单纯感觉神经移位在猕猴尺神经高位损伤修复中的应用

[目的]应用桡神经浅支端侧移位修复猕猴尺神经高位损伤(肘关节以上),观察手内在肌组织学及吻合口神经病理学变化。[方法]选用成年的雄性猕猴9只,以上肢为研究单位,将9只猕猴双侧上肢随机分为3组,每组6侧上肢。实验组:于猕猴上臂上段切断尺神经,再重新吻合。于远端切断桡神经浅支,移位于腕部与尺神经作外膜开窗端侧吻合。对照组(1):于猕猴上臂上段切除尺神经2.5 cm,两侧断端分别折叠后结扎。腕部处理同实验组。对照组(2):上臂尺神经处理与实验组相同。腕部不作处理。观察术后猴尺神经所支配的手内在肌萎缩程度。取术后1、4、8、12个月猕猴尺神经支配的手内在肌端侧吻合口、端侧吻合口以远的神经干及小鱼际肌组织,做成切片,光镜下观察其显微结构变化。[结果]术后12个月观察到实验组猕猴手内在肌自主活动恢复,实验组术侧手内在肌肌肉萎缩不明显,对照组(1)手内在肌肌肉萎缩,程度较对照组(2)轻,对照组(2)手内在肌肌肉萎缩明显。组织学观察结果显示术后实验组神经纤维数量和密度随时间延长渐增,对照组(1)术后神经纤维数量和密度达到一定数值后无明显变化,但未见肌肉出现变性坏死。对照组(2)神经纤维数量明显减少,肌纤维数量明显减少,最终大部分肌纤维萎缩并玻璃样变、间质出血、肉芽组织形成。[结论]桡神经浅支端侧移位修复猕猴尺神经高位损伤能有效防止猕猴手内在肌萎缩、变性、纤维化,为尺神经高位损伤修复后的再生、长入创造了良好条件。     

神经端侧吻合的实验研究

目的：研究神经多个端侧吻合后远端神经的再生情况,并与一干单一神经端侧吻合进行比较,探讨其可行性及临床应用价值。方法：选用Wistar雄性大鼠36只,随机分成A、B组。A组：于右侧锁骨下将肌皮神经、尺神经、桡神经切断,并在正中神经干侧方的外膜上分别开3个1mm“小窗”。将离断神经的远端依次端侧吻合到正中神经的“开窗”处,B组：于右侧锁骨下将尺神经切断,远端端侧吻合到正中神经侧方的“开窗”处,两组左侧均不予处置,为对照侧,术后行神经电生、组织学、电镜及神经纤维计数等检查。结果：神经端侧吻合后,肌皮神经、尺神经、尺神经、桡神经远端均有不同数量的有髓神经纤维再生,且A、B组的尺神经远端神经再生数量的差异显著性。两组的正中神经主干功能的未受到明显影响。结论鼠类动物神经端侧吻合后,远端神经可再生。     

神经高位端端与低位端侧或侧侧缝合相结合提高神经修复能力的实验研究

目的对无缺损的周围神经高位损伤，提出高位端端与低位端侧或侧侧缝合相结合的新方法，观察神经再生和靶器官的恢复情况。方法SD大鼠80只，高位切断左侧胫神经。随机分为5组：A组：胫神经两断端行端端缝合，远端于膝关节水平与腓神经干行侧侧缝合。B组：断端处理同A组，远端移植正中神经作胫腓神经干之间的端侧桥接缝合。C组：单纯作断端的端端吻合。D组：胫神经干近端结扎并固定，远端与腓神经干行侧侧缝合。E组：近端处理同D组，远端切除部分神经段后，与腓神经干行端侧缝合。术后行肌电图检查及组织学观察并作统计学分析。结果术后早期（4周）D、E组有神经再生，术后12周A、B组的神经再生、传导功能及靶肌肉和运动终板的恢复情况均优于C、D、E组。结论高位端端与低位端侧或侧侧缝合相结合的方法，可尽早恢复对靶组织的营养和神经再支配，为高位缝合处高质量神经的长入赢得时间，提高了有效功能的恢复。     

