颈神经后支卡压综合征

目的：从解剖和临床两方面探讨颈神经后支卡压综合征的机制及诊治方法。方法：对１７具成人固定尸体中Ｃ１～Ｃ８颈神经后支进行解剖学研究。对２４例颈神经后支卡压综合征的患者进行了临床观察和分析。结果：（１）颈神经后支自椎间孔处发出后,穿过由项部肌群附着于颈椎关节囊的交叉纤维、上下关节突关节和内侧椎板组成的骨纤维管,然后发出关节突关节支、肌支、皮支和交通支,穿行于颈后肌群及其腱性纤维组织间。（２）临床发现保守治疗近期虽有一定疗效,但不理想。结果：颈神经后支卡压综合征的病因是以颈后肌群为主的腱性交叉纤维压迫颈神经后支所致。结经保守治疗无效的患者行颈神经后支松解术,有可能是解除颈神经后支卡压的切实有效的方法。     

枕大神经的应用解剖

目的 探讨枕大神经痛发病的解剖学基础。方法 防腐固定成人尸体标本10具（20侧）和新鲜标本2具（4侧），观察枕大神经的走行分布及其与邻近组织的关系。结果 根据枕大神经走行特点，可将其分为肌肉段和筋膜内段。肌内段活动度大，不易受压。筋膜内段位于致密纤维管道内易致卡压。神经自椎管穿出进入肌肉处，穿出肌肉进入筋膜处，神经浅出皮下处，此3点最易造成卡压。枕大神经浅出皮下处始与枕动脉伴行。结论 枕大神经穿行的骨性纤维孔、纤维管道及项部肌群的腱性交叉纤维对神经的固定作用，是颈部运动或组织劳损时造成枕大神经卡压的解剖学基础。     

肩胛下孔内肩胛上神经卡压的解剖学研究

肩胛下孔内肩胛上神经卡压的解剖学研究王震寰，杨其云，王小标，王芳，苗华国内外学者对肩胛上神经卡压综合征的解剖学和临床研究多集中于肩胛上孔处［１～４］。鉴于肩胛上神经冈下肌支和下关节支在分别进入冈下肌和肩关节囊前，尚穿肩胛下骨纤维孔。本文对冈下肌支和下...     

枕大神经卡压综合征的应用解剖学和针刀治疗研究

目的为枕大神经卡压综合征临床治疗提供应用解剖学依据和针刀治疗之法。方法在20侧成人尸体头颈标本上,对枕大神经的行径、动静脉穿斜方肌腱膜的部位、深筋膜以及易发生卡压的部位进行了解剖观察和测量。对200例具有枕大神经卡压症状的颈椎病患者应用针刀分离松解术,采用不同方向和大小范围分离松解,进行对比性治疗,观察治疗效果有何差异。结果枕大神经在枕外隆突下方(28±02)cm,旁开(26±01)cm处穿斜方肌腱膜至皮下;动静脉穿斜方肌腱膜和深筋膜的部位约位于枕外隆突至乳突尖连线的中、上1/3交界点;穿出点有大量腱纤维和筋膜束缠绕枕动静脉,是神经血管发生卡压的部位。结论采用枕大神经穿出腱膜和筋膜点的稍内侧进针,从外上向内下方(与后正中线约40°夹角)分离松解,便可解除因神经主干受压引起后半头麻痛。有时往往还需要扩大松解范围,因为枕外隆突至乳突尖连线中1/3外上方枕大神经分支浅出皮下处的分支,易被深筋膜硬化组织粘连和卡压,结合压痛点范围进行扩大松解,才能获得最佳治疗效果。     

