出圆孔处到鼻腔外侧壁、正中矢状面的距离,观察上颌神经与上颌动脉的关系。 结果　上颌神经出圆孔处到鼻腔外侧壁的距离为（13.78±2.18）mm;距正中矢状面的距离为（17.89±2.67）mm 。上颌神经与上颌动脉的位置关系是：63.3％动脉位于神经的外下方,37.7％在神经下方。 上颌神经与上颌动脉之间的距离为 （7.68±1.35）mm（6.60~11.10 mm）。 结论　本研究可为上颌神经手术提供解剖学参数。     

Surgical anatomy of the pudendal nerve and its clinical implications

A study of the surgical anatomy of the pudendal nerve (PN) was performed in 13 female and 7 male cadavers. The knowledge of the precise anatomy and anomalies of this important nerve would help in better localization of the nerve and its roots and branches for neurostimulation or for pudendal canal decompression in pudendal canal syndrome. Two routes were used in the dissection: gluteal and perineal. The PN was identified and its course was followed from its roots to its termination. The PN was composed of three roots derived from the 2nd, 3rd, and 4th anterior sacral rami (S 2,3,4). The roots received a contribution from S 1 in five cadavers and from S 5 in one. The three roots formed two cords. The first root continued as the upper cord while the second and third root fused together producing the lower cord. The PN was formed by union of the two cords a short distance proximal to the sacrospinous ligament, and then crossed the back of the ligament. In no specimen did the nerve cross the ischial spine. The inferior rectal nerve arose from the PN in the pudendal canal in 18 cadavers. In two cases it came out proximal to the canal; this would spare the two subjects the anorectal manifestations of the pudendal canal syndrome. As the PN crossed the back of the sacrospinous ligament, it gave origin to a branch that supplied the levator ani muscle. This branch was only found in male cadavers and we call it “accessory rectal nerve”; the levator ani muscle in such cadavers was doubly innervated on its perineal aspect. © 1995 WiIey-Liss, Inc.     

Anatomical basis of transgluteal pudendal nerve block

Background  The pudendal nerve may become entrapped either within the pudendal canal or near the sacrotuberous ligament resulting in a partial conduction block. The goal of the present anatomical study was to assess a new transgluteal injection technique in terms of the precise injection site and the resulting distribution of the injected agent. Materials and methods  This study was carried out using eight fresh human cadavers. An epidural needle with a removable wing was inserted and the catheter position visualized using MRI. Through the catheter 10 ml of gadolinium contrast medium was injected into three of the cadavers. A further four cadavers were injected with latex and blue pigment and the pelvi-perineal area of each then separated from the trunk for freezing before being cut into 4–8 mm thick sections with an electric bandsaw. One final cadaver was injected with a mix of gadolinium (5 ml) and latex (5 ml) and both the MRI and anatomical procedures outlined above were performed. Results  Using MRI, we clearly imaged both the site of injection, near the trunk of the pudendal nerve, and the gadolinium contrast medium in different pelvic and perineal areas and around the fascia of the obturator internus and levator ani muscle. Concerning the anatomical study, latex was observed mainly around the sacrotuberous ligament, along the obturator internus muscle and in the perineal area in contact with the dividing branches of the pudendal nerve. The mixed injection of latex and gadolinium in the pudendal canal was found with the same localization between MRI and anatomical studies. Conclusion  This easily performed technique should provide a new approach for treating perineal neuralgia via pudendal nerve block in the consultation room without the need for computed tomography.     

Caverno-pudendal nervous communicating branches in the penile hilum

Classically, the peripheral neural pathways for erection are proerectile, issuing from the parasympathetic sacral fibres, and antierectile from the thoracolumbar sympathetic trunk. The cavernous nerves as terminal branches of the pelvic plexus convey the parasympathetic fibres to the penis. The pudendal nerve conveys sensory fibres from the penis and somatic fibres to the bulbospongiosus and ischiocavernosus striated mm. In animals, it has been demonstrated that the dorsal nerve of the penis contains sympathetic fibres. These findings suggest that communicating branches exist between the cavernous nerves and the dorsal nerve. Our aim in this study was to demonstrate the presence of such connections in man. We dissected 20 fresh male cadavers. The pelvic plexus and pudendal nerves were dissected to identify their terminal branches and connections. Histologic study was performed. Our results showed evidence of communicating nervous branches between the cavernous nerves and the dorsal nerve of the penis. Several variants existed concerning the number and type of connections. The presence of such communicating branches proves that the supralevator and infralevator neural pathways communicate and suggest the possibility of a kind of plasticity of the nervous supply of penile erection. Further studies are needed to identify the nature of these communicating branches.     

