尺神经部分转位肌皮神经二头肌支治疗早晚期臂丛神经损伤

[目的]臂丛神经上中干损伤的修复治疗中肘屈曲功能是最为重要的.在已有的几种恢复肘关节屈曲功能的神经转位手术中,部分尺神经转位肌皮神经的手术(Oberlin' s method)是最新的方法.本报告应用Oberlin' s手术治疗早期和晚期臂丛神经上中干损伤的初步经验.[方法]5例臂丛神经上中干损伤的患者采用了Oberlin's手术进行伤肢肘关节屈曲功能的恢复治疗.患者平均年龄28岁,随访6～15个月.早期手术2例,分别伤后6个月和8个月手术.晚期病例3例,分别于伤后12～18个月实施手术.术后持续性进行肱二头肌、肘关节屈曲肌力、手内肌握力、尺神经支配区感觉测试.[结果]所有病例都恢复了肘关节的屈曲功能,都有3级以上的肱二头肌肌力恢复.2例早期病例术后1周内出现肱二头肌主动收缩,肘关节主动屈曲功能正常恢复时间平均6个月,平均肌力恢复4+级.3例晚期病例术后平均3个月出现肱二头肌收缩,肘关节主动屈曲功能正常恢复时间平均10个月,平均肌力恢复3+级.3例术后出现尺神经支配区感觉减退,1个月后自动恢复.[结论]Oberlin' s手术是治疗臂丛神经上中干损伤,快速有效恢复肘关节主动屈曲功能的有效方式.     

Brachialis muscle transfer to reconstruct finger flexion or wrist extension in brachial plexus palsy

PURPOSE: Tendon transfers are a routine procedure used to improve hand function in brachial plexus injuries; however, muscles from forearm donors are not always available for transfer. In this situation a distant muscle may be used. This study describes transfer of the brachialis muscle to the forearm muscles to reconstruct finger flexion or wrist extension in patients with brachial plexus injuries. METHODS: In 6 patients the brachialis muscle was transferred to the flexor digitorum profundus and the flexor pollicis longus to restore finger and thumb flexion with the goal of reconstructing a key pinch and hook grasp. In 3 patients the brachialis muscle was transferred to the extensor carpi radialis brevis to restore wrist extension. The patients were evaluated at regular intervals and had final assessments between 10 and 12 months after surgery. RESULTS: Brachialis transfer to the flexor digitorum profundus and the flexor pollicis longus resulted in active motion with full range of digital flexion in the 2 patients who had partial flexion before surgery, and for the 4 patients who had no finger flexion before surgery it resulted in a pulp-to-palm distance for the middle finger of 1 cm in 3 patients and of 2 cm in 1 patient. A lateral key pinch and hook grasp reconstruction was achieved in all patients. Grasping and lateral pinch strengths averaged 110 and 94 mm Hg, respectively. When the brachialis was transferred to the wrist extensors the patients recovered 20 degrees of active wrist extension against resistance. CONCLUSIONS: Brachialis muscle transfer to the forearm muscle constitutes a valid strategy in the reconstruction of finger and thumb flexion and wrist extension after brachial plexus injury when forearm donor muscles are not available. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

臂丛损伤后神经移位寄养法预防失神经支配肌萎缩的实验研究

目的研究臂丛损伤后神经移位端侧缝合寄养法是否有预防失神经支配骨骼肌肌萎缩的作用。方法64只SD大鼠随机分成两组。对照组：切断肌皮神经，造成肱二头肌失神经支配。实验组：切断肌皮神经后，胸内侧神经分支移位与肌皮神经远端作端侧缝合寄养失神经支配的肱二头肌。术后2、4、6、8周观察大鼠的行为变化与肱二头肌的萎缩程度，检测肱二头肌肌肉纤颤电位或再生电位、肱二头肌肌肉湿重、肌纤维截面积和Na-K-ATP酶活性。以左侧为实验侧，右侧为自身对照侧，将左侧测量值除以右侧测量值，求各观察值恢复率，比较组间各观察值的恢复率。结果术后对照组随着失神经时间延长，肌肉萎缩程度逐渐加重，屈肘功能不能恢复，纤颤电位波幅逐渐下降，肌肉湿重、肌纤维截面积和酶的活性均逐渐下降；而实验组随着神经寄养时间的延长，肌肉萎缩程度逐渐减轻，屈肘功能逐渐恢复，出现再生电位，肌肉湿重、肌纤维截面积逐渐增加，酶活性逐渐升高，虽不及正常组，但明显不同于肌肉萎缩严重的失神经组。结论神经移位端侧缝合寄养法可以有效地预防失神经支配骨骼肌肌萎缩。     

