脑瘫患者脊神经后根运动阈值的研究

目的:研究脊神经后根电刺激的运动阈值与脑瘫(CP)患者肌痉挛程度的关系，探讨依据运动阈值实施选择性脊神经后根切断术(SPR)的合理性和应用价值。方法:22例痉挛性CP患者行胸腰段(T12～L2)椎板切开，确定两侧L2-S1脊神经后根，电脉冲刺激脊神经束．将运动阈值较低的神经束切断。结果:离断神经束的运动阈值显著低于保留神经束，患者术前痉挛评分与离断比例呈正相关关系，所有患者术后症状均有显著改善，无严重并发症的发生。结论:根据运动阈值进行SPR手术是完全可行的，患者肢体痉挛程度越高，运动阈值低的神经束比例越高，后根纤维切断的比例越大。     

辅加双侧S2后根选择性切断治疗脑瘫踝痉挛

目的 对双下肢痉挛伴严重踝痉挛的的27脑瘫患者(A组),行L2～S2选择性脊神经后根切断术(SPR),并与以往一组接受L2～S1SPR的24例患者进行比较(B组),观察踝痉挛改善情况.方法 全麻下行T12～L1椎板切除,显露并确认脊髓圆锥及各脊神经后根.将各后根均匀分为3～5个神经束,对每个神经束进行电刺激,对下肢多组肌肉及肛门括约肌收缩情况进行肌电图监测,切断扩散范围异常的神经束,同时保留刺激后出现明显括约肌收缩的神经小束.结果 A组S2后根的切断比例为32.14%.比较两组患者手术前后踝痉挛改善情况,A组效果好于B组.结论 对踝痉挛症状严重,Ashworth评分≥4的患者,建议SPR的手术范围应包括S2后根,且应在肌电图监测下进行.正确识别S2后根,保护与括约肌功能有关的S2后根小束,对保证疗效,防止并发症具有重要意义.     

选择性脊神经后根切断术治疗脑瘫马蹄足

目的评价L4～S1选择性脊神经后根切断术治疗脑瘫马蹄足的疗效.方法对15例以踝部痉挛为主的脑瘫病人进行L4～S1椎板切除术.显露L4、L5和S1脊神经后根,将各后根分为3～5个小束,采用同心圆电极进行刺激,通过肉眼观察及肌电图所示肌肉收缩情况,将运动阈值明显减低的小束切断.跖屈肌群肌张力按照Ashworth法进行评估,随访6个月并观察疗效.结果所有病人踝部痉挛明显缓解,行走功能改善,无明显并发症.结论L4～S1选择性脊神经后根切断术治疗脑瘫踝痉挛有效,但应严格掌握手术适应证.     

痉挛性瘫痪的神经外科治疗:功能性选择性神经后根切断术

目的 通过术中电生理与显微外科技术，探讨选择性神经后根切断术对严重肌痉挛的治疗效果。方法 总结46例不同原因所致的肢体痉挛性瘫痪的功能性选择性神经后根切断术的治疗经验。其中，脑瘫34例，脑外伤后痉挛性瘫痪4例，脊髓损伤后痉挛瘫痪4例，脑卒中后严重肌痉挛与强直2例，脊髓髓内室管膜瘤术后严重肌痉挛与疼痛1例，脊髓空洞症伴严重肌痉挛1例。对下肢肌痉挛，采用经胸11至腰1或腰2至骶1椎板切开并复位，对腰2至骶2神经后根作选择性切断术；对上肢肌痉挛，采用经颈5至颈7椎板切开或半侧椎板切开，行颈5至胸1神经后根选择性切断术。术中根据电刺激神经后根小枝所诱发的肌肉收缩反应、电刺激阈值、异常肌电图等因素决定是否切断该神经小枝，神经根小枝切断数目不超过60％。结果 所有病例术后即刻表现出肌痉挛程度明显下降，随访6月以上，所有患者肢体运动功能均有不同程度改善。结论 选择性神经后根切断术能够有效地控制各种原因引起的肌痉挛从而改善丧失的迄动功能：加强显微操作与术中肌电图监测，能更好地提高神经后根切断术的效果。     

