肩胛上神经严重撕脱时副神经移位修复的处理对策

目的探讨臂丛神经损伤肩胛上神经严重撕脱常规锁骨上前入路术式难以修复肩胛上神经时,后入路副神经移位修复肩胛上神经的疗效。方法2003年2～10月对6例臂丛严重撕脱患者应用后入路副神经移位术式修复肩胛上神经,并观察肩胛冈上缘水平副神经与肩胛上神经的关系、术后斜方肌各部分肌力的变化及肩关节功能的恢复情况。结果6例患者均顺利完成后入路副神经移位修复肩胛上神经。在肩胛冈上缘水平,副神经走行于斜方肌深面、筋膜下,定位于肩胛冈与肩胛骨内侧缘相交附近,肩胛上神经位于肩胛横韧带深侧肩胛切迹内,二者位置相对固定,相距3．5～5．5 cm,在肩胛冈上缘横切口内二者在无张力情况下直接拉拢端端吻接；术后随访18～26个月对斜方肌上部功能无明显影响,肩外展恢复35°～55°。结论当臂丛损伤肩胛上神经撕脱严重常规手术难以解剖、进行修复时,后入路副神经移位术式是一种很好的选择。     

副神经移位修复肩胛上神经的入路术式比较

副神经移位治疗臂丛神经根性撕脱伤是经典术式,副神经是治疗臂丛神经损伤最常用的移位动力神经之一[1].肩胛上神经支配的冈上肌、冈下肌是肩关节外展的"启动肌",又是上举的"主要肌"和上臂外旋的"关键肌",修复肩胛上神经对臂丛神经损伤患者肩关节功能恢复的具有重要作用.副神经是斜方肌的主要支配神经,斜方肌上部对于维持肩部外形和完成耸肩、肩外展动作非常重要.而副神经与肩胛上神经距离近,用副神经移位于肩胛上神经已是常规术式[2-3].     

多组神经移位治疗臂丛上、中干根性撕脱伤重建肩外展及屈肘功能

目的 观察联合应用多组神经移位治疗臂丛上、中干根性撕脱伤的临床效果。方法 我科于2012年4月至2014年4月收治臂丛上、中干根性撕脱伤损伤患者16例,采用副神经斜方肌肌支移位修复肩胛上神经、桡神经肱三头肌长头支移位修复腋神经肌支及Oberlin术式,联合修复臂丛上、中干根性撕脱伤,恢复肩外展及屈肘功能。术后随访采用DASH评分表进行手术疗效评估。结果 术后16例患者中14例得到随访。随访24—28个月(平均25个月),患者肩关节外展恢复至75°-90°,恢复时间9-18个月(平均14个月)。屈肘恢复至100°-160°,恢复时间4-7.5个月（平均5.8个月）。DASH评分8-14分,平均14.6分。结论 臂丛上、中干损伤使用多组神经移位联合治疗,可较好恢复肩外展及屈肘功能,尺神经部分束支移位修复肌皮神经肱二头肌支对手内在肌功能无明显影响。     

选择性正中、尺神经部分束联合副神经移位治疗颈5,6根性撕脱伤

目的探讨选择性正中、尺神经部分束联合副神经移位治疗臂丛颈5、6根性撕脱伤的疗效。方法22例臂丛颈5、6根性撕脱伤,行选择性正中神经内侧一神经束移位修复腋神经外侧半、尺神经内侧一神经束移位修复肌皮神经肱二头肌支,联合副神经斜方肌支移位修复肩胛上神经。结果术后时间超过12月随访16例,平均随访24月。15例屈肘100°～150°,肌力M4～M5;肩外展90°～120°,肌力M3～M4。1例屈肘90°;肩外展75°。按中华手外科学会标准,优15例,良1例。结论选择性正中、尺神经部分束联合副神经斜方肌支移位治疗臂丛颈5、6根性撕脱伤,可很好恢复屈肘、肩外展功能,且手术简便、功能恢复时间较短。     