大鼠周围神经可塑性的实验研究

目的 通过建立大鼠感觉神经束(前臂内侧皮神经)近端与运动神经束(肌皮神经)远端吻合的神经再生模型,观察在靶器官改变时感觉神经的结构与功能发生的可塑性变化.方法 取健康成年SD大鼠30只,雌雄不限,体重200～250 g,随机分成3组,每组10只.每组大鼠左上肢制备实验模型,右上肢为正常对照,不作任何处理.A组:于距前臂内侧皮神经起点5 mm处切断该神经,将其近端与切断的肌皮神经远端行无张力端端吻合;B组:于距肌皮神经入肌点5 mm处切断该神经,将其远端与切断的前臂内侧皮神经近端行无张力的端端吻合;C组:切断肌皮神经和前臂内侧皮神经后不予吻合,形成肱二头肌失神经支配模型.于术后观察各组大鼠的一般情况、屈肘功能、肱二头肌湿重、肌纤维横截面积、诱发电位的潜伏期和波幅,行吻合口近端的神经乙酰胆碱酯酶(acetylcholinesterase,AchE)染色观察.结果 术后所有大鼠一般情况良好,切口无感染,均存活至24周.术后各组大鼠左侧肘关节主动屈曲功能丧失,24周时A、B组大鼠主动屈肘功能均有恢复.根据"泼水清理实验"评估,A组获4～5分肢体7例,B组5例,均较C组O例有明显恢复(P＜0.05),A、B组间差异无统计学意义(P＞0.05).在肱二头肌湿重、肌纤维横截面积方面,A、B组明显优于C组(P＜0.05),A组与B组差异无统计学意义(P＞0.05).A、B两组大鼠电生理均可测得肱二头肌的诱发电位,吻合口近端的前臂内侧皮神经在AchE染色后可见到轴突深染的有髓神经纤维(运动神经纤维),在屈肘功能的恢复情况、诱发电位的潜伏期和波幅、吻合口近端的运动神经纤维数量方面,两组差异均无统计学意义(P＞0.05).结论 当靶器官改变时感觉神经的结构及功能均发生了适应性的重塑,这种重塑可能为修复周围神经损伤提供一种新方法.     

骨间前神经旋前方肌支移位在高位尺神经损伤中的应用

目的研究高位尺神经损伤后用骨间前神经旋前方肌肌支移位修复尺神经深支的手术方法。方法2002年10月-2005年8月，对18例高位尺神经损伤的患者，应用骨间前神经旋前方肌肌支移位与尺神经腕部深支进行吻合。结果术后15例获得随访，随访时间为3个月～3年，平均1．7年。手内肌肌力恢复M2 2例，M3 2例，M4 6例，M5 5例，优良率为73％。结论骨间前神经旋前方肌支转位修复尺神经深支可达到肌支-肌支修复，缩短了神经再生的距离和时间，有利于手内在肌功能的恢复，是一种有效的手术方法。     

神经断端肌同埋入防治残端神经瘤的实验研究

周围神经切断端发生神经瘤是周围神经损伤的常见并发症，经１０％患者有顽固性疼痛。为研究神经断端肌内埋入防治残端神经瘤的机理，选用ＳＤ大白鼠１６只，将双侧坐骨神经切断后，左则神经经断端肌内埋入为实验侧，右侧神经断端自然回缩不作处理为对照侧，运用组织学和电生理学检测。结果表明，对照侧的神经近端在术后１个月就有神经瘤形成，而实验侧其神经断端的神经纤维分散长入肌纤维间，无明确的神经瘤形成。说明，神经断端肌内     