胸腰段微创椎弓根螺钉进钉点的解剖学及临床研究

目的为直视经皮微创椎弓根螺钉内固定技术提供解剖学基础并在此基础上分析经皮椎弓根螺钉的可行性及其优点。方法选用6具经防腐处理的尸体，经乳胶灌注。在解剖显微镜下对T11、12～L5脊柱后部结构进行解剖观察，观测肌肉血供、神经支配及关节突、横突间的脊神经后支的走向及分布规律，并在此基础上选择有适应证的患者进行直视下微创植入椎弓根螺钉，研究其可行性及术中、术后的优缺点。结果胸腰段脊神经后支于椎间孔外由脊神经发出主干为0．5～1．0mm向后走行分内、外支。内侧支较细。跨过横突根部，绕过小关节突外缘，到乳突与副突间的骨纤维管，呈树状分布，支配同一平面骶棘肌内侧束、小关节、棘突、棘间韧带。外侧支较粗，沿横突上缘自骶棘肌深面向下、外、背侧行走，支配骶棘肌的中间份和外侧份。节段动脉的后支在椎间孔的上方绕向后下方，走行于脊神经的下方和下位椎体上关节突的外方，分为内外2支，支配腰部深层肌肉。静脉与动脉伴行在横突部形成静脉丛。选择8例有手术适应证的患者，C臂定位后，直视下小切口常规器械植入椎弓根螺钉系统，并与同期适应证相同的26例行常规手术切口的术中、术后各指标进行比较。结论微创椎弓根螺钉进钉区无主要的营养和支配关节突、后部肌肉的血管和神经支，采用经皮微创小切口直视下植入椎弓根螺钉内固定系统治疗胸腰段骨折是可行的，术中避免了损伤支配骶棘肌的脊神经后支、节段动静脉和减少对脊柱后方结构的剥离，术中出血明显减少，术后恢复快、并发症少，是一种易于操作与推广的新技术。     

腓肠肌内侧头肌支神经切断小腿减肥术应用解剖及临床效果观察

目的介绍将腓肠肌内侧头肌支神经切断使之萎缩,改善小腿粗壮外形的方法。方法解剖20具尸体腿,观察、测量腓肠肌内侧头肌支神经,为手术提供解剖学基础。对16例腓肠肌内侧头肥大者行腓肠肌内侧头肌支神经切断小腿减肥术,测量并记录小腿周径和外形变化。结果腓肠肌内侧头肌支神经在窝处从胫神经发出,以独立1支走向肌门者占40%,中途分成2支者占30%,与腓肠内侧皮神经共干起始者占30%。以股骨内上髁水平线为基线,该肌支起点平均高度为(-6.6±13.7)mm,起始处宽度(2.3±0.4)mm,长度为(42±12)mm。16例术后小腿最大周径平均缩减(3.5±1.1)cm,内侧曲线平缓。术后早期可下地行走,无明显肿胀。随访半年,日常活动未受影响。结论腓肠肌内侧头肌支神经切断小腿减肥术简便、安全、效果明显,不影响受术者的行走功能。     

肩胛背神经卡压：不典型胸廓出口综合征

报告１０例２０侧肩胛背神经和胸长神经的解剖学研究及３４例肩胛背神经卡压的临床病例。解剖观察发现肩胛背神经的起始段常和胸长神经合干，由前内侧向后外侧从中斜角肌中穿过，此处常有腱性组织，和胸长神经分开后，有分支走向肩部和腋下，并可再发分支加入胸长神经。肩胛背神经起始部卡压在临床上可引起颈肩背部的不适和酸痛，手术治疗时观察到切断前中斜角肌后可使肩胛背神经的压迫得到缓解或解除，要彻底减压需切断肩胛背神经浅层的全部中斜角肌及其腱性组织。２２例患者作２４侧手术治疗，１９例患者２０侧完全或大部分解除了症状。     

肩胛上神经卡压的诊断及治疗

肩胛上神经卡压是较少见的周围神经卡压性疾病,肩胛上神经卡压在诊断上不易与颈肩部的其他疾病区分。本文归纳了近期的文献报道,以进一步认识该疾病的病因及相应治疗。 1 解剖学 肩胛上神经起源于臂丛上干(第5、6颈神经根),第4神经根也参与它的组成。自臂丛发出后,往下进入斜方肌内,直至肩胛骨上缘的切迹,肩胛上动静脉跨过该处肩胛上横韧带进入肩胛窝,肩胛上神经在此韧带下穿过,发出运动支支配冈上肌和感觉支支配2/3的肩关节囊。主干继续沿着肩胛冈走行,穿过由肩胛冈关节盂韧带(又名肩胛下横韧带)和肩胛冈组成的纤维-骨性隧道,转至冈     