多组神经移位治疗臂丛C5~C7根性撕脱伤重建肩外展及屈肘功能

目的观察联合应用多组神经移位治疗臂丛上、中干根性撕脱伤重建肩外展及屈肘功能的临床效果。方法我科于2012年4月至2014年4月收治臂丛上、中干根性撕脱伤患者16例,采用副神经斜方肌肌支移位修复肩胛上神经、桡神经肱三头肌长头支移位修复腋神经肌支及尺神经部分束支移位肌皮神经（Oberlin术式）,联合修复臂丛上、中干根性撕脱伤,以恢复肩外展及屈肘功能。术后随访采用臂肩手功能障碍（the disabilities of the arm, shoulder and hand, DASH）评分表评估疗效。结果16例患者中有14例术后得到随访。随访时间为24~28个月（平均为25个月）,患者肩关节外展恢复至75°~90°,恢复时间为9.0~18.0个月（平均为14.0个月）。屈肘恢复至100°~160°,恢复时间为4.0~7.5个月（平均为5.8个月）。DASH评分为8.0~16.0分,平均为14.6分。结论使用多组神经移位联合治疗臂丛上、中干损伤,可较好恢复肩外展及屈肘功能,尺神经部分束支移位修复肌皮神经肱二头肌支对手内在肌功能无明显影响。     

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.     

副神经移位修复臂丛损伤受区神经选择的探讨

目的探讨副神经移位恢复肩关节功能的最佳受区神经选择.方法随访副神经移位治疗臂丛神经损伤54例,观察、比较肩关节功能的恢复.结果随访9～34个月(平均16.6个月),副神经移位到肩胛上神经肩外展≥30°恢复率75%,移位到腋神经肩外展≥30°恢复率33.3%,移位到上干后股肩外展≥30°恢复率30.8%.结论副神经移位到肩胛上神经效果优于移位到腋神经或上干后股,应把移位修复肩胛上神经作为首选.     

肋间神经移位术修复腋神经

在肩外展功能的神经移位修复术式中,应用比较广泛的有副神经移位修复肩胛上神经、肋间神经移位修复腋神经以及桡神经肱三头肌肌支移位修复腋神经等[1],其中副神经移位修复肩胛上神经已经证实具有比较理想的效果并成为臂丛神经损伤修复中的肩外展功能修复经典术式.本文总结2008年之前在本院行肋间神经移位修复腋神经的患者4例,获得一些临床经验.     

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。     

后进路副神经移位修复肩胛上神经术式的解剖学研究

目的　研究副神经移位到肩胛上神经以恢复臂丛神经损伤患者肩外展功能的后进路术式。方法　选用陈旧尸体 10具 2 0侧 ,新鲜尸体 4具 8侧 ,解剖观测在肩胛冈上缘水平副神经和肩胛上神经的关系。设计后进路副神经移位到肩胛上神经的新术式 ,并试用于临床。结果　肩胛上神经 10 0 % (2 8/ 2 8)位于肩胛横韧带深侧的肩胛上切迹内 ,位置恒定 ;副神经降支行于斜方肌深面、筋膜下 ,在肩胛冈上缘水平位于肩胛骨内侧缘 [(10 .42± 4.2 4)mm , x±s,下同 ] ,在该水平与肩胛上神经的最近距离为 (4.94± 1 2 2 )cm。游离切断后 ,可与肩胛上神经在无张力下直接拉拢缝合。临床试用于 10例病人 ,均顺利完成副神经移位到肩胛上神经的手术。术后检查斜方肌上部肌力无明显影响。结论　后进路副神经移位到肩胛上神经的术式是安全的、可行的     

Avulsion of the peripheral nerve of the trigeminal nerve

There are variety of surgical methods in treating trigeminal neuralgia. They can all be devided in two large groups: less invasive procedures and decopmressive procedures in the region of pontocerebelar angle. Peripheral neurectomy, exeresis or avulsion of peripheral branches of trigeminal nerv are methods for elderly patients with serious cardiopulmonal disturbances. We performed avulsion of peripheral branches at 58 patients, all older than 60 years. In 32 patients we did avulsion of only one of three branches of trigeminal nerv, while in 26 patients the combined avulsion of two branches was performed. There were no postoperative complications.     