膈神经端侧吻合移位治疗肌皮神经损伤的实验研究

目的 研究膈神经端侧吻合移位至肌皮神经治疗臂丛神经撕脱伤的可行性.方法 取雄性SD大鼠51只,随机分成4组:A组,单侧全臂丛神经撕脱组;B组,膈神经端端吻合组;C组,膈神经端侧吻合组;D组,膈神经螺旋状端侧吻合组(B、C、D组膈神经均移植2.0 cm腓肠神经至肌皮神经).并于术后进行肢体功能、组织学和神经电生理检测.另取绿色荧光蛋白(green fluorescent protein,GFP)转基因F344大鼠9只,通过荧光显微镜观察膈神经轴突再生情况.方果 各实验组术后手术侧肢体功能逐渐恢复,术后神经电生理和组织学检测表明,术后3个月,C、D组左侧肱二头肌肌张力恢复率和肌湿重恢复率,分别为B组的76.4%和86.3%、85.6%和87.7%,即端侧吻合组肱二头肌功能达到端端吻合组的80%以上,同时保留了膈肌的功能.荧光显微镜观察发现膈神经轴突通过端侧吻合口长入移植神经.方论 膈神经端侧吻合治疗臂丛神经损伤的手术方法是有效、可行的.     

神经断端肌内埋入防治残端神经瘤的实验研究

周围神经切断端发生神经瘤是周围神经损伤的常见并发症，约１０％患者有顽固性疼痛。为研究神经断端肌内埋入防治残端神经瘤的机理，选用ＳＤ大白鼠１６只，将双侧坐骨神经切断后，左侧神经断端肌内埋入为实验侧，右侧神经断端自然回缩不作处理为对照侧，运用组织学和电生理学检测。结果表明，对照侧的神经近端在术后１个月就有神经瘤形成，而实验侧其神经断端的神经纤维分散长入肌纤维间，无明确的神经瘤形成。说明，神经断端肌内埋入可以防治残端神经瘤形成。     

端端吻合与端侧吻合治疗臂丛神经上干损伤实验研究

目的采用端端吻合和端侧吻合尺神经与肌皮神经肱二头肌肌支,观察周围神经再生和效应肌恢复情况。方法雄性SD大鼠60只,体重200～250g,随机分成A、B两组(n=30)。均制作肌皮神经损伤模型,并在相同水平,A组采用1/12尺神经束支与肌皮神经肱二头肌肌支端端吻合,B组将肌皮神经肱二头肌肌支与尺神经主干端侧吻合。分别于术后4周和12周取材,行神经电生理检测、肱二头肌湿重比、肌纤维横截面积测定和有髓神经纤维计数(count of myelinated nerve fibers,CMF),并观察实验大鼠行为改变。结果术后4周,B组神经传导速度(nerve conduction velocity,NCV)延迟较A组明显,潜伏期波幅(amplitude,AMP)较A组减小,差异均有统计学意义(P0.05);术后12周,A、B组NCV及AMP均相近,组间差异均无统计学意义(P0.05)。术后4、12周,A、B两组肱二头肌湿重比以及肌纤维横截面积差异均无统计学意义(P0.05)。术后4周,A组CMF为230.15±60.25,B组为160.73±48.77,组间差异有统计学意义(P0.05);术后12周,A组CMF为380.26±10.01,B组为355.63±28.51,组间差异无统计学意义(P0.05)。结论采用端侧吻合与采用端端吻合尺神经部分束支(1/12)的方法治疗臂丛神经上干损伤恢复肱二头肌功能,远期疗效相似。     

肌皮神经与尺神经端侧缝合重建屈肘功能的实验研究

目的 研究周围神经端侧缝合后侧支发芽再生能力及用于臂丛上干撕脱伤重建屈肘功能的可行性.方法 选用24只Wistar大鼠.左前肢为实验侧:于距肱二头肌入肌点12mm处切断肌皮神经,远断与外膜开窗1.0mm×0.5mm的尺神经做端侧缝合.右前肢为对照侧:切断1/2尺神经束,近端与肌皮神经远断端做端端外膜缝合.按取材时间随机分为A、B、C三个时间组,每组8只,分别于术后3、6、12周取材,进行大体观察.神经组织学、电生理、肱二头肌收缩力和肌湿重、辣根过氧化物酶(HRP)示踪检测.结果A组实验侧再生纤维数目和B组实验侧动作电位振幅、潜伏期与对照例相比有显著性差异(P<0.01),实验侧均低于对照例.随术后时间的延长,其余各项指标无显著性差异(P>0.05).结论 肌皮神经与尺神经端侧缝合后确实存在侧支发芽能力,并获得部分神经肌肉功能恢复,为临床治疗臂丛神经上干撕脱伤重建屈肘功能提供了新思路.     

