桡神经肱三头肌长头支修复腋神经瘫的临床应用

背景腋神经损伤临床较为常见,治疗方法不尽一致,效果也各不相同,多要牺牲相邻一条神经功能来进行神经修复.目的介绍用肱三头肌长头支转位修复腋神经的解剖学特点和临床应用效果.设计以神经干走行方向纵向观察研究.地点和对象资料收集于广州医学院附属市一人民医院,采用灌注成人尸体标本16具及本院收治的6例患者.方法采用灌注成人尸体标本16具,常规解剖显露腋神经和肱三头肌长头支,主要观察腋神经和桡神经肱三头肌支的分支数量、毗邻关系以及测量各神经支的口径.根据解剖学特点,前瞻性地应用于临床6例,术后进行随访,定期检查腋神经肌力.主要观察指标解剖观察结果和临床应用效果.结果肱三头肌长头支与腋神经相隔于长头本身,转位方便,其横径与腋神经前、后支横径相近,便于吻合.临床应用6例,术后经随访6～16个月,4级以上肌力5例,3级肌力1例,伸肘无影响.结论桡神经肱三头肌长头支转位修复腋神经,术式简便,容易操作,适用于臂丛部分损伤、肱三头肌正常的腋神经瘫的修复.     

桡神经肱三头肌长头支修复腋神经瘫的临床应用

背景：腋神经损伤临床较为常见，治疗方法不尽一致，效果也各不相同。多要牺牲相邻一条神经功能来进行神经修复。目的：介绍用肱三头肌长头支转位修复腋神经的解剖学特点和临床应用效果。设计：以神经干走行方向纵向观察研究。地点和对象：资料收集于广州医学院附属市一人民医院，采用灌注成人尸体标本16具及本院收治的6例患者。方法：采用灌注成人尸体标本16具，常规解剖显露腋神经和肱三头肌长头支，主要观察腋神经和桡神经肱三头肌支的分支数量、毗邻关系以及测量各神经支的口径。根据解剖学特点，前瞻性地应用于临床6例，术后进行随访，定期检查腋神经肌力。主要观察指标：解剖观察结果和临床应用效果。结果：肱三头肌长头支与腋神经相隔于长头本身，转位方便，其横径与腋神经前、后支横径相近，便于吻合。临床应用6例，术后经随访6～16个月，4级以上肌力5例，3级肌力1例，伸肘无影响。结论：桡神经肱三头肌长头支转位修复腋神经，术式简便，容易操作，适用于臂丛部分损伤、肱三头肌正常的腋神经瘫的修复。     

腋窝入路桡神经肱三头肌支转位移植修复腋神经的应用解剖

背景:上臂后上切口入路肱三头肌肌支转位移植修复腋神经牵拉三角肌时易损伤腋神经后支及锁骨上臂丛,探查和联合其他神经转位时需变更体位.目的:分析腋窝入路桡神经肱三头肌支转位移植修复腋神经的可行性.方法:取常规甲醛固定成人上肢标本10具20侧,于标本平卧,上肢外展外旋位,腋窝入路,对腋窝处神经血管进行显微解剖.测量腋神经起始处至分支处距离及其分支起始处的横径,肱三头肌各肌支起始处横径,各肌支由入肌点向近端进行无损伤分离长度.结果与结论:腋神经肩胛下肌下缘分成前后两支,前支横径平均为2.5(1.6~3.4) mm.桡神经肱三头肌长头支,起点处横径为2.2(1.4-2.8) mm.桡神经与腋神经距离平均为18.2(10.2~30.0) mm.腋神经前支与桡神经肱三头肌支横径相似,距离短.表明腋窝入路可暴露和辨别腋神经前后分支,桡神经肱三头肌支在背阔肌腱表面水平靠近腋神经,可选择任一肌支转位移植修复腋神经.     

