End-to-side neurorrhaphy for defects of palmar sensory digital nerves.

Ten traumatic nerve defects at the palm or digit level were treated by end-to-side (ETS) neurorrhaphy. The technique included removal of an epineurial window on the donor nerve and coaptation of the sharply cut distal end of the injured nerve by epineurial stitches under microscopic magnification. At final follow-up, the static two-point discrimination test (2 pd) scored at an average of 9.1 mm (range, 6-12 mm) on the repaired nerve, compared to an average of 4.6 mm (range, 4-6 mm) on the contralateral uninjured control side. Moving 2 pd scored at an average of 7 mm (range, 4-9 mm) on the repaired nerve compared to an average of 2.6 mm (range, 2-4 mm) on the control side. This short series showed that ETS neurorrhaphies are effective and give comparable results with those of nerve grafts or vein conduits.     

End-to-side neurorrhaphy

End-to-side neurorrhaphy, a possible strategy for treating nerve lesions without useable proximal nerve stumps, has been experimentally and clinically investigated. In end-to-side neurorrhaphy, three main elements should be considered: 1) the induction of axonal collateral sprouting in the donor nerve; 2) the ability of the collateral axons to pierce the different conjunctival layers, including the ability the donor nerve basal laminae, to reinnervate the recipient nerve; and 3) the functional plasticity and behavioral readjustment of single motoneurons that have eventually adopted new motor units. This article reviews the following areas of research and clinical investigation: animal models, axonal collateral sprouting from end-to-side neurorrhaphy, effect of epineurotomy and perineurotomy on axon regeneration, motor reinnervation, and clinical trials.     

周围神经端侧吻合的时限研究

目的 观察研究不同时间预变性神经端侧吻合的效果,探讨神经端侧吻合的最佳时机.方法 将Wistar大白鼠36只随机分为6组,每组6只,右侧腓总神经切断后,近端反转结扎,预变性0、1、2、4、8、16周后,远端与胫神经外膜开窗处行端侧吻合,端侧吻合术后3个月,行双侧腓总神经、胫前肌电生理及组织学检查、胫前肌肌湿重测定、运动终板检查 结果 (1)预变性0、1、2周组电生理检测动作电位恢复率、肌肉单次收缩力恢复率、强直收缩力恢复率均显著高于预变性4、8、16周组,再生神经纤维数目、肌湿重、肌纤维截面积、运动终板面积及着色均显著优于预变性4、8、16周组.(2)预变性0、1、2周组之间J各检测指标差异无统计学意义(P＞0.05),预变性4、8、16周各组之间差异有统计学意义(P＜0.05),各检测指标随时间的延长逐渐衰退.结论 神经端侧吻合的最佳时机应控制在2周之内,超过4周后,神经端侧吻合的效果逐渐变差.     

End-to-side neurorrhaphy: an experimental study in rabbits

The concept of end-to-side nerve repair was recently introduced; however, most authors have reported conflicting results with this technique. This study was conducted to assess the effectiveness of end-to-side nerve repair in both fresh and predegenerated specimens by histological evaluation in an animal study in rabbits. Thirty male rabbits were divided into three groups. In group 1 (n = 14), the peroneal nerve was divided and sutured end-to-side to the tibial nerve via an epineurial window. In group 2 (n = 13), the peroneal nerve was divided and sutured end-to-side to the tibial nerve after a 1-week "predegeneration period." In group 3 (n = 3), which was considered the control group, the peroneal nerve was divided and sutured to the adjacent soft tissues. After 3 months, specimens were harvested for histological evaluation. Nerve fiber count, in normal peroneal nerves, averaged 532/cross section. In groups 1 and 2, average nerve fiber count in implanted peroneal nerves was 6.24 and 7.00/cross section, respectively. No significant statistical difference was observed between fresh and "predegenerated" groups (P = 0.90). These data suggest that collateral sprouting of donor nerves is possible after end-to-side neurorrhaphy through an epineurial window, but the number of nerve fibers in recipient nerves is too low to result in any functional recovery in the target organ.     

