选择性颈神经后根切断术

于１９９２年２月～１９９５年６月，作者对１２例上肢痉挛性脑瘫患者施行了选择性颈神经后根切断术．术中观察了Ｃ５～Ｔ１各脊神经后根的形态、位置，各后根按比例切除．术后短期随访，异常增高的上肢肌张力，明显缓解．该术式可较佳解除上肢痉挛．     

选择性脊神经后根切断（SPR）治疗下肢痉挛性脑瘫

目的：探讨选择性脊神经后根切断术（SPR）治疗下肢痉挛性脑瘫疗效。方法：对38例下肢痉挛性脑瘫,将L2－S1各神经后根分开,分为5－8个亚束,用神经阈值探测仪检测,将阈值低的亚束切断1cm,切除比例据病情定。结果：术后肌张力平均下降Ⅲ级,关节畸形平均减轻5－10,腱反射消失30例,正常8例,病理征全部消失,未发现严重并发症。结论：选择性脊神经后根切断术（SPR）是治疗下肢痉挛性的有效方法。     

锐意进取精勤开拓——记上海交通大学附属第一人民医院骨科主任王秋根教授

医术精湛 锐意开拓 王秋根教授1984年从第四军医大学医疗系毕业后,即被分配到第二军医大学附属长海医院骨科工作.从实习医生、住院医生到主治医生,再到主任医师,最后从人才济济的国家重点学科——上海长海医院骨科脱颖而出,担任行政副主任. 王秋根教授早年服从组织分配,从事显微外科工作,尽管后来由于种种原因未能继续,但是这一段早年经历练就了他扎实的外科基本功.20世纪90年代,他开展了脑瘫的矫形外科手术并较早地将选择性脊神经根切断术(SPR)引入脑瘫的治疗中,并在《中华显微外科杂志》上先后发表了《选择性颈神经后根切断术治疗上肢痉挛性脑瘫》和《脊神经后根小范围选择性切断术治疗痉挛性脑瘫》两文,获得了较好的反响.2001年,王秋根教授主编了《脑瘫》一书,该书全面地阐述了脑瘫的病因学、流行病学、病理生理学、临床表现、诊断与鉴别诊断、药物治疗、外科治疗、康复治疗及预防与控制等,系统介绍了他多年从事脑瘫临床积累的一些经验和体会.     

脑瘫多种手术治疗研究

[目的]通过分析痉挛性脑瘫病人采用肌腱延长、畸形骨矫形和神经选择性部分切断等不同手术的治疗效果,探讨单一或多种手术组合治疗痉挛性脑瘫病人的适应证和注意事项,提高脑瘫的手术治疗效果。[方法]应用传统的软组织松解延长手术、截骨手术、选择性脊神经后根切断术、脊神经后根选择性切断逆向吻合术,以及选择性周围神经切断等手术,对642例年龄在10个月~37岁的脑瘫病人采用不同的手术组合治疗,随访6个月~4年,平均18个月。[结果]传统的软组织松解延长手术仍然是痉挛性脑瘫病人肢体矫形的主要手术,传统的软组织手术虽然不能降低高肌张力,但可矫正固定性挛缩和畸形。能降低肌张力的决定性手术是在神经部位手术,选择性脊神经后根切断术和选择性周围神经切断术早期有部分的肌张力下降,由于降低了肌张力,使关节活动度和肢体控制能力增强,功能明显好转。[结论]手术前仔细分类,严格掌握各种术式的适应证,充分了解不同手术的潜在并发症,采用各种术式互补可提高手术治疗的综合效果,减少痉挛和畸形复发以及防止并发症的发生,术后加强功能训练也是治疗的基本方法。     

选择性脊神经后根切断术治疗脑瘫痉挛（附40例报告）

选择性脊神经后根切断术治疗脑瘫痉挛（附４０例报告）卢一生，黄宏前，杨永，王云波，王宝虎痉挛性脑瘫以往采用非手术治疗和矫形外科治疗，因不能有效地解除痉挛和改善肢体功能，故临床疗效不佳。近年来，国内新开展的选择性脊神经后根切断术治疗脑瘫等肢体痉挛，获得了...     

改良腰骶SPR治疗痉挛性脑瘫

目的：通过对腰骶段选择性脊神经后根切断术(SPR)的改良，以期提高治疗痉挛性脑瘫的疗效，减少并发症。方法：对23例痉挛性脑瘫患者行腰骶段SPR，采用全椎板切下原位同植；6例肢体痉挛较重者同时做选择性脊神经前根切断术(SAR)；5例患肢挛缩畸形较重者，选择性神经根切断后，Ⅰ期行矫形于术。结果：23例术后1周内疗效评价：优21例(91％)；良2例(9％)。19例得到8个月～3．6年(平均2年)随访，疗效评定优15例（80％）；良4例(20％)。结论：SPR术中采用全椎板切下原位回植能维持腰椎稳定性，部分SPR结合Ⅰ期矫形术能够提高治疗效果。     