带血管的胸背神经转位治疗颈椎手术并发神经根严重损伤

目的 探讨颈椎手术并发神经根严重损伤患者的功能重建方法.方法 10例颈椎手术并发C5、C6神经根损伤患者,功能障碍明显,对于C5神经根损伤患者采取带血管的胸背神经吻合腋神经三角肌支治疗三角肌麻痹所致的肩外展功能障碍,C6神经根损伤患者采用带血管的胸背神经吻合肌皮神经肱二头肌肌支治疗肱二头肌麻痹所致的屈肘功能障碍.结果 10例患者9例受累肌肉肌力恢复至3级以上,其中6例肌力恢复至4级以上,肩肘功能得以明显改善,所有患者背阔肌功能无明显影响.结论 带血管的胸背神经转位可有效重建C5、C6神经根损伤所致功能障碍,是治疗颈椎手术所致节段性神经根麻痹的有效方法.     

肩袖损伤合并腋神经损伤的解剖学特征

目的:探讨肩袖损伤合并腋神经损伤的原因及其临床意义。方法:实验于2005-10/2006-01在南方医科大学解剖学研究所完成。选取南方医科大学解剖学研究所防腐固定的成人尸体16具,男11具,女5具,共32侧。常规解剖显露三角肌、肩袖、四边孔和腋神经,观测腋神经及其分支的体表投影、直径、起始、走行、分布和肩袖的解剖关系。结果:腋神经出四边孔处的体表投影点位于肩峰平面下方3.8～7.2cm,平均(5.0±1.5)cm、三角肌后缘前方2.7～5.6cm,平均(4.0±1.4)cm处。小圆肌支入肌前长约0.8～2.6cm,平均(1.6±0.8)cm,支配小圆肌;后支入肌前长约1.0～4.2cm,平均(2.5±1.5)cm,后支横径为1.3～2.1cm,平均(1.7±0.3)cm,支配三角肌后部和肱三头肌长头附近的皮肤。前支入肌前长约2.0～4.2cm,平均(3.1±0.8)cm,横径为1.7～2.9cm,平均(2.1±0.7)mm,支配三角肌前份和三角肌区下部的皮肤。结论:腋神经内在的解剖因素是肩袖损伤合并腋神经损伤的基础,肩部外伤是肩袖合并腋神经损伤的直接原因,临床应注意避免漏诊。     

“功能康复链”在全臂丛根性撕脱伤手术过程中的实施探讨

目的:介绍一种治疗全臂丛神经根性撕脱伤的新术式及其全程康复治疗。方法:收集全臂丛神经根性撕脱伤患者13例,分行一期膈神经移位修复肩胛上神经和对侧股薄肌移植手术,以恢复肩外展功能和重建屈肘与伸拇、伸指功能;部分患者二期行同侧股薄肌移植重建患肢屈拇、屈指功能。注意在术前、术中和术后进行综合性康复治疗。结果:随访时间超过1年的8例患者,在术后3～5个月,出现移植肌肉神经再生电位;12月屈肘60°～90°、肌力M4,伸拇、伸指肌力M3～M4,3例行肩胛上神经修复者,肩外展30°～45°。2例二期手术后六七个月,移植肌肉有随意收缩;12个月屈拇、屈指肌力M3～M4,但手部感觉尚未恢复。结论:早期股薄肌皮瓣移植联合神经移位修复全臂丛神经根性撕脱伤,已显示初步的疗效。应注重患者的术前、术中、术后的全程康复治疗。     

桡神经深支损伤的修复和功能重建

目的：探索桡神经深支损伤后的的修复与效果。方法：对1990年－2000年收治的21例因各种原因所致的桡神经深支损伤患者的治疗方法与效果进行总结，完全断裂9例，不全断裂6例，挫伤4例，不可逆损伤2例，均于伤后2小时－8个月内作神经探查，行神经吻合12例（1例桡神经深支和伸肌群缺损，经尺桡骨缩短后吻合），神经松解4例，神经移植修复3例，肌腱移位2例。结果：21例均获18－24个月随访。胺Highet运动分级法评定，优：M4以上，良：M3，可：M3，差：M1或M1。其中优14例，良5例，可2例，优良率90．5％，结论：不熟悉桡神经深支局部解剖导致损伤并误诊误治；对桡神经深支损伤者确诊后应尽快手术探查，行神经吻合，松解，可获得满意效果；对不可逆损伤在6个月以上，应行肌腱移位重建伸拇伸指功能。     