枕颈后外侧入路显露枢椎齿突的应用解剖

目的　研究显露枢椎齿突的枕颈后外侧入路的应用解剖学并图示。方法　解剖并观察了 12具尸体的枕颈区 ;对 9具尸体的头颈部进行了冠状、矢状或水平断面的断层解剖学研究。结果　 (1)皮肤、浅筋膜、封套筋膜 (或斜方肌 )、头夹肌和头半棘肌可被认为该入路的浅结构。 (2 )头下斜肌和第二颈神经节为该入路的标志性结构。 (3)经寰枢椎侧关节和第二颈神经节及其相连的硬膜囊间显露枢椎齿突 ,必要时可切除部分寰枕关节 ;寰椎后弓下缘或枢椎椎板上缘至齿突的水平距离约 2cm ;(4)术中易于辨认和保护椎动脉。结论　枕颈后外侧入路容易显露枢椎齿突 ,能在直视下保护脊髓 ,并可同时做枕颈融合或 /和寰枢侧关节融合术以稳定脊柱。     

超声下头半棘肌平面的解剖学特点

目的:超声下观察头半棘肌平面(SCP)的解剖学特点,为临床有效实施超声引导下SCP阻滞提供参考。方法:健康成年志愿者30名(60侧)项区SCP的6个区域进行超声检查,重点检查与描述头半棘肌(SCA)、SCA深面间隙及间隙内结构的解剖学特点。结果:(1)项区寰椎后弓处横切超声图像显示SCA肌腹被一斜行筋膜分隔为内侧头和外...     

肩胛背神经卡压的应用解剖学研究

观察并分析腱性纤维束是否为造成肩胛背神经卡压的主要因素。方法：在３２侧成人尸体标本上，观测肩肿背神经的起源、走行、分支、分布及其与中斜角肌的解剖关系。结果：肩胛背神经７５％（２４／３２）从Ｃ５神经根发出；由前内侧向后外侧从中斜角肌穿过，其长度为１．２±０．３ｃｍ，在其内侧缘有大部分键性纤维组织存在。该神经除发出２～５支肌支外，另有２５％（８／３２）还发出细小分支走向肩背部。结论：中斜角肌内侧缘的限性结构特点是造成肩胛背神经卡压的形态学基础。     

A case involving complete removal of C2 dumbbell type neurinoma with preservation of the surrounding supportive tissue

We report a case in which C2 neurinoma was completely removed with preservation of the surrounding supportive tissue. A 47-year-old female was admitted to our hospital with gait disturbance and spinal tumor identified in other hospital. Neurological examination on admission revealed hyperreflexia in bilateral limbs and pathological reflexes. Cervical plain X-radiography showed erosion of the left C2 lamina. Axial Gd-enhanced T1 weighted magnetic resonance (MR) images showed partial enhancement of a dumbbell shaped tumor at the C1-2 level, revealing compression of the spinal cord to the right and extending to postero-laterally, and coronal MR images demonstrated that the tumor was clearly surrounded by the semispinalis capitis, semispinalis cervicis and inferior oblique muscles. The tumor was resected through a posterior approach without injuring the surrounding supportive tissue. Post operatively, she did not complain of nuchal pain during neck movement. After a 6-month follow-up period, cervical plain X-radiography showed preservation of cervical alignment, and coronal Gd-enhanced T1-weighted MR images demonstrated preservation of the posterior group of cervical muscles. It is desirable to preserve the surrounding supportive tissue as far as possible in order to minimize the postoperative neck pain and instability of cervical spine, like this case.     

Anatomy of the obturator region: relations to a trans-obturator sling

Our objective was to determine the relationships between a trans-obturator sling and anatomic structures within the obturator region. The obturator regions of six cadavers were dissected and distances from the mid-point of the ischiopubic ramus to the muscles, nerves, and vessels of the region were measured. A trans-obturator sling was placed and distances from the device to the same anatomic structures were determined. Four additional cadavers were dissected to determine the device route of passage. The obturator canal is on average 4.4 cm from the midpoint of the ischiopubic rami. The trans-obturator sling passes on average 2.4 cm inferior-medial to the obturator canal. The anterior and posterior divisions of the obturator nerve are on average 3.4 and 2.8 cm, respectively, from a passed trans-obturator device. The device passed on average 1.1 cm from the most medial branch of the obturator vessels. Vascular and nerve structures are within 1–3 cm of the path of any device passed through the obturator foramen. A trans-obturator sling risks injury to these structures, although the small caliber of the vessels and the confined space in which they would bleed make the consequences of injury uncertain.Editorial Comment: The authors performed anatomic dissections in fresh frozen cadavers to better understand the anatomy faced during the performance of a transobturator sling procedure. Since this anatomy has not been critically analyzed by the vast majority of pelvic surgeons, it is important for the practicing pelvic surgeon to attain a very clear image of the vascular and neurologic relationships in this area. The dissections were performed with the patients in high lithotomy position. Therefore, there is great clinical value to these dissections. However, the surgeon must also realize that a significant degree of variability exists, especially as related to vascular anatomy. This has implications for the safe performance of this novel approach to stress incontinence     