选择性臂丛神经根切断治疗上肢痉挛脑瘫的远期疗效评价

目的评价选择性臂丛神经根切断治疗上肢痉挛性脑瘫的远期疗效。方法对1997年3月-2002年1月间施行选择性臂丛神经根切断术治疗上肢痉挛性脑瘫的患者，进行随访并对远期功能进行评价，采用Lazareg肌张力分级标准评定临床效果。结果16例17侧获得随访，随访时间为5．0～9．7年，平均8．6年。手术方式为选择性臂丛神经根全根切断10侧，部分切断2侧，高选择性分束切断5侧；其中切断神经根为颈63次，颈816次。术后远期疗效优3例，有效5例，无效8例9侧。结论选择性臂丛神经根切断治疗上肢痉挛性脑瘫远期大多数疗效下降和无效，但术前严格选择痉挛较局限的病例、术中进行高选择性臂丛神经根分束切断、术后坚持长期康复训练仍然能获得较好的疗效。     

神经根切断术治疗痉挛性脑瘫

目的 研究治疗痉挛性脑瘫新的手术方法。方法 利用臂丛神经根相互代偿的原理设计了选择性臂丛神经根断术以及腰骶神经根选择性切断术治疗痉挛性脑瘫的方法,对９例病例进行治疗（上肢７例,下肢２例）结果术后９例患者肢体痉挛明显减轻,功能得到显著改善。结论 选择性神经根切断术对减轻脑瘫肢体痉挛疗效显著。     

选择性臂丛神经根切断术治疗痉挛性脑瘫的实验研究

目的 探讨选择性臂丛神经根切断术治疗上肢痉挛性脑瘫疗效的研究。方法 ＳＤ大鼠１６只,分为实验组和对照组,每组８只。用脑立体定位技术,选择性毁损左侧锥体束,造成大鼠中枢性痉挛瘫痪模型。实验组：切断右侧Ｃ６神经根,而对照组不切断。分别在术前、麻醉清醒后、术后４８ｈ、术后１周等４个时间组,检测大鼠右侧肱二头肌的肌痉挛电位,比较两组肌痉挛电位的最大波幅和持续时间。结果 在大鼠中枢性痉挛性瘫痪模型上行单根臂丛神经根切断,可有效地解除相应肌肉的痉挛。结论 选择性臂丛神经根切断术治疗脑瘫引起的上肢痉摩是一种有效的手术方法,远期疗效尚有待观察。     

选择性脊神经后根切断术的临床应用

目的：选择性脊神经后根切断术治疗痉挛性脑瘫的临床应用。方法：对经过SPR手术的58例患术后情况进行分析。：SPR手术对解除肌痉挛、降低异常的肌张力效果显，但术后的下肢乏力和脊柱不稳不容忽视。结论：SPR手术是治疗痉挛性脑瘫的有效方法，但应配合术后的康复训练。     

Neurosurgical treatment of spasticity: indications in children

Today, we have several efficient neurosurgical treatments of spasticity in children with cerebral palsy. A good indication is possible only if a consensus about the goal of the surgery is found between the surgeon, the child and his/her family, and the reeducation team. This goal is not always functional. Clinical examination is not limited to the analytical assessment of spasticity, but must take into account the general and orthopedic state of the child, and his/her functional evolution, cognitive abilities, habits and general environment. The struggle against spasticity is part of a therapeutical programme which extends over several years. It must be considered before muscular contractures. On lower limbs, in the cases of general spasticity, we propose posterior rhizotomy or intrathecal baclofen administration. Posterior rhizotomy is proposed when a more aggressive intervention is preferred for some muscular groups or when the child's general environment does not allow for the medical care imposed by intrathecal administration. In the case of localized spasticity, botulinum toxin injection permits delaying until the child reaches the age for selective neurotomy. On upper limbs, in children with quadriplegia the indication is essentially physical and occupational therapy. We cannot count on the positive side effects of rhizotomy or intrathecal administration of baclofen on the upper limbs. In children with hemiplegia, with localized or global spasticity of the upper limb, botulinum toxin is proposed as the first form of treatment. Neurotomy or rhizotomy can follow toxin, according to the efficacy of the toxin.     

脑瘫SPR手术前后微循环变化的观察

目的 :探讨痉挛型脑瘫患儿甲襞微循环的变化。方法 :用国产XG -8多媒体多功能微循环检测仪 ,观测选择性脊神经后根切断术 (SPR)治疗脑瘫手术前后微循环的变化。结果 :手术后患儿甲襞微循环较手术前有明显改善。结论 :选择性脊神经后根切断能改善肢体的微循环。     

脊神经后根小范围选择性切断术治疗痉挛性脑瘫

目的 报道选择性脊神经后根切断术（ＳＰＲ）加内收肌切断术治疗痉挛性脑瘫珠临床效果。方法 对１８例以下肢痉挛为主要症状的脑瘫施行ＳＰＲ术及内收肌切断术。结果 通过术后２年以上随访,症状较轻的８例中,有６例能单腿站立,症状较重的１０例中,有６例能在室内脱手行走。术后无并发症发生。结论 内收肌切断术加ＳＰＲ手术治疗痉挛性脑瘫,不但缩小了ＳＰＲ在脊柱上的手术范围,而且减少了手术后并发症的发生,是一种安全、     

