椎管内外神经根移位整体化治疗臂丛神经根性撕脱伤的实验研究

目的：研究臂丛神经根性撕脱伤后,椎管内、外神经根移位治疗臂丛神经根性撕脱伤的疗效。方法随机选取SD大鼠60只,随机分为实验组及对照组。实验组采用椎管内C5,C6神经根原位修复及健侧C7神经移位修复C8,T1神经根治疗臂丛根性撕脱伤;对照组为膈神经修复肌皮神经,副神经修复肩胛上神经,健侧C7移位修复C8,T1神经根治疗臂丛根性撕脱伤。术后6个月时取材,进行电生理检测,肌肉湿重的测量,肌肉纤维横截面积的检测,HE染色检测观察肌纤维数量,电镜观察神经纤维数量及神经直径。结果实验组神经损伤修复6个月时,其肌肉湿重、肌肉纤维横截面积、肌肉运动诱发电位恢复率、神经生长情况优于对照组。结论椎管内神经根原位修复及椎管外神经根移位整体化治疗臂丛神经根性撕脱伤,无论从肌肉湿重、还是肌肉纤维横截面积比率,或者肌肉运动诱发电位及再生神经生长情况等方面,都取得了良好的效果。     

Brachial plexus reconstruction based on the new definition of level of injury

SUMMARY: Although brachial plexus reconstruction remains a challenge to microsurgeons, especially when attempting to reconstruct cases with total root avulsion, much improvement in results has been recently achieved by a better understanding of various new methods of reconstruction, such as nerve transfer, functioning free muscle transplantation and prolonged postoperative rehabilitation. To better understand these improved results, we classified our patients into four levels of injury: (1) preganglionic root; (2) postganglionic spinal nerve; (3) pre- and retro-clavicular; (4) infraclavicular brachial plexus injury. Nerve transfer, functioning free muscle transplantation or local muscle transfer are the only possible solutions for the level 1 injury. Nerve transfers include extraplexus, intraplexus, close-target and end-to-side neurotisation. Neurolysis, nerve repair, nerve grafts, C-loop vascularised ulnar nerve grafts, nerve transfer and functioning free muscle transplantation are options for levels 2, 3 and 4 injuries. Tendon transfer, functioning or functional muscle transfer, arthrodesis or orthotics can be used for late palliative reconstruction. Taken together, these options can make brachial plexus surgery a worthy pursuit and make a useless limb useful.     

Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus

Recent interest in reconstruction of the upper limb following brachial plexus injuries has focused on the restoration of prehension following complete avulsion of the brachial plexus. The authors use free muscle transfers for reconstruction of the upper limb to resolve the difficult problems in complete avulsion of the brachial plexus. This article describes the authors' updated technique--the double free muscle procedure. Reconstruction of prehension to achieve independent voluntary finger and elbow flexion and extension by the use of double free muscle and multiple nerve transfers following complete avulsion of the brachial plexus (nerve roots C5 to T1) is presented. The procedure involves transferring the first free muscle, neurotized by the spinal accessory nerve for elbow flexion and finger extension, a second free muscle transfer reinnervated by the fifth and sixth intercostal nerves for finger flexion, and neurotization of the triceps brachii via its motor nerve by the third and fourth intercostal motor nerves to extend and stabilize the elbow. Restoration of hand sensibility is obtained via the suturing of sensory rami from the intercostal nerves to the median nerve. Secondary reconstruction, including arthrodesis of the carpometacarpal joint of the thumb and glenohumeral joint, and tenolysis of the transferred muscle and distal tendons, improve the functional outcome. Based on the long-term result, selection of the patient, donor muscle, and donor motor nerve were indicated. Most patients were able to achieve prehensile functions such as holding a can and lifting a heavy box. This double free muscle transfer has provided prehension for patients with complete avulsion of the brachial plexus and has given them new hope to be able to use their otherwise useless limbs.     

