肋间神经移位腋神经的解剖学研究

目的 为利用肋间神经移位腋神经恢复肩外展功能提供解剖学依据.方法对30侧成人尸体标本中第三至第六肋间神经自腋中线至锁骨中线的长度和相应肋间神经自腋中线起点处穿过皮下隧道至四边孔腋神经缝合口处的距离(在肩外展45°和90°两种情况下)进行比较.结果 在肩外展45°时第三肋间至第六肋间自腋中线到锁骨中线的选取长度与相应肋间自腋中线自皮下隧道至四边孔距离差值分别为(3.89±0.85) cm、(4.14± 1.15)cm、(2.99± 1.33) cm和(0.25±1.49)cm.在肩外展90°时,差值分别为(2.54±0.87) cm、(2.37± 1.51)cm、(1.04± 1.74) cm和(-1.59± 1.95)cm.结论 第三、第四、第五、第六肋间选取自腋中线至锁骨中线经皮下隧道至四边孔与腋神经直接缝合是可行的.其中若选用第六肋间神经作为移位神经直接修复腋神经,可适度增加肋间神经或腋神经游离长度,以实现肩外展90°情况下的无张力缝合.     

肋间神经移位肩胛上神经的解剖学研究

目的探讨第3～6肋间神经移位肩胛上神经重建肩关节外展功能的可行性。方法取15具30侧成人躯干标本,解剖测量第3～6肋间神经自腋中线至锁骨中线可切取长度以及自腋中线至锁骨中点(拟定神经吻合点)的移位距离,并进行统计学比较。结果 30侧标本中,第3、4肋间神经均可切取自腋中线至锁骨中线范围内的全段神经,且可切取长度均较移位距离长(P<0.01)。6侧第5肋间神经及16侧第6肋间神经在未到达锁骨中线时被肋软骨覆盖,其中第5肋间神经可切取长度与移位距离相似(P>0.01),第6肋间神经可切取长度较移位距离短(P<0.01)。肩胛上神经通过游离切断,可翻转至锁骨中点下方2 cm以上。第5肋间神经切取长度与肩胛上神经翻转长度(2 cm)之和,可超过移位距离(P<0.01),但第6肋间神经总长度仍较移位距离短(P<0.01)。结论第3～5肋间神经可直接移位肩胛上神经重建肩关节外展功能,而第6肋间神经需增加游离切取长度范围或采用神经移植修复。     

带肋间神经外侧前支脐旁感觉皮瓣的应用解剖

目的为形成带感觉神经的脐旁游离皮瓣提供解剖学基础。方法在２０具４０侧成人躯干标本上,观测了下位肋间神经外侧前支与腹壁下血管形态、分支及分布规律。结果腹壁下动脉起点外径为（２．３±０．３）ｍｍ,伴行静脉（３．６±０．４）ｍｍ。下位肋间神经外侧前支在腋前线前后１～２ｃｍ相应肋间穿出,神经在锁骨中线附近浅出皮下。第８～１０肋间神经外侧前支浅出皮下在脐上０～７ｃｍ范围内,恰好支配脐旁皮瓣设计的范围。结论可设计以腹壁下血管带第８～１０肋间神经外侧前支的脐旁感觉皮瓣。     

腋神经中三角肌功能束组在四边孔平面分布的显微解剖及组织学研究

目的观察研究腋神经中支配三角肌的功能束(组)于四边孔平面在神经干中的分布规律及组织学特征。方法根据自然分束逆行显微解剖分离12具(24侧)福尔马林灌注固定成人尸体标本(左右各半)的腋神经,于四边孔平面观察记录三角肌功能束组在神经干中的分布情况并测量其直径;另取新鲜冷冻尸体上肢标本6具(左右各半),对腋神经束组于四边孔平面断面取材,组织横断面切片,分别行乙酰胆碱酯酶染色(Karnovsky-Roots法)及Loyez髓鞘染色,观察断面纤维束性质及行纤维计数。结果腋神经在四边孔平面可分为两大束组,支配三角肌的腋神经前支组成的束组走行于神经干外侧,截面积为(2.449±1.327)mm2,占神经干面积的55.4%±9.3%;纤维束性质表现为运动纤维;纤维计数为(2112±631)根,占神经纤维总数的45.6%±1.1%。结论在臂丛神经根性损伤进行神经移位重建肩外展功能时,将移位神经选择性与腋神经外侧束组吻接,会减少纤维散失,提高功能恢复率。     

