肩胛上神经卡压症针刀手术入路研究

目的提供肩胛上神经卡压症针刀手术入路的解剖学基础。方法在30侧经10％福尔马林固定及灌注红色乳胶的成人上肢标本上行局部层次解剖。①观察肩胛上神经位置,行程和分布,以及与周围结构的相互毗邻关系。②测量肩胛上下孔;肩胛上下横韧带的相关数据。③设定肩胛上神经的体表测量标志,并测量相关数据。结果：①肩胛上神经由臂丛C5、6形成后,越过颈后三角向外,经肩胛上孔入冈上窝,分出冈上肌支、上关节支,其主干改名为冈下肌支穿肩胛下孔入冈下窝,分出冈下肌支、下关节支。②肩胛上孔横径7．90±3．0mm;纵径6．2±1．2mm;肩胛下孔横径9．81±1．53mm纵径7．81±2．40mm;肩胛上横韧带长13．4±0．5mm;肩胛下横韧带长25．3～3．9mm。③引用黄德清所测数值：设定肩胛上孔为A点,肩胛下孔为B点,肩胛上角为C点,肩峰外侧端为D点。肩胛冈内侧端与肩胛骨内侧缘相交处为E点。AD／AC相对值为1．26±0．47;BD／BE相对值为0．60±0．08。结论肩胛上神经卡压症的解剖学研究数据能为肩胛上神经卡压症针刀手术提供较安全的入路及定位标志。     

肩胛上神经卡压机制的临床解剖学研究

目的　探讨肩胛上神经卡压症的解剖学机制,为临床诊断和治疗提供解剖学依据。 方法　22具(男13具,女9具)44侧成尸标本,解剖观测肩胛上切迹,冈盂切迹的形态特点以及肩胛上神经走行、分支及分布的解剖学特点,所测数据统计学处理。 结果　肩胛上切迹类型：U型占40.91%（18侧）,浅U型占22.73%（10侧）,大弧型占27.27%（12侧）,方形占9.01%（4侧）四种。肩胛上切迹的厚度为（1.55±0.36）mm。肩胛上神经主干与冈上肌支所成角为(86.04±1.28)°。冈下肌支的入肌点,有22.73%在该肌的起点处,77.27%在中或外1/3处。冈盂切迹的厚度在（6.82±1.21）mm 。肩胛上神经自肩胛上孔穿出点至肩胛冈基底部的高度为（11.13±0.21）mm;至冈盂切迹的水平距离为（14.03±0.64）mm 。肩胛上神经转折角为（49.65±1.63）°。 结论　肩胛上切迹的类型、肩胛上切迹和冈盂切迹的厚度,肩胛上神经转折角的大小、神经主干与冈上肌支的角度以及冈下肌支的入肌点等均是肩胛上神经卡压的危险因素。     

肩胛上神经卡压综合征的临床研究

目的：探讨肩胛上神经卡压征的诊断依据和治疗方法，提高对该病的诊治水平。方法：对我院收治的12例肩胛上神经卡压征的临床症状、体征、影像学资料及诊疗方法进行回顾性分析。结果：保守治疗6例中4例有效，有效率66．67％；手术治疗8例，随访2～3年，症状完全消失，肌力较术前增加Ⅱ～Ⅲ级，未发现有复发，但肌肉萎缩无明显改善。结论：本病早期用保守疗法可使部分患治愈，如治疗2个月无效、或出现明显肌肉萎缩，应积极手术治疗。     

肩胛上神经冈下肌支卡压1例

1临床资料 患者,男,25岁,喜欢打篮球。右肩胛部疼痛3月,理疗无效,右肩部肌肉萎缩、活动乏力而就诊。查体：右肩胛部冈下肌明显萎缩,肩胛冈中外1／3交界下方压痛,压痛范围1cm×1cm。皮肤感觉正常,右肩关节各向活动范围正常,外旋肌力减弱。肌电图表现为传导速度减慢,潜伏期延长。行手术治疗,沿肩胛冈中点向外侧切开至肩峰,切断部分斜方肌、三角肌在肩胛冈上的附着部,分别将冈上、下肌自肩胛冈两侧剥离并牵开,于外侧见肩胛上神经冈下支神经血管束穿行于冈盂切迹与肩胛下韧带构成的骨纤维孔道,肩胛上神经冈下支水肿及瘢痕增生。切除肩胛下韧带及冈盂切迹内侧部分骨质,骨蜡涂抹切骨处,神经外膜松解。术后肩胛部疼痛消失。术后半年两侧肩部肌肉对称。     