Sporadic malignant nerve sheath tumour of the oculomotor nerve

Malignant peripheral nerve sheath tumours (MPNST) are exceedingly rare in an intracranial location. In this report clinical and pathological evidence for the diagnosis of a MPNST arising from of the oclumotor nerve is presented. To our knowledge this is the first such case reported in the medical literature.     

移植神经长度对膈神经移位肌皮神经疗效的影响

目的 探讨移植神经长度对膈神经移位肌皮神经治疗臂丛神经根性撕脱伤疗效的影响.方法 对2007年至2010年于我院行膈神经移位肌皮神经治疗臂丛损伤的患者进行临床随访,其中17例需要做神经移植.通过检测肱二头肌肌力与体重指数(BMI)评定手术疗效.结果 17例患者的总体有效率82.4％,移植神经长度以及BMI与屈肘功能恢复无明显相关性.结论 臂丛损伤患者尤其是全臂丛损伤患者中,膈神经移位肌皮神经的临床疗效不受移植神经长度以及BMI的影响.     

Anterior interosseous nerve transfer to the motor branch of the ulnar nerve for high ulnar nerve injuries

Primary repair of a high ulnar nerve injury results in a uniformly poor outcome as a result of the great distance between the site of injury and the innervated muscles. In this study the authors present two cases of high ulnar nerve injuries in adults. Reconstruction was performed using the distal branch of the anterior interosseous nerve, which was transferred to the distal motor branch of the ulnar nerve. This resulted in timely return of function to the ulnar-innervated intrinsic muscles of the hand, which was documented further by electromyography. For high ulnar nerve injuries, this type of nerve transfer is a much better approach than the traditional primary neurorrhaphy.     

Numbering of the dorsal spinal nerve roots in man from the 12th thoracic nerve to the coccygeal nerve

A bilateral study for locating the dorsal root filaments of specific nerves was accomplished from the twelfth thoracic to the coccygeal level and this using 26 fetal and 8 adult specimens. After laminectomy from the thoracic to coccygeal levels, incision of the dural sac permitted visualisation of the dorsal root filaments, the successive rootlets corresponding to each segmental level (T12 to Co1 ) were counted with the aid of a binocular microscope where they penetrated the spinal medulla at the posterior sulcus. Statistical evaluation shows that for each dorsal nerve the average number of root filaments is greater on the right compared with the left. Numbering the dorsal nerve root filaments in the cephalo -caudal direction allows to assert with 99% probability up to the L5 level and with 95% probability up to the S1 level that one is at a given spinal level of the respective segmental range; caudal-cephalic direction numbering permits to affirm with 99% probability up to the S1 level and 95% probability up to the L4 level that one is at a given spinal level of the respective segmental range.     

Variant location of the musculocutaneous nerve during axillary nerve block

We present the case of a 56-year-old man who underwent axillary nerve block for a wrist arthroscopy procedure, with real-time ultrasound and peripheral nerve stimulator guidance. The ulnar nerve and radial nerve were located medial and posterior to the brachial artery, respectively. A large complex structure was noted in the position typically occupied by the median nerve. Contact of this structure with the stimulating needle produced strong biceps contraction, and slight adjustment of the needle resulted in forearm pronation. After injection of 10 mL of local anesthetic near this structure, it appeared to consist of two separate components on ultrasound. We believe that these components represented the median and musculocutaneous nerves lying together, lateral to the artery. Radial, median, ulnar, and musculocutaneous nerve block ensued, and wrist arthroscopy was carried out uneventfully. Knowledge of this anatomical variation may improve anesthesiologists' ability to provide effective axillary block.     

Digital nerve grafting using the dorsal sensory branch of the ulnar nerve

The dorsal sensory branch of the ulnar nerve has been found to have the appropriate size and sufficient length for use as a digital nerve graft. This donor nerve was utilised fifteen times in twelve patients for the bridging of defects in thirteen digital nerves of the fingers. After an average follow-up of 23.2 months, only one patient failed to achieve any two point discrimination in the area supplied by the involved digital nerve. The other eleven patients had an average two point discrimination of 9.5 mm with a range of 5 to 18 mm. Painful neuroma formation or loss of hand function related to the use of the dorsal sensory branch of the ulnar nerve as a donor for digital nerve grafts was not encountered.