周围神经端侧吻合对失神经肌肉及运动终板保护作用的实验研究

目的 研究周围神经端侧吻合对失神经肌肉及运动终板的保护作用。方法 Wistar大白鼠26只,随机分实验组和对照组,每组13只。实验组右侧腓总神经切断后,近端反转结扎,远端与胫神经外膜开窗处行端侧吻合;对照组右侧腓总神经切断后,两端均反转结扎,两组动物左侧作正常对照,不作处理。术后3个月,行双侧腓总神经、胫前肌组织学检查,胫前肌肌湿重测定,运动终板检查。结果 实验组与对照组的胫前肌肌湿重、肌纤维横截面积、运动终板的面积和着色具有极显著性差异(P<0.01)。结论 神经端侧吻合对失神经肌肉及运动终板具有保护作用。     

End-to-side anastomosis of transected nerves to prevent neuroma formation

Neuroma can be painful and physically and psychologically disabling. Among the many methods of treatment available, one of the more successful is centrocentral nerve union with an autologous graft. However, it cannot be used in small nerves that lack two fascicles. This study evaluated neuroma prevention in an end-to-side anastomosis, a new technique applicable to all nerves. The lateral branch of the right sciatic nerve in 20 rats was transected at the midthigh level. The proximal segment was looped back to the main nerve and an end-to-side epineural anastomosis was performed. The lateral branch of the left sciatic nerve was transected to serve as a control, and the proximal nerve stump was closed by interrupted epineural sutures. The animals were sacrificed 12 weeks after the operation. Histologic analysis of specimens from the 12 controls showed neuroma formation. Specimens from 12 side-to-end anastomoses contained regenerated nerve tissues and formed smaller masses compared with that of the controls. The regenerated tissues at the anastomoses were orientated more orderly than were tissues from the controls in 75% of cases. The differences were statistically significant. Electron microscopic study on specimens from the remaining eight controls showed the presence of abundant large abnormal myelinated fibers (10-15 microns) with thick irregular myelin sheaths scattered among smaller myelinated fibers (2-10 microns) that had thin myelin sheaths. In the remaining eight end-to-side anastomoses, large abnormal myelinated fibers were absent. The myelinated fibers were 2 to 10 microns in diameters and had a normal appearance with thin myelin sheaths. End-to-side anastomosis formed a smaller mass of regenerated nerve tissues. Ultrastructurally they were formed better and orientated more orderly resembling normal nerve.     

周围神经损伤端侧吻合法进展

本世纪初Ｂａｌａｎｃｅ首先报道了周围神经端侧吻合方法 ,将离断的面神经与副神经作端侧吻合治疗面神经瘫 ,虽因术后出现面部和肩部同时产生运动而放弃了该术式 ,但却肯定了端侧吻合方法的有效性。几十年来 ,周围神经损伤缺损的外科治疗出现了许多新的方式和方法 ,但与临床应用均有相当的距离 ,特别是在神经缺损太多、无法端端吻合的情况下 ,仍以自体、异体神经移植为主。由于自体神经来源有限 ,而异体神经存在排异反应等问题 ,效果不尽如人意 ,而组织工程才刚刚起步 ,所以探索神经缺损的治疗方法和机制仍是目前急待解决的问题。进入 90年…     

End-to-side neurorrhaphy as a salvage procedure for irreparable nerve injuries. Technical note

After a few reports on end-to-side nerve repair at the beginning of the last century, the technique was put aside until its recent reintroduction. The authors present their results in three patients with median nerve defects that were between 15 and 22 cm long and treated using end-to-side median-to-ulnar neurorrhaphy through an epineurial window. The follow-up times were between 32 and 38 months. Sensory evaluation involved superficial touch, pinprick, and two-point discrimination tests. Motor evaluation was completed by assessing the presence of opposition and by palpating the abductor pollicis brevis muscle. Sensory recovery was observed in all patients in the median nerve dermatome, and motor recovery was absent, except in Case 1. End-to-side nerve repair can be a viable alternative to nerve grafting in patients with long gaps between the ends of the injured nerve.     