针刀治疗肩胛上神经卡压综合征进针定位点及深度的解剖推算

目的:探索肩胛冈的准确定位点,为采用斜口型\月芽型针刀,切断肩胛上横韧带诊治肩胛上神经卡压综合征提供解剖形态学依据.方法:对30例成人干燥肩胛骨的肩胛冈、肩峰角、肩胛切迹以及喙突为定位点进行测量,通过AB/BE,BC/BE 2组和AF/DE组建立一元回归方程得到理论可靠性定位点,然后把理论定位点与实际定位点进行比较分析,以验证结果的可靠性.结果:BC/BE组y=0.1685x+17,964,R2 =0.1167具有相关性,为进针点定位；AF/DE组y=0.63x+12.917,R2 =0.3296具有相关性,为确定进针深度.结论:通过对照验证与比较,用此方法定位在理论上具有可靠性.     

肩胛上神经穿肩胛上横韧带1例

作者在处理废旧男尸体标本时见其左侧肩胛上神经穿过纵置型的肩胛上横韧带 ,此种变异少见 ,现报道如下。据林萍等分型 (中国临床解剖学杂志 ,1994,12 (4 ) :2 77～2 79) ,左侧肩胛切迹呈圆形 ;迟焕方等分型 (中国临床解剖学杂志 ,1994,12 (4 ) :2 80～ 2 82 ) ,韧带呈纵置型。本例变异的肩胛上横韧带分为上、下两束 ,两束均呈附着端宽而中部窄的带状。上束长 1.61cm ,中部宽 0 .19cm ,厚 0 .4mm。下束长 1.10cm ,中部宽 0 .11cm ,厚 0 .3mm。两束围成横椭圆形的上孔。上孔长 1.14cm ,中部宽 0 .3 3cm ,在孔的最宽处有肩胛上神经穿过 ,在肩胛…     

肩胛上神经卡压综合征的基础和诊断治疗

目的：探讨肩胛上神经卡压征的诊断依据和治疗方法，提高对该病的诊治水平。方法：对收治的12例肩胛上神经卡压的临床症状、体征、影像学资料及诊疗方法进行回顾性分析。结果：保守治疗6例中4例有效，有效率66．67%。手术治疗8例，随访2－3年，症状完全消失，肌力较术前恢复至Ⅳ-Ⅴ级，未发现有复发者，但肌肉萎缩无明显改善。结论：本征早期用保守疗法可使部分患者治愈，如治疗2个月无效或出现明显肌肉萎缩者，应积极手术治疗。     

肩胛上神经卡压综合征的电生理诊断

目的：探讨肩胛上神经卡压综合征电生理诊断方法。方法：对10例肩胛上神经卡压综合征的病人应用肌电图（EMG）观察自发电位,检测肩胛上神经支配肌冈上肌、冈下肌;腋神经支配肌三角肌;肩胛背神经支配肌提肩胛肌的复合肌肉动作电位（CMAP）,观察指标为潜伏期、波幅的变化。结果：10例病人冈上肌均见自发电位,募集反应减弱,CMAP潜伏期延长,波幅降低,且波形离散。结论：电生理是诊断和鉴别诊断肩胛上神经卡压综合征的重要辅助手段。     

肩胛上血管神经的解剖及其临床意义

在６０侧成人尸体上观察了肩胛上血管神经与肩胛上横韧带的关系，有４种类型：（１）神经在韧带的下方，血管在韧带的上方（６５．０％）；（２）血管、神经均在韧带下方（２３．３％）；（３）神经和静脉在韧带下方，动脉在韧带上方（１０．０％）；（４）血管和神经均在韧带上方（１．７％）。在尸体标本上摹拟了肩胛上血管神经与肩胛上横韧带和动态关系。提出肩胛上血管受压导致供血不足也可能是某些肩痛的原因之一。建议切除切除     

肩胛上神经损伤原因的解剖学分析

目的:探讨肩胛上神经损伤的解剖学原因。方法:观察人肩胛切迹的形态,肩胛上神经和肌肉的关系,同时测量肩胛上神经在肩胛下孔处的转折角、肩胛上、下孔的横径、肩胛上、下横韧带的长度。结果:肩胛切迹U型58.82%,弧形17.65%,V型19.12%,半封闭型2.94%,全封闭型1.47%;肩胛上神经经过肩胛上孔进入冈上窝,之后经冈盂切迹进入冈下窝,此处有1个51.18°±6.93°的转折角,即肩胛上神经转折角;肩胛上孔由肩胛切迹和肩胛上横韧带围成,肩胛上孔横径(7.81±3.29)mm,韧带长(12.23±4.89)mm;肩胛下孔是由冈盂切迹和外侧的肩胛下横韧带(冈盂韧带)围成,其横径(8.79±3.96)mm,韧带长(21.26±5.45)mm。同时肩胛上神经主干主要在肌肉和肩胛骨面之间。结论:肩胛上神经自身走行的路径是其损伤的基础,肩关节反复活动对神经的牵拉是损伤的直接原因。     

