改良高选择性脊神经后根部分切断术中前后根神经分束的应用解剖(英文)

背景:高选择性脊神经后根部分切断术中前后根的神经分束应达到神经小束水平,分束越多越利于电刺激选择,利于准确地切断阈值低的引起痉挛的Ia类神经纤维,也越可能最大限度地保留后根中的感觉神经纤维。目的:根据限制性和高选择性脊神经后根切断术的要求,对脊神经前后根进行显微解剖,确定神经小束的分束标准和数目,为临床手术提供可靠的依据和新的手术标准。设计:以成人尸体标本为观察对象,单一样本实验。单位:锦州医学院附属第一医院骨科和锦州医学院解剖教研室。对象:实验于1999-12在锦州医学院解剖学实验室进行。以志愿捐献的15具成人尸体标本为观察对象,男11具,女4具,生前均签署志愿捐献书。方法:①在15具(30侧)成人脊柱标本上,对L1～S2节段的脊神经前后根进行形态学观察和显微测量。②取新鲜尸体的L5脊神经前后根进行免疫组化染色,将脊神经后根起始部、中间部和椎间孔外部3个部位切片,分别测定神经纤维总数、引起痉挛的Ia类神经纤维的数目及其占神经纤维总数的百分率,比较3个部位Ia类神经纤维的分布规律和数量。主要观察指标:①脊神经根神经分束情况及神经小束的直径。②脊神经后根起始部、中间部和椎间孔外部计数100μm2神经纤维总数及Ia类神经纤维占神经纤维总数的百分率。结果:①脊髓圆锥部脊神经根是由根丝逐步汇合而成。应用显微外科技术,后根一般可分为10～18小束,前根一般分为6～11小束,其小束的直径是基本一样,数值较为恒定。②脊神经后根起始部、中间部和椎间孔外部计数100μm2总的神经纤维数为(3243±143)根,Ia类神经纤维为(1702±85)根,占总神经纤维数的52.5%。Ia类神经纤维在后根内呈均匀分布,没有集中分布区。结论:改良脊神经后根部分切断术的最大特点即脊神经前后根的分束标准应尽量细,这样有利于准确切断Ia类神经纤维,一般前根达到6～11小束,后根达到10～18小束,切断最大比例应不超过后根神经纤维总数的1/2。     

改良高选择性脊神经后根部分切断术中前后根神经分束的应用解剖

背景：高选择性脊神经后根部分切断术中前后根的神经分束应达到神经小束水平，分束越多越利于电刺激选择，利于准确地切断阈值低的引起痉挛的Ia类神经纤维，也越可能最大限度地保留后根中的感觉神经纤维。目的：根据限制性和高选择性脊神经后根切断术的要求，对脊神经前后根进行显微解剖，确定神经小束的分束标准和数目，为临床手术提供可靠的依据和新的手术标准。设计：以成人尸体标本为观察对象，单一样本实验。单位：锦州医学院附属第一医院骨科和锦州医学院解剖教研室。对象：实验于1999—12在锦州医学院解剖学实验室进行。以志愿捐献的15具成人尸体标本为观察对象，男11具，女4具，生前均签署志愿捐献书。方法：①在15具（30侧）成人脊柱标本上，对L1～S2节段的脊神经前后根进行形态学观察和显微测量。②取新鲜尸体的L5脊神经前后根进行免疫组化染色，将脊神经后根起始部、中间部和椎间孔外部3个部位切片，分别测定神经纤维总数、引起痉挛的Ia类神经纤维的数目及其占神经纤维总数的百分率，比较3个部位Ia类神经纤维的分布规律和数量。主要观察指标：①脊神经根神经分束情况及神经小束的直径。②脊神经后根起始部、中间部和椎间孔外部计数100μm^2神经纤维总数及Ia类神经纤维占神经纤维总数的百分率。结果：①脊髓圆锥部脊神经根是由根丝逐步汇合而成。应用显微外科技术，后根一般可分为10-18小束，前根一般分为6～11小束，其小束的直径是基本一样，数值较为恒定。②脊神经后根起始部、中间部和椎间孔外部计数100μm^2总的神经纤维数为（3243&;#177;143）根，Ia类神经纤维为（1702&;#177;85）根，占总神经纤维数的52．5％。Ia类神经纤维在后根内呈均匀分布，没有集中分布区。结论：改良脊神经后根部分切断术的最大特点即脊神经前后根的分束标准应尽量细，这样有利于准确切断Ia类神经纤维，一般前根达到6～11小束，后根达到10～18小束，切断最大比例应不超过后根神经纤维总数的1／2。     

