神经移位治疗早期臂丛神经根性损伤13例临床分析

目的:探讨在臂丛神经根性损伤早期及时采用神经移位治疗的临床效果.方法:回顾性分析我科13例臂丛神经根性损伤患者经颈椎CTM 诊断后1周内应用神经移位方法手术治疗的临床资料.结果:术后均获5～48个月的随访,患者不同程度地恢复了上肢大部分功能.结论:应用颈椎CTM检查可诊断臂丛神经根性损伤,指导早期手术.根据臂丛神经根损伤的程度,早期应用神经移位的方法治疗效果可靠.     

颈丛代臂丛的应用解剖学研究

为探讨对臂丛神经根撕脱损伤的修复,我们用神经分离方法,在20例成人尸体上,研究了以颈丛代替臂丛神经根的显微外科应用解剖。为臂丛神经根的重建,提供了新的供体。     

臂丛损伤脊髓运动神经元与神经根GAP-43 mRNA表达

目的：探讨臂丛根性撕脱伤后脊髓腹角运动神经元胞体及其神经根GAP-43 mRNA的表达变化及其影响因素,为臂丛损伤的修复治疗提供理论依据.方法：本实验创立三种臂丛根性撕脱伤模型：C7前根撕脱（Ⅰ组）;C7前根撕脱＋切断同侧C5～T1后根（Ⅱ组）;C7前根撕脱＋C5和C6之间作同侧脊髓半横断（Ⅲ组）.术后2周按CBS评分标准检查动物神经缺失症状,用SYBR Green荧光定量RT-PCR方法检测脊髓腹角运动神经元胞体及其神经根GAP-43 mRNA的表达改变.结果：根据CBS评分标准,对照组计为0分,Ⅰ组计分较低、Ⅲ组计分最高.对照组C7神经元胞体和C7神经根中GAP-43 mRNA表达量相近,但三种损伤组术后2周神经元胞体内GAP-43 mRNA表达均上调,而神经根内表达却下调.结论：（1）臂丛根性撕脱伤后脊髓腹角运动神经元胞体GAP-43 mRNA表达受突触前机制的调控;（2）臂丛损伤2周时神经元胞体内GAP-43 mRNA表达呈现高峰期,此时进行神经移位术将显著提高神经修复的效果.     

臂丛及其有关血管的研究

目的 为了获得臂丛的解剖学资料,并为手术提供定位数据。方法 对３２具尸体的臂丛进行调查和测量。结果 将６４例臂丛的类型,位置,变异等情况进行分析归类并与临床的关系进行探讨。结论本研究结果对臂丛神经根损伤的诊治具有积极的指导意义。     

前锯肌与颈椎旁肌在C_(5～7)臂丛神经根性损伤电生理诊断中的价值

目的:为了探讨前锯肌与颈椎旁肌在C_(5～7)臂丛神经根性损伤电生理检测中的诊断价值。方法:C_(5～7)臂丛神经根性损伤患者50例,在肌电图检测过程中同时检测前锯肌与C_(5～7)椎旁肌,测定内容包括静息状态时自发电活动。观察比较前锯肌与椎旁肌自发电活动在C_(5～7)臂丛神经根性损伤中的阳性率。结果:前锯肌见到自发电活动的阳性率为97%,椎旁肌见到自发电活动的阳性率为52.4%,前锯肌在C_(5～7)臂丛神经根性损伤中的阳性率更高。讨论:前锯肌在臂丛神经C_(5～7)根性损伤电生理定位诊断中有重要意义。     

臂丛神经根体感诱发电位成人正常参考值的建立及应用

目的建立臂丛神经根诱发电位潜伏期及波幅的正常参考值，以应用到臂丛神经疾病的诊断及治疗中。方法：选择临床臂丛神经根性完全损伤健侧C7移位的术中病人220例，进行臂丛神经C5、C6、C7、C8、T1神经根体感诱发电位（SEP）的测定，刺激每一根神经根时作皮层记录，侧测定每一神经根诱发电位潜伏期及波幅。结果：SEP潜伏期C5（8．72±0．64）、C6（8．73±0．63）、C7（9．01±0．43）、C8（9．38±0．50）、T1（9．45±0．59）ms；波幅C5（3．19±1．98）、C6（3．24±1．89）、C7（2．89±1．56）、C8（4．17±2．83）、T1（3．25±1．84）mV。结论：建立臂丛神经根诱发电位的正常值，可应用到临床臂丛神经根疾病的诊断、治疗中去，对手术方式提供有利的证据。     

