人背阔肌肌内神经分布和肌构筑特征及其临床意义

目的:为背阔肌亚部肌移植的临床应用提供形态学基础。方法:改良Sihler’s肌内神经染色法和肌构筑法。结果:(1)支配背阔肌的胸背神经发出2～3支一级神经支入肌,入肌后发出呈树枝状分支分布到该肌,在肌中部构成网格状的神经分支密集区。(2)背阔肌内上部肌重(58.91±10.29)g、肌长(18.76±1.67)cm、生理横切面积(3.39±0.65)cm2,外下部肌重(119.60±20.89)g、肌长(29.33±1.70)cm、生理横切面积(4.69±0.92)cm2。结论:(1)背阔肌有恒定的肌内神经分支分布,可分为两个亚部:内上部和外下部。(2)背阔肌内上部在肢体运动中更多的维持肩关节的稳定;而背阔肌外下部则更多参与肢体的速度运动。     

臂丛根部的显微解剖学研究及其临床意义

目的:对臂丛根部及其周围组织进行显微解剖,为臂丛撕脱伤的诊治提供解剖学基础。方法:在15例防腐成人尸体的颈胸段标本上,观测臂丛根部的形态特点及其与周围组织的关系,2例新鲜标本行组织学检查,观察臂丛根部穿椎间孔时与周围组织的联系。结果:①臂丛前后根之间有齿状韧带相间隔;相应的后根比前根粗,后根间存在着复杂的纤维联系。②臂丛C5、C6神经根分出角小于前支分出角,C7、C8、T1神经根分出角大于前支分出角。③臂丛C5、C6神经根在椎间孔处与前、中斜角肌起点处的腱性组织交织,并与上半椎韧带融合,且有薄层纤维筋膜鞘样结构,将椎动脉、椎静脉与之包裹一起;C7、C8、T1少见或未见与前述结构的联系。结论:臂丛神经根解剖结构的差异是臂丛C5、C6神经根较C7、C8、T1神经根不易形成根性撕脱的主要原因,熟悉臂丛根部的显微解剖有助于临床臂丛根性撕脱伤的诊治。     

椎管内臂丛前后根的显微解剖及其临床意义

目的:研究臂丛椎管内前后根的显微解剖,为臂丛撕脱伤的诊治提供解剖学基础。方法:在15例防腐灌注红色乳胶的成人尸体的颈胸段标本上,对椎管内臂丛前后根的位置、形态和血供进行观察和测量。结果:臂丛前后根之间有齿状韧带相间隔;前根起始处与脊髓中线的距离从上至下由C5的2.2mm逐渐增大到T1的3.1mm,后根则从C5的4.2mm逐渐减小到T1的2.7mm;前后根与脊髓纵轴的夹角从C5的51.4°、54.8°逐渐减小到T1的21.7°、19.9°;前后根的长度从C5的14.9mm、13.9mm逐渐增大到T1的21.1mm、19.0mm;前后根的直径均以C6最为粗大,分别为2.1mm、3.3mm,后根比相应前根粗;前后根的血供来自椎动脉、颈深动脉和颈升动脉发出的节段性动脉。结论:熟悉臂丛椎管内前后根的显微解剖有助于临床臂丛根性撕脱伤的诊治。     

