部分正中神经尺神经束移位修复臂丛损伤

目的：采用部分神经束移位治疗臂丛神经C5－7或中上干撕脱伤,评价其疗效。方法：将自1997年以来采用部分神经束移位治疗臂丛神经C5－7或中上干撕脱伤的11例与以往采用膈神经,副神经移位治疗臂丛损伤的11例疗效进行随访对比。结果：部分神经束移位组的肱二头肌肌力恢复的优良率最高,但有效率和三角肌肌力恢复两组无差异。结论：采用部分正中神经束移位吻接肌皮神经肌支,所恢复的肌力比以往采用膈神经,副神经移位方法的效果更接近正常。     

Side-to-side nerve bridges reduce muscle atrophy after peripheral nerve injury in a rodent model

Background

Peripheral nerve injury can result in muscle atrophy and long-term disability. We hypothesize that creating a side-to-side bridge to link an injured nerve with a healthy nerve will reduce muscle atrophy and improve muscle function.

Methods

Sprague-Dawley rats were divided into four groups (n = 7 per group). Group 1: transection only—a 10-mm gap was created in the proximal tibial nerve; group 2: transected plus repaired—the transected tibial nerve was repaired; group 3: transected plus repaired plus nerve bridge—transected nerve repaired with a distal nerve bridge between the tibial and peroneal nerves via epineurial windows; and group 4: transected plus nerve bridge—transected tibial nerve left unrepaired and distal bridge added. Gait was assessed every 2 wk. At 90 d the following measures were determined: gastrocnemius mass, muscle and nerve nuclear density, and axonal infiltration into the nerve bridge.

Results

Groups 3 and 4 had greater improvements in walking track recovery than groups 1 and 2. Group 3's gastrocnemius muscles exhibited the least amount of atrophy. Groups 1, 2, and 4 exhibited greater histologic appearance of muscle breakdown compared with group 3 and control muscle. Finally, most bridges in groups 3 and 4 had neuronal sprouting via the epineurial windows.

Conclusions

Our study demonstrated reduced muscle atrophy with a side-to-side nerve bridge in the setting of peripheral nerve injury. These results support the application of novel side-to-side bridges in combination with traditional end-to-end neurorrhaphy to preserve muscle viability after peripheral nerve injuries.     

Vascularized nerve grafts for the treatment of large nerve gap after severe trauma to an upper extremity

We reviewed the clinical outcomes of vascularized nerve grafts for the repair of large nerve gaps (longer than 20 cm) after severe trauma to an upper extremity. Six patients who underwent vascularized sural nerve grafting (five to the median nerve and one to the ulnar nerve) with a monitoring skin flap were evaluated. The length of the vascularized sural nerve grafts ranged from 20 to 30 cm, with a mean length of 23.3 cm. All but one of the monitoring skin flap grafts was successful. In those patients for whom the monitoring skin flap graft was successful, the mean static-2PD at the corresponding fingertip was 14.2 mm (range 10–20 mm). Evaluation of these patients with the Semmes-Weinstein test produced the following results: filament 6, two patients; filament 10, three patients. The results of this study show that vascularized sural nerve grafting should be considered as a clinical alternative for nerve reconstruction in patients with nerve defects longer than 20 cm.     

明胶管修复坐骨神经缺损后运动功能的改变

目的探讨明胶管（gelatin conduit）桥接外周神经缺损后运动功能的改变。方法用明胶制成长8mm，内径1．0mm的导管，套接修复大鼠右侧坐骨神经缺损4．0mm，以未修复组作阴性对照对照，于术后6、18周进行电生理学、胆碱酯酶染色、胆碱酯酶结合银染等检查。结果术后6周明胶管内出现再生神经纤维，18周时神经纤维变致密。明胶管组18周时胫前肌肌湿重有显著改善，并能记录到动作电位，有肌内神经纤维再支配和运动终板再生。明胶管变薄，无异物反应及炎症反应，无粘连。结论作为一种新材料，明胶管修复神经损伤后能有效改善运动功能。     

经皮电刺激促进腓总神经损伤后神经再生的临床研究

目的证实经皮电刺激对周围神经(本文选择腓总神经)完全损伤后神经再生的促进作用,并探讨最佳的电刺激的参数、波形优化组合等治疗方案。方法对30例腓总神经完全损伤患者,随机分为电刺激组和对照组,每组15例,在行神经缝合术后,各组同时服用神经营养药物治疗,电刺激组在术后4周石膏拆除后加用电刺激治疗。经过方波和变频波的交替使用,之后均使用变幅脉冲波+肌肉训练波,并适度增加肌肉训练波的治疗时间。术后随访内容:术后6个月进行足趾伸屈力,神经电生理检测。结果电刺激组的临床肌力与肌电图结果均优于对照组,两组差异有统计学意义(P<0.05)。电刺激组的肌力恢复时间与肌电图恢复时间也明显短于对照组,两组差异有统计学意义(P<0.05)。结论经皮电刺激治疗具有促进受损周围神经再生和传导功能恢复的作用,并且能减少受损骨骼肌的萎缩,尤其对电刺激仪的工作参数、电流波形进行优化组合后,可获得更好的疗效。     