Ultrasonographic evaluation and morphometric measurements of the suprascapular notch

Background:  The aim of this study was to define the sonographic evaluation and morphometric measurements of the suprascapular notch. Methods  The suprascapular notch was evaluated by ultrasound on both sides in 50 volunteers (25 males, 25 females). By means of ultrasound, the notch width, the notch depth and the distance between the skin and the notch base (skin–notch base interval) were measured and imaging of the superior transverse scapular ligament was attempted. Furthermore, imaging of the suprascapular artery and vein was performed by Doppler ultrasound. Results  On the measurements performed, the notch was found to be deeper in men than in women on both the right (P = 0.022) and the left (P = 0.011) sides. Taking all volunteers into account without grouping sex, no differences were detected between the two sides with respect to the measurements of the notch width, notch depth and distance between the skin and the notch base. The superior transverse scapular ligament was demonstrated in 48 (96%) of 50 volunteers. On color Doppler ultrasound, the artery–vein complex was visualized in a total of 43 (86%) volunteers. Conclusions  Suprascapular notch measurements and the visualization of the anatomical neighborhood, which may be beneficial for the suprascapular nerve blockade procedure, can be successfully performed by the use of high-frequency ultrasound imaging.     

Clinical significance of suprascapular nerve mobilization

The anatomy of the suprascapular nerve is important to surgeons when focal nerve lesions necessitate surgical repair. Recent experience with a patient who had a complete suprascapular nerve lesion in the retroclavicular region (combined with axillary and musculocutaneous nerve lesions) is presented to illustrate that successful direct nerve repair is possible despite resection of a neuroma. Specifically, we found that neurolysis and mobilization of the suprascapular nerve and release of the superior transverse scapular ligament provided the necessary nerve length to achieve direct nerve repair after the neuroma was removed. A combined supraclavicular and infraclavicular approach to the suprascapular nerve provided excellent visualization, especially in the retroclavicular region. Postoperatively, the patient recovered complete shoulder abduction and external rotation with the direct repair, an outcome uncommonly achieved with interpositional grafting. Based on our operative experience, we set out to quantify the length that the suprascapular nerve could be mobilized with neurolysis. Mobilization of the nerve and release of the superior transverse scapular ligament generated an average of 1.6 cm and 0.7 cm of extra nerve length respectively, totaling 2.3 cm of additional usable nerve length overall. The ability to expose the suprascapular nerve in the retroclavicular/infraclavicular region and to mobilize the suprascapular nerve for possible direct repair has not been previously emphasized and is clinically important. This surgical approach and technique permits direct nerve repair after resection of a focal neuroma in the retroclavicular or infraclavicular region, thus avoiding interpositional grafting, and improving outcomes.     

小针刀治疗肩胛上神经嵌压症的应用解剖

目的为小针刀减压治疗肩胛上神经嵌压症提供形态学基础.方法在34侧常规固定的成人尸体标本上解剖出冈上孔、冈下孔和肩胛上神经及血管,观察冈上孔、冈下孔及其与肩胛上神经、血管的走行位置关系,测量有关数据.结果冈上孔位于锁骨锥状结节的后端深面,由肩胛切迹和横架于其上方的肩胛上横韧带围成,距体表(4.75±0.79)cm.冈下孔位于肩胛冈中外1/3交界处下方2cm处的深面,由冈盂切迹和连于肩峰根部及肩胛骨背面的肩胛下横韧带围成,距体表(3.93±0.95)cm.肩胛上神经起自臂丛上干,行向后外下,穿冈上孔人冈下窝,再向后穿冈下孔入冈下窝,沿途发支至冈上肌、冈下肌和肩关节.肩胛上血管经肩胛上横韧带的外上方入冈上窝与神经伴行.结论本文提出同时扩大或开放两孔进行治疗的新思路,提供的有关数据和定位方法,可提高小针刀治疗肩胛上神经嵌压症的准确性和安全性.     