家兔腰段脊神经后根组织化学特点及显微结构的研究

目的:通过观察家兔腰段脊神经后根不同部位神经小束的分布形态及Ⅰa类传入神经纤维的含量及分布特点.为选择性脊神经后根切断术(SPR)选择手术部位提供参考.方法:6只成年新西兰白兔,显微解剖腰3(L3)～腰5(L5)脊神经后根,分别行圆锥起始部、中段及椎间孔部冰冻切片、HE及乙酰胆碱酶(AChE)组织化学染色,观察Ⅰa类传入纤维在L3～L5脊神经后根神经束中的组织化学和分布特点及不同部位神经小束的分束情况:Image-Pro Plus 6.0图像分析软件进行不同小束Ⅰ a类传入纤维计数分析.结果:后根神经小束在圆锥起始部间隔较开,排列较规则,大致平行排列;后根中间部各神经小束未见交叉或再次分束、各小束间距离缩小,排列趋于紧密;椎间孔部各神经小束之间的距离进一步缩小,排列更加紧密;HE染色显示家兔后根神经小束內Ⅰa类传入神经纤维分布均匀,直径粗大,轴突深染,髓鞘不着色;AChK染色发现脊神经后根Ⅰa类传入神经纤维染色为阴性,轴突不着色,髓鞘也不染色;后根神经小束AChE浅染组Ⅰa类传入神经纤维含量和含量百分比均高于深染组(P＜0.05).结论:家兔腰段脊神经后根分束固定,不同部位神经小束排列不同,圆锥部较椎间孔部易于分离;Ⅰa类传入神经纤维在不同神经小束分布不均匀,在AChE染色中浅染含量相对较高,深染的神经小束Ⅰa类传入神经纤维含量相对较少.     

脊神经后根对大鼠排尿和勃起功能的选择性传导机制研究

目的:探讨脊神经后根神经小束对SD大鼠排尿和勃起功能的选择性传导机制。方法:成年雄性SD大鼠40只,10只用逆行神经示踪技术确定SD大鼠排尿和勃起功能的脊髓中枢,并对其腰骶部脊神经后根进行显微解剖学研究;30只进行电生理学研究:分别对大鼠排尿及勃起反射中枢所在脊髓节段的脊神经后根神经小束进行电刺激,同时记录膀胱内压、尿道灌注压和阴茎海绵体内压的变化情况,观察各神经小束对膀胱逼尿肌、尿道外括约肌和阴茎海绵体的选择性传导作用。结果:SD大鼠排尿和勃起功能的低级中枢主要位于L6、S1脊髓节段。后根分束可达神经小束水平,电刺激L6、S1脊神经后根某些小束时,膀胱内压上升,但尿道灌注压和阴茎海绵体内压的变化幅度不大;电刺激其他一些小束时,尿道灌注压上升,但膀胱内压和阴茎海绵体内压在刺激前后的变化不大;或是阴茎海绵体内压急剧上升,但膀胱内压和尿道灌注压在刺激前后的变化不大;或是引起上述两个或三个压力的同时改变。结论:SD大鼠L6、S1脊神经后根不同小束对膀胱逼尿肌、尿道外括约肌和阴茎海绵体的传导效能存在差异;通过显微解剖及电刺激可以区别L6、S1中主要传导膀胱逼尿肌、尿道外括约肌及阴茎海绵体的不同的后根神经小束。     

痉挛性脑瘫SPR手术及程序化治疗

目的研究选择性脊神经后根切断术 (SPR)、局部矫形手术及康复训练治疗痉挛性脑瘫的疗效。方法采用L1—S1双侧节段开窗式部分椎板切除 ,将L2 —S1的脊神经后根进行分束 ,电刺激仪测各后根阈值 ,将阈值较低神经束切断。神经根切断比例结合肌张力、肌力、体重及肌群功能进行量化 ,均 <3 0 %。术后下肢部分挛缩畸形未能改善者行局部矫形手术 ,术后行康复训练。结果经随访 ,本组 2 8例患者痉挛解除率 90 % ,功能改善率 80 %。结论选择性脊神经后根切断术 程序化治疗能有效地改善脑瘫下肢痉挛。     