桡神经浅支移植修复桡神经缺损及供区功能重建的临床观察

目的 观察桡神经浅支移植修复桡神经缺损,同时应用端侧吻合的方式重建供区功能的疗效.方法 采用桡神经浅支移植修复桡神经缺损同时应用端侧吻合的方式重建供区功能34例,观察供区及受区的恢复情况.结果 经过12～24个月随访,受体桡神经功能恢复,优23例,良5例,可6例,优良率82.53%;供体神经感觉恢复,优27例,良5例,可2例,优良率94.12%.结论 该方法是治疗神经缺损的较好选择.     

肌腱移位及术后康复治疗桡神经不可逆性损伤

桡神经损伤首先治疗方法是神经修复,但对损伤严重,失去了修复性或早期修复不满意者,可通过肌腱移位及术后积极康复训练最大限度恢复其伸腕伸拇指功能.采用 Riordan法肌腱移位及术后康复训练治疗本病 20例,效果满意.     

“功能康复链”在全臂丛根性撕脱伤手术过程中的实施探讨

目的：介绍一种治疗全臂丛神经根性撕脱伤的新术式及其全程康复治疗。方法：收集全臂丛神经根性撕脱伤患者13例，分行一期膈神经移位修复肩胛上神经和对侧股薄肌移植手术，以恢复肩外展功能和重建屈肘与伸拇、伸指功能；部分患者二期行同侧股薄肌移植重建患肢屈拇、屈指功能。注意在术前、术中和术后进行综合性康复治疗。结果：随访时间超过1年的8例患者，在术后3-5个月，出现移植肌肉神经再生电位；12月屈肘60&;#176;-90&;#176;、肌力M4，伸拇、伸指肌力M3-M4，3例行肩胛上神经修复者，肩外展30&;#176;-45&;#176;。2例二期手术后六七个月，移植肌肉有随意收缩；12个月屈拇、屈指肌力M3-M4，但手部感觉尚未恢复。结论：早期股薄肌皮瓣移植联合神经移位修复全臂丛神经根性撕脱伤，已显示初步的疗效。应注重患者的术前、术中、术后的全程康复治疗。     

Restoration of elbow extension via functional electrical stimulation in individuals with tetraplegia

Functional electrical stimulation of the triceps is a method of restoring elbow extension to individuals with paralyzed triceps. Eleven arms of individuals with cervical-level spinal cord injuries (SCIs) received a triceps electrode as an addition to a hand-grasp neuroprosthesis. Stimulation was controlled either as part of a preprogrammed pattern or via a switch or an accelerometer that was connected to the neuroprosthesis external controller. The outcome measures were (1) elbow extension moments at different elbow positions, (2) performance in controllable workspace experiments, and (3) comparison to an alternative method of providing elbow extension in these individuals--a posterior deltoid (PD) to triceps tendon transfer. Stimulated elbow extension moments in 11 arms ranged from 0.8 to 13.3 N.m. The stimulated elbow extension moments varied with elbow angle in a manner consistent with the length-tension properties of the triceps. Triceps stimulation provided a significantly stronger elbow extension moment than the PD to triceps tendon transfer. The elbow extension moment generated by the tendon transfer and triceps electrode being activated together was always greater than either method used separately. Stimulation of the long head of the triceps should be avoided in persons with weak shoulder abduction, since the long head adducts the shoulder and limits shoulder function in these cases. Statistically, elbow extension neuroprostheses significantly increased the ability to successfully reach and move an object and significantly decreased the time required to acquire an object while reaching.     