Topographical anatomy of the suprascapular nerve and vessels at the suprascapular notch

Suprascapular nerve entrapment caused by the superior transverse scapular ligament (STSL) causes pain, and limitation of motion in the shoulder. To relieve these symptoms, suprascapular nerve decompression is performed through the resection of STSL. To describe and classify the topographic anatomy of the suprascapular notch, 103 cadaveric shoulders were dissected. The mean length and width of STSLs were 11.2 and 3.4 mm, respectively. The bony bridges replacing STSL in four shoulders were 8.2 mm long and 3.5 mm wide on average. The suprascapular nerve always ran through the notch under the STSL. All shoulders had a single suprascapular artery, while multiple suprascapular veins appeared in 21.3%. The arrangement of the suprascapular vessels was classified into three types: in Type I (59.4%), all suprascapular vessels ran over the STSL; in Type II (29.7%), the vessels ran over and under the STSL simultaneously; in Type III (10.9%), all vessels ran under the STSL. In 48.9% of cadavers, these types were bilaterally matched. The omohyoid muscle originated distantly from the STSL in 38.0%, was adjacent to it in 44.0%, and was partially over the STSL in 18.0%. The number of suprascapular vessels running under the STSL was positively correlated with the size of the STSL and the middle diameter of the suprascapular notch. Age was inversely correlated with the length of STSL. The STSL was wider in males than in females. This study provides details of the structural variations in the region of the suprascapular notch.     

腰椎关节突关节的应用解剖与在微创术中的定位价值

目的　通过解剖标本和影像资料测量腰椎关节突关节及毗邻结构的相关数据,探讨关节突关节作为腰椎微创术中重要解剖定位标志的可行性。 方法　收集新鲜成年人体腰椎标本10具20侧,共计80个节段。腰椎X线影像资料50例,200个节段。以关节突关节最高点(Highest point of lumbar zygapophysial joint, HP)作为测量中心,从微创手术应用解剖的角度,分别观测HP与手术相关结构的距离和角度。 结果　HP至腰神经距离随椎间隙向下,数值逐渐增大,而角度趋于变小;HP至邻近椎间盘的距离,向下逐渐增大;HP和相邻椎间盘中平面垂直距离为0.8~1.5 mm,HP垂直高度位于椎间盘厚度范围内。 结论　腰椎关节突关节具备位置稳定、显露简单、容易辨认、对应关系易于掌握、准确性高的特点。是理想的解剖标志。在临床腰椎后路微创手术中可发挥一定的解剖定位作用。     

Morphological study of the inferior transverse scapular ligament

The suprascapular nerve can be compressed by the inferior transverse scapular ligament (ITSL), also known as the spinoglenoid ligament, and this entrapment results in dysfunction of the external rotation of the upper arm owing to isolated weakness of the infraspinatus muscle. The morphology of the ITSL has not been adequately characterized. The aim of this study was to clarify the morphological characteristics of the ITSL. In total, 110 shoulders from 72 cadavers were dissected in this study. The ITSL was present in 73 (66.4%) of the 110 specimens, and comprised membrane in 40 (36.4%), ligament in 25 (22.7%), and both membrane and ligament in eight (7.3%). This structure could be classified into three types on the basis of its shape: band‐like (33.6%, type I), triangular (15.5%, type II), or irregular (17.3%, type III). In the spinoglenoid notch, the suprascapular nerve was always close to the lateral margin of the scapular spine. The length of the ligament between its origin and insertion sites ranged from 8.7 to 23.4 mm at its superior margin and from 8.9 to 17.5 mm at its inferior margin. The ligament width and thickness at its midportion ranged from 1.6 to 10.0 mm and from 0.1 to 1.2 mm, respectively. The results of this study improve understanding of the ITSL and will be helpful for successful diagnoses and treatments for selective suprascapular nerve entrapment. Clin. Anat. 27:707–711, 2014. © 2013 Wiley Periodicals, Inc.     

