肘部尺神经内囊肿三例报告

目的 总结3例肘部尺神经内囊肿的诊治过程,并对该病进行相关的文献综述,为临床提供治疗经验.方法 2011年3月至2012年10月,对3例临床和神经电生理诊断为肘部尺神经损伤的患者进行手术治疗.术中探查发现尺神经主干外膜下有囊性肿块,囊肿位于肘关节下方,均行囊肿切开引流术,对其中2例含有囊肿的尺神经关节支予以结扎、切除.结果 术后随访2～ 16个月,平均8.7个月.术后肘部胀痛消失,尺侧一指半刺痛觉好转.按照肘管综合征功能评定标准评定:良2例,可1例.结论 肘部尺神经内囊肿十分罕见.对于临床诊断明确的患者,目前多行神经外膜切开引流术.     

手部神经肿瘤的诊治

目的探讨手部神经肿瘤的诊治。方法1998年1月至2003年12月，对诊治的6例手部神经肿瘤采用手术切除。1例术前误诊为腱鞘炎、腱鞘结核，术后病理诊断为正中神经脂肪纤维瘤。1例术中误将尺神经浅支与肿瘤一同切除，行神经修复术，术后诊断为神经鞘瘤。3例手背、1例指背感觉支神经纤维瘤。结果6例随访8个月～2年，除1例环指尺侧、小指感觉稍减退外，余几例感觉、运动功能均正常，肿瘤无复发。结论手部浅表肿瘤的症状与体征较相似，容易误诊、误治；对手部神经肿瘤采用手术切除是主要的治疗方法。     

神经束膜吻合术与神经外膜吻合术治疗尺神经损伤的效果比较

目的比较神经束膜吻合术和神经外膜吻合术治疗腕部尺神经损伤的效果。方法将80例腕部尺神经断裂伤患者按治疗方法分为神经束膜吻合组(42例)与神经外膜吻合组(38例)。比较两组患者术后尺神经传导速度、复合肌肉动作电位波幅和临床疗效。结果患者均获得12个月随访。术后3、6、12个月,尺神经传导速度、复合肌肉动作电位波幅神经束膜吻合组明显优于神经外膜吻合组(P 0.001)。术后12个月临床疗效优良率神经束膜吻合组(81.0%)高于神经外膜吻合组(47.4%)(P 0.05)。结论神经束膜吻合术治疗腕部尺神经损伤的效果优于神经外膜吻合术。     

肘部单切口下二氧化碳灌注内窥镜辅助下尺神经松解及前置术

目的 介绍一种在单个小切口下利用二氧化碳(CO2)气泵于肘部尺神经行经处创造气腔,在内窥镜辅助下彻底松解尺神经并前置的方法.方法 2005年至2008年,对12例临床确诊为肘管综合征的患者在肘内侧做单个纵行小切口,利用气腹机在肘部皮下与前臂或臂部深筋膜之间产生的CO2气腔内,采用℃角内窥镜下行尺神经松解及屈肌筋膜下前置术.采用Dellon及改良Bishop评分系统进行手术前后评估.结果 术前根据Dellon评分,12例肘管综合征中轻度5例、中度5例、重度2例.肘部手术切口长(15±3)mm,CO2气腔均成功建立,尺神经松解长度为(18±2)cm,内窥镜下的神经松解及筋膜下前置手术均顺利,整个手术持续时间为(30±5)min.术后所有患者的尺神经症状均较术前有改善,无并发症发生.随访时间为12～18个月,按改良Bishop 评分:优10例(占83.3％),良2例(占16.7％).结论 肘部单个小切口下,CO2灌注产生的皮下气腔可以更好地暴露尺神经,结合内窥镜肘部尺神经松解及前置术减少了对神经分支及血供的损伤.该方法简单安全,创伤小,恢复快.     