腋神经与四边孔关系的解剖学研究

目的　对四边孔处的腋神经进行显微解剖学研究 ,为提高臂丛损伤患者腋神经修复后的疗效提供依据。方法　取福马林固定的成人尸体 10具 ,在头戴式放大 2 .5倍手术显微镜下 ,对 2 0侧腋神经进行显微解剖 ,观察其在四边孔处的行径及分支。结果　腋神经在肩胛下肌下缘分为内外侧两大束组 ;走行至小圆肌下缘 ,分为前后两大分支 ,并可无损伤地分离至肩胛下肌下缘上方 1.4cm处 (均数 ) ;三角肌肌支在腋神经起始段、四边孔前界和后界处分别位于腋神经主干的外侧半、外侧束组和前侧分支 ;三角肌肌支的横截面积占腋神经横截面积的 6 3%。结论　三角肌肌支在四边孔处主要集中在腋神经的前支 ,选择性修复前支有利于三角肌功能的恢复     

可桥接血管神经肋骨瓣移植术的解剖学研究

目的　为四肢伴血管神经损伤的骨缺损提供一种治疗方法。　方法　在 3 0侧经动脉灌注红色乳胶成人背标本上 ,观察第 7、8、9肋肋角外侧 8cm段的形态结构及肋间血管、神经在该段的走行、分支、分布和吻合 ;在 2侧尸体标本上模拟手术。　结果　该段肋骨高 ( 1 4± 0 2 )cm ,厚 ( 0 6± 0 1)cm ;肋间血管、神经在该段行于肋沟中 ,肋间动脉、静脉、神经该段的起始外径分别为 ( 1 4± 0 2 )mm、( 2 1± 0 4)mm、( 2 4± 0 5 )mm ,终末外径分别为 ( 1 0± 0 2 )mm、( 1 3±0 3 )mm、( 1 5± 0 4)mm。　结论　设计可桥接血管神经的肋骨瓣移植术是可行的     

胸背神经双分支的解剖研究与临床应用

目的 对胸背神经的外侧束和腋神经穿越四边孔后支配的三角肌肌支进行显微解剖研究,并应用于临床,为臂丛神经损伤后功能重建提供新的方法。方法 取17具成人尸体,在手术显微镜下对31侧胸背神经外侧束和液神经三角肌肌支进行解剖,观察其可应用长度、直径及分支情况,并取神经标本经HE染色、石蜡切片,对有髓神经纤维进行计数。临床上进行3例手术。例1钭胸背神经外侧束与四边孔内切断的腋神经三角肌肌支吻合,例2在例1休式基础上,用胸背神经内侧束支配的部分背阔肌重建屈肘功能,例3将背阔肌按内、外侧束的支配区域,剪切成两部分,移位的同时重建屈肘、屈指功能,结果 胸背神经在人背阔肌处开始分为内、外侧束,外侧束明显较内侧束粗大,外侧束在背阔肌内可利用的长度平均为58.2mm直径平均为1.46mm,有髓纤维数平均为1519根,90.4%的外侧束可再分为2支或3支,腋神经三角肌肌支直径平均为2.31mm,有髓纤维数 平均为2341根,61.3%的三角肌肌支可再分为3支,32.3%的三角肌肌支可再分为2支,3例术后情况：例1三角肌肌力为4级;例2三角肌肌力为4级,屈肘时肌力为4级;例3屈肘、指时肌力均达到4级。结论 应用胸背双分支的解剖基础。将胸背神经外侧束与腋神经三角肌肌支相吻合恢复三角肌的功能,从理论和[实践上是统一的,是行这有效的方法,充分利用胸背神经双分支的原理可以重建两块失神经支配的肌群功能。     

选择性肌支神经转位治疗臂丛上干损伤

目的 选择最好的肌支神经转位治疗臂丛上干损伤。方法 采用选择性肌支神经转位治疗臂丛上干损伤１６例２４人次,供转位的胸背神经,副神经,胸长神经和肋间神经等与腋神经的三角肌支,肌皮神经的肱二头肌支缝接。结论 手术的关键是肌支神经与肌支神经的缝接,从而使吻合口靠近肌肉,关节功能恢复快,转位神经中以胸背神经转位效果最好。     