神经端侧吻合重建足部皮瓣手术后感觉功能

目的 重建小腿部皮瓣移转术后足部皮肤感觉功能。方法 小腿内侧隐神经营养血管筋膜皮瓣移转后,将被切断的隐神经远侧段与腓肠神经端侧吻合。小腿逆行皮神经营养血管皮瓣（腓肠神经伴行血管供血）移转术后,将皮瓣近端携带的腓肠神经与足背皮神经端侧吻合。另可切取次要皮神经与足背皮神经端侧吻合,其远段植入移转至足部的失神经支配皮瓣的感觉功能等方法。结果 临床手术３例病人分别经２０、９和３６个月随诊,效果转好。结论     

Results of termino-lateral neurorrhaphy to original and adjacent nerves

In this comprehensive investigation, we studied three different neurorrhaphy models in an attempt to elucidate the potential of termino-lateral nerve repair to original and adjacent nerves. In experimental group 1, the peroneal nerve was sectioned and then attached to the posterior tibial nerve in a termino-lateral fashion. In experiment group 2, the motor nerves to the gastrocnemius muscle were sectioned and then attached to the posterior tibial nerve in a termino-lateral fashion. In experimental group 3, the obturator nerve (L_2–4) was sectioned and attached to the sciatic nerve (L_4–6) in a termino-lateral fashion. For the control in each group, the same type of nerve used in each respective group was transected without repair. Experimental groups 1 and 2 showed viable axons in the peroneal nerve distal to the neurorrhaphy site. Experimental group 3 showed no viable axons at these sites. No regeneration was observed in the transected nerve without repair in all three control groups. This study suggests that termino-lateral neurorrhaphy is a viable means of repairing damaged nerves if the distal segment of the sectioned nerve is reattached to its original trunk distal to its original branch point. However, the results from experimental group 3 demonstrate that termino-lateral neurorrhaphy cannot be used to repair nerves when the donor and recipient nerves originate from different spinal cord levels. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:276–281, 1998     

End-to-side neurorrhaphies of the ulnar and median nerves at the wrist: report of two cases without sensory or motor improvement

The authors present two unsuccessful clinical cases of end-to-side neurorrhaphy. In the first patient the distal median nerve was coapted in an end-to-side manner to the intact ulnar nerve. In the other patient four cables of sural nerve graft were used to bridge the ulnar nerve and the intact median nerve by two end-to-side coaptations. Neurorrhaphies were performed via epineural sutures through epineural windows. Both of the cases failed to demonstrate any signs of regeneration either clinically or as evidenced by electromyography, Semmes-Weinstein monofilament test, or 256-Hz vibration tests at 18 and 21 months' follow-up respectively.     

End-to-side neurorrhaphy: evaluation of axonal response and upregulation of IGF-I and IGF-II in a non-injury model.

This research group has introduced a model of end-to-side neurorrhaphy, in which reinnervation occurs without frank damage to donor axons. The current study used in situ hybridization to test the hypothesis that insulin-like growth factor (IGF-I and IGF-II) mRNA levels increase at the coaptation site and grafted nerve following end-to-side repair, and that this increase is associated with axonal sprouting and growth. One week after end-to-side coaptation, IGF-I mRNA was localized predominantly on the epineurial side of the graft perineurium, while IGF-II was seen mainly on the endoneurial side. IGF-I hybridization was greatest at this time and declined by 2 weeks post-procedure. No changes in IGF mRNA levels occurred in the distal donor nerve. The increase in IGF-I mRNA at 1 week preceded the appearance of myelinated axons. The presence of myelinated axons within the graft 2 weeks after end-to-side coaptation was associated with a decline in IGF-I mRNA. These data are the first to demonstrate increased IGF mRNA levels associated with axonal sprouting and growth following end-to-side neurorrhaphy. Moreover, the findings support those of earlier studies by others implicating IGFs in axonal regeneration. The increase in IGF mRNA during sprouting and axonal growth into an end-to-side coaptation indicates that the local therapeutic augmentation of endogenous IGF levels at the coaptation site may enhance axonal sprouting from a minimally injured donor nerve, and thereby increase the number of axons that reinnervate the graft.     