肘关节僵硬治疗中尺神经的处理与预后

[目的]比较研究尺神经在重度肘关节僵硬治疗中行尺神经松解前置术与否的预后.[方法]2002年7月～2007年10月共收治44例O'[KG-48x]DriscollⅡ型重度肘关节礓硬患者,术前均无尺神经功能障碍.其中22例患者接受彻底的肘关节僵硬切开松解术,14例采用后正中入路,8例采用内外侧联合入路,手术同时行尺神经松解术并予深筋膜下前置.另外22例患者采用同样手术方式松解,16例采用后正中入路,6例内外侧联合入路,但术中尺神经不予处理.根据Amadio肘部尺神经损害的疗效评价标准,对比研究术后尺神经的预后.[结果]尺神经松解前置组22例患者随访13～52个月(平均28.7个月),按照Amadio肘部尺神经损害的疗效评分为平均8.7±0.6;对照组22例患者随访12～52个月(平均30.9个月),Amadio肘部尺神经损害的疗效评分为平均8.0±0.8.两组尺神经的功能评分差异具有统计学意义(P<0.05).[结论]重度肘关节僵硬的治疗过程中常规行尺神经松解前置,可预防尺神经在肘关节松解术后发生功能障碍,改善尺神经预后.     

臂丛及周围神经鞘瘤手术治疗38例

[目的]探讨臂丛及周围神经鞘瘤的治疗要点和疗效。[方法]1999～2007年共收治经临床和病理证实的神经鞘瘤38例，其中副神经1例，颈丛皮神经2例，臂丛神经6例，膜丛神经2例，上肢神经17例，下肢神经10例。其中37例均在显微镜下获得肿瘤切除，术中均用神经电生理监测，1例将肿瘤切除后，同时行神经移植术。术前复杂部位均行MRI检查，术后所有肿瘤均经病理证实为神经鞘瘤。[结果]本组38例中，36例术后神经功能未受影响，随访6个月～7年，平均4．5年，无复发。1例尺神经鞘瘤切除后出现手内肌功能部分障碍，10d后恢复。L4神经鞘瘤行肿瘤切除神经移植术后，股四头肌肌力下降为2级减，神经移植后疗效正在随访中。[结论]（1）应用显微外科技术显微镜下操作，并采用术中神经电生理监测，可最大限度的切除肿瘤，减少复发，并保留正常神经功能。（2）对于颈部、臂从、膜丛等复杂部位的神经鞘瘤术前尽可能行MRI检查。（3）术后所有神经鞘瘤均应经病理证实。     

肘部尺神经卡压症

目的 :探讨肘部尺神经卡压症的术式及并发症。方法 :8例采用单纯松解术 ,3 0例采用前置术 ,对所有病人从struths弓到屈指深肌腱膜进行探查松解 ,术中保护尺神经血供。结果 :尺神经在肘部多处可受到卡压 (平均 2 4处 )。随访平均 2 2个月 ,按 2 0 0 0年手外科学会周围神经功能评价标准评价 ,优良率 86 8%。神经卡压症状在1年内手术术后疗效好。结论 :手术对尺神经卡压的 5个部位都应进行探查、松解。根据不同的病例选择前置或单纯的松解术。     

双镜联合治疗胃神经鞘瘤4例临床分析

目的:探讨腹腔镜联合胃镜治疗胃神经鞘瘤的临床应用。方法:回顾分析4例胃神经鞘瘤患者临床及诊疗资料。结果:4例患者术前均行胃镜及腹部CT检查(肿瘤直径均<3 cm),仅1例诊断为胃神经鞘瘤;联合腹腔镜及胃镜切除肿瘤,术中快速病理报告均诊为胃间质瘤;手术均顺利完成,手术平均时间(83±15)min;术中平均出血量(43±10)m L;无出血、狭窄等并发症;随访未出现复发及转移。术后病理诊断均为胃神经鞘瘤。结论:腹腔镜联合胃镜对直径<3 cm的胃神经鞘瘤是安全可行的,但术前诊断率仍有待提高。     

神经松解术治疗上肢原因不明的神经炎

目的 为探索原因不明神经炎的诊断与治疗方法,以提高对此类疾患的认识和治疗水平。方法 对8例原因不明的上肢神经炎进行临床分析,其中尺神经6例,桡神经2例,病最短5个月,最长达4年,将切除的神经外膜送病理检查,均为非特异性炎性改变。治疗采取神经外膜或束膜切开松解手术加局部注射醋酸强的松龙。结果 尺神经6例中5例术前疼痛消失、感觉和运动功能障碍（包括手内在肌萎缩）已完全恢复、1例感觉功能完全恢复,运动功能及手内肌萎缩部分恢复,术后1年另侧肢体出现同样体征,治疗后的效果待进一步随访。桡神经2例,1例完全恢复,另1例剧痛完全缓解。结论 原因不明的周围神经炎的诊断有待进一步探讨,神经松解手术加注射皮质激素的治疗效果较非手术疗法的效果要好,值得推荐。     