肌电图与MRI检查结合诊断臂丛神经损伤的研究

目的：评价肌电图和MRI检查以及两者结合在臂丛神经损伤诊断治疗中的价值。方法：对27例臂丛神经损伤患进行术前肌电图、MRI和术中肌电图检查,并与手术探查中的发现进行比较;比较术前肌电图与MRI检查同术中体感诱发电位（SEP）在确定神经完全性损伤中的作用。结果：术前肌电图检查对臂丛损伤定性、定位诊断的完全符合率为70．37％,符合率为96．3％术前肌电图和MRI检查对臂丛神经根撕脱诊断的符合率分别为55．56％和68．52％,术前肌电图检查和MRI检查结合可提高诊断符合率至85．19％;SEP对完全性臂丛损伤的诊断率高于肌电图和MRI,但差异无显著性。结论：肌电图检查和MRI检查可明显提高完全5和基本符合率,是一种有前途的辅助诊断、指导治疗臂丛神经损伤的途径,术中进行SEP检查更加有利于手术方式的选择。     

臂丛根部的显微外科解剖研究及其临床意义

为进一步认识臂丛神经诸根间根部损伤后其病理特点差异的形态学基础，用显微外科解剖及ＨＥ，Ｍａｓｓｏｎ＇ｓ染色组织病理检查方法对椎管内臂丛神经诸根的显微结构进行观测。结果提示：臂丛神经诸根之间在解剖结构上存在一定的差异，由于这种差异的存在，造成颈５．６神经根在受到同等暴力作用下较７．８及胸１神经根不易形成根性撕脱。即使颈５．６神经根根性撕脱，亦往往伴有节后损伤。作者认为对于臂丛上干近椎间孔的节后损伤，     

人羊膜上皮细胞移植修复兔臂丛神经损伤

背景：目前人们把目光多集中在干细胞修复脊髓损伤方面,而对于干细胞移植治疗周围神经损伤的研究却不多,尤其人羊膜上皮细胞修复治疗周围神经损伤的研究和报道更少。 目的：探讨人羊膜上皮细胞对臂丛神经的修复作用。 方法：应用测力神经根拉钩水平牵拉臂丛神经根的方法制备大白兔臂丛损伤模型,提取人羊膜上皮细胞并扩增培养,扫描电子显微镜下观察人羊膜组织及羊膜上皮细胞的超微结构,人羊膜上皮细胞转染绿色荧光蛋白标记并注射入臂丛神经损伤区,苏木精-伊红染色及荧光显微镜观察羊膜上皮细胞对兔臂丛神经损伤的修复作用。 结果与结论：①分离得到的人羊膜上皮细胞表达上皮细胞标志物角蛋白CK19,不表达间充质细胞标志物波形蛋白,不同程度表达CD29,CD73。扫描电子显微镜观察到人羊膜上皮细胞胞体饱满,连接紧密,细胞状态良好。②人羊膜上皮细胞移植到新西兰大白兔臂丛神经损伤模型后18周,免疫荧光检测到神经损伤区可见有表达绿色荧光蛋白的羊膜上皮细胞。③术后6周实验组大白兔前爪功能开始恢复,术后12,18周实验组大白兔前爪功能得到明显改善,功能评分明显提高,对照组几乎没有恢复。以上结果可见人羊膜上皮细胞参与了臂丛神经损伤的修复。 中国组织工程研究杂志出版内容重点：肾移植;肝移植;移植;心脏移植;组织移植;皮肤移植;皮瓣移植;血管移植;器官移植;组织工程全文链接：     

神经电生理检查对外伤性臂丛神经损伤的诊断价值

目的：分析冲经电生理检测对外伤性臂从神经损伤的诊断作用。方法：对40例外伤性臂扶冲经损伤患者进行神经传导检测和对该神经所支配的肌肉进行针极肌电图检查并结合分析。结果：全臂丛伸经损伤13例（其中10例完全损伤）;臂丛上干损伤21（其中完全损伤6例）;臂丛下干损伤3例（其中完全损伤1例）;束支平面损伤3例;合并神经根撕脱伤15例。结论：神经电生理检查对臂丛神经损伤有指导治疗和评价预后的重要作用。     

膈神经的解剖及临床应用研究进展

目的:为膈神经移位治疗臂丛根性撕托伤,提供应用解剖学资料.方法:查阅与膈神经移位治疗臂丛根性撕托伤相关的解剖与临床文献资料,分析其应用价值和意义.结果:提供膈神经在颈部、胸腔内和膈肌内的走行、位置、毗邻及分支分布资料.结论:膈神经移位是用来治疗臂丛根性撕托伤的主要动力神经;臂丛探索仍是诊断臂丛损伤的全标准.     