模拟肩峰下前外侧扩展入路肱骨近端骨折复位内固定的解剖学特点

背景：临床用于肱骨近端骨折的常用入路主要有两种：前内侧入路、肩峰下前外侧入路,然而现有的手术入路存在一定局限性。目的：分析臂部前外侧腋神经与肱骨上段及三角肌前、中亚部的解剖关系,为复位内固定治疗肱骨近端骨折寻找新入路提供解剖学依据。方法：解剖12具成人（男7例,女5例）防腐上肢标本20侧,了解腋神经前支在三角肌前、外亚部中的走行,比较经过两亚部时跨越肌缝的神经分支形态。完成初步数据收集后,进行尸体上模拟复位内固定实验。结果与结论：腋神经前支横向行走于三角肌肌腹深面中上1/3水平,距离肩峰外下缘（6.0±1.3）cm,前亚部仅有1支一级神经支支配,两亚部间为一连续的乏血管横越的肌缝,肌缝位于肩峰前角向下的延长线处,肉眼观为一白色结缔组织条带,腋神经通过肌缝时无分支,游离后跨缝段长度均大于1cm,放置钢板后腋神经张力不高。通过肩峰下三角肌前、中亚部肌缝入路,显露腋神经支配前亚部的一级神经支并进行分离保护后,可以向下延伸切口,能够安全地暴露上段肱骨,在直视下进行骨折复位和金属植入物内固定等操作。     

Compression neuropathy of the radial nerve due to pentazocine-induced fibrous myopathy

Fibrous myopathy is a common, well-known side effect of repeated pentazocine injection. However, compression neuropathy due to fibrotic muscle affected by pentazocine-induced myopathy has not previously been reported. In a 37-year-old woman with documented pentazocine-induced fibrous myopathy of triceps and deltoid muscles bilaterally and a three-week history of right wrist drop, electrodiagnostic examination showed a severe but partial lesion of the right radial nerve distal to the branches to the triceps, in addition to the fibrous myopathy. Surgery revealed the right radial nerve to be severely compressed by the densely fibrotic lateral head of the triceps. Decompression and neurolysis were performed with good subsequent recovery of function.     

Iatrogenic axillary neuropathy after intramuscular injection of the deltoid muscle

A previously healthy 26-yr-old male presented for an electrodiagnostic evaluation with complaints of significant right deltoid muscle atrophy and shoulder abduction weakness after receiving an intramuscular (IM) deltoid injection of an antiemetic 4 wk earlier. Electrodiagnostic evaluation confirmed an acute axillary neuropathy. We hypothesize that direct mechanical trauma to the anterior branch of the axillary nerve resulted in axillary mononeuropathy with axonal loss, although chemically induced nerve injury cannot be excluded. Injections in and about the shoulder complex are performed routinely for the purposes of vaccination, IM medication administration, deltoid trigger-point injections, and intra-articular and bursal steroid injections. Although such injections are considered routine office procedures, there is increased risk of neurovascular injury if they are performed incorrectly. The purpose of this brief report is to make practitioners aware of the potential for axillary neuropathy with such procedures, to review the salient anatomy, and to propose a potential guideline for clinical practice to minimize iatrogenic axillary neuropathy.     

Quantitative in vivo studies of median nerve sliding in response to wrist, elbow, shoulder and neck movements

Objective. To examine median nerve sliding in response to upper limb movements in vivo. To determine whether the median nerve can be unloaded.

Design. Exploratory study in healthy subjects.

Background. Impaired sliding may lead to neuropathic symptoms. In vivo results for neural dynamics in normal subjects are essential to understand changes in upper limb disorders.

Methods. Ultrasound imaging of the median nerve during 40° wrist extension, 80° shoulder abduction, 90° elbow extension, and 35° contralateral neck side flexion. Frame by frame cross-correlation of image sequences to measure nerve sliding and strain.

