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.     

Phrenic nerve neurotization of the musculocutaneous nerve with end-to-side neurorrhaphy: a short report in a rabbit model

This experimental study was performed to evaluate the efficacy of end-to-side coaptation between the musculocutaneous nerve and the phrenic nerve for brachial plexus injuries with nerve-root avulsions. In an experimental rabbit model, neurotization of the musculocutaneous nerve with the phrenic nerve was compared using end-to-end and end-to-side neurorrhaphy. Preliminary results from electrophysiologic and histologic examinations indicate that end-to-side neurotization of the musculocutaneous nerve with the phrenic nerve is an effective means for musculocutaneous nerve repair. The effectiveness of the phrenic nerve is attributed to its large number of motor axons.     

Direct repair (nerve grafting), neurotization, and end-to-side neurorrhaphy in the treatment of brachial plexus injury

OBJECT: The authors present the long-term results of nerve grafting and neurotization procedures in their group of patients with brachial plexus injuries and compare the results of "classic" methods of nerve repair with those of end-to-side neurorrhaphy. METHODS: Between 1994 and 2006, direct repair (nerve grafting), neurotization, and end-to-side neurorrhaphy were performed in 168 patients, 95 of whom were followed up for at least 2 years after surgery. Successful results were achieved in 79% of cases after direct repair and in 56% of cases after end-to-end neurotization. The results of neurotization depended on the type of the donor nerve used. In patients who underwent neurotization of the axillary and the musculocutaneous nerves, the use of intraplexal nerves (motor branches of the brachial plexus) as donors of motor fibers was associated with a significantly higher success rate than the use of extraplexal nerves (81% compared with 49%, respectively, p = 0.003). Because of poor functional results of axillary nerve neurotization using extraplexal nerves (success rate 47.4%), the authors used end-to-side neurorrhaphy in 14 cases of incomplete avulsion. The success rate for end-to-side neurorrhaphy using the axillary nerve as a recipient was 64.3%, similar to that for neurotization using intraplexal nerves (68.4%) and better than that achieved using extraplexal nerves (47.4%, p = 0.19). CONCLUSIONS: End-to-side neurorrhaphy offers an advantage over classic neurotization in not requiring sacrifice of any of the surrounding nerves or the fascicles of the ulnar nerve. Typical synkinesis of muscle contraction innervated by the recipient nerve with contraction of muscles innervated by the donor was observed in patients after end-to-side neurorrhaphy.     

在胸腔内窥镜镜视下切取膈神经的实验研究

目的研究在胸腔内窥镜镜视下切取尸体膈神经的行径,提供足够长度的膈神经作为动力神经。方法新鲜尸体１５具,１５侧作膈神经在胸腔内走行与毗邻关系的解剖研究;１５侧作实验用。胸腔镜从第５、６肋间锁骨中线外侧插入胸腔,于膈肌上２ｃｍ处切断膈神经后,从锁骨上臂丛切口内拉出膈神经。结果膈肌上２ｃｍ处可见膈神经４～５支分支,距膈肌２ｃｍ以上处切断膈神经,可顺利抽出长度为１９～２５ｃｍ的膈神经。在抽出过程中膈神经无１根断裂。结论该术式在尸体实践中操作安全,膈神经长度足以作为修复臂丛神经根性撕脱伤的动力神经。为临床应用提供了一个切取膈神经的新术式。     

膈神经副神经肌电图检查对提高臂丛神经根性损伤诊断符合率的机制和意义

目的阐明膈神经、副神经肌电图检查对提高臂丛神经根性损伤诊断符合率的机制和意义。方法对１００例术中证实为全臂丛或上中干根性损伤的术前肌电图资料（包括膈神经、副神经和臂丛神经）进行分析，总结Ｃ５神经根性损伤中节前、后的发生率，术前诊断符合率及膈神经、副神经的功能。结果１００例臂丛神经根性损伤中，Ｃ５神经根性损伤的诊断符合率为８７％，比过去提高３１．９％；节后损伤的诊断符合率为８１．９％，提高３０．８％。膈神经、副神经完全损伤者Ｃ５神经根均为节前损伤。膈神经完全损伤１３例，不全损伤７例中５例（７１．４％）为节前损伤；副神经完全损伤５例，不全损伤１４例中８例（５７．１％）为节前损伤。结论对膈神经、副神经进行肌电图检测，可提高Ｃ５神经根性损伤的术前诊断符合率；并可判断膈神经、副神经的功能是否适合作神经移位术的动力神经     

