同侧C7神经根移位后对其支配肌影响的初步观察

目的：观察C7神经移位后对C7神经根所支配肌肉功能的影响。方法：1996年2月至2000年2月,对7例臂丛上干或C5,6神经根损伤患者,均采用同侧C7神经根（全部）移位修复,并观测手术前、后背阔肌、肱三头肌及指总伸肌肌力及肌电的变化。术后1周7例,术后4个月6例,术后1年5例进行了肌力测定及肌电检查。结果：术后1周背阔肌、肱三头肌及指总伸肌的肌力较术前均有所下降,下降幅度多在1级以内。肌力的下降均呈可逆性,术后4个月三块肌肉的肌力均已恢复正常。术后3个时间组三块肌肉CMAP(复合肌肉动作电位）的波幅、潜伏期和术前比无明显影响。结论：臂丛上干损伤采用同侧C7移位后,供区背阔肌肌力下降最明显,肱三头肌次之,指总伸肌最小。     

肱三头肌及指总伸肌电生理支配权重分析在同侧C7神经根移位术中的临床意义

目的 分析在健侧C7神经根移位术中得出的臂丛神经各干对肱三头肌/指总伸肌的电生理支配权重,推断其对于同侧C7神经根移位术的影响,为探讨其安全性和适应证提供电生理依据.方法 随机选择2007年8月-2007年10月15例全臂丛神经根性撕脱伤,行健侧C7神经根移位的患者.男13例,女2例:年龄18～49岁,平均28岁.致伤原因:坠落伤1例,压砸伤2例,余均为车祸伤.左侧8例,右侧7例.术中依次刺激健侧臂丛神经上、中、下干,于肱三头肌/指总伸肌记录复合肌肉动作电位(compound muscle action potential,CMAP),比较各干的CMAP波幅所占百分比,确定臂丛神经各干对肱三头肌,指总伸肌的电生理支配权重.术后6个月内随访肱三头肌/指总伸肌肌力,并复查肌电图了解其自发电活动和主动募集反应情况.结果 15例患者均获随访6个月.肱三头肌的电生理支配权重:上中干型3例(20%),中下干型3例(20%),全干型7例(47%),中干型2例(13%);指总伸肌:中下干型3例(20%),全干型10例(67%),下干型2例(13%).肱三头肌:术后1个月,2例出现肱三头肌肌力4级,募集反应单纯相,至术后3个月恢复正常.余患者术后1个月肌力均达5级,募集反应单纯混合相或混合相.指总伸肌:术后1个月,患者肌力及募集反应均恢复正常.结论 对于各种电生理支配权重的患者,C7神经根的切取均不会造成肱三头肌和指总伸肌的实质性损害,同侧C7神经根移位术是安全可行的;但对于中干支配权重高的患者,采用同侧C7神经根全干移位应慎重,有可能造成肱三头肌短期内的肌力下降.     

不同术式切断C7神经根后对神经支配肌影响的实验研究

目的　研究切断大鼠 C7神经根不同纤维束组后其支配肌的肌电图变化 ,为临床选择性 C7神经根移位术提供理论根据。方法　 SD大鼠 2 4只 ,按手术术式不同随机分成 3组 ,每组 8只鼠。A组 :单纯切断上干 ;B组 :切断上干及部分中干 ( C7前股前外侧部分 ) ;C组 :切断上干及全中干。左侧为实验侧 ,右侧为自身正常对照组。术后 4周 ,各组大鼠测定双侧背阔肌、肱三头肌、指总伸肌的复合肌肉动作电位 ( CMAP) ,并计算其潜伏期和波幅。所得数据进行统计学处理。结果　与对照组相比 ,C组背阔肌、肱三头肌及指总伸肌 CMAP的波幅及潜伏期均有明显的变化 ,波幅衰减、潜伏期延长 ;以背阔肌受的影响最为显著。A、B两组上述肌肉 CMAP的波幅及潜伏期均无明显改变。结论　单纯上干损伤后切取 C7神经根前股前外侧束组对 C7神经根主要支配肌 (背阔肌、肱三头肌、指总伸肌 )并无多大影响 ;而 C7全干切断后对上述肌肉影响较大     

臂丛颈7神经根支配主要代表肌的电生理研究

目的 通过电生理检测分析臂丛颈,神经根的主要代表肌.方法 选择16例臂丛神经根性撕脱伤行健侧颈7神经根移位的患者,术中采用电生理检测,对颈7神经根支配肌的波幅进行分析,确定颈7神经根的主要代表肌.结果 电生理检测表明背阔肌与肱三头肌长头均可较好地代表颈7神经根的功能.尤其是肱三头肌长头在所有16例患者的检测中,刺激颈7神经根所得复合肌肉动作电位(CMAP)波幅值均明显大于其余神经根所得波幅值;而背阔肌有4例(占25.0%),在刺激颈6神经根时所得CMAP波幅值与颈,神经根接近.结论 将肱三头肌长头、背阔肌作为定位颈,神经根的代表肌更具有合理性与科学性.     