二期多组神经移位治疗臂丛神经根性撕脱伤的临床应用和疗效

目的 分析治疗臂丛神经根性撕脱伤的二期手术方法及其效果。方法 2001年8月～2003年4月8例全臂丛神经根性撕脱伤患者，年龄18～38岁。平均伤后6个月内，均应用以下术式治疗。手术步骤：一期手术，膈神经移位至臂丛上干前股，副神经移位至肩胛上神经；健侧C7神经移位至患侧尺神经；二期手术，第4、5、6、7肋间神经移位至桡神经和胸背神经，健侧C7神经经尺神经移位至正中神经。结果 术后8例均获随访，时间为二期术后l3～25个月，平均21个月。所有患者均有不同程度恢复，相应靶肌肉肌力恢复大于或等于M3为有效恢复，肌皮神经有效恢复6例，恢复率为75．0％；肩胛上神经有效恢复3例，恢复率为37．5％；桡神经有效恢复3例，恢复率为37．5％；胸背神经有效恢复6例，恢复率为75．0％；正中神经有效恢复5例，恢复率为62．5％。感觉恢复情况：正中神经感觉4例为S3，3例为S2，1例为S1。结论 二期多组神经移位安全有效，对部分早期臂丛神经损伤并要求缩短手术次数的患者，是一种可选择的方法。     

Technique of intercostal nerve harvest and transfer for various neurotization procedures in brachial plexus injuries

Brachial plexus palsy caused by traction injury, especially spinal nerve-root avulsion, represents a severe handicap for the patient. Despite recent progress in diagnosis and microsurgical repair, the prognosis in such cases remains unfavorable. Neurotization is the only possibility for repair in cases of spinal nerve-root avulsion. Intercostal neurotization is a well-established technique in the treatment of some severe brachial plexus lesions in adults. In this article, we describe our experience and technique of intercostal nerve harvest for transfer in various neurotization strategies in posttraumatic brachial plexus reconstruction. Intercostal nerve harvest is a technique requiring meticulous technique and careful dissection along with proper hemostasis. It is also very important to preserve the serratus anterior muscle insertion and keep soft tissue stripping to a minimal. We do not osteotomize the ribs and believe that this adds to the morbidity and length of the procedure. Neurotization using intercostal nerves is a very viable procedure in avulsion injuries of the brachial plexus; however, there is some concern that in the presence of ipsilateral phrenic nerve palsy, it may lead to a significant compromise of respiratory function. In our experience, this is negligible with good long-term results.     

背阔肌功能恢复后再移位重建屈肘屈指功能

[目的]探讨利用经神经移位修复胸背神经而恢复的背阔肌作为动力肌再移位重建屈肘、屈指功能的疗效。[方法]2000年3月~2003年6月,共有全臂丛根性撕脱伤患者经多组神经移位术后屈肘功能无恢复而背阔肌恢复良好者5例,屈指功能无恢复,背阔肌功能良好者3例,均采用恢复的背阔肌再移位重建屈肘、屈指功能。[结果]术后随访1 a~3 a 6个月,移位背阔肌皮瓣全部成活,肘关节活动度为伸肘10°~25,°屈肘100°以上,肌力达Ⅲ~Ⅳ级。手指可抓握,各指屈距掌纹2 cm左右,肌力达Ⅲ级。[结论]利用经神经移位恢复的背阔肌作为动力肌再移位重建屈肘、屈指功能疗效可靠,因此在治疗全臂丛根性撕脱伤患者时应常规修复胸背神经以恢复背阔肌功能。     

胸腔镜下切取膈神经移位重建全臂丛根性撕脱伤手部功能初步报告

目的探讨胸腔镜下膈神经超长切取、移位重建全臂丛根性撕脱伤手部功能的可行性。方法全臂丛根性撕脱伤3例,胸腔镜下于邻膈肌处切断膈神经,逆行游离胸腔内全长膈神经及其血管组织蒂,并由第二肋间引出,经胸大肌下移位至上臂上内侧,分别与尺神经前内侧部吻合2例,与移植股薄肌之闭孔神经前支吻合1例。结果2例膈神经联合第3～6肋间神经运动支移位修复尺神经者,结合短期免疫抑制剂FK506口服治疗,术后12个月手内肌肌电图检测均出现再生电位,1例随访15个月出现手内肌收缩。1例用以重建屈肘、屈指屈拇的移植股薄肌术后7月出现肌肉收缩,随访12个月肌力达M3。结论胸腔镜下全长切取膈神经,作为运动性动力神经移位应用于全臂丛根性撕脱伤的治疗,可在短时间内有效重建屈指屈拇功能,并有使手内肌神经再支配、开始恢复手内肌收缩功能的迹象。     

Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long-term results

BACKGROUND: Recent interest in reconstruction of the upper limb following brachial plexus injuries has focused on the restoration of prehension following complete avulsion of the brachial plexus. METHODS: Double free muscle transfer was performed in patients who had complete avulsion of the brachial plexus. After initial exploration of the brachial plexus and (if possible) repair of the fifth cervical nerve root, the first free muscle, used to restore elbow flexion and finger extension, is transferred and reinnervated by the spinal accessory nerve. The second free muscle, transferred to restore finger flexion, is reinnervated by the fifth and sixth intercostal nerves. The motor branch of the triceps brachii is reinnervated by the third and fourth intercostal nerves to restore elbow extension. Hand sensibility is restored by suturing of the sensory rami of the intercostal nerves to the median nerve or the ulnar nerve component of the medial cord. Secondary reconstructive procedures, such as arthrodesis of the carpometacarpal joint of the thumb, shoulder arthrodesis, and tenolysis of the transferred muscle and the distal tendons, may be required to improve the functional outcome. RESULTS: The early results were evaluated in thirty-two patients who had had reconstruction with use of the double free muscle procedure. Twenty-six of these patients were followed for at least twenty-four months (mean duration, thirty-nine months) after the second free muscle transfer, and they were assessed with regard to the long-term outcome as well. Satisfactory (excellent or good) elbow flexion was restored in twenty-five (96 percent) of the twenty-six patients and satisfactory prehension (more than 30 degrees of total active motion of the fingers), in seventeen (65 percent). Fourteen patients (54 percent) could position the hand in space, negating simultaneous flexion of the elbow, while moving the fingers at least 30 degrees and could use the reconstructed hand for activities requiring the use of two hands, such as holding a bottle while opening a cap and lifting a heavy object. The results were analyzed to identify factors affecting the outcome. CONCLUSIONS: The double free muscle procedure can provide reliable and useful prehensile function for patients with complete avulsion of the brachial plexus.     

A surgical approach for concomitant spinal cord and brachial plexus surgery: an anatomical study

Spinal cord surgery is not the current treatment for brachial plexus avulsion injuries. However, several experimental and a few clinical cases have been reported with promising results. This surgical strategy in the near future, might prove to be useful. Different simultaneous anatomical approaches to the brachial plexus and spinal cord were studied in attempt to discover the best route to be used in the surgical reconstruction of avulsion lesions of the brachial plexus by spinal cord surgery. Eleven fresh subjects were used to compare: a) simultaneous dorsal approaches to the brachial plexus and spinal cord, b) the dorsal approach to the spinal cord and the anterior approach to the brachial plexus, c) a dorsal approach to the spinal cord combined with a dorsal approach through the triceps muscle to the terminal branches of the brachial plexus and d) a purely anterior approach to the spinal cord and brachial plexus. During the study, special attention was paid to the length of the grafts needed for repair, the possibility of entire exposure of the brachial plexus and the possibility of performing concomitant nerve transfers. As a result of the anatomical findings, we would suggest a dorsal approach to the spinal cord, suprascapular nerve and sometimes to the axillary nerve, combined with an anterior exposure to the brachial plexus in order to have the whole plexus explored and routine simultaneous nerve transfers performed. In selected cases, with limited root injuries, the dorsal approach to the brachial plexus and spinal cord and the anterior approach to the brachial plexus and spinal cord might be of interest.     

Neurophysiologic and clinical outcome following medial pectoral to long thoracic nerve transfer for scapular winging: a case report

The use of nerve transfers (neurotization) in the reconstruction of nerve palsy is not new, but its clinical efficacy is still largely based on reports of successful restoration of elbow flexion and shoulder abduction following brachial plexus avulsion. Although its potential application extends beyond the brachial plexus, little has been written about additional indications or associated postoperative outcomes. The case described in this report illustrates yet another indication for which neurotization may be a useful technique. Medial pectoral nerve transfer to the long thoracic nerve was performed via an 11-cm sural nerve graft to treat scapular winging 4 months following nerve injury caused during axillary node dissection. Neurophysiologic and clinical outcome 18 months postoperatively revealed successful reinnervation of the serratus anterior muscle, decreased scapular winging, and symptomatic improvement from the patient's perspective.     