经食管超声心动图在微创心脏外科直视手术中的应用

目的 探讨经食管超声心动图(TEE)在微创心脏外科直视手术(MIDCS)中的应用价值。方法 回顾性研究。纳入淮北矿工总医院2018年7月-2019年11月接受MIDCS的患者20例,其中男8例、女12例,年龄(57.5±10.2)岁。术前诊断:先天性心脏病6例,瓣膜病13例,左心房黏液瘤1例。20例患者术前均常规行经胸超声心动图(TTE)检查,术中均采用TEE监测。麻醉诱导后TEE检查修正诊断,指导建立体外循环,开放升主动脉前指导心腔排气;术中,于病变处理完成后即时TEE监测心内血流、瓣膜及心功能情况;于手术操作完成、心脏复跳后,应用TEE评价手术疗效,以无残余分流、瓣周漏、瓣膜关闭不全及左心室射血分数(LVEF)>50%为治愈。结果 经术中引导,20例患者均准确置于引流管、排空心脏。经TEE检查修正诊断5例:1例下腔型房间隔缺损术中发现另有一小的房间隔缺损,术中一并予以修补;1例房间隔缺损者房水平仅有微量分流,无需处理;2例三尖瓣关闭不全患者合并三尖瓣前叶裂,均行瓣叶修复后再予三尖瓣成形术;另1例则排除了左心房血栓。病变处理完成后,因术中TEE即时评估疗效不满意而更改手术方式2例:1例三尖瓣成形术后瓣膜关闭不满意者改行三尖瓣置换术,1例室间隔修补术后残余分流者改行胸骨正中切口继续修补。另有2例术毕即时通过TEE发现低心排血综合征,行主动脉内球囊反搏术。全组未见食管损伤和相关并发症,无手术死亡病例。术后均无残余分流、瓣周漏及少量以上反流,黏液瘤完全切除;术后患者症状明显缓解,LVEF为54%~69%(61.40%±3.65%),与术前[44%~67%(58.70%±5.19%)]比较差异有统计学意义(t=2.896, P<0.05)。本组患者治愈率100%。结论 术中TEE监测应用于MIDCS中,在补充修正诊断、引导体外循环建立、手术操作完成后监测心内排气、评价手术疗效等方面具有明显优势,为微创心脏外科直视手术的成功提供重要保障。     

微创临床局部解剖学教学体系的建立和探索

目的随着临床医学中微创手术的广泛开展,传统局部解剖学的教学模式明显不切合于现在的临床应用,我们在近3年的局部解剖学教学中,尝试建立基础与临床相结合的临床微创局部解剖学教学体系,实现了医学生培养上的多赢。方法在北京大学医学部的3个年级临床医学专业的医学生中,分成传统局部解剖学(局解组)和微创局部解剖学(微创局解组)。微创局解组同学借助模拟腔镜等微创手术器械,开展微创临床解剖学的教学。结果与传统局解组相比,微创局解组同学在学习兴趣,学习的主动性,知识的牢固性,解剖动手能力,临床思维能力,解剖和临床知识的互补性,讨论及交流能力和师生互动等方面均有不同程度的提高。结论微创解剖学教学体系不仅能够满足医学生尤其是临床医学生早期接触临床微创手术及手术器械的需要,并且还可以促进解剖学老师深入了解临床手术的进展,有利于进一步明确教学目的,并促进了基础解剖与临床进展的交流。     

Clinical results of minimally invasive open-heart surgery in patients with mitral valve disease: comparison of parasternal and low-sternal approach

Clinical results of minimally invasive mitral valve surgery were retrospectively reviewed, and two different surgical approaches were compared in this study. Between 1997 and 2004, a total of 86 patients with mitral valve disease underwent minimally invasive surgery at the Yonsei University Cardiovascular Center. Age of patients averaged 41.6 +/- 14.0 years and 69 patients were female. Surgical approach included low- sternal incisions with mini-sternotomy, and right parasternal or thoracotomy approach. Either direct aortic or femoral arterial and bicaval cannulations were used in all patients. Patients were divided into two groups according to the method of surgical approach (parasternal (P) vs low-sternal (L)), and the results were compared. Postoperative NYHA functional class improved to 1.1 +/- 0.4 in all patients (no significant statistical difference between two groups). Mean wound length (P: 9.21 +/- 1.10 vs L: 11.24 +/- 0.82 cm, p < 0.05), and mechanical ventilation time (P: 10.42 +/- 4.36 vs L: 12.90 +/- 5.00 min, p=0.04) was significantly shorter in parasternal group, and mean operation time(P:294.74 +/- 59.41 vs. L:259.31 +/- 54.36 min, p=0.03) was significantly shorter in low-sternal group. Mean cardiopulmonary bypass time, and aortic cross clamp time was also shorter in low-sternal group without statistical difference. There were 2 minor wound complications in all patients (p=NS), and no hospital death. Comparing the two different surgical approach of minimally invasive mitral valve surgery, parasternal approach is thought to be more beneficial in reducing postoperative scar, and intubation time.