End-to-side neurorrhaphy supported by transposed active nerve fibers: its functional end result in a rat model

 End-to-side nerve repair is an old-fashioned technique which has been abandoned since the beginning of this century. Recently, new treatment modalities have been investigated to overcome problems associated with peripheral nerve injury where the proximal stumps are not available. In this study, 30 rats were divided into three groups. In the first group the peroneal nerves were sectioned and their distal ends were sutured to the tibial nerve trunk. In the second group, the proximal part of the peroneal nerve was similarly sutured to the tibial trunk. A primary end-to-end neurorrhaphy performed on the peroneal nerves was the control group. At 2, 4, 8, 12, 20, and 28 weeks, functional assessment of nerve regeneration was performed using walking track analysis. The number of myelinated fibers and fiber diameters were measured, and an electron microscopic evaluation was carried out. With morphometric analysis, the values were significantly different in favor of the control group following the end-to-side repair technique. But, according to gait analysis, both groups had a similar satisfactory functional recovery; the classic end-to-side repair group had an unsatisfactory result. It is concluded that end-to-side neurorrhaphy, supported by transposed active nerve fibers, may result in a good integration network at the repair site and is a possible functional reconstruction model where the proximal stump is not available after peripheral nerve injury. Received: 23 September 1996 / Accepted: 24 March 1997     

周围神经端侧缝合与端端缝合疗效比较的实验研究

目的比较周围神经损伤后端侧缝合与端端缝合方法疗效的优劣。方法ＳＤ大鼠１２只,按手术先后随机分成Ａ,Ｂ两个时间组。左侧腓总神经切断后作端端缝合。右侧腓总神经切断后,远断端与近断端上方０．５ｃｍ束外膜开窗处作自身端侧缝合。分别于术后１、３个月时作肌电图后取材,测肌湿重及作组织学检查。结果Ａ、Ｂ两组,端侧缝合与端端缝合比较,肌电图中诱发电位潜伏期延长、波幅降低。胫前肌肌湿重减轻。肌纤维截面积、有髓神经纤维数均减少。经配对ｔ检验,Ｐ值均＜０．０５。结论周围神经断伤作端侧缝合后,其神经再生质量不及端端缝合优良。     

神经端侧吻合术与侧侧吻合术对神经干损伤后功能恢复作用的比较

目的　比较神经端侧吻合与神经侧侧吻合后功能恢复作用的差异。方法　将Wistar大鼠 18只分成A、B两组 ,每组 9只。端侧吻合组 :左侧腓总神经切断并在胫神经干上外膜开窗后 ,与胫神经主干作端侧吻合 ;侧侧吻合组 :左侧腓总神经切断后与胫神经作侧侧吻合。术后 3个月 ,行形态学检查、电生理检查、肌湿重检查及图像分析 ,评价神经再生及肌肉功能恢复的情况。结果　神经端侧吻合组和神经侧侧吻合组神经纤维的数目分别为 73 2 .8± 5 3 .4、712 .5± 5 8.4,其截面积分别为 (712 .5± 5 8.4) μm2 、(182 .3± 3 9.7) μm2 ,神经的传导速度分别为 (2 5 .6± 8.3 )m /s、(18.5± 9.8)m/s ,胫前肌肉的湿重两组分别为 (2 0 5 .6± 2 0 .7)mg、(2 0 1.8± 2 1.3 )mg ,肌纤维的面积分别为 (13 2 0 .6± 10 3 .9) μm2 、(14 0 3 .7± 13 8.4) μm2 ,再生的运动终板面积分别为 (15 3 7.5±5 2 7.8) μm2 、(1774.2± 45 8.7) μm2 ,吸光度值为 0 .42± 0 .15、0 .5 5± 0 .17,所有测量值差异无显著性 (P <0 .0 5 )。结论　神经端侧吻合术与神经侧侧吻合术的功能恢复差异无显著性     