骨间后神经及其拇示指肌支的解剖学特征

目的　观察前臂骨间后神经及其拇示指肌支的解剖学特征。 方法　解剖43具尸体的86侧上肢部桡神经深支及其分支到腕背部,观测骨间后神经的行程与投影及其拇示指肌支起始部位横径、长度和骨性标志线与神经干间夹角关系等参数。 结果　骨间后神经及其各分支均呈扁薄的窄带状神经束,其主干和多数肌支都走行在前臂后面中2/4段浅、深层肌之间,终末支止于腕背侧的梭形膨大部;主干起始处横径为（3.79±0.64）mm,各分支在起始部的平均横径（除指伸肌支约2.0 mm外）均小于1.0 mm;在旋后位,它呈向桡侧开放的弓形线段投影在肱骨外上髁至尺骨茎突连线的尺侧,半旋前位时则投影于该连线上或其桡侧。 结论　前臂后面中2/4段是骨间后神经主干及其大多数拇示指肌支在临床上易被损伤、误伤发生的高风险区域。     

The probability of finding nerve branches to the external anal sphincter

Introduction  Normal defecation is a combination of several elements of reflex and voluntary functions. The issue of external anal sphincter innervation is of theoretical and clinical significance; however, literature on the subject is still scarce. Most study reports discuss the course of the pudendal nerve with no close insight into inferior rectal nerves supply to the external anal sphincter. We have not found any statistical “mapping” of the site of the nerve branches insertion into the external anal sphincter. Thus, the purpose of the present study was to determine the least and most typical location of nerve branches to the external anal sphincter. One hundred and ten pudendal nerve preparations were analysed. Following the dissection of the pudendal nerve and its branches, a beam compass was used to take linear measurements from the apex of the coccygeal bone to the point of nerve branch insertion to the external anal sphincter. The distance between coccygeal bone apex and the central tendon of the perineum was also measured. For the purpose of comparison, results are presented as relative Bi/A values. Computer programmes devised by the author of this paper within Turbo Pascal were then used to determine the probability of finding nerve branches to the external anal sphincter. Results  Based on the analysis of 110 preparations of the pudendal nerve and its branches, one might conclude that the former was the main although not necessarily the only source of external anal sphincter innervation. While analysing the most and the least probable location of nerve branches to the external anal sphincter, the muscle length was expressed as percentage, i.e., 0% of sphincter length = the apex of the coccygeal bone; 100% of sphincter length = the central tendon of the perineum. The length was then divided into 5% intervals with the probability of finding nerve branches determined by programmes written in Pascal. Within 30–85% of external anal sphincter length, the probability of finding nerve branches to the external anal sphincter is greater than 0.3 with peak probability of 0.68 in the interval between 55 and 65%. Discussion  Sphincter innervation and clinicoanatomical function of anal canal closure apparatus has been discussed with reference to external anal sphincter injury. Transcutaneous electrostimulation of the pudendal nerve and the use of anal canal electrodes have also been mentioned. Conclusions  The most probable location of nerve branches to the external anal sphincter is half way of its length, i.e., at hour 3 or 9 of the knee-elbow position or lithotomy position. The external anal sphincter can also be directly supplied by nerve branches originating from the sacral nerve root S4; the branches then go towards the posterior part of the sphincter.     

Anatomic bases of graciloplasty using end-to-side nerve pudendal anastomosis

The objective of this study was to evaluate the possibilities of reinnervation of the gracilis muscle, transposed around the anus, by the pudendal nerve using an end-to-side nerve anastomosis. This study was carried out in 14 cases (7 adult human cadavers bilaterally). The gracilis muscle and its vascular-nervous bundle have been dissected and the nerve innervating the gracilis muscle has been cut at its origin. The gracilis muscle, accompanied by its nerve, has then been transposed around the anus. The pudendal nerve has been dissected from its extrapelvic part. The reinnervation using an end-to-side nerve anastomosis has been considered as feasible when the proximal ending of the nerve of the gracilis was put into a tension-free contact with the extrapelvic part of the pudendal nerve. The extrapelvic part of the pudendal nerve has a common trunk in 12 cases. The width of the extrapelvic part of the pudendal nerve was 2.6±0.7 mm, range 1–3.5. The width of the proximal endings of the nerve innervating the gracilis muscle was 2.3±0.5 mm, range 2–3. The reinnervation of the gracilis muscle by the pudendal nerve has been possible in 14 cases. An average supplementary length of 17.4±15.4 mm was available (range 5–52). These results suggest an eventual practical aspect of this technique for the reconstruction of a functional sphincter using the gracilis muscle transposed around the anus.     

跟内侧神经与神经源性跟痛症关系的解剖学基础

目的　探讨跟内侧神经的局部解剖特点及其与神经源性跟痛症的关系，为临床诊断治疗提供解剖学依据。 方法　32侧防腐成人尸体下肢标本，解剖观察跟内侧神经的起源、分支、走行和分布特点。 结果　跟内侧神经41.42%起源于胫神经，28.57%起源于胫神经分叉处，18.57%起源于足底内侧神经，11.42%起源于足底外侧神经。起点距O点（内踝尖最下缘与跟骨结节内侧突连线中点）(30.22±15.34)mm。跟内侧神经穿出屈肌支持带后分布于足跟内侧及跟底的皮肤和跟垫组织。 结论　跟内侧神经在踝管内，浅出屈肌支持带处及跟管内可能被卡压；神经卡压或病变可能与足底腱膜炎发生及疼痛有关。