椎板切开复位选择性脊神经后根切断治疗痉挛性脑瘫

目的:探讨通过显微神经外科和电生理技术,进行椎板切开复位选择性脊神经后根切断术对痉挛性脑性瘫痪的治疗效果.方法:行T11～L1椎板切开复位,显微镜下在脊髓圆锥水平将L1～S2神经后根分离成神经小枝,观察电刺激神经后根小枝所诱发的肌肉收缩和肌电图反应,切断异常反应的神经后根小枝.神经后根小枝切断数目不超过60%.结果:所有病例术后肌痉挛程度立即出现明显下降,随访发现所有患者肢体运动功能均有改善,术后未出鲻现腰椎前凸、畸形及滑脱现象.结论:T11～L1椎板切开复位,脊髓圆锥入路选择性L1～S2神经后根切断,能够有效地控制脑瘫所引起的下肢肌痉挛,改善运动功能并减少术后并发症的发生.     

选择性脊神经后根切除治疗下肢痉挛性瘫痪

采用对选择性脊神经后根切除术(SPR),治疗下肢痉挛性瘫痪8例,行L2～S1双侧节段开窗式椎板切除,将L2～S1的脊神经后根进行分束,电刺激仪测阈值,将阈值较低的神经束切断,切断比例均<30%。结果术后肌张力平均下降2级,痉挛解除率90%,功能解除率80%。     

选择性脊神经后根切除治疗下肢痉挛性瘫痪

采用对选择性脊神经后根切除术(SPR)，治疗下肢痉挛性瘫痪8例，行L2～S1双侧节段开窗式椎板切除，将L2～S1的脊神经后根进行分束，电刺激仪测阈值，将阈值较低的神经束切断，切断比例均&;lt;30%。结果术后肌张力平均下降2级，痉挛解除率90%，功能解除率80％。     

痉挛型脑性瘫痪患儿脊神经背根形态计量学分析

目的研究脑性瘫痪患者选择性脊神经根切断术(SPR)手术切断的脊神经背根的纤维成分,为脑瘫患儿的手术提供理论依据。方法采用SPR术切断电刺激诱发引起相应的肌痉挛阈值较低者的L5～S1两侧脊神经背根,利用形态计量学方法测定轴突直径、神经纤维直径、g比值(轴突直径与神经纤维直径比)、髓鞘厚度,并通过统计学分析探讨上述指标与患儿Ashworth肌张力分级的关系进行分析。结果神经纤维直径为(5.2331±1.6288)μm,g比值为0.5797±0.0575介于Ⅰ类与Ⅱ类纤维之间;经等级相关检验,轴突直径、神经纤维直径、g比值、髓鞘厚度与Ashworth肌张力分级负相关。结论切断的纤维是Ⅰ类与Ⅱ类的混合神经,脑瘫患者脊神经背根神经纤维直径与g比值与Ashworth肌张力分级有关。     

选择性脊神经后根切断术病人的护理

选择性脊神经后根切断术病人的护理王金玉关键词脑瘫，选择性脊神经后根切断术，护理Ｋｅｙｗｏｒｄｓ：ＣｅｒｅｂｒａｌｐａｌｓｙＳｅｌｅｃｔｉｖｅｐｏｓｔｅｒｉｏｒｒｈｉｚｏｔｏｍｙＮｕｒｓｉｎｇｃａｒｅ选择性脊神经后根切断术，是一项新的神经显微外科技术。...     