犬化学去细胞神经同种异体移植的实验研究

目的以化学去细胞同种坐骨神经移植修复犬坐骨神经的长段缺损，观察其功能恢复及神经再生。方法15犬分成去细胞同种神经组(实验组)6犬、自体神经组(对照组Ⅰ)6犬、新鲜同种神经组(对照组Ⅱ)3犬。右侧坐骨神经造成5．0cm长缺损，以上述三种移植物桥接修复。术后6个月行步态分析、神经电生理及神经再生观察。结果实验组和对照组Ⅰ在运动功能恢复，踝关节运动步态，小腿二头肌运动诱发电位、感觉诱发电位，移植段内新生轴突、血管及雪旺细胞，远端胫神经内有髓神经纤维及靶肌肉运动终板等方面非常相似。对照组Ⅱ神经功能始终无恢复，移植段被吸收。结论化学去细胞同种神经移植物修复犬粗大长段神经缺损时不会被宿主排斥和吸收，其近期功能恢复及神经再生与自体神经移植无明显差别。     

周围神经缺损神经移植修复对神经元细胞凋亡的影响

目的：应用移植神经的方法修复周围神经损伤,观察其对神经元的保护作用。方法：选用雄性SD大鼠30只。随机分成正常对照组、神经缺损组、神经损伤组、神经移植组,实验组每组9只大鼠,并按手术先后随机分成7、14、28d3个时间组。将大鼠左侧坐骨神经在梨状肌下缘碾挫或切除0．5cm,分别制备神经损伤或缺损动物模型,并采用神经原位移植的方法修复神经缺损。按术后不同时间处死动物。于术后7、14、28d取L4－6脊髓作TUNEL标记检测,标记凋亡的运动神经元数目。切片作HE、甲苯胺兰染色后计算脊髓内运动神经元的数目。结果：在术后28d,神经移植组的凋亡细胞明显少于另2组（U1＝2．10;U2＝2．89 P＜0．05）。各时间组的神经元数目,神经移植组明显多于另2组（t1=6.84;t2=6.95 P＜0．05）。结论：移植神经对周围神经损伤后的相应神经元,有一定的保护作用。     

经皮电刺激促进桡神经损伤后神经再生的临床研究

目的 探讨经皮电刺激对上臂桡神经完全损伤后神经再生的促进作用,并对电刺激的参数、波形进行优化组合,以寻求最佳治疗方案.方法 对28例上臂段桡神经完全损伤患者,随机分为电刺激组和对照组,每组14例,在行桡神经缝合术后,各组同时服用神经营养药物治疗,电刺激组在术后4～6周石膏拆除后加用电刺激治疗.第1个月使用方波治疗,脉冲频率为2 Hz;第2个月使用变幅脉冲波治疗,脉冲频率为15 Hz;第3个月起继续使用变幅脉冲波治疗,脉冲频率为15Hz,同时每次附加肌肉训练波,脉冲频率为60 Hz;之后均使用变幅脉冲波+肌肉训练波,并适度增加肌肉训练波的治疗时间.术后随访内容:伸腕、伸指肌力,神经电生理检测.结果 电刺激组的临床伸腕、伸指肌力与肌电图结果均优于对照组,两组差异有统计学意义(P＜0.05).电刺激组的肌力恢复时间与肌电图恢复时间也明显短于对照组,两组差异有统计学意义(P＜0.05).结论 经皮电刺激治疗对促进上臂段桡神经损伤后神经再生的效果明显,在对电刺激仪的工作参数、电流波形进行优化组合后,可获得良好的疗效.     