椎管哑铃形肿瘤的显微外科治疗

目的 总结显微手术切除椎管哑铃形肿瘤而尽量保护脊柱稳定性的方法。方法 我科从2004年5月～2006年7月，采用显微手术切除椎管哑铃形肿瘤22例。其中颈段肿瘤16例．分别采用改良的极外侧入路、颈前入路、分次后正中和前路联合切除并行内固定加植骨融合。后正中入路全椎板切除加椎管成形或半椎板切除。胸段肿瘤2例采用半椎板切除，1例采用全椎板切除。3例腰段肿瘤采用半椎板切除，其中2例行钉棒固定。结果 肿瘤全切除20例，次全切除2例。所有病例术后症状均明显改善。18例随访9～18个月，无复发或脊柱不稳定。结论 大部分椎管哑铃形肿瘤可采用半椎板切除手术，极外侧入路适用于微创切除体积较大的高颈段肿瘤，对骨质破坏严重的肿瘤和完全切除一侧小关节者需行内固定手术。     

脊髓圆锥段选择性脊神经后根切断术治疗脑瘫 (附22例报告)

目的 探讨脊髓圆锥段选择性脊神经后根切断术(selective posterior rhizotomy，SPR)中识别L2～S1各脊神经后根的初步方法。方法对22例痉挛性脑瘫(cerebral palsy，CP)患者进行圆锥段SPR治疗．通过T12～L2椎板切除，显露脊髓圆锥，确认L2～S1各神经根，将各后根分为3～5个神经小束，用同心圆电极进行刺激。观察相应节段对应肌群的收缩情况．将运动阈值较低者切断。结果先根据椎间孔确认两侧的L2脊神经后根，然后根据局部神经分布特点及神经根受刺激后的肌肉反应情况，确定两侧L2～S1的脊神经后根。结论在脊髓圆锥段可以识别L2～S1各脊神经后根，在此节段采用SPR手术治疗痉挛性脑瘫，疗效肯定，无明显并发症。     

选择性脊神经后根切断术的并发症分析

目的 探讨选择性脊神经后根切断术(SPR)治疗痉挛性脑瘫术后并发症的原因及防治方法。方法共22例患者接受了SPR手术。通过T12～L2椎板切除．显露脊髓圆锥后确认L2～S1各神经后根,将各后根分为3～5个小束,同心圆电极进行刺激,通过肉眼观察及肌电图记录显示肌肉收缩情况。将运动阈值较低者切断,术后随访2年。结果本组病例术后出现短暂高热、下肢乏力、麻木、疼痛、浅感觉减退、缝线反应及尿滁留。无喉头水肿、脑脊液漏、切口感染发生。经随访,未见感觉障碍、肢体无力、括约肌功能障碍及顽固疼痛。腰椎X片未见脊柱变形。结论SPR是治疗脑瘫痉挛的有效方法,注意显微外科操作及围手术期护理可有效降低手术并发症。     

后路手术治疗胸腰段脊柱脊髓损伤52例疗效分析

目的探讨后路手术应用椎弓根钉内固定技术治疗胸腰段骨折伴脊髓损伤的方法及疗效。方法取俯卧位,采用气管插管全麻,以伤椎为中心后正中入路切口,显露椎板,臂透视定位后,在伤椎上下邻近1～2个椎体准确打入椎弓根钉,全椎板切除减压或椎弓根侧方减压后安装符合生理曲度的预弯钛棒,并适度撑开,两侧横突丰富植骨,生理盐水反复冲洗后放置引流管,关闭切口。结果全部病例随访0.5～4a,平均2a。疗效标准按Frankel评分:优40例,良9例,差3例,优良率94.22%。结论后路手术应用椎弓根钉内固定技术治疗胸腰段骨折伴脊髓损伤疗效确切,值得临床推广使用。     