女性乳房神经分布解剖研究

目的：研究乳房的神经来源、走向及分布,为乳房整形美容手术提供依据,方法：对7具尸体13例乳房进行大体与显微解剖,并对乳头乳晕区神经分布进行组织学研究。结果：第2－6肋间神经的外侧皮支与前皮以都到达并支配乳房,未发现锁骨上神经分支到达乳房。肋间神经支分深、浅两支进入乳房、,走向呈“立体发散”模式到达乳房腺体及皮肤。乳头和乳晕区的神经主要来自于第3－5肋间神经的外侧皮支与前皮支,以第4肋间神经占主导地位,有少量神经伴随乳腺导管走行到达乳头。结论：乳房、乳头和乳晕的神经支配丰富且存在个体差异。     

隆乳术肋间神经阻滞麻醉的临床解剖学

目的为乳房局部手术提供乳房神经的解剖学依据。方法对15具(30侧)成年女性标本胸部进行解剖，观测第2～6(T2～T6)肋间神经前支外侧皮支(LCAIN)及前皮支(ACAIN)分布情况。结果T2～T6穿出点至前正中线的距离逐渐增大，穿出点横径依次递减，穿出点至腋前线距离亦逐渐增大。T2～T6 ACAIN位置较为恒定，于前正中线2．5cm处，穿出点横径逐渐减小。且肋间神经前支呈节段性、重叠性分布于乳房区的皮肤及皮下组织。结论采用阻滞ACAIN和LCAIN，完全可以满足隆乳术及乳房缩小术等乳房局部手术的镇痛要求。     

Nerve transfer to deltoid muscle using the intercostal nerves through the posterior approach: an anatomic study and two case reports

PURPOSE: To evaluate the feasibility of restoring the deltoid function in patients with C5 through C7 root avulsion injuries by transferring 2 intercostal nerves to the anterior branch of the axillary nerve through a posterior approach. The preliminary results of the clinical application of this procedure also are reported. METHODS: The study was performed on 10 fresh cadavers. The lengths of the third, fourth, and fifth intercostal nerves from the costochondral junction to the midaxillary line were recorded. The distance from the pivot point at the midaxillary line to the anterior branch of the axillary nerve was recorded as the tunnel length. All histomorphometric measurements of the axon number were recorded. Based on the anatomic study, the fourth and fifth intercostal nerves were transferred directly to the anterior branch of the axillary nerve in 2 patients. RESULTS: The average distances from the costochondral junction of the third, fourth, and fifth intercostal nerves to the pivot points were 12, 15, and 16 cm, respectively. The average tunnel distances of the third, fourth, and fifth intercostal nerves were 11, 13, and 15 cm, respectively. The average numbers of myelinated nerve fibers of the third, fourth, and fifth intercostal nerves were 742, 830, and 1,353, respectively. At the 2-year follow-up evaluation the preliminary clinical results showed that the deltoid recovered against resistance (M4). The range of motion for shoulder abduction and external rotation were both 95 degrees in the first case and 105 degrees and 95 degrees , respectively, in the second case. Useful functional recovery was achieved and classified as a good result in both patients. CONCLUSIONS: This anatomic study with 2 case reports supports the idea that transfer of 2 intercostal nerves to the anterior branch of the axillary nerve through the posterior approach could be an alternative method for reconstruction of the deltoid muscle in C5 through C7 root avulsion injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

The anatomic branch pattern of the axillary nerve

The purpose of this study is to determine the surgical anatomy and innervation pattern of the branches of the axillary nerve and discuss the clinical importance of the presented findings. We dissected 30 shoulders in 15 fixed adult cadavers under a microscope through anterior and posterior approaches. The axillary nerve was examined in 2 segments in relation to the underlying subscapularis muscle. The axillary nerve gave off no branches in the first segment in 85% of cases. When the posterior approach was used, the axillary nerve and its branches were observed to be in a triangular-shaped area. The mean distance from the posterolateral corner of the acromion to the axillary nerve and its branches was 7.8 cm. In all cases, the posterior branch of the axillary nerve gave off its first muscular branch to innervate the teres minor. The joint branch of the axillary nerve was observed to branch out in 3 different patterns. The acromial and clavicular parts of the deltoid muscle were observed to be innervated from the anterior branch of the axillary nerve in all cases. The posterior part of the deltoid muscle was observed to be innervated in 3 different patterns. The posterior part of the deltoid was innervated from the branch or branches coming only from the posterior branch in 70% of cases, from the anterior and posterior branches in 26.7% of cases, and from the anterior branch in 3.3% of cases. The findings of this study are useful for identifying each of the branches of the axillary nerve and have implications for surgeries related with selective innervation.     