Anatomy and quantitation of the subscapular nerves

Information regarding branches of the brachial plexus can be of utility to the surgeon for neurotization procedures following injury. Sixty-two adult cadaveric upper extremities were dissected and the subscapular nerves identified and measured. The upper subscapular nerve originated from the posterior cord in 97% of the cases and in 3% of the cases directly from the axillary nerve. The upper subscapular nerve originated as a single nerve in 90.3% of the cases, as two independent nerve trunks in 8% of the cases and as three independent nerve trunks in 1.6% of the cases. The thoracodorsal nerve originated from the posterior cord in 98.5% of the cases and in 1.5% of the cases directly from the proximal segment of the radial nerve. The thoracodorsal nerve always originated as a single nerve from the brachial plexus. The lower subscapular nerve originated from the posterior cord in 79% of the cases and in 21% of the cases directly from the proximal segment of the axillary nerve. The lower subscapular nerve originated as a single nerve in 93.6% of the cases and as two independent nerve trunks in 6.4% of the cases. The mean length of the lower subscapular nerve from its origin until it provided its branch into the subscapularis muscle was 3.5 cm and the mean distance from this branch until its termination into the teres major muscle was 6 cm. The mean diameter of this nerve was 1.9 mm. The mean length of the upper subscapular nerve from its origin to its termination into the subscapularis muscle was 5 cm and the mean diameter of the nerve was 2.3 mm. The mean length of the thoracodorsal nerve from its origin to its termination into the latissimus dorsi muscle was 13.7 cm. The mean diameter of this nerve was 2.6 mm. Our hopes are that these data will prove useful to the surgeon in surgical planning for potential neurotization procedures of the brachial plexus.     

男性盆丛神经的观察及其临床意义

目的：直肠癌扩大根治术是提高术后生存率，减少癌细胞转移的重要术式，但其术后排尿和性功能障碍并发症较多，其原因是术中损伤了盆丛神经。本文对盆丛的研究可为改进直肠癌扩大根治术，降低并发症，提高生存质量，提供解剖学资料。方法：用３０侧男性盆腔标本，通过冰醋酸松解剥离方法，对盆丛的起源、组成和分支分布进行了详细观测。结果：盆丛长径为４１．６±７．３ｍｍ，宽径２９．８±８．５ｍｍ。盆丛又继续形成直肠丛、膀胱丛和前列腺丛，三个次级丛参与管理排尿功能和性功能。结论：手术中如能对盆丛及其次级丛神经加以保护，免受或减少损伤，可防止或减少术后并发症的发生。     

尺神经中第七颈神经成份的行径及临床意义

用神经束追踪分离法解剖观察100侧成人第七颈神经分布至尺神经内的纤维行径。结合临床观察认为,尺神经内部有来自颈七的纤维,主要经4个交通部位加入到尺神经分布区内。证明脊神经相应节段与骨骼肌或肌群的支配关系是恒定的,只是由于在胚胎发生上臂丛组合的不同,使脊神经的分支到所支配的骨骼肌间的行径出现差异。上述研究结果,对臂丛中、下干损伤准确定位诊断有重要意义。     

Brachial plexus anatomy in the miniature swine as compared to human

Brachial plexus injury (BPI) occurs when the brachial plexus is compressed, stretched, or avulsed. Although rodents are commonly used to study BPI, these models poorly mimic human BPI due to the discrepancy in size. The objective of this study was to compare the brachial plexus between human and Wisconsin Miniature Swine^TM (WMS^TM), which are approximately the weight of an average human (68–91 kg), to determine if swine would be a suitable model for studying BPI mechanisms and treatments. To analyze the gross anatomy, WMS brachial plexuses were dissected both anteriorly and posteriorly. For histological analysis, sections from various nerves of human and WMS brachial plexuses were fixed in 2.5% glutaraldehyde, and postfixed with 2% osmium tetroxide. Subsequently paraffin sections were counter-stained with Masson's Trichrome. Gross anatomy revealed that the separation into three trunks and three cords is significantly less developed in the swine than in human. In swine, it takes the form of upper, middle, and lower systems with ventral and dorsal components. Histological evaluation of selected nerves revealed differences in nerve trunk diameters and the number of myelinated axons in the two species. The WMS had significantly fewer myelinated axons than humans in median (p = 0.0049), ulnar (p = 0.0002), and musculocutaneous nerves (p = 0.0454). The higher number of myelinated axons in these nerves for humans is expected because there is a high demand of fine motor and sensory functions in the human hand. Due to the stronger shoulder girdle muscles in WMS, the WMS suprascapular and axillary nerves were larger than in human. Overall, the WMS brachial plexus is similar in size and origin to human making them a very good model to study BPI. Future studies analyzing the effects of BPI in WMS should be conducted.     