上中下三干后股对指总伸肌及肱三头肌长头交叉支配的电生理研究

目的通过术中电生理检测,在臂丛神经中找到指总伸肌支配神经的相对集中区,为神经移位重建伸指功能新术式的设计提供理论依据。方法2008年2月-2009年10月,17例臂丛神经撕脱伤行健侧C7神经根移位术。应用Keypoint型肌电图仪,术中分别对上、中、下三干后股进行电刺激,在指总伸肌及肱三头肌长头记录复合肌肉动作电位（compound muscle action potential,CMAP）。结果指总伸肌记录到的CMAP最大波幅有76．5％（13／17）为电刺激下干后股,17．6％（3／17）为电刺激中干后股,5．9％（1／17）为电刺激上干后股。电刺激上、中、下三干后股在指总伸肌记录到的CMAP波幅平均值分别为：0．75±1．16mV,1．64±1．54mV,5．32±4．58mV。在肱三头肌长头记录到的最大CMAP波幅有53％（9／17）为电刺激中干后股,47％（8／17）为电刺激下干后股。电刺激中干及下干后股在肱三头肌长头记录到的CMAP平均波幅分别为4．57±3．84mV,5．98±8．43mV。结论支配指总伸肌的神经纤维来自下千后股比C7后股的多,而下干后股亦是肱三头肌长头的主要支配神经。     

带血管神经蒂背阔肌胸大肌移位重建屈肘功能

我院近年来分别为3例不完全臂丛神经损伤患者,采用带血管、神经蒂背阔肌、胸大肌肌瓣移位重建屈肘功能获得成功。 例1 男,20岁。因左肩着地摔伤致左臂丛神经损伤11个月入院。检查发现左侧三角肌、肱二头肌、喙肱肌肌力为0级,提肩胛肌、斜方肌、背阔肌肌力Ⅴ级,肱三头肌力Ⅴ级,手及腕部诸肌力正常。入院后先行左肩关节融合术,术中6个月再行左侧带血管、神经蒂背阔肌肌瓣移位代肱二头肌术。术后切取整块背阔肌,保留近端止点及神经血管蒂,在背阔肌     

大鼠臂丛上中干损伤后肱三头肌背阔肌功能状态变化的实验研究

目的:研究大鼠臂丛神经下干对上肢三头肌、背阔肌的支配权重,为临床臂丛上干损伤后,同侧C_7移位的可行性提供依据。方法:成年SD大鼠,将一侧臂丛中、上干切除,术后2周、2个月后,分别做同侧三头肌、背阔肌电生理检测,健侧对照。结果:术后2周,三头肌、背阔肌动作电位波幅明显下降,动作电位潜伏期明显延长。术后2个月,该两项指标均可以恢复到正常水平。结论:臂丛下干单独存在时,在短期内肱三头肌、背阔肌功能明显下降,但随着时间延长,该两肌肉可以恢复正常电活动。     

C_7神经根移位治疗臂丛损伤术中胸背神经电生理检测的意义

目的探讨术中肌电生理检测对预测C7神经根移位术中胸背神经损伤程度的价值。方法7例全臂丛神经根性撕脱伤患者,均行健侧C7神经根移位术,术中切断C7之前分别刺激健侧臂丛上、中、下干,以及C7神经根各束支,采用肌电仪记录背阔肌动作电位波幅(Amp),了解各神经对背阔肌的支配权重。结果干部刺激后,背阔肌复合肌肉动作电位Amp在上、中、下干分别为(2.26±1.17)mv,(3.47±1.48)mv及(2.67±1.21)mv,中干与上、下干之间均存在统计学差异(P<0.05),而C7各股束支中,后股总体Amp为(4.14±1.94)mv,明显高于前股(2.08±1.24)mv(P<0.01),且后股内侧Amp最大,为(3.97±1.53)mv,大于后股外侧(2.87±1.41)mv(P<0.05)。背阔肌支配权重在臂丛干部,以中干(41.30%±2.56%)为大,而中干又以中干后股(66.90%±1.72%)、后股内侧(38.37%±1.65%)为大。结论术中电生理检测可以较精确定位背阔肌的支配神经来源,对合理选择C7神经根移位术式、提高C7神经根移位术式安全性具有重要的临床指导意义。     