Mechanical hyperalgesia after an L5 ventral rhizotomy or an L5 ganglionectomy in the rat

An L5 spinal nerve ligation (SNL) in the rat leads to behavioral signs of mechanical hyperalgesia. Our recent finding that an L5 dorsal root rhizotomy did not alter the mechanical hyperalgesia following an L5 SNL suggests that signals originating from the proximal stump of the injured nerve are not essential. We postulate that Wallerian degeneration of L5 nerve fibers leads to altered properties of adjacent intact nociceptive afferents. To investigate the role of degeneration in sensory versus motor fibers, five injury models were examined concurrently in a blinded fashion. An L5 ganglionectomy produced a selective lesion of sensory fibers. An L5 ventral root rhizotomy produced a selective lesion of motor fibers. The three control lesions included: (1) SNL with L5 dorsal root rhizotomy; (2) L5 dorsal root rhizotomy; and (3) exposure of the L5 roots without transection (sham). Paw withdrawal thresholds to mechanical stimuli were measured at three sites in the rat hindpaw corresponding to the L3, L4, and L5 dermatomes. Both the ganglionectomy and the ventral rhizotomy produced a significant, lasting (>or=20 d) decrease of mechanical withdrawal thresholds that was comparable to that produced by the SNL lesion. The L5 dorsal rhizotomy, by itself, produced a short lasting (相似文献   

Mechanosensitivity of dorsal root ganglia and chronically injured axons: A physiological basis for the radicular pain of nerve root compression

The radicular pain of sciatica was ascribed by Mixter and Barr to compression of the spinal root by a herniated intervertebral disc. It was assumed that root compression produced prolonged firing in the injured sensory fibers and led to pain perceived in the peripheral distribution of those fibers. This concept has been challenged on the basis that acute peripheral nerve compression neuropathies are usually painless. Furthermore, animal experiments have rarely shown more than several seconds of repetitive firing in acutely compressed nerves or nerve roots. It has been suggested that "radicular pain" is actually pain referred to the extremity through activation of deep spinal and paraspinal nociceptors. Our experiments on cat lumbar dorsal roots and rabbit sural nerves have confirmed that acute compression of the root or nerve does not produce more than several seconds of repetitive firing. However, long periods of repetitive firing (5-25 min) follow minimal acute compression of the normal dorsal root ganglion. Chronic injury of dorsal roots or sural nerve produces a marked increase in mechanical sensitivity; several minutes of repetitive firing may follow acute compression of such chronically injured sites. Such prolonged responses could be evoked repeatedly in a population of both rapidly and slowly conducting fibers. Since mechanical compression of either the dorsal root ganglion or of chronically injured roots can induce prolonged repetitive firing in sensory axons, we conclude that radicular pain is due to activity in the fibers appropriate to the area of perceived pain.     

Dorsal root section elicits signs of neuropathic pain rather than reversing them in rats with L5 spinal nerve injury

Mechanical allodynia- and hyperalgesia-like behavior which develops in rats after L5 spinal nerve lesion has been suggested to be due to ectopic activity in the lesioned afferent neurons originating at the lesion site and/or in the dorsal root ganglion because it is eliminated by section of the dorsal root. Here we reevaluated the effect of a dorsal rhizotomy in rats after L5 spinal nerve lesion. Using calibrated von Frey hairs, paw withdrawal threshold to single stimuli and paw withdrawal incidence to repetitive stimulation were tested before and after nerve section. Neuropathic pain behavior of similar time course and magnitude also developed after cutting the L5 dorsal root, and L5 spinal nerve lesion-induced abnormal behavior could not be reversed by dorsal rhizotomy. The neuropathic pain behavior elicited by dorsal root section also developed when impulse conduction in the dorsal root axons was blocked during rhizotomy by a local anesthetic, i.e. when the immediate injury discharge was prevented from reaching the spinal cord. These results challenge the widely accepted idea that neuropathic pain behavior developing after spinal nerve lesion is dependent on ectopic activity in the lesioned afferent neurons. However, the present results do not rule out the possibility that after the two nerve lesions the mechanisms generating neuropathic pain behavior are different. After dorsal rhizotomy neuropathic pain behavior may be related to deafferentation whereas after spinal nerve lesion it may be caused by ectopic activity.     