Patterns of connections between the musculocutaneous and median nerves in the axilla and arm

Variations in connections between the musculocutaneous and median nerves in the arm are not as uncommon as was once thought. This opinion led us to perform a study in 138 cadavers (66 male, 72 female). These variations were seen in 64 cadavers (46.4%), 9 bilaterally and 55 unilaterally (26 right and 29 left); in total, therefore, variations were observed in 73 out of 276 arms (26.4%), 42 male and 31 female. No statistically significant differences by gender and side were observed. We classify the variations in three main patterns: Pattern 1, fusion of both nerves (14 arms, 19.2%); Pattern 2, presence of one supplementary branch between both nerves (53 arms, 72.6%); and Pattern 3, two branches (5 arms, 6.8%). Pattern 2 was further subdivided into a sub-group 2a when a single root from the musculocutaneous nerve contributed to the connection (51 arms, 69.9%), and 2b when there were two roots from the musculocutaneous nerve (2 arms, 2.7%). A combination of Patterns 1 and 2a was observed in one case (1.4%). Further variations are described, published classification systems are reviewed and a meta-analysis of previous results is presented. An overall incidence of 33% of variant arms was observed. Of these variant arms, Pattern 1 represented 13.1%, Pattern 2 represented 75.4%, and Pattern 3, 8.5%, similar to our figures.     

Assessment of the usefulness of X-ray myelography and magnetic resonance myelography,performed with an open low-field device,in diagnosing perinatal preganglionic injuries of the brachial plexus

Introduction

The goal is to assess the usefulness of diagnostic imaging in diagnosing perinatal preganglionic injuries of the brachial plexus.

Material and methods

The clinical material included 40 children of both genders, aged 2 to 35 months. The authors analysed the results of diagnostic imaging examinations (myelography in 20 cases and magnetic resonance [MR] myelography in 20 cases), intraoperative view and clinical course.

Results

In 13 out of 40 (32.5%) examined children, no evidence of avulsion of the roots of the spinal nerves was found either by diagnostic imaging or during the surgery. In 3 cases (7.5%) with avulsed roots of the spinal nerves, the diagnostic imaging and intraoperative appearance were in agreement. Total agreement of the diagnostic imaging and intraoperative view was found in 40% of cases. In 9 patients (22.5%) suspected avulsion of roots of the spinal nerves was not confirmed during the surgery. However, the further clinical course of the disease in these cases indicated high probability of avulsion of roots without their pull-out from the intervertebral foramens. In the remaining cases, the findings were as follows: false positive results – 7 (17.5%), false negative results – 1 (2.5%), results underestimating injury – 3 (7.5%), results overestimating injury – 2 (5%).

Conclusions

It was determined that the usefulness of pre-operative diagnostic imaging is limited. Due to the risk of occurrence of false positive and false negative results, final decisions concerning selection of the surgical technique must be based on the analysis of the intraoperative view and preoperative clinical symptoms.     

Microanatomical study on the functional origin and direction of the thoracodorsal nerve from the trunks of brachial plexus

Ipsilateral C7 nerve root transfer or neurotization has been used for the repair of brachial plexus avulsions. In this procedure, the ipsilateral C7 nerve root is used as a donor nerve and is implanted into the damaged nerve of the brachial plexus in order to reinnervate distal muscles. However, this procedure may result in unintended injury to the thoracodorsal nerve, which receives motor fascicles form the cervical nerves of C6, C7, and C8, but mainly from C7. Damage to the thoracodorsal nerve ultimately results in weakness or paralysis of the latissimus dorsi muscle, which it innervates. In the present study, 20 adult cadaveric brachial plexus specimens and 3 fresh specimens were dissected using microscopy. The origin and direction of motor fascicles from the three trunks of the brachial plexus to the thoracodorsal nerve were investigated. Motor fiber counts of C7 and the thoracodorsal nerve were also performed. Several observations can be made: (1) The origin of the thoracodorsal nerve can be divided into three types: Type A, the thoracodorsal nerve originated from the superior and middle trunks; Type B, the thoracodorsal nerve originated from the inferior and middle trunks; and Type C, the thoracodorsal nerve originated from all three trunks. (2) More than 52% of the motor fibers in the thoracodorsal nerve originated in the C7 nerve root. (3) Motor fascicles from C7 to the thoracodorsal nerve were mostly localized in the posterior-internal part of C7 at the trunk-division boundary. In conclusion, we suggest that: (1) Because of variation in the origin of the thoracodorsal nerve, electromyography should be routinely performed intraoperatively during C7 nerve root transfer to determine the origin type and avoid thoracodorsal fascicle injury. (2) Preservation of the posterior-internal part of C7 (selective C7 transfer) can protect thoracodorsal nerve fascicles from damage and prevent postoperative dysfunction of the latissimus dorsi muscle.     