神经束移位治疗臂丛神经根性撕脱伤70例临床报告

目的 观察应用神经束移位治疗臂丛神经根性撕脱伤的效果。方法 对７０例患者,于上臂上中部切取正中神经、心神经、胸背神经及健侧Ｃ７神经束移位给肱二头肌肌支、三角肌肌支等,重建肩、肘关节的功能。结果 供区部分神经切取后对肢体功能无明显影响。正中神经、尺神经部分束文、胸背神经、健侧Ｃ７束支移位比全干移位对肌功能的影响小,且同样有效。结论 肱二头肌肌支、三角肌肌支的神经纤维数量少,用供体神经部分神经束即可提供充足的神经纤维,且能保证移位的神经纤维能良好地长入肱二头肌和三角肌。     

Treatment of brachial plexus injury with modified contralateral C7 transfer

Objective: To study the curative effects of different surgical methods using a contralateral C₇ transfer technique for treatment of brachial plexus injury induced by root avulsion. Methods: Sixty‐four patients with brachial plexus injury due to root avulsion were divided into two groups: 30 patients were included in Group A and 34 in Group B. In Group A, the contralateral C₇ roots were partially transected and anastomosed to one end of an ulnar nerve graft which had been removed from the affected limb. The other end of the ulnar nerve was divided into two parts and anastomosed to the distal ends of the recipient median and radial nerves, respectively. In Group B, the whole of the contralateral C₇ roots was transected and anastomosed to one side of an ulnar nerve graft, the other side of which was anastomosed eight months later to the distal ends of the recipient median and radial nerves. All subjects were followed up and the outcomes assessed. Results: Neurological deficit and recovery time of the donor limb in group A were less than those in group B. The nerve transfer procedure to the affected limb was easily completed in group A with less morbidity, and the tension of the stoma in group A was less than that in group B. However, there was no statistical difference between group A and B in the recovery of motor function and results of electrophysiological testing of the affected side (P > 0.05). Conclusions: The method of partial C₇ root transfer results in equally good motor function as does transfer of the whole root, while occurrence of motor and sensory damage is less than that which occurs with transfer of the whole root.     

神经移植术修复幼年大鼠臂丛神经损伤后对神经元保护作用的实验研究

目的研究神经移植术修复幼年大鼠臂丛神经损伤后对神经元的保护作用。方法将出生18 d SD大鼠24只等分为2组。神经根切断组：将右侧颈，神经根切除0．3cm。神经根修复组：颈5神经根部分切除后取腓肠神经移植修复。采用True Blue注射法逆行标记神经元。于术后4周取颈，脊髓和背根神经节，应用TUN-EL法检测运动及感觉神经元中细胞凋亡情况，并观察两组神经元数量的变化。结果与神经根切断组相比，神经根修复组神经元数量显著增加（P〈0．01），凋亡细胞数明显减少（P〈0．01）。结论神经移植术修复幼年大鼠臂丛神经损伤后对近端运动和感觉神经元有保护作用。     

神经移位治疗臂丛上干根性撕脱伤

目的 阐明神经移位治疗臂丛上干根性撕脱伤的疗效。方法 1990年3月至1998年2月,对14例臂丛干根性撕脱伤患者,将同侧胸前外侧神经直接移位于腑神经,胸背神经直接移位于肌皮神经,以重建三角肌、肱三头肌功能。结果 术后随访1年以上,三角肌肌力8例恢复至M4,4例M3,2例为M3－;肱二头肌肌力14例均恢复至M4。结论 运用同侧胸前外侧神经、胸背神经移闰的方法治疗臂丛上干根性撕脱伤,疗效较好;对原有的臂丛中、下干神经的主要功能无明显影响。     