尺神经手背支卡压所致腕尺侧痛的解剖和临床研究

目的 对尺神经手背支卡压引起腕尺侧痛的机理进行研究并探讨尺神经手背支卡压症的诊断和治疗。方法 对40侧福尔马林固定的成人尸体前臂部和腕部进行大体解剖和显微解剖。在临床上诊治了13例尺神经手背支卡压的病例并进行分析。结果 尺神经手背支在尺骨茎突以近5.6-6.8cm处尺侧腕屈肌（腱）深面内侧缘穿出,紧贴尺骨行走,在尺骨小头内侧分成2－3大支,其中的横支紧贴骨膜,横跨尺骨小头或绕经尺骨小头远端斜行向桡侧,腕关节活动和尺骨小头的位置改变极易对其造成损伤。临床发现患该症的患者尺骨小头远端或尺侧缘有一显著而局限的压痛点,其周围有局部的皮肤感觉改变。13个病例中,7例局部封闭,6例手术,其中9例随访4个月－1年,未见复发。结论 腕关节反复屈伸时尺神经手背支尤其是横支被牵拉和压迫是造成尺神经手背支卡压的解剖学基础。临床上对腕尺侧痛并有皮肤感觉改变的病例,应考虑尺神经手背支卡压的可能性。     

后入路副神经移位至肩胛上神经的应用解剖

目的 对斜方肌内的神经支配进行解剖学观察,为寻找副神经移位到肩胛上神经的最佳移位点和移位方式提供解剖依据.方法 选用成人尸体标本10具20侧.观察副神经在斜方肌内的行径及分支.并取不同水平副神经、肩胛上神经横断面制病理切片,计数各神经断面的神经纤维数,进行比较.结果 副神经在锁骨上2～3 cm进入斜方肌内,在肩胛冈中点前上方3～4 cm处,有来自颈丛的交通支加入后形成终末支.副神经的神经纤维计数:入斜方肌处(A点)为(1245±46)条,颈丛的交通支汇入前(B点)为(830±36)条,汇入后(C点)为(1074±38)条.结论 (1)副神经在与颈丛交通支合干后H-G段内的各断点,是副神经的最佳移位点.(2)后进路副神经移位术不影响斜方肌上部神经支配,充分利用了颈丛交通支,且缩短了神经再生距离,值得推广.     

A cadaveric study of the motor nerves to the levator scapulae muscle

Understanding the surgical anatomic relationships of the motor nerves to the levator scapulae muscle is imperative for reducing postoperative shoulder dysfunction in patients undergoing neck dissection. To elucidate this relevant anatomy, cervical (C3, C4) and brachial (C5 via dorsal scapular nerve) plexi contributions to the levator scapulae were assessed with respect to posterior triangle landmarks in 37 human cadaveric necks. An average of approximately 2 (actual 1.92) nerves from the cervical plexus (range 1 to 4 nerves) emerged from beneath the posterior border of the sternocleidomastoid muscle in a cephalad to caudad progression to enter the posterior triangle of the neck on their way to innervating the levator scapulae. These cervical plexus contributions exhibited a fairly regular relationship to the emergence of cranial nerve XI and the punctum nervosum along the posterior border of the sternocleidomastoid muscle. After emerging from the posterior border of the sternocleidomastoid to enter the posterior triangle of the neck, cervical plexus contributions to the levator scapulae traveled for a variable distance posteriorly and inferiorly, sometimes branching or coming together. Ultimately these nerves crossed the anterior border of the levator scapulae as 1 to 3 nerves (average 1.94) in a regular superior to inferior progression. The dorsal scapular nerve from the brachial plexus exhibited highly variable anatomic relations in the inferior aspect of the posterior triangle, and was found to penetrate or give branches to the levator scapulae in only 11 of 35 neck specimens. We have found that the levator scapulae receives predictable motor supply from the cervical plexus. Our data elucidate surgical anatomy useful to head and neck surgeons. (Otolaryngol Head and Neck Surg 1997;117:671-80.)     