End-to-side neurotization with the phrenic nerve in restoring the function of toe extension: an experimental study in a rat model

The phrenic nerve being transferred to the posterior division of the lower trunk with end-to-end neurorrhaphy is reported to be effective in restoring the function of digit extension in literature. However, the phrenic nerve is extremely important in respiration. We designed an animal experiment to discover whether the phrenic nerve being transferred to the posterior division of the lower trunk with end-to-side neurotization was feasible and provided the theoretical basis. A sum of 36 Sprague-Dawley rats was randomly assigned to one of two groups. In Group A, the phrenic nerve was transferred to the posterior division of the lower trunk with end-to-side neurotization. In Group B, the posterior division of the lower trunk was directly sutured. The results of behavioral assessment, electrophysiology, histology and nerve fiber count and muscle weight at 12 weeks postoperatively were recorded. In Group A, none of the rats experienced tachypnea. The motion of slight toe extension was observed. The results of electrophysiology, histology and nerve fiber count and muscle weight in Group A were not as well as those of Group B, but gradually improved with time. The phrenic nerve being transferred to the posterior division of lower trunk with end-to-side neurotization can partially restore the function of toe extension in a rat model. Whether the function of digit extension can be restored by the phrenic nerve with end-to-side neurotization in humans still needs more practice in clinic.     

Restoration of Elbow Flexion by Transfer of the Phrenic Nerve to Musculocutaneous Nerve after Brachial Plexus Injuries

Traumatic brachial plexus injuries are a devastating injury that results in partial or total denervation of the muscles of the upper extremity. Treatment options that include neurolysis, nerve grafting, or neurotization (nerve transfer) has become an important procedure in the restoration of function in patients with irreparable preganglionic lesions. Restoration of elbow flexion is the primary goal in treating patients with severe brachial plexus injuries. Nerve transfers are used when spinal roots are avulsed, and proximal stumps are not available. In the present study, we analyze the results obtained in 20 patients treated with phrenic–musculocutaneous nerve transfer to restore elbow flexion after brachial plexus injuries. A consecutive series of 25 adult patients (21 men and 4 women) with a brachial plexus traction/crush lesion were treated with phrenic–musculocutaneous nerve transfer, but only 20 patients (18 men and 2 women) were followed and evaluated for at least 2 years postoperatively. All patients had been referred from other institutions. At the initial evaluation, eight patients received a diagnosis of C5-6 brachial plexus nerve injury, and in the other 12 patients, a complete brachial plexus injury was identified. Reconstruction was undertaken if no clinical or electrical evidence of biceps muscle function was seen by 3 months post injury. Functional elbow flexion was obtained in the majority of cases by phrenic–musculocutaneous nerve transfer (14/20, 70%). At the final follow-up evaluation, elbow flexion strength was a Medical Research Council Grade 5 in two patients, Grade 4 in four patients, Grade 3 in eight patients, and Grade 2 or less in six patients. Transfer involving the phrenic nerve to restore elbow flexion seems to be an appropriate approach for the treatment of brachial plexus root avulsion. Traumatic brachial plexus injury is a devastating injury that result in partial or total denervation of the muscles of the upper extremity. Treatment options include neurolysis, nerve grafting, or neurotization (nerve transfer). Neurotization is the transfer of a functional but less important nerve to a denervated more important nerve. It has become an important procedure in the restoration of function in patients with irreparable preganglionic lesions. Restoration of elbow flexion is the primary goal in treating patients with severe brachial plexus injuries. Nerve transfers are used when spinal roots are avulsed, and proximal stumps are not available. Newer extraplexal sources include the ipsilateral phrenic nerve as reported by Gu et al. (Chin Med J 103:267–270, 1990) and contralateral C7 as reported by Gu et al. (J Hand Surg [Br] 17(B):518–521, 1992) and Songcharoen et al. (J Hand Surg [Am] 26(A):1058–1064, 2001). These nerve transfers have been introduced to expand on the limited donors. The phrenic nerve and its anatomic position directly within the surgical field makes it a tempting source for nerve transfer. Although not always, in cases of complete brachial plexus avulsion, the phrenic nerve is functioning as a result of its C3 and C4 major contributions. In the present study, we analyze the results obtained in 20 patients treated with phrenic–musculocutaneous nerve transfer to restore elbow flexion after brachial plexus injuries.     