A cadaveric study on the anatomy of the deltoid insertion and its relationship to the deltopectoral approach to the proximal humerus

Elevation of the deltoid insertion (DI) has been recommended, but little is known about its anatomy or importance for deltoid function. The purpose of this study is to determine the dimensions of the DI with specific reference to the deltopectoral approach. The deltoid was exposed and detached at its origin in 36 cadaveric shoulders. The morphology of the DI was documented, and its relationship with the pectoralis major insertion and the axillary and radial nerves was recorded. The anterior, middle, and posterior deltoid muscle fibers entered into the DI in a V-shaped tendinous confluence with a broad posterior band and a narrow separate anterior band, which accounted for the anterior one fifth of the DI (0.44 cm). The deltoid insertion was separated from the pectoralis major insertion by as little as 2 mm in 31 of 36 specimens. The distance between the axillary nerve and the DI averaged 5.6 cm anteriorly and 4.5 cm posteriorly. The distance between the radial nerve and posterior deltoid insertion averaged 2.4 cm proximally and 1.6 cm distally. Exposure during the deltopectoral approach is most limited by the close proximity of the deltoid and pectoralis major insertions. Our study would suggest that partial anterior DI release (greater than one fifth) could compromise the anterior deltoid. The axillary and radial nerves are not at significant risk when operating in the region of the anterior DI.     

Nerve transfer to deltoid muscle using the nerve to the long head of the triceps,part I: an anatomic feasibility study

PURPOSE: To experimentally evaluate the feasibility of restoring the motor function of the deltoid muscle in patients with complete C5-C6 root injury (upper brachial plexus injury) by transferring the nerve to the long head of the triceps to the anterior branch of the axillary nerve through a posterior approach. METHODS: The study was performed on shoulder girdles of 36 formalin-embalmed cadavers. The number, diameter, and length of the branches of the axillary nerve at the level of the quadrilateral space were noted. The length and diameter of the nerves to the long head and to the lateral head of triceps at the level of triangular space were recorded. The distances from the acromion angle to the bifurcation of the anterior branch of the axillary nerve, to the origins of the nerve to the long head, and to the origin of the lateral head of the triceps were recorded as well. Nerve biopsy specimens of the axillary nerve and the nerve to the long head of the triceps were obtained from 6 fresh cadavers for histomorphometric evaluation. RESULTS: The average length of the anterior branch of the axillary nerve in this study, measured from the quadrilateral space to the innervating site, was 44.5 mm (range, 26-62 mm), and the average length of the nerve to the long head of triceps, measured from its origin to the innervating site, was 68.5 mm (range, 30-69 mm). The average diameter of the anterior branches of the axillary nerve and the nerve to the long head of the triceps were 2.1 and 1.1 mm, respectively. The average number of axon fibers in the anterior branch of the axillary nerve was 2,704 and in the nerve to the long head of the triceps was 1,233. CONCLUSIONS: Using the acromial angle as the landmark, the combined length of the two 2 nerves was longer than the distance between them. The diameter, the number of axons, and the anatomic proximity of the nerve to the long head of the triceps make it a potential source for reinnervation of the anterior branch of the axillary nerve by direct nerve transfer without nerve grafting through posterior approach for the management of upper brachial plexus injuries.     

Unique minithoracotomy assisted by videothoracoscopy facilitates a maximal view even with a minimal wound for resection of primary lung cancer

Resection for primary lung cancer with an unique minithoracotomy and use of videothoracoscopy is described. Through an incision of approximately 10 cm at an ausculatory triangle, the 5th intercostal thoracotomy is done following dissection of muscles. At the anterior and posterior portion of the 6th rib, the 6th intercostal vessels and nerve were dissected and the rib was resected. This approach makes feasible opening of a thoracic window without injury to the nerve and removal of the rib. Thoracoscopy is introduced through a midaxillary wound of 2 cm. We report nine patients in whom we achieved resection for primary lung cancer by using this approach. This technique facilitates a standard operation for lung cancer and an almost painless postoperative state.     