周围神经端侧缝合与端端缝合疗效比较的实验研究

目的比较周围神经损伤后端侧缝合与端端缝合方法疗效的优劣。方法ＳＤ大鼠１２只,按手术先后随机分成Ａ,Ｂ两个时间组。左侧腓总神经切断后作端端缝合。右侧腓总神经切断后,远断端与近断端上方０．５ｃｍ束外膜开窗处作自身端侧缝合。分别于术后１、３个月时作肌电图后取材,测肌湿重及作组织学检查。结果Ａ、Ｂ两组,端侧缝合与端端缝合比较,肌电图中诱发电位潜伏期延长、波幅降低。胫前肌肌湿重减轻。肌纤维截面积、有髓神经纤维数均减少。经配对ｔ检验,Ｐ值均＜０．０５。结论周围神经断伤作端侧缝合后,其神经再生质量不及端端缝合优良。     

Axonal supercharging technique using reverse end-to-side neurorrhaphy in peripheral nerve repair: an experimental study in the rat model

OBJECT: In an attempt to improve peripheral nerve repair, the influence of the addition of reverse end-to-side neurorrhaphy for an injured peripheral nerve was investigated in the rat sciatic nerve transection model. METHODS: Twelve Sprague-Dawley rats were divided into two groups (six rats in each group). In Group I, the right sciatic nerve was cut at a point distal to the gluteal notch and repaired using end-to-end neurorrhaphy with four 10-0 nylon epineurial sutures. In Group II, after performing the same procedure as in Group I, the left sciatic nerve was cut distally and passed through a subcutaneous tunnel to the right side. The proximal stump of the left sciatic nerve was coapted to the epineurial window of the right sciatic nerve distal to the injured point in an end-to-side fashion using 10-0 nylon epineurial sutures. The effects were evaluated using analgesimeter recordings for the hind paw, electrophysiological tests, measurement of the muscle contraction force, a double-labeling technique, weight measurement and histological examination of the gastrocnemius muscle, histological examination of the bilateral sciatic nerves, and immunofluorescent staining. RESULTS: Results from the many tests used to evaluate the reverse end-to-side neurorrhaphy technique indicated that functional recovery of the denervated target organs was promoted by axonal augmentation. CONCLUSIONS: The reverse end-to-side neurorrhaphy technique could be useful in peripheral nerve repair.     

Long-term evaluation of rabbit peripheral nerve repair with end-to-side neurorrhaphy in rabbits

This study was designed to quantitatively assess long-term end-to-side neurorrhaphy in rabbits. The cut right ulnar nerve was repaired and sutured to the median nerve, in which a perineurial window was created in an end-to-side fashion 3 cm above the elbow joint. Both the extent of the reinnervation and the integrity of the intact donor nerve were evaluated in 36 rabbits randomly treated with fresh or delayed nerve repair. Evaluations included motor nerve conduction velocity (MNCV), dry muscle weight (DMW), and histological examinations at 9 and 12 months postoperatively. The recovery rates of MNCV were 90.1% and 92.8% for the ulnar nerve, and 95.7% and 96.8% for the median nerve, compared to intact contralateral nerves at 9 and 12 months, respectively. MNCV was not detectable for the ulnar nerve in control animals, while it was normal for the median nerve. Recoveries of flexor carpi ulnaris dry muscle weight of about 90.7% and 94.5% were observed at 9 and 12 months postoperatively, respectively. However, muscle mass measurements revealed a recovery of only 31.3% and 27% for control groups at 9 and 12 months postoperatively. The differences between experimental groups and control groups were statistically significant (P < 0.01). Neurofilament and silver stains showed numerous sprouting axons originating from the median nerve to the ulnar nerve. The results indicate that end-to-side neurorrhaphy could induce axonal sprouting from the main nerve trunk of upper limbs in rabbits, leading to useful functional recovery.     