Concepts of nerve regeneration and repair applied to brachial plexus reconstruction

Brachial plexus injury is a serious condition that usually affects young adults. Progress in brachial plexus repair is intimately related to peripheral nerve surgery, and depends on clinical and experimental studies. We review the rat brachial plexus as an experimental model, together with its behavioral evaluation. Techniques to repair nerves, such as neurolysis, nerve coaptation, nerve grafting, nerve transfer, fascicular transfer, direct muscle neurotization, and end-to-side neurorraphy, are discussed in light of the authors' experimental studies. Intradural repair of the brachial plexus by graft implants into the spinal cord and motor rootlet transfer offer new possibilities in brachial plexus reconstruction. The clinical experience of intradural repair is presented. Surgical planning in root rupture or avulsion is proposed. In total avulsion, the authors are in favor of the reconstruction of thoraco-brachial and abdomino-antebrachial grasping, and on the transfer of the brachialis muscle to the wrist extensors if it is reinnervated. Surgical treatment of painful conditions and new drugs are also discussed.     

Clinical results of contralateral C7 root neurotization to the median nerve in brachial plexus injuries with total root avulsions

This prospective study was carried out to assess motor and sensory recovery after contralateral C7 root to median nerve neurotization in brachial plexus injuries with total root avulsions. The survey was carried out from 1993 to 1995 and the patients were followed up for at least 3 years. There were 96 male patients with ages ranging from 13 to 48 years. All had a unilateral brachial plexus injury with avulsion of all roots. This was confirmed by clinical assessment and exploration. The anterior part of the contralateral C7 root was used for neurotization via a reversed pedicular ulnar nerve graft and the proximal end of the graft was connected to the median nerve. Furthermore, phrenic nerve to suprascapular nerve and spinal accessory nerve (via a sural nerve graft) to musculocutaneous nerve neurotizations were also carried out to obtain shoulder abduction and elbow flexion. At the 3 year follow-up, most patients had encouraging recovery of sensory function in the hand but motor function of the forearm and hand muscles was rather poor. Acceptable motor function was found in only 50 to 60% of the patients who were younger than 18 years.     

Technique of intercostal nerve harvest and transfer for various neurotization procedures in brachial plexus injuries

Brachial plexus palsy caused by traction injury, especially spinal nerve-root avulsion, represents a severe handicap for the patient. Despite recent progress in diagnosis and microsurgical repair, the prognosis in such cases remains unfavorable. Neurotization is the only possibility for repair in cases of spinal nerve-root avulsion. Intercostal neurotization is a well-established technique in the treatment of some severe brachial plexus lesions in adults. In this article, we describe our experience and technique of intercostal nerve harvest for transfer in various neurotization strategies in posttraumatic brachial plexus reconstruction. Intercostal nerve harvest is a technique requiring meticulous technique and careful dissection along with proper hemostasis. It is also very important to preserve the serratus anterior muscle insertion and keep soft tissue stripping to a minimal. We do not osteotomize the ribs and believe that this adds to the morbidity and length of the procedure. Neurotization using intercostal nerves is a very viable procedure in avulsion injuries of the brachial plexus; however, there is some concern that in the presence of ipsilateral phrenic nerve palsy, it may lead to a significant compromise of respiratory function. In our experience, this is negligible with good long-term results.     