Restoration of the penile sensory pathway through end-to-side dorsal root neurorrhaphy in rats

Objective: Spinal cord injury often leads to the loss of penile sensation, and severely affects the individual’s sexual function. The present study aimed to restore the penile sensory pathway through end-to-side dorsal root (DR) transfer neurorrhaphy in rats, and preliminarily verified the feasibility of the operation.Design: 40 male adult Sprague–Dawley rats were divided into three groups. In the model (n = 20) and resection (n = 10) groups, the right L6 DR, S1 DR, and the contralateral branch of the dorsal nerve of the penis (DNP) were transected. The distal stump of L6 DR in the model group was then anastomosed to the intact L4 DR. The sham group (n = 10) was not subjected to neural damage. Four months later, retrograde and transganglionic neural labeling, morphological examination, immunofluorescence (IF), and ultrastructural observation were carried out to test the reconstruction of the afferent pathway. Reflective erection (RE) was assessed by detecting the intracavernous pressure elicited by DNP stimulation.Results: The neural labeling tests indicated the integrity of the entire rebuilt penile afferent pathway. The morphological studies, IF, and ultrastructural observation showed that the regeneration of L6 axons in the model group was significantly better than that in the resection group; however, it had not reached the level of the sham group. The sham group rats exhibited typical RE following DNP stimulation, while the model and resection groups produced negative results.Conclusion: Our studies demonstrated the feasibility of end-to-side DR transfer neurorrhaphy for restoring the penile sensory pathway in rats.     

桡神经-正中神经端侧吻合在桡神经长段缺损修复中的应用

交通、工矿事故等严重创伤和神经源性肿瘤切除等造成的桡神经缺损,由于缺乏有效的治疗手段多造成患肢功能障碍.令人可喜的是,相关基础研究表明,神经端侧吻合后正常的神经可发出侧支长入到损伤神经断端,并沿髓鞘生长重新恢复其传导功能,从而促进受损神经的功能恢复.此结果为端侧吻合修复周围神经缺损提供了理论支持.近年来的相关临床应用报道亦逐渐增多.自1999年1月至2007年12月之间,我们采用正中神经-桡神经端侧吻合修复桡神经长段缺损19例,现就疗效进行评价和分析.     

Repair of sensory nerves distal to the wrist

Treatment of patients with severed distal sensory nerves is an exercise in simultaneous gratification and frustration. The gratification comes from realizing that the results of distal sensory nerve repair exceed those obtained after repair of other nerves. The frustration follows from the knowledge that truly normal sensation virtually never follows the most successful repair.     

膈神经端侧吻合移位治疗肌皮神经损伤的实验研究

目的 研究膈神经端侧吻合移位至肌皮神经治疗臂丛神经撕脱伤的可行性.方法 取雄性SD大鼠51只,随机分成4组:A组,单侧全臂丛神经撕脱组;B组,膈神经端端吻合组;C组,膈神经端侧吻合组;D组,膈神经螺旋状端侧吻合组(B、C、D组膈神经均移植2.0 cm腓肠神经至肌皮神经).并于术后进行肢体功能、组织学和神经电生理检测.另取绿色荧光蛋白(green fluorescent protein,GFP)转基因F344大鼠9只,通过荧光显微镜观察膈神经轴突再生情况.方果 各实验组术后手术侧肢体功能逐渐恢复,术后神经电生理和组织学检测表明,术后3个月,C、D组左侧肱二头肌肌张力恢复率和肌湿重恢复率,分别为B组的76.4%和86.3%、85.6%和87.7%,即端侧吻合组肱二头肌功能达到端端吻合组的80%以上,同时保留了膈肌的功能.荧光显微镜观察发现膈神经轴突通过端侧吻合口长入移植神经.方论 膈神经端侧吻合治疗臂丛神经损伤的手术方法是有效、可行的.