臂丛根性撕脱伤后神经根回植术的大鼠动物模型

目的：建立合理的臂丛根性撕脱伤后神经根回植术的大鼠动物模型。方法：在手术显微镜下，采用前入路，将C6神经根从脊髓上撕脱，咬除同侧C5椎体下外部分，显露脊髓；切断肌皮神经，切取长约30mm尺神经桥接肌皮神经与脊髓间的缺损，并将神经近端植入脊髓。术后观察手术侧前后肢的一般情况；6个月后，观察神经的解剖与组织学的连续性。结果：大鼠存活良好，手术侧前肢无坏死、溃疡、脱落，后肢无瘫痪；从脊髓到肱二头肌，神经的连续性完整；组织学检查见桥接神经段内有神经纤维再生。结论：该模型显露脊髓和切取桥接用神经方便，再植位置准确，便于直接观察神经根再植后神经再生及功能恢复情况，无明显的脊髓损伤并发症，较好模拟了臂丛根性撕脱伤后神经前根的回植。     

Anatomical study to investigate the feasibility of pedicled nerve, free vessel gastrocnemius muscle transfer for restoration of biceps function.

A challenging problem is the patient with a total brachial plexus injury with nerve root avulsions. In these patients nerve repair is not possible and no local functioning muscles are available for transfer. Current techniques involve either nerve repair using donor nerves from the contralateral limb or free muscle transfer neurotized by intercostal nerves. The problem with both these techniques is that they are dependent on neural regeneration, which is imperfect. To overcome the problem we propose a technique of transferring a distant muscle whilst retaining its neural supply. Gastrocnemius is a strong muscle and one suitable for free tissue transfer. This study assessed the possibility of transferring gastrocnemius on its neural supply by determining the length of nerve available and whether it was possible to dissect the nerve to gastrocnemius from the main body of the sciatic nerve. We found that the latter was possible, and that the length of dissected nerve would allow transfer of the innervated muscle from the calf to the axilla.     

Anatomical study and clinical significance of the rami communicantes between cervicothoracic ganglion and brachial plexus

The aim of this study was to provide a detailed characterization of the rami communicantes between the stellate (or cervicothoraic) ganglion (CTG) and brachial plexus (BP). Rami communicantes of 33 fixed adult cadavers were macroscopically observed, and connection between CTG and spinal nerves and branching was investigated. In all cases, except one, the hibateral medial rami communicantes was found to be positioned symmetrically between the CTG and C7, C8 spinal nerves. Gray rami communicantes arising from the CTG joined C8, C7, C6 nerve roots on 66, 63, and 6 sides, respectively, and branched from the rami communicantes to C7, C6, C5 nerve roots lying on 51, 41, and 2 sides, respectively. Forty‐five sides of the branches from rami communicantes derived from CTG to C8 were observed to ascend through the transverse foramina of the C7 nerve. The branches from rami communicantes derived from CTG to C7 to the C6 nerve were observed ascending through the foramen transversarium of the six cervical vertebrae along with the vertebral artery and joining the C6 spinal nerve in 41 sides. Knowledge about the general distribution and individual variations of the rami communicantes between CTG and BP will be useful toward studies involving the inference of sympathetic nerve stimulation of the upper limbs and could be important for surgeons who perform surgical procedures in the cervical region or medical blockade of nerve fibers. Clin. Anat. 23:811–814, 2010. © 2010 Wiley‐Liss, Inc.     