An experimental study of the treatment of root avulsion of brachial plexus using contralateral C7 nerve neurotization (nerve transfer)]

This study compared the functional results of contralateral C7 root neurotization with homolateral phrenic nerve transfer for repairing root avulsion of brachial plexus in rats. It was found that in the C7 nerve root group all the parameters of evoked muscle potential amplitude (EMPA), regenerating axon count, biceps weight and muscle fibre area, and muscular maximal tetanus tension were statistically superior (P < 0.05-0.01) to those in the phrenic nerve group; while there were no significant differences between these two groups in motor nerve latency regenerating axon area and persisting time of muscular maximal tetanus tension (P > 0.05). The reasons why C7 root neurotization is superior to phrenic nerve transfer were also discussed.     

膈神经移位治疗臂丛损伤的临床应用和早期疗效

目的探讨膈神经移位至肌皮神经重建屈肘功能的临床应用及早期疗效。方法对8例臂丛根性撕脱伤行膈神经移位术，膈神经与上干前股的肌皮神经束直接吻合5例，膈神经通过神经移植桥接至肌皮神经3例，术后随访评定其屈肘功能。结果8例经10月-2年随访，肱二头肌肌力在2级以上5例，有效率62．5％。结论膈神经移位术是治疗臂丛根性撕脱伤的理想术式，重视术前和术中膈神经功能的评估、神经移位时吻合方法的合理选择和术后综合康复锻炼是提高手术疗效关键。     

端侧缝合与神经移位修复臂丛损伤的比较研究

目的 为临床提供端侧缝合与神经移位修复臂丛损伤疗效优劣的实验依据。方法 Wistar大鼠36只,按术后取材时间分为1、2、3个月组,每组12只。按手术方法分为2组。(1)端侧缝合组(前肢右侧):于臂丛内侧束远端外侧外膜上开窗,将桡神经远断端和内侧束开窗处作外膜端侧缝合。(2)神经移位组(前肢左侧):在正中神经远端切断神经,将其近端和桡神经远断端作端端缝合。术后两组各时间组行电生理、肌湿重、肌纤维截面积、运动终板面积及抗神经丝(neurofilament,NF)免疫组化和神经超微结构观察。结果 端侧缝合组的运动神经传导速度,诱发电位潜伏期,NF阳性表达强度均劣于神经移位组(P<0.01);肌湿重、肌纤维截面积及运动终板面积两组差异无显著意义(P>0.01)。结论 端侧缝合组术后远端神经虽可再生但疗效明显差于神经移位组,故临床上是否可用其来修复臂丛神经损伤尚需进一步研究。     

臂丛撕脱伤患者同侧膈神经诱发电位的研究

目的研究臂丛撕脱伤患者同侧膈神经的功能状态，为临床选用膈神经移位治疗臂丛撕脱伤提供依据。方法测定１００例臂丛神经撕脱伤膈肌诱发电位的潜伏期、波幅，并对其功能进行评价。将表面电极置在胸锁乳突肌后缘，在平环状软骨水平进行电刺激，于腋前线水平在第７、８肋间记录肌肉诱发电位。同时在膈神经移位术中取一段膈神经，观察其病理变化。结果诱发电位的资料证实，有１８例膈神经存在不同程度的损伤，其中１１例为完全损伤，７例为不全损伤。病理学观察发现膈神经部分损伤时，光镜下见神经纤维部分髓鞘崩解，髓鞘之间散在性地分布着瘢痕化组织。膈神经完全损伤时，可见神经髓鞘崩解，髓鞘之间布满瘢痕化组织。结论１００例臂丛撕脱伤中１８％的膈神经有损伤，其中７％为不全损伤。应重视这部分病例中膈神经的部分损伤，以便改进手术方法，提高移位术的疗效     

Effect of ipsilateral C7 nerve root transfer on restoration of rat upper trunk muscle and nerve function after brachial plexus root avulsion