多组神经移位治疗臂丛C5~C7根性撕脱伤重建肩外展及屈肘功能

目的观察联合应用多组神经移位治疗臂丛上、中干根性撕脱伤重建肩外展及屈肘功能的临床效果。方法我科于2012年4月至2014年4月收治臂丛上、中干根性撕脱伤患者16例,采用副神经斜方肌肌支移位修复肩胛上神经、桡神经肱三头肌长头支移位修复腋神经肌支及尺神经部分束支移位肌皮神经（Oberlin术式）,联合修复臂丛上、中干根性撕脱伤,以恢复肩外展及屈肘功能。术后随访采用臂肩手功能障碍（the disabilities of the arm, shoulder and hand, DASH）评分表评估疗效。结果16例患者中有14例术后得到随访。随访时间为24~28个月（平均为25个月）,患者肩关节外展恢复至75°~90°,恢复时间为9.0~18.0个月（平均为14.0个月）。屈肘恢复至100°~160°,恢复时间为4.0~7.5个月（平均为5.8个月）。DASH评分为8.0~16.0分,平均为14.6分。结论使用多组神经移位联合治疗臂丛上、中干损伤,可较好恢复肩外展及屈肘功能,尺神经部分束支移位修复肌皮神经肱二头肌支对手内在肌功能无明显影响。     

The longitudinally split vascularized fibula with a vascularized periosteal flap for the reconstruction of large segmental bone defects of the tibia

Summary A new principle in reconstructive surgery is presented: The immediate reconstruction of a missing bone segment with a primary osteoperiosteal tube that will secondarily be transformed into a complete osseous tube. In 5 out of 7 baboons, a bone tube with an almost normal bone cavity was achieved after 16 to 28 weeks. In 2 cases, we failed to reconstruct the tube because of an intraoperative fault and postoperative plate fracture with subsequent destruction of the vascularized periosteal flap. On the basis of this study, we describe a new concept in reconstruction of segmental bone defects of the lower extremity. The osteoperiosteal tube is formed by the combination of two successful experimental and clinical techniques: the vascularized fibular transfer which is modified by splitting the bone graft longitudinally, and transfer of vascularized periosteum (concept of the substitution of a missing bone segment by an organ-like tube). In the most stressed marginal region of the bone defect, there is vascularized cortical bone from the longitudinally split fibular graft and an increasing amount of lamellar bone being produced under the vascularized periosteal flap. By splitting the graft, nutrition depends entirely on the periosteal blood supply. The concept of the dual blood supply was initially described by Berggren et al. and Papanastasiou et al. [4, 18]. The significance of the concept of the vascularized periosteum transfer for reconstruction of a segmental bone defect is well illustrated. Only in cases where the vascularized periosteal flap was intact and securely sutured to the fibulae graft and the two tibia stumps could a bone tube be reconstructed. The arrangement of both vascularized grafts as an osteoperiosteal tube exemplify the concept of the given space as described by Stock et al. [26]. Inside the osteoperiosteal tube, a consolidation chamber is created in which all the factors required for bone formation can be concentrated. Comparison of the results of successfully reconstructed bone tubes with the solid bone column in the defect of the baboon where no bone tube could be reconstructed underline the concept of combination of different vascularized grafts for reconstruction of segmental bone defects in long bone defects of the lower extremity.This work was presented at the 5th German-Austrian-Swiss Congress of Traumatology in Berlin in November of 1987. The part of vascularity analysis was supported by a grant from the Friedrich-Baur-Stiftung     

尺神经损伤误诊18例分析

尺神经是周围神经中损伤发生率最高的神经之一，因为举前臂挡住头面部是人类的自然保护性动作之一，当前臂及手的尺侧位于前面时，创伤来临，尺神经多难以幸免。尺神经损伤诊断并不困难，但常有一些特殊情况而被漏诊误诊，2006年至2007年，共收治尺神经漏诊病例18例，其中绝大部分病例来自基层医院，为防止尺神经损伤漏诊的发生，现就漏诊原因及初诊应注意的一些问题作一回顾性分析。     

改良的尺神经桥接健侧C7治疗臂丛神经撕脱伤

目的 探讨肘上段尺神经桥接健侧C7神经修复正中神经，治疗臂丛神经撕脱伤的可行性。方法 尺神经在进入肘管前切断，然后将近端分离至内侧束，将尺神经经胸大肌的深面穿出，经胸前及颈部皮下隧道牵至健侧颈部切口与C7神经根缝合，二期修复正中神经。术中观察尺神经远端的血供并测量长度。结果 本组全臂丛神经撕脱伤13例，中、下干撕脱伤2例，均为男性，年龄14～45岁，平均27岁；受伤时间：1．5～11个月，平均5个月。肘上段尺神经翻转与健侧C7神经根缝合12例；肘上段尺神经及前臂内侧皮神经一起翻转与健侧C7神经根缝合3例。肘上段尺神经的长度21cm～-27cm，平均24．7cm，15例尺神经远端血供均良好。尺神经自穿出胸大肌处至健侧C7的距离15cm～2cm，平均17．8cm。结论 肘上段尺神经桥接健侧C7神经修复正中神经治疗臂丛神经撕脱伤较传统的手术方法简便、易行。     