The anatomic relation among the nerve roots, intervertebral foramina, and intervertebral discs of the cervical spine

STUDY DESIGN: An anatomic study of the cervical intervertebral foramina, nerve roots, and intradural rootlets performed using a surgical microscope. OBJECTIVES: To investigate the anatomy of cervical root compression, and to obtain the anatomic findings related to cervical foraminotomy for the treatment of cervical radiculopathy. SUMMARY OF BACKGROUND DATA: Cervical foraminotomy is a procedure performed frequently for the management of cervical radiculopathy. However, anatomic studies of cervical foraminotomy have not been fully elucidated. METHODS: In this study, 18 cadavers were obtained for the study of the cervical spine. All the soft tissues were dissected from the cervical spine. Thereafter, laminectomy and facetectomy were performed on C4 through T1 using a surgical microscope. The nerve roots and surrounding anatomic structures, including intervertebral discs and foramina, were exposed. In addition, the intradural rootlets and their intersegmental connections were observed. RESULTS: The shape of the intervertebral foramina approximated a funnel, the entrance zone being the most narrow part and the root sleeves conical, with their takeoff points from the central dural sac being the largest part. Therefore, compression of the nerve roots occurred at the entrance zone of the intervertebral foramina. Anteriorly, compression of the nerve roots was caused by protruding discs and osteophytes of the uncovertebral region, whereas the superior articular process, the ligamentum flavum, and the periradicular fibrous tissues affected the nerve posteriorly. The C5 nerve roots were found to exit over the middle aspect of the intervertebral disc, whereas the C6 and C7 nerve roots were found to traverse the proximal part of the disc. The C8 nerve roots had little overlap with the C7-T1 disc in the intervertebral foramen. The C6 and C7 rootlets passed two disc levels in the dural sac. Also, a high incidence of the intradural connections between the dorsal rootlets of C5, C6, and C7 segments was found. CONCLUSIONS: This study demonstrated the anatomy of the nerve roots, rootlets, and intervertebral foramina, and may aid in understanding the pathology of cervical radiculopathy. The presence of intradural connections between dorsal nerve roots and the relation between the course of the nerve root and the intervertebral disc may explain the clinical variation of symptoms resulting from-nerve root compression in the cervical spine. To perform cervical foraminotomy for cervical radiculopathy, it is necessary to understand the detailed anatomy of the intervertebral foramina thoroughly.     

Interconnections of the upper ventral rami of the human sacral plexus: A reappraisal for dorsal rhizotomy in neurostimulation operations

The extension of a dorsal rhizotomy in bladder stimulation patients is partly determined by connections between the ventral rami of the second, third, and fourth sacral spinal nerves. The literature is inconclusive on interconnections of these ventral rami in the human sacral plexus. The sacral plexuses of ten human cadavers were dissected in this gross anatomy study. In nine cases a branch connecting the ventral rami of the second and third sacral spinal nerves was found. Electron microscopy demonstrated the presence of thick myelinated fibers in this branch. In the male plexuses this branch formed the only link between the second sacral spinal segment and the pelvic plexus. The ventral ramus of the second sacral nerve always contributed to the pudendal nerve, whereas involvement of the ventral rami of the first and third sacral nerves differed individually and intersexually.     

Selective peripheral denervation for spasmodic torticollis involving the levator scapulae muscle

Patients with laterocollis or rotatory type torticollis tend to show abnormal contraction of the levator scapulae muscle and the scalene muscles. These muscles are innervated from the anterior branches of the cervical spinal nerves. Because of this, the traditional Bertrand operation dealing with posterior branches does not adequately affect the symptoms of laterocollis. The authors report selective denervation of the levator scapulae muscle in three patients and discuss its rationale. All the three patients underwent denervation of both the C1-C6 posterior spinal rami and the branches from the C3 and C4 anterior rami to the levator scapulae muscle. We added myotomy of the scalene muscle in one patient, and denervation of the omohyoid muscle which is innervated from the ansa cervicalis and the descending branch of the hypoglossal nerve. The pre/post-operative Tsui scores were 12/4, 15/1, and 14/3 respectively. There were no complications. We conclude that selective peripheral denervation of the levator scapulae muscle is safe and effective in the treatment of laterocollic type torticollis.