内窥镜下尺神经松解联合内上髁微小切除治疗伴尺神经滑脱的肘管综合征

目的探讨内窥镜下尺神经松解联合内上髁微小切除治疗伴尺神经滑脱的肘管综合征效果。方法 2004年6月-2009年6月,对11例伴尺神经滑脱的肘管综合征患者行内窥镜下尺神经松解联合内上髁微小切除术。男7例,女4例;年龄18～47岁,平均36岁。均有患侧小指及环指尺侧半刺痛感减退。第1骨间背侧肌伴小鱼际肌萎缩(++～+++)9例,肌萎缩不明显2例。术前肌电图检查示尺神经于肘部传导速度为(27.0±7.5)m/s。病程3～18个月,平均7个月。结果术后切口均Ⅰ期愈合,无相关并发症发生。患者均获随访,随访时间6～37个月,平均19个月。术后1个月11例感觉基本恢复正常。术后3个月7例肌力恢复至4级以上,4例为3～4级。术后3个月复查肌电图,尺神经于肘部传导速度为(43.5±9.5)m/s,与术前比较,差异有统计学意义(P0.05)。按Amadio肘部尺神经损害疗效评价标准,获优7例,良4例。结论内窥镜下尺神经松解联合内上髁微小切除治疗伴尺神经滑脱的肘管综合征安全、简便、有效,创伤小,术后恢复快。     

游离尺动脉腕上皮支皮瓣修复手指皮肤缺损

目的探讨应用尺动脉腕上皮支皮瓣游离移植修复手指皮肤缺损的临床效果。方法采用尺动脉腕上皮支皮瓣游离移植修复12例手指缺损,根据手指皮肤缺损形状及面积设计皮瓣,皮瓣大小:1.5 cm×4.5cm～4.0 cm×8.0 cm;皮瓣血管蒂分别与受区指动脉及浅静脉作端端吻合。结果皮瓣全部成活。患者均获随访,时间6～30个月。术后6个月按中华医学会手外科学会上肢部分功能评定试用标准:优7例,良3例,可2例。结论采用尺动脉腕上皮支皮瓣游离移植修复手指皮肤缺损,皮瓣切取方便,血管解剖较恒定,供区隐蔽且损伤小,受区外形和功能恢复良好。是修复手指软组织缺损较理想的方法之一。     

Ulnar Nerve Compression in the Cubital Tunnel by an Epineural Ganglion: A Case Report

Epineural ganglia are considered to be a usual cause of peripheral nerve compression. In this report, we present a rare case of ulnar nerve compression by an epineural ganglion in the cubital tunnel. A 28-year-old right-handed female secretary developed progressive pain, numbness, and weakness in her right elbow, forearm, and hand for 6 months. Atrophy of the adductor pollicis and the first dorsal interosseous muscles was apparent. Clinical examination revealed a cystic mass at the posterior side of the elbow. Magnetic resonance imaging identified a ganglion while electrophysiologic studies revealed a severe conduction block of the ulnar nerve at the elbow. During surgery a 2-cm diameter epineural ganglion was identified compressing the ulnar nerve and was excised using microsurgery techniques. Two months postoperatively, the clinical recovery of the patient was very satisfactory, although the postoperative electrophysiologic studies demonstrated a less dramatic improvement.     

联合尺神经束支和臂丛外神经移位治疗臂丛损伤

目的 观察联合尺神经束支和臂丛外神经移位治疗臂丛损伤的临床效果.方法 臂丛损伤6例,其中单纯上干损伤4例;上中干为主,合并下干部分损伤2例.伤后平均2.8个月接受手术.术式包括尺神经部分束支转位至肌皮神经肱二头肌肌支,膈神经或者副神经斜方肌支转位至肩胛上神经,桡神经肱三头肌长头肌支转位修复腋神经肌支.用肱二头肌、岗上肌和三角肌肌力,肩外展和上举角度,尺神经功能损失等指标对手术方式和效果进行评估.结果 6例中5例得到随访,平均随访时间18个月,肱二头肌均在术后3～4个月开始恢复肌力.随访时间18个月以上的4例屈肘M_4~+～M_5;随访时间4个月的1例屈肘M_3~+.其中3例行外展功能重建,单用膈神经修复的病例上臂可上举至180°,外展肌力M_4~+;联合副神经和肱三头肌长头肌支修复的病例上肢可外展90°,肌力M_4~-;单用副神经修复的病例上肢可外展80°,肌力M_3~+.3例手部握持力与术前相同,2例增强.4例手部尺神经供区功能无明显影响,1例小指掌侧皮肤感觉减退,第一骨间背侧肌萎缩.结论 尺神经部分束支转位修复肱二头肌支可以有效的恢复臂丛损伤后屈肘功能;用膈神经修复肩胛上神经可能取得更好的肩外展和上举效果;本组臂丛下干部分损伤的病例受伤均在3个月内,采用此术式同样恢复了肱二头肌功能,未加重原有的手功能障碍.     