Pathology of the peripheral nervous system

This review deals with papers on important topics in peripheral nerve surgery. Some new diagnostic tools and microsurgical procedures are brought to the attention of neurosurgeons. The first four papers are related to new surgical strategies in treating brachial plexus injury (BPI), particularly root avulsion. Concepts based on experimental studies are applied to clinical practice. Re-establishment of the continuity of interrupted spinal roots or reimplantation of the avulsed spinal roots into the spinal cord are attempted. The authors demonstrate how computed tomography (CT) myelography can be used to plan surgical treatment correctly. The use of reinnervated free-muscle transfer after complete brachial plexus C5-T1 root avulsion is described and critically evaluated. The results obtained after repair of interrupted spinal roots or reimplantation of avulsed spinal roots into the spinal cord are not as clear as described by the authors. Further experimental studies and surgical outcomes are necessary before accepting the efficacy of such surgical procedures in BPI. Reinnervated free-muscle transfer appears to be a promising method for treating such severe lesions. The fifth paper is a case report in which the trapezius branch of the spinal accessory nerve was neurotized with the dorsal branch of the third cervical nerve. This procedure was performed after an injury to the spinal accessory nerve in the neck. The proximal stump of the spinal accessory nerve was available only intracranially. Using this procedure, the risk related to an intracranial approach to the spinal accessory nerve is avoided. A review of one case of primitive neuroectodermal malignant tumor of the median nerve is used to discuss some controversies related to the treatment of malignant tumors involving peripheral nerves.     

周围神经损伤诊断与治疗进展

目的综述周围神经损伤诊断和治疗的最新进展.方法复习国内外文献,并结合研究及临床经验,总结出周围神经损伤近几年取得的主要成果.结果全臂丛神经根性撕裂伤近年的进展有:健侧C7神经根通过颈椎前食管后方的通道直接移至患侧;吻合血管神经的股薄肌移植;MRI和CTM能早期诊断.对于臂丛神经上干或下干根性撕脱伤可用臂丛内神经移位术:即用尺神经部分束移位至肱二头肌肌支;健侧C7神经根选择性束组(保留前股前内侧)移位术或肱肌肌支移位至正中神经屈指肌束或骨间前神经.胸廓出口综合征多见于常保持头直视前方姿势的人群中、易发生颈肌劳损者.放射性神经病尽早用肾上腺皮质素、抗凝药和高压氧治疗.结论虽然在周围神经损伤修复中已有很大进展,但在促进神经再生、功能重建方面尚需深入研究.     

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。     

膈神经移位治疗臂丛损伤的临床应用和早期疗效

目的探讨膈神经移位至肌皮神经重建屈肘功能的临床应用及早期疗效。方法对8例臂丛根性撕脱伤行膈神经移位术，膈神经与上干前股的肌皮神经束直接吻合5例，膈神经通过神经移植桥接至肌皮神经3例，术后随访评定其屈肘功能。结果8例经10月-2年随访，肱二头肌肌力在2级以上5例，有效率62．5％。结论膈神经移位术是治疗臂丛根性撕脱伤的理想术式，重视术前和术中膈神经功能的评估、神经移位时吻合方法的合理选择和术后综合康复锻炼是提高手术疗效关键。     

Contralateral C7 transfer in adult plexopathies

In the current study, a retrospective review of 56 patients with posttraumatic root avulsion brachial plexus injuries who underwent contralateral C7 transfer using the selective contralateral C7 technique is presented. The intraoperative findings of the involved brachial plexus, the surgical technique of preparation of the donor C7 nerve root, and the various neurotization procedures are reported. The surgical outcomes as well as the potential adverse effects of the procedure are analyzed. We conclude from this study that the selective contralateral C7 technique is a safe procedure that can be applied successfully for simultaneous reconstruction of several different contralateral muscle targets or for neurotization of cross chest nerve grafts for future free muscle transplantation.     

Cross-chest radial nerve transfer in brachial plexus injuries. Experimental and anatomical basis

Brachial plexus avulsion injuries are devastating injuries to the upper limb, and nerve transfer remains the only option in reconstruction. Despite the encouraging results concerning recovery of shoulder and elbow function, no option is available for treatment of the paralytic hand. In rats, we sectioned the radial nerve in the elbow region and transferred it across the chest to reinnervate the lesioned contralateral medial cord of the brachial plexus. Rats were then evaluated for motor and sensory recovery, electrophysiologically, behaviorally and morphologically. Forepaw functional recovery was estimated to be 90%. In cadavers, the radial nerve and profunda brachii artery were dissected. It was observed that the radial nerve vascularized by the profunda brachii artery was able to reach the contralateral brachial plexus distal to the shoulder region without nerve grafts. After sectioning the radial nerve, sensory loss is minimal and motor palsy can be easily restored by tendon transfers. The results of tendon transfer for radial nerve palsy are better than for any other nerve. Cross-chest radial nerve transfer might be of clinical interest in the reconstruction of hand function in entire injury to the brachial plexus.     