Changes of calcitonin gene-related peptide in primary sensory neurons and their central branch after nerve root compression of the dog

OBJECTIVE: To investigate changes in axonal flow after nerve root compression by using immunohistochemical techniques to detect calcitonin gene-related peptide (CGRP), which is thought to be involved in pain sensation. DESIGN: Experimental, controlled study. SETTING: University medical school in Japan. ANIMALS: Forty adult mongrel dogs (weight, 7-15kg). INTERVENTIONS: In dogs, the lumbar nerve roots were compressed using 4 types of clips with different pressures. Changes of CGRP levels in the spinal dorsal horn, dorsal root, and dorsal root ganglia (DRG) were examined immunohistochemically after compression for 24 hours or for 1 week. MAIN OUTCOME MEASURES: CGRP-positive neurons and CGRP-positive fibers. RESULTS: After compression, axonal flow in the dorsal root was impaired, accumulation of CGRP was observed distal to the site of compression, and the number of DRG cells showing positively for CGRP decreased. Compression for 1 week resulted in a decrease in the number of CGRP-positive fibers in the spinal dorsal horn. CONCLUSIONS: These findings indicate that CGRP dynamics are modified by nerve compression.     

颈神经在颈椎间孔及脊神经沟处受嵌压的解剖学因素

背景神经根型颈椎病中神经根能否受累,不仅与所在骨管是否狭窄、周围软组织是否存在炎性病变和肿胀有关,还与神经根外径的相对大小有关.目的通过颈神经在颈椎间孔及脊神经沟处受累的出现率,探讨神经根型颈椎病发生的解剖学因素.设计单一样本观察.单位承德医学院解剖研究室.对象甲醛固定成尸60具(男28,女32)120侧.方法在60具成尸上,用精确度0.02 mm的游标卡尺和直角规测量①脊神经沟外口宽度及其沟内段脊神经前支横径.②颈椎间孔及其脊神经根的前后径、上下径.计算颈神经前支横径与相应颈椎脊神经沟外口宽度的比值和脊神经根前后径、上下径与相应椎间孔前后径、上下径的比值.得出颈神经前支横径大于或等于脊神经沟外口宽度的出现率和脊神经根各径线大于或等于相应椎间孔各径线的出现率.主要观察指标①C3～6颈神经前支横径大于或等于相应脊神经沟外口宽度的出现率.②C3～6颈神经根上下径、前后径分别大于或等于相应颈椎间孔上下径、前后径的出现率.结果共测量成尸60具120侧(男56侧,女64侧).①颈神经根在椎间孔处可造成嵌压男女合计总出现率为24.6%其中女性明显高于男性(35.2%,10.9%,x2=6.72,P＜0.01).②颈神经前支在颈椎脊神经沟处可造成嵌压男女总出现率为6.3%,其中男性明显高于女性(8.9%,3.9%,x2=6.65,P＜0.01).结论颈神经受累不仅与骨管狭窄有关,而且与周围软组织损伤有关,通过神经根外径与椎间孔的比值和颈神经前支与脊神经沟外口宽度比值,选其≥1的出现率可直接获得神经受压的出现率.     

脑瘫患者脊神经根亚显微病变及意义

目的：探讨脑瘫患儿在其后的生长发育过程中，周围神经受累改变的病理及意义。方法：应用光镜及透射电镜对２０例痉挛型瘫患者脊神经背根进行了亚星微形态学观察。结果：粗有髓神经纤维受累明显，表现为不同程度脱髓鞘病变，轴索病变相对不明显；无髓神经纤维以其周围的雪旺氏细胞病变为主。束内微血管亦有病变。神经受损后无修复与再生现象。结论：本病周围神经的继发性病变不仅广泛存在，且为不可逆性，选择性脊神经背根切断术可以     

Behavioral and electrophysiological effects of various types of peripheral nerve lesions in the rat: a comparison of possible models for chronic pain

Three types of nerve lesions involving the brachial plexus were produced in rats: (1) multiple dorsal rhizotomy; (2) spinal nerve section just distal to the dorsal root ganglia (DRG); (3) section of the median, ulnar and radial nerves. The 3 types of lesion caused self-mutilation (autotomy) of the denervated forelimb. Significant differences were found in the time course and severity of this abnormal behavior among the 3 groups. Rats that had undergone spinal nerve lesion (group 2) performed significantly less severe autotomy than rats with dorsal rhizotomy (group 1) or peripheral nerve lesions (group 3). The latency to the onset of autotomy was significantly shorter for group 2 than for groups 1 and 3. Electrophysiological investigation of rats in group 2 revealed neural activity in the dorsal roots. The characteristics of the neural discharge were largely a function of postoperative survival times. The possible role of the various types of nerve lesion in producing chronic pain states is discussed.     