The effects of ipsilateral cervical nerve root transfer on the restoration of the rat upper trunk muscle and nerve brachial plexus root avulsion were studied. After simulated root avulsion of the upper trunk brachial plexus, 120 rats were randomly divided into 4 groups: (A) ipsilateral C7 root transfer group; (B) Oberlin group; (C) phrenic nerve group; and (D) no axillary nerve restoration group. At 3, 6, and 12 weeks postoperatively, Ochiai score, Barth feet overreaching test, Terzis grooming test, and indices of neurotization were determined in 10 rats from each group. Twelve weeks postoperatively, nearly all the behavioral, neuroelectrophysiological, and histological outcomes of the axillary nerve and deltoid muscle and some of the indices of musculocutaneous nerve and biceps brachii function in the ipsilateral C7 group were superior to those in the other 3 groups. No significant difference was found between the ipsilateral C7 group and the other 3 groups in recovery rate of wet biceps muscle weight. No significant difference was found between the ipsilateral C7 group and the Oberlin group in the recovery of the axillary nerve compound muscle action potential and biceps brachii cell size. No significant difference was found between the ipsilateral C7 group and the phrenic nerve and no axillary nerve restoration groups in amplitude recovery rate of musculocutaneous nerve compound muscle action potential. No significant difference was found between the ipsilateral C7 and the Oberlin groups in the early recovery of musculocutaneous nerve compound muscle action potential, but recovery was significantly better in the ipsilateral C7 group at 12 weeks. Ipsilateral C7 root transfer can improve the quality of restoration of muscle and nerve function in the rat upper trunk after brachial plexus root avulsion.     

臂丛神经根性撕脱伤患者三叉神经支配区感觉改变与交感神经功能状态关系的探讨

目的：研究臂丛神经根性撕脱伤患者面部三叉神经支配区感觉变化与交感神经功能状态的关系。方法：对38例臂丛神经根性撕脱伤患者面部三叉神经支配区感觉和交感神经功能状况进行临床检查与分析。同时对臂丛神经，膈神经和融神经损伤情况进行电生理学检查，结果：38例臂丛神经根性撕脱伤患者中，19例伴有交感神经损伤，13例面部感觉减退，交感神经功能减退的19例患者中，12例伴有面部感觉减退（63.2%)；面部感觉减退的13例患者中，12例伴有交感神经功能减退（92.3%)，臂丛神经根性撕脱伤患者受伤短期内，可有患侧头面部交感神经功能和面部感觉减退，一段时期以后，患侧面部三叉神经支配区感觉可随交感神经症状的消失而逐渐恢复，结论：臂丛神经根性撕脱伤患者常伴有颈部交感神经损伤，可能患侧面部三叉神经支配区感觉减退与颈部交感神经损伤有关。     

End-to-side neurorrhaphy of motor nerves: reinnervation of free muscle transplants—first clinical application

End-to-side neurorrhaphy may offer a practical solution in limited cases of nerve reconstruction when no donor nerve or nerve transfer is available for direct end-to-end nerve suture, or when extremely long distances for nerve regeneration cause irreversible atrophy of the targets. We report our experience with the successful clinical use of a completely new technique of end-to-side neurorrhaphy for motor reinnervation of free functional muscle transplants. Since 1995 we have used end-to-side nerve repair for motor or sensory reinnervation in 13 cases. A free functional muscle graft was reinnervated by an end-to-side neurorrhaphy in four patients after tumor resection (two myocutaneous latissimus dorsi flaps), Volkmann's contracture (one myocutaneous latissimus dorsi flap), and in a long-standing brachial plexus lesion (one gracilis muscle flap). All four patients showed reinnervation of their muscle graft through the end-to-side nerve suture site. Two functional muscle grafts to the upper extremity had positive outcome of M3-M4 for elbow and finger extension in one case, and M4 for finger flexion in one case more than 2 years after transplantation. The transplant in the brachial plexus lesion is too early for a final functional result. One patient had a M3 for knee extension 8 months postoperatively. In the clinical cases there was no downgrading of the muscle functions supplied by the "donor" nerve. Good and clinically relevant reinnervation of a functional muscle graft is possible through an end-to-side nerve suture. Proximal avulsion, missing proximal nerve stumps, partial recovery, shortening of long distances for nerve regeneration, and prevention of long nerve grafts in proximal lesions are good indications for reinnervation of a functional muscle transplant by end-to-side neurorrhaphy without harm to the donor nerve. Donor nerves supplying synergists should be preferred.     