Results. Nerve excursion in the forearm and upper arm ranged from 0.3 mm for neck side flexion to 10.4 mm for elbow extension. Additional strain in the forearm for wrist extension was 1.1% (SEM, 0.2%), for shoulder abduction 1.0% (SEM, 0.2%), and for neck side flexion 0.1% (SEM, 0.1%). With the limb flexed, sliding was delayed and sometimes the nerve or the nerve fascicles had a wavy appearance.

Conclusion. The median nerve is unloaded when the shoulder is adducted or elbow flexed. When the arm is extended (90° shoulder abduction, 60° wrist extension, and elbow straight) the total additional strain in the forearm will be 2.5–3.0%. Even in this position the strain is likely to be below levels that impair blood flow or conduction. Therefore, the median nerve appears well designed to cope with changes in bed length caused by limb movements.Relevance

These results will provide baseline data that can be used to examine entrapment neuropathies.     

Acquired isolated axillary neuropathy: an unusual complication of quadriplegia

This report describes a rare case of acquired axillary neuropathy in a 17-year-old C-5 quadriplegic man who developed right axillary neuropathy after sleeping for six hours in a far-right lateral decubitus position. Two days after the onset of shoulder weakness, his shoulder abduction strength was found to have decreased 1 1/2 grades from measurements made 2 weeks before. Electrodiagnostic studies demonstrated no voluntary activity of the deltoid and no deltoid evoked response on stimulation at Erb's point, while shoulder nerve conduction latencies to other C-5 and posterior cord innervated muscles were within normal limits, suggesting a diagnosis of axillary nerve compression in the region of the quadrilateral space. Six and one-half months later, after strengthening exercises and shoulder joint support to prevent subluxation, the patient recovered deltoid strength and upper extremity function beyond that seen at the onset of the axillary neuropathy. This case emphasizes the importance of proper body positioning of spinal cord injured (SCI) patients to prevent peripheral nerve compression and further disability.     

Dynamic inferior stabilizers of the shoulder joint

BACKGROUND: The glenohumeral joint is soft-tissue balanced. However, few studies have focused on its dynamic inferior stabilizers. OBJECTIVE: The objective of this study was to investigate the dynamic contributions of five shoulder muscles to inferior stability of the glenohumeral articulation in four joint positions. METHODS: The anterior, lateral and posterior deltoid, supraspinatus, short head of biceps, coracobrachialis and long head of triceps from ten cadaveric shoulders were tested in 0 degrees, 30 degrees, 60 degrees and 90 degrees of glenohumeral abduction. A constant inferior force of 15 N was applied to the humerus. The tendons were loaded sequentially in proportion to their respective muscle's cross-sectional area. Translations of the humeral head on the glenoid were recorded with a 3-Space tracking device. RESULTS: The lateral deltoid (8.2 mm, SD 4.8 mm) was potentially most effective in superior translation of the humeral head followed by the posterior deltoid (7.7 mm, SD 4.8 mm). The coracobrachialis and short head of biceps had considerable capability to translate the humeral head superiorly (2.8 mm, SD 1.3 mm) while the supraspinatus showed the weakest effects (1.3 mm, SD 0.5 mm). RELEVANCE: Strengthening exercises of the deltoid may be useful in the treatment of inferior glenohumeral instability, while the supraspinatus seems to be less important for inferior glenohumeral stability than previously assumed.     

重症肌无力的重复神经刺激技术研究

目的研究重复神经刺激技术(RNS)对重症肌无力(MG)疾病的诊断价值。方法对36例MG患者的面神经,腋神经及尺神经分别进行RNS检查,共检查108条神经。结果108条神经中RNS阳性率为60.2％(65条),其中以腋神经对应的三角肌阳性率最高77.8％(28/36),尺神经对应的小指展肌阳性率最低41.7％(15/36)。同一患者有一条或多条神经RNS阳性的病例数为总例数的86.1％(31/36).所有RNS阳性的MG患者在低频刺激即可获得阳性结果,最佳刺激频率为3～5Hz。结论对MG患者同时进行腋神经,面神经和尺神经的重频刺激,可提高RNS的阳性率。