肋间神经移位修复桡神经肱三头肌肌支的长期随访疗效

目的 分析探讨肋间神经移位修复桡神经肱三头肌肌支的长期随访疗效.方法 回顾性随访2004年至2008年于我院行肋间神经移位修复桡神经肱三头肌肌支的23例患者术后肱三头肌肌力的恢复情况.其中16例患者诊断为全臂丛神经根性撕脱伤,7例患者诊断为C5～G7根性撕脱伤合并下干损伤(非根性撕脱伤).患者受伤至接受肋间神经移位手术的时间间隔为5.7个月;平均随访时间48.7个月.结果 肱三头肌肌力恢复优良率(肌力恢复至M3及以上)为39.1％,肌力恢复至M2的患者占30.4％,肌力恢复至M1及以下占30.5％.G5～C7根性撕脱伤合并下干损伤患者肱三头肌肌力恢复优于全臂丛神经根性撕脱伤患者.使用2根或2根以上的肋间神经移位修复肱三头肌肌支术后疗效未见明显差异.结论 肋间神经移位修复桡神经肱三头肌肌支可使肱三头肌得到一定程度的恢复.     

颈7神经根切断术后的肌电电生理改变（II）

为进一步研究颈７神经根切断后对上肢神经功能的早期影响，近年来我们对１８例应用健侧颈７神经根移位桥接治疗的臂丛神经损伤患者，于同一个体相同检测条件下测定并观察切断颈７神经根术前、术后２周内，健侧上肢的肌电电生理变化。观察内容及结果１．肌电：背阔肌、肱三头肌、伸指总肌和尺侧屈腕肌，术后均无明显失神经改变。２．周围神经传导：（１）五个手指指神经的腕感觉神经动作电位（ＳＮＡＰ），术后１￣３指ＳＮＡＰ波幅均     

Electrophysiologic study of influence on C7 innervated muscles after transection of different C7 fascicles

An experimental study was conducted to observe the electrophysiologic changes in C7 innervated muscles following transection of different fascicles of C7 nerve root in the brachial plexus with already transected C5 and C6. Twenty-four Sprague-Dawley rats were randomized into groups A, B, and C. C5 and C6 transection, C5, C6, and partial C7 (anteriolateral fascicles of the anterior division) transection, and C5, C6, and C7 transection were done in group A, B, and C, respectively. One month postoperatively, compound muscle action potentials of the latissimus dorsi, triceps, and extensor digitorum communis were recorded. Decreased amplitude and a prolonged latent period were seen in all three muscles of group C. No obvious changes, however, were found in groups A and B. This suggests that when the upper trunk of the brachial plexus is injured, partial transection of C7 does not obviously impair C7 innervated muscle function. Selective ipsilateral C7 transfer is safe for the treatment of upper-trunk avulsion.     

同侧颈7移位修复臂丛上干不全损伤的疗效与背阔肌功能的关系

目的：分析用同侧颈7移位治疗臂丛上干不全损伤的疗效与背阔肌功能的关系，方法：1997例3月至2000年9月，对9例臂丛神经上干损伤或上，中干不全损伤伴膈神经损伤患者采用同侧颈7移位于上干前股以恢复屈肘功能，术前检查伤侧背阔肌肌力，并在术后分析疗效时观察同侧颈7移位与背阔肌肌力的关系。结果：6例术前背阔肌肌力正常者作同侧颈7移位于上干前股后，伤侧屈肘功能均得到恢复，3例术前背阔肌肌力减退或肌力消失者，术后屈肘功能均未恢复。结论：臂丛神经上，中干不全损伤时如伤侧背阔肌肌力减退或肌力消失时，不应选择同侧颈7作动力神经。     

The radio-radial nerve transfer for elbow extension restoration in C5 to C7 nerve root injury

Extension of the elbow is required to oppose gravity; however, activation of the triceps brachii is frequently underestimated during the surgical planning for brachial plexus injuries. This report aims to describe a novel technique of distal nerve transfer designed for elbow extension reconstruction in patients sustaining a C5-C7 nerve root injury. We report a patient sustaining a brachial plexus injury with triceps palsy and preserved finger extension motion; after careful intraneural dissection of the radial nerve, a fascicle innervating the extensor digitorum communis muscle was sectioned, derouted and connected to a motor branch to the lateral head of the triceps. Eleven months after surgery, elbow extension strength scored MRC M4. No deficits on finger extension were observed.     