A rare variation of posterior cord brachial plexus branching coexisting with the intercalated ectopic muscle

During a dissection of the brachial plexus we found a rare variation of left posterior cord branching coexisting with an unusual intercalated ectopic muscle. This muscle originated from the shoulder joint capsule at the lesser tubercle on insertion of the subscapularis then pierced between the brachial plexus, enclosed by two roots of the radial nerve, and inserted into the upper part of the latissimus dorsi muscle. The variant posterior cord divided into two roots; a thin lateral and thick medial root. The lateral root gave off the thoracodorsal nerve that penetrated and also innervated the ectopic muscle. The medial root gave off five nerve branches; two upper subscapular, one lower subscapular, one axillary and one terminal branch. A terminal branch fused with the lateral root to form a loop enclosing the ectopic muscle then continued as the radial nerve. This type of variation may be useful to interpret unexplained clinical signs and symptoms and provided additional knowledge to surgeons who perform brachial plexus surgery.     

An aberrant axillary artery penetrating the origin of the radial nerve from deep to superficial

An aberrant axillary artery that penetrated the radial nerve from deep to superficial during its course, was observed. The brachial plexus in the present case was classified as the Adachi's C-type brachial plexus. Further, an accessory radial root existed, which was a nerve bundle branching from the deep aspect of the inferior trunk and communicating with the radial root from the posterior cord to form the radial nerve. The axillary artery went on along the lower border of the brachial plexus and passed between the radial root and the accessory radial root from deep to superficial at its third section. As the axillary artery penetrated the origin of the radial nerve from deep to superficial, it was judged to reach deep under the posterior cord, hence deeper than the brachial plexus.     

The deep axillary artery

An aberrant axillary artery running deep to the brachial plexus during its course was observed. The brachial plexus in this case was formed by the fourth cervical nerve to the first thoracic nerve and the radial nerve received a small nerve bundle (accessory radial nerve root) from the posterior aspect of the lower trunk. The axillary artery passed between the lateral and the medial cords of the brachial plexus, the same as for an ordinary axillary artery. In addition, it passed between their posterior divisions, forming the posterior cord, and further ran between the radial nerve root and the accessory radial nerve root from deep to superficial. This axillary artery was recognized as the deep axillary artery, the same as the axillary artery we have reported previously. It was thought that the branches to the subscapularis and serratus anterior muscles, nutrient branch to the radial nerve root and the subscapular artery played important roles in its formation.     

膈神经移位至臂丛上干前股的临床应用及疗效分析

目的：报道膈神经移位至臂丛上干前股的临床应用，分析疗效欠佳的原因并探讨应对措施。方法：回顾白1999年3月-2005年2月行膈神经移位至臂丛上干前股术式的38例患者手术情况，对肌皮神经恢复情况进行随访并功能评定，并对影响疗效的各因素进行分析以探讨相应的防治措施。结果：获15个月以上随访患者共29例，优良率为62．1％，功能恢复优良组与非优良组患者的病程及牵拉伤比率存在显著性差异（P〈0.05）。再手术探查发现手术失败的原因有：神经吻接口张力大、存在臂丛的组成变异及多段损伤等。基于神经解剖特点，作者针对减低膈神经吻接口张力提出了手术改良措施并取得满意的疗效。结论：影响该术式疗效的因素有多种，严格把握手术适应症及术中仔细探查是提高治疗效果的关键；通过术式改良可有效降低神经吻接口张力，有助于神经恢复。     

39例分娩性臂丛神经损伤新生儿的神经电生理评价

目的:探讨新生儿期电生理检测在评价分娩性臂丛神经损伤中的价值。方法:应用肌电一诱发电位仪对39例分娩性臂丛神经损伤新生儿进行检测。测试项目包括:①患侧臂丛神经五大分支腋神经、肌皮神经、正中神经、尺神经及桡神经运动神经传导速度测定;患侧正中神经、尺神经及桡神经感觉神经传导速度测定;②采用同芯针电极检测臂丛神经支配远端肌肉(三角肌、肱二头肌、4伸指总肌、外展拇短肌、外展小指肌或骨问肌)肌电图。结果:39例新生儿中全臂丛神经损伤11例(28％);上干损伤18例(46％);下干损伤3例(8％);后束损伤7例(18％)。节前损伤11例(28％)。结论:新生儿期神经电生理检测对早期评价分娩性臂丛神经损伤的范围、性质、部位及程度具有重要的临床价值。     