Nerve fiber analysis on the so-called accessory subscapularis muscle and its morphological significance

A rare muscular anomaly, so-called accessory subscapularis muscle, was found in the left axillary fossa of a 95-year-old male cadaver during a student dissection practise. The muscle arose near the lateral margin of the scapula from the surface of the subscapularis muscle and ran upward to fuse with the capsule of the shoulder joint via a tendon. It measured 1.0 cm in width, 7.0 cm in length and 1.5 mm in thickness, and was separated from the underlying subscapularis muscle by the axillary and inferior subscapular nerves. Macroscopically, the anomalous muscle received its nerve supply from a branch arising from the lower root of the radial nerve near the origin of the thoracodorsal nerve and entered the muscle from its ventral surface. Nerve fiber analysis showed that the supplying nerve originated from fibers of the dorsal element of C7 immediately cranial to the thoracodorsal nerve. These findings indicate that the present anomalous muscle might be close to the formation of the latissimus dorsi muscle in its derivation rather than the subscapularis muscle.     

用大网膜或背阔肌填塞术治疗肝或胸脓腔的解剖学研究

通过测量40具成年男女尸体大网膜和背阔肌体积的对比研究。提供了带蒂大网膜和背阔肌移植术治疗成人脓胸的基础资料,并评价了带蒂大网膜和背阔肌移植术在脓胸填塞术中的治疗地位。本研究亦为带蒂大网膜移植术治疗肝脓肿提供了解剖学资料。     

Musculocutaneous and median nerve branching: anatomical variations. Case Series from UR clinical anatomy and literature review

IntroductionThe brachial plexus is highly variable, which is a well-known anatomical fact. Repeated observations on anatomical variations, however, constitute current trends in anatomical research.Case seriesIn an anatomical dissection course, three uncommon variations in the brachial plexus were identified in three young adults'' cadavers. In one case, the musculocutaneous nerve gave a branch to the median nerve, while the median nerve gave or received musculocutaneous branches in the two remaining corpses.ConclusionAnatomical variations of the brachial plexus do occur in our setting. The cases we presented are about anatomical variations of branching patterns of the median and musculocutaneous nerves. Knowledge of those variations is essential for surgery and regional anesthesia of the upper limbs.     

根管内段神经根的形态特点及其临床意义

目的：了解腰骶神经前根、后根、后根神经节位置关系及其变异,为下腰椎神经根造影提供解剖学依据。方法：解剖４６具尸体的腰骶神经,对神经根管内段的形态进行了肉眼观察。结果：①前、后根在神经根管内汇合后根据神经根前支是否分离分为分离型和非分离型２类,分离型进一步分为Ａ、Ｂ、Ｃ３型：Ａ型前支分上下２支,但前根和后根神经节不分离;Ｂ型在Ａ型基础上前根也分离;Ｃ型在Ｂ型基础上后根神经节也有分离。Ｌ４和Ｌ５全部为分离型,其频度分别为Ａ型３．３％;Ｂ型７５％;Ｃ型２１．７％。与Ｌ４和Ｌ５相反,Ｓ１神经根全部为非分离型;②神经根管内脊神经被根鞘的疏松结缔组织包围,尽管神经根分离,根鞘并不将神经根分隔。结论：神经根造影时可呈现复杂的表现。     

超声引导技术在肌间沟臂丛神经两点阻滞中的应用

目的比较超声引导定位法与神经刺激器引导定位法用于肌间沟臂丛神经阻滞的效果。方法拟行上肢手术的患者90例随机分为3组(n=30),对照组:神经刺激器定位单点阻滞组;US组:超声引导与神经刺激器确认相结合定位单点阻滞组;UD组:超声引导与神经刺激器确认相结合定位两点阻滞组。各组均给予0.5%的罗哌卡因30 mL,其中UD组被阻滞的两支目标神经各给予15 mL。结果UD组阻滞平均起效的时间明显短于US组和对照组。UD组感觉神经阻滞完善率明显高于US组和对照组。结论超声引导下行肌间沟臂丛神经阻滞起效快,并发症少;超声引导下两点阻滞法可明显改善阻滞效果。