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.     

Fibrolipomatous hamartoma of nerve. A clinicopathologic analysis of 26 cases

Nineteen cases of fibrolipomatous hamartoma of nerve without macrodactyly and seven cases with macrodactyly are discussed. Twenty-five involved the hand, wrist, palm, and finger, and one case involved the foot. Nineteen patients had isolated fibrofatty enlargement of nerve, while seven had macrodactyly in addition to the peripheral nerve changes. Involved nerves included the median nerve, ulnar nerve, an unidentified nerve near the elbow, and a nerve on the dorsum of the foot. Four of nine patients with neurologic symptoms of pain or paresthesias had physical findings compatible with compression neuropathy, and two others were described as having carpal tunnel syndrome. Most patients had been aware of a mass for several years. Microscopically, the lesion was characterized by fibrofatty enlargement of nerve with massive epineural and perineural fibrosis. In two of the cases with macrodactyly, the fibrofatty enlargement of the nerve was associated with overgrowth of bone and the surrounding subcutaneous tissues. In one case, the perineural fibrosis was associated with metaplastic bone. The histogenesis of fibrofatty overgrowth of nerve has been disputed. Mature fat cells have been described within the normal nerve sheath, and it is thought that proliferation of these cells leads to the fatty enlargement of the nerve and its coverings. The relationship of these neural changes to the development of macrodactyly remains controversial. Follow-up in 18 patients (69%) reveals a benign course following biopsy, limited excision, or division of the flexor retinaculum in the wrist.     

Clinical application of distal ulnar artery perforator flap in hand trauma

The clinical value of distal ulnar artery perforator flap in composite defects of the hand is demonstrated in a case series of nine patients with severe injuries of the hand. Soft tissue loss with a mean diameter of 3?×?4 cm on the dorsum of the hand, volar and dorsal side of the wrist and palm was reconstructed with this flap. The mean size of flaps was 5.2?×?5.2 cm. Tendon and nerve injuries, and metacarpal fractures accompanied the soft tissue loss in seven patients. Subsequent reconstructive procedures were; Hunter rod placement and tendon grafting in two patients, nerve grafting in one, primary extensor or flexor tendon repair in three, and metacarpal bone fixation in one patient. The mean follow-up period was 18 months. No complications related to the flap were observed. In this article, the advantage and disadvantages of distal ulnar artery perforator flap in hand and wrist reconstruction is discussed together with a review of literature.     

Neural fibrolipoma of the ulnar nerve in the hand: a case report.

The author reports an unusual case of neural fibrolipoma (lipofibromatous hamartoma) of the ulnar nerve in the hand. A 20-year-old man presented with a fusiform soft tissue mass in his right hand. Neurological examination was normal except to minimal pain on palpation. Surgical exploration revealed that ulnar nerve and its digital branches were infiltrated by fibrofatty tissues. Fibrofatty tissues were dissected and removed from the nerve by microsurgical technique. Histological examination confirmed the diagnosis as a lipofibromatous hamartoma of the nerve. The result of surgical debulking was satisfactory.     