Influence of chronic inflammation in peripheral target tissue on recovery of crushed nerve injury

An experimental study was performed to investigate the influence of chronic inflammation in peripheral target tissue on recovery of the sciatic nerve after crush injury. Thirty-four male Wistar rats, weighing 300–370 g were used. The sciatic nerve was crushed unilaterally with an aneurysm clip (250 gf; holding force; 5 min). One week before the operation, chronic inflammation, localized in the tibiotarsal joint of one hind limb, was produced by the intraarticular injection of complete Freund's adjuvant. The animals were divided into five groups, as follows: CIA (crush injury with ipsilateral arthritis), CCA (crush injury with contralateral arthritis), C (crush injury without arthritis), A (sham operation and ipsilateral arthritis), and S (sham operation without arthritis). Specimens for histological examination were taken from the nerve at a site 5 mm distal to the crush injury 4 weeks postoperatively. Histological study showed that the diameters of the axons in group CIA were significantly smaller than those in group CCA and those in group C. No significant differences were observed between group CCA and group C. In conclusion, peripheral nerve recovery after crush injury was suppressed by chronic inflammation in peripheral target tissue. Received: June 1, 2000 / Accepted: May 10, 2001     

Comparison of acellular nerve allograft modification with Schwann cells or VEGF

Background

Individual contributions of exogenous Schwann cells (SCs) and vascular endothelial growth factor (VEGF) were evaluated in acellular nerve allografts (ANAs). ANA processing removes SCs and vasculature, likely contributing to reduced regeneration compared to autografts. Exogenous SCs may improve the regenerative microenvironment, and VEGF has been shown to stimulate angiogenesis. Replacing these components in ANAs may improve regeneration.

Methods

A rat sciatic nerve transection model was used to study 20-mm grafts. Four graft types were studied: (1) isograft, (2) ANA, (3) ANA-SCs, and (4) ANA-VEGF. After 10 weeks in vivo, the midgraft and distal nerve to the grafts were analyzed for axonal regeneration using histomorphometry to assess total myelinated axon counts, density, width, and percent neural tissue.

Results

The most axons in the distal nerve were regenerated in the isograft followed by the ANA- SC group, with 9171 ± 1822 and 7103 ± 1576 regenerated axons respectively. Both the ANA and ANA-VEGF groups had significantly fewer regenerated axons compared to the isograft (p < 0.05) with 5225 ± 2994 and 5709 ± 2657 regenerated axons, respectively. The ANA and ANA-VEGF groups also had significantly reduced fiber density and percent nerve compared to the isograft; the isograft and ANA-SC groups were not significantly different (p < 0.05).

Conclusions

These results show that SCs improve axonal regeneration in a 20 mm ANA to a greater extent than VEGF. VEGF treatment showed a trend toward increased axonal regeneration but was not significantly different compared to the untreated ANA. The role of VEGF may be clearer in longer grafts where ischemia is a greater factor.     

大鼠正中神经修复后不同时段的电生理变化与神经再生的相关性分析

目的 探讨大鼠正中神经切断缝合后的不同时段,其复合神经动作电位(CNAP)与形态学方面的特点及其相关性分析.方法 在大鼠上臂正中神经中段切断缝合后的不同时间点(2、3、4、6、8和12周)进行CNAP检测,随后取正中神经组织进行形态学检查.结果 术后第2周可以记录到CNAP.术后再生神经记录的CNAP幅度比对照组显著减低(P<0.01),波幅下面积(Area)也显著低于对照组(P<0.01),传导速度(CV)显著慢于对照组(P<0.01).术后2～6周的潜伏期(Lat)均比对照组明显延长(P<0.05);术后2～8周刺激强度,即阈强度(THI)和超大刺激强度(SSI)显著低于对照组.CNAP的第一峰波幅(FPA)、峰-峰波幅(PPA)、Area、CV变化趋势为随时间增加而逐渐增高,而其参数Lat、THI、SSI随时间增加而逐渐降低.神经修复后2周缝合口远端已有少量的新生轴突,随着再生时间延长,越来越多的再生轴突延伸至远端.远端记录的CNAP波幅与其有髓神经纤维计数之间有强的正相关(相关系数为0.953).线性回归分析表明,存在线性关系.术后8周髓鞘趋向于成熟.结论 CNAP是早期诊断和评价损伤神经再生程度的良好指标.正常正中神经的CNAP波幅可能与有髓神经纤维的计数呈线性关系.术后第8周,CNAP参数趋向于稳定,神经髓鞘渐趋向于成熟.