Applied anatomy of the axillary nerve for selective neurotization of the deltoid muscle

Morphologic and internal topographic features of the axillary nerve were studied in 40 cadaveric shoulders to provide anatomic data for selective neurotization of the deltoid muscle in axillary nerve injury. The axillary nerve can be divided into three segments. Proximal to the subscapularis muscle, the axillary nerve is a single nerve trunk. Nerve fascicles to the deltoid muscle are identified at its lateral part. In front of the subscapularis muscle, the axillary nerve forms into the lateral and medial fasciculi groups. Distal to the subscapularis muscle, the nerve divides into anterior and posterior branches, which are continuations of the lateral and medial fasciculi groups, respectively. The anterior branch contains all fibers that innervate to the anterior and middle deltoid muscle. In 90% of cases, the posterior branch contains part or all nerve fibers to the posterior deltoid muscle. Nerve fibers to the teres minor and cutaneous sensory fibers are found in the posterior branch. In neurotization of the deltoid muscle, the best approach is to match the donor nerve to the lateral fasciculi group, which will give the highest percentage of reinnervation of the deltoid muscle.     

带肋间神经外侧后支背阔肌感觉皮瓣的应用解剖

目的：为形成带感觉神经的背阔肌游离皮瓣提供解剖学基础,方法：在20具40侧成人躯干标本上,采用大体解剖方法结合4倍显微镜,解剖后背区及侧胸区层次结构,观测分布于背阔肌区域的间神经的来源,走行及分布规律。结果 T5－10神经外侧支的后支在腋前线1－2cm相应间穿出,水平向后背走行较长距离,在肩胛下角线附近浅出皮下,呈节段性,重叠性分布肩胛线以外的背阔肌区皮肤,并与下位胸脊神经后支在肩 胛下 线相吻合,其中T6－8外侧支的后支分支分布于皮瓣范围较大,神经蒂较长并与血管蒂较近,结论：可设计以第6－8肋间神经外侧后支为神经[蒂的背阔肌感觉皮瓣。     

The posterior branch of the axillary nerve: an anatomic study

BACKGROUND: Surgery on the posterior aspect of the shoulder has become accepted practice for a number of pathological conditions affecting the scapula and the glenohumeral joint. Despite this trend, the anatomy of the posterior branch of the axillary nerve has not been well characterized. The purpose of the present study was to determine the innervation pattern and surgical relationships of the posterior branch of the axillary nerve. METHODS: Nineteen fresh-frozen human cadaveric forequarter amputation specimens were dissected through a posterior approach. The location of the posterior branch of the axillary nerve and its anatomical relationships with surrounding structures were documented and measured with use of digital calipers. RESULTS: The posterior branch separated from the main anterior circumflex branch of the axillary nerve immediately anterior to the origin of the long head of the triceps muscle at the six o'clock position on the glenoid. It coursed posteriorly, adjacent to the inferior aspect of the glenoid rim for an average distance of 10 mm (range, 2 to 17 mm) before dividing into the superior-lateral brachial cutaneous nerve and the nerve to the teres minor. The nerve to the teres minor coursed medially along the posterior aspect of the inferior part of the glenoid rim for an average distance of 18 mm (range, 11 to 25 mm) before entering the muscle at its inferior border. The superior-lateral brachial cutaneous nerve coursed inferiorly, deep to the posterior aspect of the deltoid. It became superficial by passing around the medial border of the muscle at an average of 8.7 cm (range, 6.3 to 10.9 cm) inferior to the posterolateral corner of the acromion. CONCLUSIONS: The posterior branch of the axillary nerve has an intimate association with the inferior aspects of the glenoid and shoulder joint capsule, which may place it at particular risk during capsular plication or thermal shrinkage procedures. The superior-lateral brachial cutaneous nerve and the nerve to the teres minor always arise from the posterior branch. Thus, loss of sensation over the deltoid may indicate loss of teres minor function. The posterior aspect of the deltoid has a more consistent supply from the anterior branch of the axillary nerve, necessitating caution when performing a posterior deltoid-splitting approach to the shoulder.