联合尺神经束支和臂丛外神经移位治疗臂丛损伤

目的 观察联合尺神经束支和臂丛外神经移位治疗臂丛损伤的临床效果.方法 臂丛损伤6例,其中单纯上干损伤4例;上中干为主,合并下干部分损伤2例.伤后平均2.8个月接受手术.术式包括尺神经部分束支转位至肌皮神经肱二头肌肌支,膈神经或者副神经斜方肌支转位至肩胛上神经,桡神经肱三头肌长头肌支转位修复腋神经肌支.用肱二头肌、岗上肌和三角肌肌力,肩外展和上举角度,尺神经功能损失等指标对手术方式和效果进行评估.结果 6例中5例得到随访,平均随访时间18个月,肱二头肌均在术后3～4个月开始恢复肌力.随访时间18个月以上的4例屈肘M_4~+～M_5;随访时间4个月的1例屈肘M_3~+.其中3例行外展功能重建,单用膈神经修复的病例上臂可上举至180°,外展肌力M_4~+;联合副神经和肱三头肌长头肌支修复的病例上肢可外展90°,肌力M_4~-;单用副神经修复的病例上肢可外展80°,肌力M_3~+.3例手部握持力与术前相同,2例增强.4例手部尺神经供区功能无明显影响,1例小指掌侧皮肤感觉减退,第一骨间背侧肌萎缩.结论 尺神经部分束支转位修复肱二头肌支可以有效的恢复臂丛损伤后屈肘功能;用膈神经修复肩胛上神经可能取得更好的肩外展和上举效果;本组臂丛下干部分损伤的病例受伤均在3个月内,采用此术式同样恢复了肱二头肌功能,未加重原有的手功能障碍.     

副神经移位治疗臂丛神经损伤的进展

副神经是神经移位治疗臂丛神经损伤的重要动力神经。本文介绍副神经移位治疗臂丛神经损伤的历史，及近年来副神经解剖的进展；并重点讨论、比较副神经各种移位方式及其恢复效果，分析副神经移位术式的趋势，认为副神经移位修复肩胛上神经，恢复肩关节外展功能是较好的选择，且在副神经移位时保留斜方肌上部功能，利用副神经的远端终支移位是现在临床应用的趋势；并讨论了影响副神经移位疗效的各种因素。     

全臂丛神经损伤健侧颈7移位术后大鱼际肌功能的远期随访

目的 随访全臂丛神经根性撕脱伤患者行健侧颈7移位术后手内在肌的远期功能恢复情况.方法 对5例行健侧颈7移位于正中神经的全臂丛神经损伤患者进行远期随访,随访时间24～ 118个月,了解患肢受体神经所支配肌肉的肌力及其支配区域皮肤感觉恢复、神经电生理检测结果等.结果 5例患者(2例儿童,3例成人),其患侧大鱼际肌均获得不同程度的恢复.拇短展肌肌力恢复达M2者为4例,M1者1例;电生理检测拇短展肌动作电位有2例为单纯相,3例为少量运动单位电位(MUP);感觉恢复达S3者4例,S2者1例.结论 健侧颈7移位术治疗全臂丛神经损伤可使大鱼际肌得到一定程度的恢复.     

内镜下小切口切取前臂部尺神经移位的解剖学研究及临床意义

目的 研究前臂部尺神经及其毗邻结构的解剖,为内镜下小切口切取前臂部尺神经移位治疗臂丛神经根性撕脱伤提供依据。方法 以6例福尔马林液固定的成人尸体上肢标本为对象,解剖前臂部尺神经及周围的毗邻结构,观察、测量及定位周围相关组织结构,设计入路及操作方法,并在6侧新鲜尸体标本上进行模拟手术。结果 尺神经在前臂部除肱骨内上髁下部穿经尺侧腕屈肌、远侧手背支穿尺侧腕屈肌和尺骨之间外,其他部分均行于肌间隙中,不再交叉穿经组织,与尺动脉伴行直至豆状骨水平,始终位于动脉的尺侧,与周围毗邻结构之间由疏松结缔组织相隔,易于分离。6次模拟手术均获成功。结论 前臂部尺神经解剖较恒定,行径中不与重要结构交叉,在豌豆骨上方和肱骨内上髁下方分别3—5cm处取l一2cm切口,直视下处理两处与肌肉交叉及主要分支后,其余部分与周围毗邻结构之间易于分离,故内镜下切取前臂部尺神经移位是安全可行的．     