Mechanical hyperalgesia after an L5 spinal nerve lesion in the rat is not dependent on input from injured nerve fibers

An injury to a peripheral nerve in animals often leads to signs of neuropathic pain including hyperalgesia to heat, cold and mechanical stimuli. The role of injured and intact nerve fibers in mechanical hyperalgesia was evaluated in rats subjected to an L5 spinal nerve ligation-and-cut ('modified SNL lesion'). To assess the contribution of injured afferents, an L5 dorsal rhizotomy was performed immediately before, or 7 days after the modified SNL lesion. To study the role of adjacent intact spinal nerves, an L4 dorsal rhizotomy was performed 7 days after the modified SNL lesion. The up-down method of Dixon (Dixon WJ, Annu Rev Pharmacol Toxicol 1980;20:441-462) was used to measure the paw withdrawal threshold to mechanical stimuli at three sites on the rat hindpaw corresponding to the L3, L4, and L5 dermatomes. We found that the modified SNL lesion produced a significant, lasting (20 days) decrease of the mechanical withdrawal threshold. The severity and duration of mechanical hyperalgesia varied across testing sites. The L5 and L4 dermatome test sites developed the most severe and lasting mechanical hyperalgesia. In contrast, the L3 testing site developed significantly less severe and shorter lasting mechanical hyperalgesia. L5 dorsal rhizotomy, by itself, produced a transient decrease in mechanical withdrawal thresholds. L5 dorsal rhizotomy performed before, or 7 days after, the modified SNL lesion did not prevent or resolve the observed decrease in mechanical withdrawal thresholds. L4 dorsal rhizotomy performed 7 days after the modified SNL lesion resulted in an immediate reversal of mechanical withdrawal thresholds back to baseline values. These results suggest that, after L5 spinal nerve ligation-and-cut, mechanical hyperalgesia develops and persists independent of input from injured afferents. We propose that the Wallerian degeneration that develops after a nerve injury leads to interactions between the degenerating fibers of the injured spinal nerve and the intact fibers of adjacent spinal nerves. This leads to changes in the intact fibers that play a critical role for both initiation and maintenance of mechanical hyperalgesia.     

周围动脉闭塞性病变治疗前后脊髓及背根神经节P物质的变化

背景:周围动脉闭塞性病变是一种常见的周围动脉疾病,发病机制及病变过程尚不完全明确,其临床症状多较重,且治疗效果不佳。目的:观察肢体负压对周围动脉闭塞性病变犬中枢神经脊髓及背根神经节中P物质免疫反应阳性神经纤维的影响。设计:随机对照的实验研究。单位:武警陕西总队医院麻醉科和解放军第四军医大学西京医院普外三科。对象:实验于2003-04/2004-05在解放军第四军医大学西京医院动物实验室完成。选用健康杂种清洁级犬17只,体质量12～18kg,动物编号后,按随机数字表法分为3组,治疗组10只,非治疗组5只,正常对照组2只。方法:将治疗组动物制作左后肢缺血模型,在造模后14d开始行患肢负压治疗,1次/d,15min/次,负压治疗10d后行动物灌注。分别切取L1～L5的脊髓及背根神经节,行免疫组织化学染色,检测P物质免疫反应阳性神经纤维;非治疗组除不进行患肢负压治疗外,处理、检查均同治疗组。正常对照组不行缺血模型制作及负压治疗,仅行免疫组织化学染色检测。主要观察指标:各组犬脊髓及背根神经节的感觉神经纤维中P物质的变化。结果:非治疗组脊髓及背根神经节中,患侧P物质免疫反应阳性纤维(平均灰度值分别为:70.20±3.70,67.00±3.30)较正常对照组(20.00±2.80,35.50±6.40)染色明显加深,而治疗组(48.50±6.60,51.70±4.00)较非治疗组染色变浅,但仍较正常对照组加深(P均<0.01)。结论:周围动脉闭塞性疾病发病后,脊髓及背根神经节中的P物质免疫反应阳性神经纤维数量明显增多,可能是机体的一种自身保护机制。肢体负压疗法可减少肢体动脉闭塞性病变伤害性刺激的传入,缓解肢体疼痛。