辅加单侧脊神经S2后根选择性切断治疗脑瘫踝痉挛的疗效观察

目的评价脊神经S2后根选择性切断术治疗脑瘫踝痉挛疗效。方法25例痉挛性脑瘫患者均为双下肢受累,对踝痉挛较重的一侧下肢采用L2~S2SPR术,对另一侧踝痉挛相对较轻者采用L2~S1SPR术。术中将各后根分为3~5个小束,采用同心圆电极进行刺激,通过肉眼观察及肌电图记录显示肌肉收缩情况,将肌肉收缩范围明显异常的小束切断。踝痉挛情况按照Ashworth法进行评估,随访16.3±4.9个月,观察疗效并比较两侧肢体踝痉挛改善情况。结果S2后根的切断率为32%。病人术后踝痉挛均明显缓解,行走功能改善,无括约肌功能障碍。手术范围包括S2后根时,该侧踝痉挛改善更佳。结论对踝痉挛严重的脑瘫患者,采用选择性脊神经后根切断术治疗时,手术范围应包括S2后根。     

胸椎间盘突出的诊断和治疗

本文报告10例胸椎间盘突出,均发生于下部胸椎。中央到突出6例,旁中央型突出4例。经胸椎平片、脊髓造影和磁共振检查证实。均采用手术治疗,其中,椎板切除后路手术2例,术后稍有改善;经椎弓根入路改进法手术8例,此法切除骨质少,显露足用,并对在手术显微镜下操作,病在切除较彻底,术后显著改善6例,改善2例。     

Functional assessment following selective posterior rhizotomy in spastic cerebral palsy

This study used the Pediatric Evaluation of Disability Inventory as a functional assessment tool for children with spastic cerebral palsy undergoing selective posterior rhizotomy. Sixteen patients were followed for 3–12 months following surgery. Improvement in self-care, mobility, and social functional skills were found. Overall, the patients required less caregiver assistance and needed fewer modifications for self-care. The results suggest that selective posterior rhizotomy improves the quality of life in children with spastic cerebral palsy.     

Electrophysiological evidence for afferent nerve fibers in human ventral roots

This study was designed to test the hypothesis that ventral roots in humans contain afferent nerve fibers. We made direct electrophysiological recordings of compound nerve action potentials in dorsal and ventral roots in children undergoing selective dorsal rhizotomy for spastic cerebral palsy. We stimulated the saphenous or sural nerves, which are pure sensory nerves, with electrical stimuli while systematically recording from ventral and dorsal roots from L3 to S2. In addition to the dorsal root nerve action potentials which we expected, we found smaller compound nerve action potentials, which were clearly afferent, in the ventral roots. This confirms the limited amount of experimental evidence that ventral roots do contain some afferent nerve fibers. The functional significance of these observations is not yet clear.     

脑性瘫痪儿童腰骶脊髓背根的电生理研究

目的：探讨脑性瘫痪儿童腰骶脊髓Ｉα背根兴奋性与肌肉痉挛的关系。方法：在１２例患儿选择性脊神经背根切断术中，直接电刺激Ｌ２～Ｓ１节段的４０８条Ｉα背根小束，观察其兴奋阈值和传导潜伏期等值的改变，并比较５例患儿１３条背根的术后电生理变化。结果：各节段脊小束兴奋阈高低不均，但传导潜伏期值在正常范围。术后残余Ｉα背根的兴奋阈明显提高（Ｐ＜０．０５），其它电生理值无改变（Ｐ＞０．０５）。结论：脑瘫患儿脊髓ｒ－环路的外周传入不均衡；手术通过减少Ｉα背根传入纤维的异常兴奋性而缓解肌痉挛     

Functional posterior rhizotomy as a surgical treatment for spastic cerebral palsy in childhood]

The author reported a case of spastic cerebral palsy in a 4-year-old boy who underwent functional posterior rhizotomy and were followed up for more than one and a half years after surgery to evaluate the degree of spasticity. The patient's preoperative ADL was highly restricted due to severe spasticity. In the surgery, the bilateral rootlets from L2 to S1 were selectively cut if an abnormal reflex activity was demonstrated by neurophysiological methods. Spasticity markedly decreased postoperatively and alleviated the family's burden for daily care. During the period of follow up, residual spasticity has subsided and the effect in controlling spasticity was long-standing. Functional posterior rhizotomy has been recognized as an established neurosurgical treatment for spastic cerebral palsy in childhood in the North America. However, the procedure is uncommon in Japan. The author outlined here the procedure and its history. Functional posterior rhizotomy is a strong armament for treating spasticity in cerebral palsy. The procedure would greatly benefit patients with spastic cerebral palsy in combination with current treatments.     