不同端-侧缝合方式修复周围神经的比较研究

目的 比较周围神经标准端-侧缝合方式与其他变体在修复效果上的差异.方法 SD大鼠126只,随机分为7组,将右侧肌皮神经切断,以同侧尺神经作为供体神经,按照端-端缝合组(end-to-end,E-E组)、端-侧缝合组(end-to-side,E-S组)、侧-侧缝合外膜开窗组(side-to-side,S-S组)、侧-侧缝合外膜不开窗组(side-to-side,S-S'组)、螺旋缠绕外膜去除组(spiral,Sp组)、螺旋缠绕外膜保留组(spiral,Sp'组)、阳性对照组(controlling group,CG组)制作模型,各组分别于术后1、2、3个月取材,进行神经电生理、病理组织学检测.结果 术后3个月,各端-侧缝合组均有明显神经再生现象,但效果均不及端-端缝合组,各种端-侧缝合术式的变体与标准端-侧缝合方式相比差异不明显(P＞O.05),保留神经外膜的两组为各组中效果最差.结论 神经外膜对端-侧缝合效果有影响,各种缝合方式差异无统计学意义,单纯通过手术方式提高神经端-侧缝合后神经再生能力的效果非常有限.     

Motor functional and morphological findings following end-to-side neurorrhaphy in the rat model.

Nerve repair cannot always be achieved by the conventional end-to-end technique. This study evaluated the functional recovery of nerves repaired with end-to-side neurorrhaphy in a rat model. The right peroneal nerves of 80 female rats were transected and divided into four groups. In group A, the nerve ends were separated and remained unrepaired; in group B, the distal peroneal ends were directly sutured to the epineurium of the tibial nerves in end-to-side fashion; in group C, the distal ends were sutured through an epineurial window at the repair site in end-to-side fashion; and in group D, the nerve ends were reconnected by the traditional end-to-end technique. Evaluation included gait analysis by calculation of a peroneal functional index, measurement of contractile function of the extensor digitorum longus muscle, wet weight of the extensor digitorum longus, and histological examination. The findings of this study suggested the following: (a) end-to-side neurorrhaphy allows effective motor functional recovery, demonstrated by earlier improvement of the peroneal functional index, stronger muscle contractile function, greater muscle weight, and higher density of regenerated axons compared with unrepaired nerves; (b) removal of the epineurium of the donor nerve at the nerve coaptation site increases the effectiveness of end-to-side neurorrhaphy, but the epineurium appears to be a partial barrier to axonal regeneration; (c) removal of the epineurium does not affect the structure and function of the donor nerve; and (d) end-to-end repair achieved the best functional recovery among the four groups; therefore, end-to-side repair should be considered as a potential alternative only when no proximal nerve is available.     

医用OB胶粘合周围神经的实验研究

目的探讨医用OB胶粘合神经后的抗牵拉强度及神经修复的效果，对其粘合神经的可行性进行评估。方法Wistar大鼠72只，以左侧坐骨神经建立修复模型，随机分为神经缝合组和粘合组，每组36只。缝合组用9-0无创尼龙线做神经外膜缝合4针，粘合组用OB胶粘合神经断端。分别于术后0d、1、2、3、4、8周进行大体观察、生物力学、电生理检测和组织学观察。结果生物力学检测，术后1周和2周粘合组与缝合组最大抗牵拉强度之间差异有统计学意义（P〈0．05）。电生理检测，术后4周和8周粘合组与缝合组运动神经潜伏期延迟比之间差异有统计学意义（P〈0．05）。组织学观察，缝合组在缝线周围可见有淋巴细胞、单核细胞等异物炎症反应；而粘合组吻合口处无明显炎症反应，再生轴突排列较缝合组更规则。结论OB胶粘合神经是一种修复周围神经损伤的有效方法。     