Functional compensative mechanism of upper limb with root avulsion of C5-C6 of brachial plexus after ipsilateral C7 transfer

Objective： To investigate the compensative mechanism of no further impairment of the upper limb after ipsilateral C7 transfer for treatment of root avulsion of C5-C6 of the brachial plexus.
Methods： Sixty Sprague Dawley （SD） rats were randomly divided into a CT-transection group and a control group, 30 rats each. In the CT-transection group, the left forelimbs of the animals underwent transection of ipsilateral C7 nerve root while C5 and C6 nerve roots were avulsed. In the control group, the left forelimbs only underwent C5 and C6 root avulsion. The representative muscles of C7 （innervated mainly by C7） including latissimus dorsi, triceps, extensor carpi radialis brevis and extensor digitorum communis were evaluated with neurophysiological investigation, muscular histology and motor end plate histomorphometry 3, 6 and 12 weeks after operation. The right forelimbs of all rats were taken as the control sides.
Results： Three weeks after operation, the recovery rates of amplitudes of compound muscle action potential （CMAP） and CMAP latency, muscular wet weight and cross-sec- tional area of muscle fibers, and area of postsynaptic membranes of those four representative muscles in the C7- transection group were significantly lower than those of the control group （P 〈0.05 or P 〈0.01）. Six weeks postoperatively, the recovery rates of CMAP amplitude and latency of the triceps showed no significant difference between the C7- transection group and the control group （P〉0.05）. For theextensor carpi radialis brevis and the extensor digitorum communis, the recovery rates of the cross-sectional area of muscle fibers, the amplitude and latency of CMAP and the area of postsynaptic membranes showed no significant dif- ference between the two groups （P 〉0.05）, while the rest parameters were still significantly different between the two group （P 〈0.05 or P 〈0.01）. As far as the ultramicrostructure was concerned in the CT-transection group, more motor end plates of four representative m     

同侧颈7神经根选择性移位术治疗臂丛上干根性撕脱伤

目的 针对臂丛上干根性撕脱伤合并膈神经损伤病例,采用新的同侧颈_7神经根选择性束组移位方法,并证实其科学性、可行性与实用性,方法 自96年6月～99年2月,运用同侧颈_7神经根选择性束组移位术12例。其中臂丛上干撕脱伤10例,臂丛上干根性撕脱伤合并中干颈_7神经根部分损伤2例。全麻下行同侧选择性颈_7神经根前股前外侧份移位,直接与上干前股显微缝合。术后随访9例,并进行疗效评价。结果 7例颈_7神经根前股外侧份移位至上于前股有明显疗效,术后2月肌电检查证实有移位神经长入;术后4～7月即见肱二头肌恢复屈肘动作,而原颈_7神经根支配肌肉功能均无明显功能障碍。结论 同侧选择性颈_7神经根纤维束组移位不仅不影响颈_7神经根原有支配肌的运动功能,而且提供动力神经源,不失为一种新的切实可行的手术治疗方法。     

Electrophysiological study of the dominant motor innervation to the extensor digitorum communis muscle and long head of triceps brachii at posterior divisions of brachial plexus

Background: Restoration of elbow and finger extension function is still challenging in management of complete brachial plexus avulsion injury, mainly because of fewer available donor nerves for transfer to the radial nerve. Selective neurotization could be a potentially alternative for overcoming this dilemma. This study was designed to identify the innervation dominance of the extensor digitorum communis muscle (EDCM) and long head of the triceps brachii (LTB) at the level of division of brachial plexus. Methods: From February 2008 to October 2009, 17 patients with complete brachial plexus avulsion injury underwent the procedure of contralateral C7 nerve root transfer. The posterior divisions of brachial plexus on the healthy donor side were intraoperatively stimulated and the compound muscle action potentials (CMAPs) from the extensor digitorum communis muscle and long head of triceps brachii were recorded by an electrophysiological device. Results: In 13 out of 17 patients (76.5%), the maximal amplitude of CMAP from EDCM was induced by stimulation of the posterior division of lower trunk (PDLT). The mean amplitudes of CMAP from EDCM with stimulation of the posterior division of upper trunk (PDUT), middle trunk (PDMT), and PDLT were 0.64 ± 0.95, 1.64 ± 1.56, and 5.32 ± 4.67 mV (P < 0.05), respectively. The maximal amplitude of CMAP from LTB was induced mainly by stimulation of the PDMT) and PDLT (6 out of 11 and 5 out of 11 patients). The mean amplitudes of CMAP from LTB with stimulation of the PDUT, PDMT, and PDLT were 0.15 ± 0.24, 5.20 ± 4.27, and 7.48 ± 9.90 mV, respectively. The differences of CMAPs between stimulation of PDUT and other two divisions were significant (P < 0.05). Conclusions: From the electrophysiological point of view, this study showed that the PDLT was the major motor division innervating EDCM, and the PDMT and PDLT shared the similar proportion of LTB innervation. © 2011 Wiley‐Liss, Inc. Microsurgery, 2011.