Nerve transfer for treatment of brachial plexus injury：comparison study between the transfer of partial median and ulnar nerves and that of phrenic and spinal accessary nerves

Objective:To compare the effect of using partial median and ulnar nerves for treatment of C5-6 orC5-7 avulsion of the brachial plexus with that of using phrenic and spinal accessary nerves.Methods:The patients were divided into 2groups randomly according to different surgical procedures.Twelve cases were involved in the first group.The phrenic nerve was transferred to the musculocutaneous nerve or through a sural nerve graft,and the spinal accessary nerve was to the suprascapular nerve.Eleven cases were classified into the second group.A part of the fascicles of median nerve was transferred to be coapted with the motor fascicle of musculocutaneous nerve and a part of fascicles of ulnar nerve was transferred to the axillary nerve.The cases were followed up from 1to 3years and the clinical outcome was compared between the two groups.     

神经转位治疗儿童臂丛损伤

目的 评价神经转位加神经移植修复儿童臂丛损伤的疗效。方法 应用显微外科技术,对6例3～6岁儿童臂丛损伤采取膈神经、副神经、颈丛运动支和肋间神经转位加神经移植。修复肌皮神经、正中神经内侧头、腋神经和桡神经。结果 随访5例,时间为6个月,术后各例肌力得到不同程度的恢复,其中以膈神经修复肌皮神经效果最好;肱二头肌肌力3～4级,正中神经支配肌肌力3级,腋神经支配肌肌力0～2级,桡神经支配肌肌力2～3级。1例处于恢复之中。结论 早期手术,利用显微技术精确地吻合神经是手术成功的关键。     

Surgical outcomes following nerve transfers in upper brachial plexus injuries

Background:

Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury.

Materials and Methods:

We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors - radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient).

Results:

Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50 - 170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).     

对臂丛神经节前损伤后行神经移位肌内种植术的评价

对移位神经肌内种植术治疗臂丛节前损伤的疗效作一评价。方法：１９９０年间共手术治疗臂丛神经损伤３０２例。其中１０例，术中发现不仅臂丛神经根性撕脱，而且神经远瑞缺损；选用膈、副、肋间、颈丛运动支作为移位神经，经神经移植种植于三角肌５块，肱二头肌４块，肱三头肌１块，胸大肌１块。术后４年进行随访，检测其有关肌肉肌力的恢复程度。结果：肌力恢复２度６块，１度３块，０度２块。结论：该法的治疗效果欠佳，有待进一步提高     

Functioning free muscle transfer for the restoration of elbow flexion in brachial plexus injury patients

BackgroundRestoration of elbow function in traumatic brachial plexus injury patients remains the priority in the reconstruction of the involved extremity. In cases of complete nerve root injuries and in delayed cases, the only option for elbow reconstruction is the functional free muscle transfer. The purpose of this paper was to present the clinical outcomes and complications of functioning free muscle transfers using the gracilis muscle for the restoration of elbow flexion in brachial plexus injury patients in a tertiary institution from January 1, 2005 to January 31, 2014.Patient and methodsA retrospective review of all patients who had functioning free muscle transfers for elbow flexion was done with a minimum of 12 months follow-up. Outcome measures were elbow flexion in terms of range of motion in degrees, muscle strength of the transferred muscle, VAS (visual analogue scale) for pain, postoperative DASH scores and complications of the procedure.ResultsThere were 39 males and three females. The average age at the time of surgery was 28.6 (SD, 8.5) years. The average delay to surgery was 16 months (range, 3–120 months). The flap success rate for viability was achieved in 38 of 42 patients. The average follow-up for the 38 patients was 30 months (range, 12–103 months, SD 19 months). Success rate of at least M3/5 muscle strength was achieved in 37 of 42 patients with an average range of elbow flexion of 107° (SD, 20.4°). The average post-operative VAS for pain was 3.6 (SD, 3.0). The average post-operative DASH score was 43.09 (SD, 14.9). There were a total of 10 minor complications and five major complications.ConclusionFunctioning free muscle transfer using the gracilis muscle was a reliable procedure in the restoration of elbow flexion in patients with incomplete brachial plexus injury treated beyond 6 months from the time of injury and in patients with complete injuries.