Abstract：

Objective To explore the characteristics of compound nerve action potential (CNAP) after rat median nerve transection and repair,and their correlation with neuromorphometry at various time points. Methods The median nerve was transected and sutured at mid-arm level. At various time points from 2 to 12 weeks postoperatively,CNAP recording was performed and the median nerve was harvested for morphological examination. Results CNAP could be recorded at 2 weeks after nerve repair. The CNAP amplitude,the area below the curve (Area) and conduction velocity (CV) of regenerated nerve were significantly lower than those of control group (P＜0.01). From 2 weeks to 6 weeks postoperatively,CNAP latency (Lat) was obviously longer than normal (P＜0.05). From 2 weeks to 8 weeks postoperatively,CNAP stimulus intensity (threshold intensity and the supramaximal stimulation intensity,THI and SSI) was significantly lower than that of the control group (P＜0.01). First peak amplitude (FPA),peak-peak amplitude (PPA),Area and CV of CNAP increased with time,while parameters such as Lat,THI and SSI decreased over time in regenerated median nerve. Regenerated axons could be seen at 2 weeks after nerve transection and repair. More and more regenerated axons were seen with the lapse of time. There was a strong positive correlation between CNAP amplitude and the number of myelinated nerve fibers,with a 0.953 correlation coefficient. Linear regression analysis revealed the existence of a linear relationship. The maturity of regenerated nerve at 8 weeks reflected by myelin sheath thickness was close to that of a normal median nerve. Conclusion CNAP recording is a valuable tool to evaluate the extent of early nerve regeneration after nerve suture repair. There might exist a linear relationship between CNAP amplitude of normal median nerve and the number of myelinated nerve fibers. CNAP parameters are inclined to stabilize and nerve myelin sheath maturation is close to normal 8 weeks postoperatively.     

Intraneural angioleiomyoma of the median nerve presenting as a forearm mass: A case report

Angioleiomyoma is a solitary form of leiomyoma which is typically encountered in the subcutis. They are mostly seen in lower extremities, and the upper extremity is the second most common location for these lesions. There are only a few reports about the presence of an angioleiomyoma within a peripheral nerve in the upper extremity. Here we report a 56-year-old male patient who was referred to our clinic after an attempt was made for removal of a forearm mass at another institution. The lesion was encased within the median nerve and there was an unusual hypervascularity around the tumor with numerous vessels entering the lesion. Removal of the tumor without apparent damage to nerve fascicles was possible. Histopathological examination of the excision material revealed an intraneural angioleiomyoma. Following surgery, the patient was free of any functional deficits and no evidence of recurrence was observed at one year follow-up. There is no data regarding recurrence in intraneural lesions due to the lack of a large series. It would not be wrong to recommend spare grossly uninvolved fascicles if the nerve in question is not expendable.     

补阳还五汤促进周围神经损伤后神经元存活的实验研究

目的 研究补阳还五汤对周围神经损伤后脊髓前角运动神经元和脊神经节感觉神经元存活的影响。方法 成年SD大鼠20只，在右侧梨状肌下缘0.5cm处切断坐骨神经，随机分为两组，对照组以生理盐水灌胃，实验组以补阳还五汤灌胃，4W后观察相应节段运动神经元和感觉神经元存活率、神经元胞体直径和面积。结果 4W后相应节段脊髓前角运动神经元存活率：对照组为59．87％，实验组为69．22％（P＜0．01）；脊神经节感觉神经元存活率：对照组为70．99％，实验组为79．13％（P＜0．01）。对照组运动神经元和感觉神经元胞体直径、面积明显小于实验组（P＜0．01）。结论 补阳还五汤能提高周围神经损伤后脊髓前角运动神经元和脊神经节感觉神经元存活率，减轻神经元胞体萎缩程度，有利于周围神经损伤后神经功能的恢复。     

Long-term results of transplantations to repair median, ulnar, and radial nerve lesions by a microsurgical interfascicular autogenous cable graft technique

A comprehensive analysis of 187 patients (78 median, 86 ulnar, and 23 radial nerve lesions) treated by an interfascicular autogenous nerve grafting technique is presented. After a follow-up of at least 18 months good motor recovery was achieved in 72% of median nerve lesions, 77% of ulnar nerve lesions, and 57% of radial nerve lesions. Good functional sensory recovery was found in 36% of median, 45% of ulnar, and 48% of radial nerve lesions. It appears by multivariate analysis that the results obtained generally were better in younger patients, in patients with a shorter preoperative delay, and in cases with a shorter transplant.