Limited selective posterior rhizotomy for the treatment of spasticity secondary to infantile cerebral palsy: a preliminary report

A limited selective posterior rhizotomy was performed on 30 children suffering from spasticity secondary to infantile cerebral palsy. As opposed to standard techniques that stimulate and divide the dorsal rootlets from L2 to S1, we dissected L4, L5, and S1 dorsal roots through an L5 to S1 laminectomy. Eight to 12 rootlets from each root were electrically stimulated with two unipolar electrodes (pulse width, 50 microseconds; 10-50 V). The muscle responses were observed visually and registered by electromyography. Those rootlets associated with an abnormal motor response as evidenced by sustained muscular contraction or by prolonged electromyographic response were divided. Spasticity was scored from 0 to +. The muscular groups assessed were those involved in the flexion of the shoulder, elbow and wrist in the upper limbs, and those involved in flexion and adduction of the hip, flexion of the leg, and plantar flexion in the lower limbs. The patients were assessed 1 week before and 6 months after the operation. Reduction of spasticity was observed in all the muscular groups, and all the patients presented functional improvement of motor abilities. These preliminary results indicate that a limited procedure that reduces the extension of the laminectomy and the length of the operation could be effective for treating spasticity secondary to infantile cerebral palsy.     

How selective is selective posterior rhizotomy?

Although selective posterior rhizotomy has become an increasingly utilized surgical treatment for spasticity, the procedure is unstandardized and is performed differently at various medical centers. Most surgeons use some form of direct dorsal rootlet stimulation with intraoperative multichannel electromyographic response monitoring. Electrophysiological monitoring offers the theoretical advantage of identifying pathologic reflex circuits for interruption while preserving those pathways that are "normal." However, the monitoring technique most commonly used has not been critically evaluated and, therefore, its value remains uncertain. In 22 selective posterior rhizotomy procedures performed for spastic cerebral palsy, the authors were unable to identify a single electromyographic response that could be called normal by presently accepted criteria. Dorsal rootlets were chosen for division on the basis of relative degrees of abnormality. Intraoperative electromyographic monitoring of a nonspastic patient produced tracings suggestive of spasticity by presently accepted criteria. These discrepancies suggest that current electrophysiological monitoring in selective posterior rhizotomy should be reevaluated.     

SPR治疗脑瘫手术前后上肢微循环变化的观测

目的 :探讨腰骶段选择性脊神经后根切断术 (SPR)治疗痉挛型脑瘫 ,上肢甲襞微循环的变化。方法 :用国产XG -8多媒体多功能微循环检测仪 ,观察腰骶段SPR治疗脑瘫手术前后上肢微循环的变化。结果 :手术后患儿甲襞微循环较术前明显改善。结论 :腰骶段SPR治疗能改善上肢微循环     

Neurosurgical treatment of spasticity: selective posterior rhizotomy and intrathecal baclofen.

The pathophysiology of spasticity and the history of posterior rhizotomies are reviewed. The rationale for selective posterior rhizotomies is that electrical stimulation identifies afferent posterior rootlets that terminate on relatively uninhibited alpha motoneurons; if these uninhibited rootlets are divided, spasticity can be alleviated without loss of other posterior root functions. Indications, technique, and results of selective posterior rhizotomies are presented. The use of continuous intrathecal baclofen (CITB) is summarized. CITB at doses of approximately 300 micrograms/day consistently reduces lower extremity spasticity and diminishes or alleviates muscle spasms in adults with spasticity of spinal origin. Single doses of intrathecal baclofen significantly decrease lower extremity muscle tone in children with cerebral palsy, and the effects can be maintained in these patients by CITB infusions which diminish muscle tone not only in the lower extremities, but in the upper extremities as well. CITB is best accomplished via an externally programmable pump that allows titration of the daily dose to attain the desired reduction in spasticity. Factors influencing the decision for rhizotomy or CITB are presented.     

选择性脊神经后根切断术改善脑瘫患者下肢功能的研究进展

脑性瘫痪是一种常见的儿童时期神经系统伤残的临床综合征,其严重影响患儿及家属的生活质量,同时给社会带来沉重的经济负担。国内外学者将选择性脊神经后根切断术应用于痉挛型脑瘫或伴有肢体痉挛的混合型脑瘫的治疗中已有很长的历史。其改善脑瘫患者下肢痉挛疗效确切,且极少出现复发现象。术后脑瘫患者结合康复治疗后,其肌力较前明显提高,关节活动度在术后即可出现明显改善,且中长期随访未见反弹,患者整体步态得到长期明显改善。笔者认为选择性脊神经后根切断术在改善脑瘫患者下肢运动功能方面疗效显著,值得推广,但必须遵循术前选择合适的病例,术中精细操作,术后及时有效康复治疗的原则,才能使其疗效更佳。