Repair of the main nerve trunk of the upper limb with end-to-side neurorrhaphy: an experimental study in rabbits

The aim of this study was to assess the effectiveness of reinnervation using end-to-side neurorrhaphy in the upper extremity of the rabbit. The cut right ulnar nerve was repaired and sutured to the side of the median nerve about 3 cm above the elbow joint. The extent of reinnervation was quantitatively evaluated, as well as the integrity of the intact donor nerve in 36 rabbits randomly treated with fresh or delayed nerve repair with or without perineurotomy. Evaluations included nerve conduction velocity (NCV) of both the ulnar and medial nerves, dry muscle weight, and histologic examination (neurofilament stain and morphometric assessment) at 3 and 6 months postoperatively. NCV recovery rates were 79% and 87% for the ulnar nerve, and 89% and 94% for the median nerve compared to contralateral intact nerves, at 3 and 6 months, respectively. Flexor carpi ulnaris muscle mass measurements revealed a recovery in dry muscle weight of about 81% and 88% at 3 and 6 months, respectively, compared to the intact contralateral flexor carpi ulnaris. Histologic studies with neurofilament staining reveal numerous axonal sprouts at the distal end of the median nerve, indicative of myelinated axonal regeneration. Morphometric analysis demonstrated no difference between fresh and delayed repairs. These results indicate that in the upper extremity of rabbits, end-to-side neurorrhaphy permits axonal regeneration from the intact donor nerve, and is associated with satisfactory recovery. The effect of the procedure on the donor nerve was negligible.     

端侧缝合与神经移位修复臂丛损伤的比较研究

目的 为临床提供端侧缝合与神经移位修复臂丛损伤疗效优劣的实验依据。方法 Wistar大鼠36只,按术后取材时间分为1、2、3个月组,每组12只。按手术方法分为2组。(1)端侧缝合组(前肢右侧):于臂丛内侧束远端外侧外膜上开窗,将桡神经远断端和内侧束开窗处作外膜端侧缝合。(2)神经移位组(前肢左侧):在正中神经远端切断神经,将其近端和桡神经远断端作端端缝合。术后两组各时间组行电生理、肌湿重、肌纤维截面积、运动终板面积及抗神经丝(neurofilament,NF)免疫组化和神经超微结构观察。结果 端侧缝合组的运动神经传导速度,诱发电位潜伏期,NF阳性表达强度均劣于神经移位组(P<0.01);肌湿重、肌纤维截面积及运动终板面积两组差异无显著意义(P>0.01)。结论 端侧缝合组术后远端神经虽可再生但疗效明显差于神经移位组,故临床上是否可用其来修复臂丛神经损伤尚需进一步研究。     

Reverse end-to-side neurotization

The authors describe a reverse end-to-side neurorrhaphy model in which the proximal end of a donor nerve is sutured to an epineurial window in the side of a recipient nerve. If effective, this technique would have useful applications in nerve reconstructive surgery. Female Sprague-Dawley rats were divided into three groups (n = 9). In Group A, the peroneal nerve was transected and directly repaired in standard end-to-end fashion. In Group B, the tibial nerve was transected and the proximal end was sutured to the side of the intact peroneal nerve through an epineurial window. In Group C, the tibial nerve was also transected and the proximal end sutured to the side of the intact peroneal nerve, but the peroneal nerve was then cut proximally. After 12 weeks, contractile forces of the extensor digitorum communis (EDC) were measured, following stimulation of the proximal sciatic nerve on all experimental (and normal) hind limbs. For Group B, the peroneal nerve was transected proximal to the repair site just prior to stimulation. Group B animals did not demonstrate any measurable contractions. No statistically significant differences were found between Groups A and C. This demonstrated the successful neurotization of a denervated muscle using a reverse end-to-side neurorrhaphy model.