Neurophysiologic and clinical outcome following medial pectoral to long thoracic nerve transfer for scapular winging: a case report

The use of nerve transfers (neurotization) in the reconstruction of nerve palsy is not new, but its clinical efficacy is still largely based on reports of successful restoration of elbow flexion and shoulder abduction following brachial plexus avulsion. Although its potential application extends beyond the brachial plexus, little has been written about additional indications or associated postoperative outcomes. The case described in this report illustrates yet another indication for which neurotization may be a useful technique. Medial pectoral nerve transfer to the long thoracic nerve was performed via an 11-cm sural nerve graft to treat scapular winging 4 months following nerve injury caused during axillary node dissection. Neurophysiologic and clinical outcome 18 months postoperatively revealed successful reinnervation of the serratus anterior muscle, decreased scapular winging, and symptomatic improvement from the patient's perspective.     

Brachial plexus neurotization with donor phrenic nerves and its effect on pulmonary function

OBJECT: To examine possible side effects of neurotizations in which the phrenic nerve was used, pulmonary function was analyzed pre- and postoperatively in patients with brachial plexus injury and root avulsions. METHODS: Twenty-three patients with complete brachial plexus palsy underwent neurotization of the musculocutaneous nerve, with the phrenic nerve as donor material. Patients who suffered lung contusions as part of the primary injury were excluded from this study. In 12 patients (five left-sided and seven right-sided neurotizations) pre- and postoperative functional parameters were compared and additional body plethysmography was performed more than 12 months postsurgery. Of the 23, no patient experienced pulmonary problems postoperatively. Nonetheless, pulmonary functional parameters showed a vital capacity in percent of the predicted value of 9.8 +/- 6.3% (mean +/- standard deviation [SD]) in all patients examined, which was a significant reduction (p = 0.0002). In right-sided phrenic nerve transfers this reduction was significant, at 14.3 +/- 3.3% (mean +/- SD), whereas left-sided transfers showed a nonsignificant reduction of 3.6 +/- 3.5% (mean +/- SD). The observed decrease in vital capacity (VC) correlates with the maximal inspiratory pressure (Pi(max)) as an indication of clinical significance. CONCLUSIONS: When the right phrenic nerve is used as a donor in neurotization of the musculocutaneous nerve, the patient incurs a higher risk of reduced pulmonary VC. If possible, the left phrenic nerve should be preferred. The Pi(max) has to be determined preoperatively to avoid any further decrease in the already reduced pulmonary function due to the initial injury.     

膈神经移位修复下干后股重建臂丛撕脱伤伸肘及伸指功能的中期随访

 目的 观察膈神经移位修复下干后股重建臂丛神经撕脱伤伸肘、伸指、伸拇功能的效果。方法 2005年6月至2008年12月采用膈神经移位修复下干后股重建43例臂丛神经撕脱伤患者的伸肘及伸指功能,男36例,女7例;年龄4~44岁,平均(23.5±9.9)岁。受伤至手术时间1~12个月,平均(3.7±1.9)个月。其中全臂丛神经撕脱伤32例,中下干撕脱伴上干部分损伤或正常5例,C6~T1神经根撕脱伴C5椎孔外断裂或部分损伤6例。取锁骨上、下臂丛神经探查联合切口,显露下干后股,向近端干支分离后切断。将后侧束、桡神经向远端游离,切断后侧束的其他分支。将下干后股、后侧束及桡神经上提,膈神经在胸廓上口内切断,将膈神经与下干后股吻合。膈神经与下干后股直接吻合33例,通过腓肠神经桥接10例。结果 全部病例获得随访,随访时间36~73个月,平均(39.7±7.1)个月。伸肘、伸指、伸拇肌力达到3或以上的比例分别为81.6%、41.9%、39.5%。结论 膈神经移位修复下干后股,其伸肘功能恢复满意,伸指、伸拇功能的恢复仍需进一步改善。