臂丛神经根性撕脱伤动物模型的研究

目的 研究臂丛神经根性撕脱伤实验动物模型。方法 选用Wistar大白鼠，取右下颌骨向下至胸大肌中部皮肤切口，显露胸大肌，分别切断胸大肌、胸小肌；暴露井剪断右锁骨，镜下解剖分离臂丛神经并紧贴近端根部将颈5至颈8剪断，造成臂丛神经根性撕脱伤模型，实验组用颈3、颈4神经修复臂丛中已损伤的颈5、颈6神经，对照组不做修复；用电生理及组织病理学观察神经肌肉组织变化，结果术后3个月病理检查发现，实验组中肌皮神经可见少量神经纤维长入，肱二共肌萎缩轻，失神经组之肌皮神经可见神经纤维变性、崩解、吸收，肱二头肌萎缩明显，电生理检查显示实验组与失神经组之诱发电位峰值电压与刺激电流比值及潜伏期时间与刺激电流强度之比值在统计学上有显著性差异（P〈0．05）。结论 该实验模型操作简单，科学，合理。为臂丛神经根性撕脱伤实验研究奠定了基础。     

Microanatomical study on the functional origin and direction of the thoracodorsal nerve from the trunks of brachial plexus

Ipsilateral C7 nerve root transfer or neurotization has been used for the repair of brachial plexus avulsions. In this procedure, the ipsilateral C7 nerve root is used as a donor nerve and is implanted into the damaged nerve of the brachial plexus in order to reinnervate distal muscles. However, this procedure may result in unintended injury to the thoracodorsal nerve, which receives motor fascicles form the cervical nerves of C6, C7, and C8, but mainly from C7. Damage to the thoracodorsal nerve ultimately results in weakness or paralysis of the latissimus dorsi muscle, which it innervates. In the present study, 20 adult cadaveric brachial plexus specimens and 3 fresh specimens were dissected using microscopy. The origin and direction of motor fascicles from the three trunks of the brachial plexus to the thoracodorsal nerve were investigated. Motor fiber counts of C7 and the thoracodorsal nerve were also performed. Several observations can be made: (1) The origin of the thoracodorsal nerve can be divided into three types: Type A, the thoracodorsal nerve originated from the superior and middle trunks; Type B, the thoracodorsal nerve originated from the inferior and middle trunks; and Type C, the thoracodorsal nerve originated from all three trunks. (2) More than 52% of the motor fibers in the thoracodorsal nerve originated in the C7 nerve root. (3) Motor fascicles from C7 to the thoracodorsal nerve were mostly localized in the posterior-internal part of C7 at the trunk-division boundary. In conclusion, we suggest that: (1) Because of variation in the origin of the thoracodorsal nerve, electromyography should be routinely performed intraoperatively during C7 nerve root transfer to determine the origin type and avoid thoracodorsal fascicle injury. (2) Preservation of the posterior-internal part of C7 (selective C7 transfer) can protect thoracodorsal nerve fascicles from damage and prevent postoperative dysfunction of the latissimus dorsi muscle.     

3D Computerized Model for Measuring Strain and Displacement of the Brachial Plexus Following Placement of Reverse Shoulder Prosthesis

The aim of the present study was to develop a method for three‐dimensional (3D) reconstruction of the brachial plexus to study its morphology and to calculate strain and displacement in relation to changed nerve position. The brachial plexus was finely dissected and injected with contrast medium and leaden markers were implanted into the nerves at predefined places. A reverse shoulder prosthesis was inserted in a cadaveric specimen what induced positional change in the upper limb nerves. Computed tomography (CT) was performed before and after this surgical intervention. The computer assisted image processing package Mimics® was used to reconstruct the pre‐ and postoperative brachial plexus in 3D. The results show that the current interactive model is a realistic and detailed representation of the specimen used, which allows 3D study of the brachial plexus in different configurations. The model estimated strains up to 15.3% and 19.3% for the lateral and the medial root of the median nerve as a consequence of placing a reverse shoulder prosthesis. Furthermore, the model succeeded in calculating the displacement of the brachial plexus by tracking each implanted lead marker. The presented brachial plexus 3D model currently can be used in vitro for cadaver biomechanical analyses of nerve movement to improve diagnosis and treatment of peripheral neuropathies. The model can also be applied to study the exact location of the plexus in unusual upper limb positions like during axillary radiation therapy and it is a potential tool to optimize the approaches of brachial plexus anesthetic blocks. Anat Rec, 291:1173‐1185, 2008. © 2008 Wiley‐Liss, Inc.