End-to-side neurorrhaphy of motor nerves: reinnervation of free muscle transplants—first clinical application

End-to-side neurorrhaphy may offer a practical solution in limited cases of nerve reconstruction when no donor nerve or nerve transfer is available for direct end-to-end nerve suture, or when extremely long distances for nerve regeneration cause irreversible atrophy of the targets. We report our experience with the successful clinical use of a completely new technique of end-to-side neurorrhaphy for motor reinnervation of free functional muscle transplants. Since 1995 we have used end-to-side nerve repair for motor or sensory reinnervation in 13 cases. A free functional muscle graft was reinnervated by an end-to-side neurorrhaphy in four patients after tumor resection (two myocutaneous latissimus dorsi flaps), Volkmann's contracture (one myocutaneous latissimus dorsi flap), and in a long-standing brachial plexus lesion (one gracilis muscle flap). All four patients showed reinnervation of their muscle graft through the end-to-side nerve suture site. Two functional muscle grafts to the upper extremity had positive outcome of M3-M4 for elbow and finger extension in one case, and M4 for finger flexion in one case more than 2 years after transplantation. The transplant in the brachial plexus lesion is too early for a final functional result. One patient had a M3 for knee extension 8 months postoperatively. In the clinical cases there was no downgrading of the muscle functions supplied by the "donor" nerve. Good and clinically relevant reinnervation of a functional muscle graft is possible through an end-to-side nerve suture. Proximal avulsion, missing proximal nerve stumps, partial recovery, shortening of long distances for nerve regeneration, and prevention of long nerve grafts in proximal lesions are good indications for reinnervation of a functional muscle transplant by end-to-side neurorrhaphy without harm to the donor nerve. Donor nerves supplying synergists should be preferred.     

Experimental studies on surgical treatment of avulsed spinal nerve roots in brachial plexus injury.

This review summarises studies aiming at a surgical treatment of spinal nerve root avulsions from the spinal cord in brachial plexus lesions. After dorsal root injury, regrowth of nerve fibres into the spinal cord occurs only in the immature animal. After ventral root avulsion and subsequent implantation into the spinal cord, neuroanatomical and neurophysiological data show that motoneurons are capable of producing new axons which enter the implanted root. Intra-neuronal physiological experiments demonstrate that new axons can conduct action potentials and elicit muscle responses. The neurons are reconnected in segmental spinal cord activity and respond to impulses in sensory nerve fibres. In primate experiments, implantation of avulsed ventral roots in the brachial plexus resulted in functional restitution. These studies indicate the possibility of surgical treatment of ventral root avulsion injuries in brachial plexus lesions in humans.     

Axillary nerve repair by fascicle transfer from the ulnar or median nerve in upper brachial plexus palsy

Object Nerve repair using motor fascicles of a different nerve was first described for the repair of elbow flexion (Oberlin technique). In this paper, the authors describe their experience with a similar method for axillary nerve reconstruction in cases of upper brachial plexus palsy. Methods Of 791 nerve reconstructions performed by the senior author (P.H.) between 1993 and 2011 in 441 patients with brachial plexus injury, 14 involved axillary nerve repair by fascicle transfer from the ulnar or median nerve. All 14 of these procedures were performed between 2007 and 2010. This technique was used only when there was a deficit of the thoracodorsal or long thoracic nerve, which are normally used as donors. Results Nine patients were followed up for 24 months or longer. Good recovery of deltoid muscle strength was seen in 7 (77.8%) of these 9 patients, and in 4 patients with less follow-up (14-23 months), for an overall success rate of 78.6%. The procedure was unsuccessful in 2 of the 9 patients with at least 24 months of follow-up. The first showed no signs of reinnervation of the axillary nerve by either clinical or electromyographic evaluation in 26 months of follow-up, and the second had Medical Research Council (MRC) Grade 2 strength in the deltoid muscle 36 months after the operation. The last of the group of 14 patients has had 12 months of follow-up and is showing progressive improvement of deltoid muscle function (MRC Grade 2). Conclusions The authors conclude that fascicle transfer from the ulnar or median nerve onto the axillary nerve is a safe and effective method for reconstruction of the axillary nerve in patients with upper brachial plexus injury.     

Brachial plexus injury after transfer of free Iatissimus dorsi musculocutaneous flap

Free latissimus dorsi muscle transfer is widely used for functional reconstruction of flexion of elbow and fingers after brachial plexus injury at later stage, as well as for soft tissue coverage because of its large size and long and reliable pedicle with adequate vessel diameter.