选择性脊神经后根切断术与切断并交叉吻合术治疗脑瘫患者疗效比较

目的 观察并比较脑瘫患者实施选择性脊神经后根切断术(SPR)和神经根部分切断并逆行交叉吻合术(SPA)的疗效.方法 广东省第二人民医院和解放军第88医院全军骨科中心自1998年1月至2008年1月共手术治疗96例脑瘫患者,其中47例患者行双侧L_3～S_1 SPR,49例患者行SPA.术后2周、1年测定患者下肢肌张力以及运动功能改善情况.结果 术后2周行2种术式的患者肌张力、运动功能的改善差异均无统计学意义(P>0.05);术后1年行2种术式的患者肌张力的改善差异无统计学意义(P>0.05).但实施SPA患者运动功能改善优于SPR患者,差异有统计学意义(P<0.05).结论 实施SPA患者运动功能的改善较好,短期内治疗效果不明显,而长期随访疗效显著.     

Spasticity in cerebral palsy and the selective posterior rhizotomy procedure

A review of the selective posterior rhizotomy procedure for reduction of spasticity in cerebral palsy is presented. The history of the procedure, selection of patients, operative technique, and results are described. The neurophysiologic basis for spasticity is considered, as well as the role of spasticity in the complex motor disorder of cerebral palsy. Cerebral palsy is a multifaceted disorder of which spasticity is only one aspect. Reduction of spasticity can be effectively achieved using the current technique of selective posterior rhizotomy, but careful patient selection and establishment of realistic goals are vital to successful outcome. Postoperative physical and occupational therapy are felt to be essential for regaining strength and improving motor function following the rhizotomy procedure. Further study in the areas of spasticity, cerebral palsy, and the effects of rhizotomy is expected to advance our treatment of spastic children.     

Somatosensory evoked potentials in cerebral palsy after partial dorsal root rhizotomy

Somatosensory evoked potentials (SEPs) were studied in 20 children with cerebral palsy and severe lower extremity spasticity before and after selective partial dorsal root rhizotomy of the lumbosacral cord. The potentials from stimulating nerves in the lower extremity were abnormal in two thirds of the children before the operation, whereas the potentials were generally normal from upper extremity nerves. Dorsal root rhizotomies caused an attenuation of nerve root entry volleys recorded over the lumbar cord but did not change SEPs recorded over the cortex. The exception to this was that the incidence of abnormal sural nerve SEPs decreased postoperatively. Lumbar cord functions measured by H-reflexes or by tendon jerks were depressed following the operation. These results indicate a significant degree of abnormality of somatosensory transmission from the lower extremity in a group of cerebral palsied children with severe spasticity. Moreover, selective sectioning of approximately 50% of the dorsal root fibers in the lumbosacral cord had little influence on cortical evoked potentials.     

内镜下选择性腰骶段脊神经后根部分切断术治疗脑瘫性下肢痉挛

目的探讨内镜在选择性腰骶段脊神经后根部分切断术治疗脑瘫性下肢痉挛中的应用.方法回顾分析2002年3月至2003年4月显微手术治疗的53例脑瘫性下肢痉挛,全部采用选择性腰骶段脊神经后根部分切断术,并在术中应用软性神经内窥镜.结果全部患者平均随访 10个月. 100%患者术后立即感痉挛状态缓解,随访期间缓解率为94.3%.术后6周内步态功能改善率为56.6%,随访期间为90.6%.生活质量提高率在随访期间为94.3%.术后发生下肢感觉障碍20例(37.7 %),肌力下降 5例(9.4%),随访期间均见好转.术后无一过性尿失禁及尿潴留发生.随访期间无复发病例.结论选择性腰骶段脊神经后根部分切断术治疗脑瘫性下肢痉挛,术中应用内窥镜有利于提高疗效、减少创伤和降低并发症发生率.