联体尺动脉穿支皮瓣在多指毁损伤修复中的临床应用

目的探讨联体尺动脉穿支皮瓣修复多指毁损伤的临床效果。方法回顾性分析2011年3月至2017年10月东莞长安新安医院收治的12例多指毁损伤患者,男8例,女4例,年龄(32.6±4.3)岁,范围18~56岁。4指毁损伤2例,3指毁损伤4例,2指毁损伤6例。皮肤软组织损伤位置均为远掌横纹或指掌横纹以远,指骨为近节以远。皮肤总缺损面积(135.6±12.3)cm^2,范围6.0 cm×16.0 cm^6.0 cm×35.0 cm,应用皮瓣总面积(143.5±11.2)cm^2,范围5.0 cm×20.0 cm^3.2 cm×47.0 cm(双侧前臂)。双前臂尺动脉穿支皮瓣5例,单侧7例,所有皮瓣均为2条以上穿支蒂。皮瓣均设计为长条状,螺旋缠绕包裹于伤指骨,皮瓣穿支动脉与相应指固有动脉或掌背动脉吻合,伴行静脉与相应指掌侧静脉或掌背静脉吻合,皮瓣浅静脉与相应指背静脉或掌背静脉吻合,皮瓣神经与相应指固有神经或掌背相应感觉神经吻合。供区除1例植皮外,其余均直接缝合。术后随访观察疗效,包括感觉、外观、血液循环、骨吸收及手运动功能、日常生活、恢复工作情况等。评价标准为中华医学会手外科学会断指再植功能评定试用标准。结果所有皮瓣均成活,1例皮瓣末稍有约1.5 cm×1.5 cm坏死,二期缝合修复。所有病例均获6个月至6.5年随访,平均16.7个月,皮瓣质地良好,无色素沉着,外观无臃肿,指端无瘢痕或磨损,两点辨距觉6~10 mm,平均8.6 mm。术后半年骨吸收发生率59.4%(19/32),指短缩平均0.8 cm,其中5例6指取髂骨植骨。伤指拿捏及持物功能部分恢复,日常生活无明显影响;患手握力平均达到健侧的60.3%。参照断指再植功能评定试用标准:优2例,良5例,差4例,劣1例,优良率58.3%(7/12)。供区外观可。结论联体尺动脉穿支皮瓣为多指毁损或脱套伤患者的临床修复提供了一种有益的思路和有效的手术方案,效果良好。     

尺神经沟扩大神经束间松解治疗重度肘管综合征临床研究

目的 总结尺神经沟扩大显微镜下神经束间松解术及尺神经前移显微镜下神经束间松解术治疗重度肘管综合征的疗效. 方法 2002年12月-2007年1月,采用尺神经沟扩大显微镜下神经束间松解治疗22例重度肘管综合征患者(治疗组),与2001年7月-2004年11月,采用尺神经前移显微镜下神经束间松解治疗的22例患者(对照组)进行比较.治疗组:男17例,女5例;年龄21～66岁,平均43.8岁.肘关节骨性关节炎17例,尺神经滑脱3例,肘外翻畸形2例.左侧8例,右侧14例.病程6～69个月.对照组:男18例,女4例;年龄20～64岁,平均42.1岁.肘关节骨性关节炎16例,尺神经滑脱4例,肘外翻畸形及肱骨内髁骨折移位畸形愈合致尺神经沟变窄变浅各1例.左侧7例,右侧15例.病程5～67个月. 结果 两组患者术后切口均I期愈合.治疗组术后1 d,患者小指麻木均明显减轻、消失;对照组术后3～5 d,患者小指麻木明显减轻、消失.两组患者均获随访,随访时间12～45个月,平均20.1个月.肌电图检查示尺神经传导速度均正常.按照中华医学会外科学会上肢部分功能评定试用标准和Lascar分级法评价疗效,治疗组优21例,良1例,优良率100%:对照组优19例,良2例,可1例,优良率95.45%.治疗组和对照组术前评分分别为(2.89±0.15)分和(2.91±0.13)分,差异无统计学意义(P＞0.05);术后分别为(11.32±1.04)分和(9.91±1.48)分,差异有统计学意义(P＜0.01). 结论 尺神经沟扩大神经束间松解和尺神经前移、神经束间松解均是治疗重度肘管综合征的有效方法,前者优于后者.     

周围神经缺损的牵引延长直接缝合治疗

周围神经缺损的修复方法很多，各有其优缺点。在组织扩张术及肢体延长术的启发下，设计了周围神经缓慢延长修复缺损后直接缝合的方法。临床应用２例，１例为肘部桡神经缺损７．２ｃｍ，另１例为肘部尺神经缺损５ｃｍ。１４天达到延长要求，修复了神经缺损。术后分别于１１９天及１４１天完全恢复了神经功能。经５年随访，患肢神经功能与健侧无差异。详细介绍了周围神经牵引延长的方法，预防结缔组织阻挡的措施，以及神经牵长的牵引力及着力点的设计等