侧侧缝合法治疗周围神经损伤的临床应用初步报告

目的应用侧侧缝合法治疗周围神经损伤。方法选择10例不适宜施行常规修复方法的周围神经损伤病例,损伤至修复术的时间为1～10个月,平均4个月。将受损神经的适宜部位与相邻神经干并拢,纵行切开两神经相邻面的神经外膜和束膜1～2cm后,侧侧紧密对合,以9/0～11/0无损伤线侧侧缝合切开的束膜和外膜。手术前后所有患者均经过临床检查和肌电图检查。结果9例患者经3个月～3年随访,平均16个月。6例达到主要支配区的M3S3级,3例达到M2S3-级,供体神经术后功能无明显影响,有4例从M5S5级下降至M4S4级,3周～3个月后恢复正常。结论神经侧侧缝合法可作为一种不能用常规方法修复的损伤神经的补救性治疗方法。     

周围神经侧侧缝合法的实验研究

目的 提出一种修复周围神经操作的新方法－－侧侧缝合法,并对侧侧缝合后神经的再生模式进行初步研究。方法 选用ＳＤ雄性大鼠１２只,双下肢随机分为实验侧和对照侧。实验侧：将腓总神经在大腿下１／３处切断,断端结扎后将其远端与相邻胫神经干适当松解后靠拢,纵行切开两神经相邻侧面的神经外膜、束膜长约０．５ｃｍ,至部分神经纤维外露。紧密对合两切开面后缝合束膜、外腊。对照侧：腓总神经在相同部位切除０．５ｃｍ,至部分     

胫-腓总神经侧侧缝合治疗下肢痉挛性脑瘫近期效果观察

目的：提出一种治疗下肢痉挛性脑瘫的新方法并探讨其机制。方法：6例下肢痉挛性脑瘫患者。将支配痉挛肌群和支配其拮抗肌群的胫神经和腓总神经干进行侧侧缝合；大腿后侧切口显露两神经干的近端约5cm后相互靠拢，切开两神经相邻面的神经外膜和束膜约2cm，切至神经纤维后，再相互并拢缝合外膜。4例患者手术同时辅以内收肌切断或跟腱延长术。结果：经过5-10个月的随访，6名患者的肢体痉挛，畸形均有缓解，其中5例患儿在不附加额外刺激的情况下，已无痉挛发作，恢复了患肢的主要功能。肢体功能尚随着时间的延长而进一步改善。结论：胫-腓总神经侧侧缝合后，脑瘫患者术后痉挛肌群可获得部分拮抗肌群神经的支配从而通过改变大脑皮层定位来最终缓解肢体痉挛，是治疗脑瘫的新的有效方法之一。     

神经束间侧侧缝接预防高位神经损伤后不可逆肌萎缩

目的探讨一种预防高位神经损伤后远端效应器官不可逆性肌肉萎缩的新方法。方法首先将高位神经损伤处如臂丛根、干部、坐骨神经出口部等,常规进行探查修复。然后在尽量接近受损伤神经所支配的主要效应器官的部位,将损伤神经与邻近的正常神经相互靠拢,切开两神经相对应侧的神经外膜和束膜1～1.5cm后,将切开处相互紧密并拢,用9-0～11-0显微外科针线分别将两条神经的束、外膜相互侧侧缝合。结果21例患者经术后2～5年(平均3.2年)随访,其中5例达到M4/S4,8例达到M3/S3,5例为M3/S2,3例为M2/S2。明显优于对照组相同部位损伤采用相同方法修复但未做远端侧侧缝合的病例,因为后者无1例达到M4/S4。结论高位神经损伤在进行常规修复的基础上,将其远端与邻近的正常神经行侧侧缝合对预防远端效应器官的不可逆性肌萎缩有一定效果。     

神经端侧缝合重建腓肠神经营养血管逆行皮瓣感觉功能的临床观察

目的　研究重建腓肠神经营养血管逆行皮瓣感觉功能的方法 ,探讨神经端侧缝合法重建皮瓣感觉的效果。　方法　在小腿后侧设计及切取腓肠神经营养血管皮瓣 ,逆行转位修复足部皮肤软组织缺损 8例 ,皮瓣切取时 ,保留腓肠神经近端足够长一段 ,与皮瓣受区供体神经呈 3 0°～ 45°端侧缝合 ,于术后 2、4、8、16、2 4周检测皮瓣的感觉及植物神经功能。　结果　 8例皮瓣完全成活 ,随访 4～ 18个月 ,术后 4周起皮瓣感觉开始有不同程度的恢复 ,随时间延长恢复程度和范围增加 ;术后 16周进行感觉功能评定 ,S2 2例 ,S2 3例 ,S3 3例 ;供体神经功能无明显影响。　结论　神经端侧缝合法可重建腓肠神经伴行血管逆行皮瓣的感觉功能 ,操作简便 ,对手足外科有重要意义。     

周围神经侧侧吻合治疗痉挛性脑瘫初步报告

目的：用周围神经侧侧吻合术治疗肢体痉挛性脑瘫并探讨其机制。方法：对１６例肢体痉挛性脑瘫患者采用正常神经干与病变神经干的侧侧吻合术,即将支配痉挛肌群的主要神经干与相对正常的邻近神经干的近端显露出５～６ｃｍ后相互靠拢,切开两神经相邻面的神经外膜和束膜１～２ｃｍ,直至神经纤维裸露后相互紧密对合再吻合其束外膜。结果：经１０～３９个月（平均２４个月）的随访,所有患者的肢体痉挛、畸形均有明显的缓解,其中６例患     

肌皮神经与尺神经端侧缝合重建屈肘功能的实验研究

目的 研究周围神经端侧缝合后侧支发芽再生能力及用于臂丛上干撕脱伤重建屈肘功能的可行性.方法 选用24只Wistar大鼠.左前肢为实验侧:于距肱二头肌入肌点12mm处切断肌皮神经,远断与外膜开窗1.0mm×0.5mm的尺神经做端侧缝合.右前肢为对照侧:切断1/2尺神经束,近端与肌皮神经远断端做端端外膜缝合.按取材时间随机分为A、B、C三个时间组,每组8只,分别于术后3、6、12周取材,进行大体观察.神经组织学、电生理、肱二头肌收缩力和肌湿重、辣根过氧化物酶(HRP)示踪检测.结果A组实验侧再生纤维数目和B组实验侧动作电位振幅、潜伏期与对照例相比有显著性差异(P<0.01),实验侧均低于对照例.随术后时间的延长,其余各项指标无显著性差异(P>0.05).结论 肌皮神经与尺神经端侧缝合后确实存在侧支发芽能力,并获得部分神经肌肉功能恢复,为临床治疗臂丛神经上干撕脱伤重建屈肘功能提供了新思路.     

神经端侧吻合重建游离皮瓣感觉功能的临床效果

目的 探讨神经端侧吻合法重建游离皮瓣感觉功能的临床效果. 方法 对软组织缺损面积为9 cm×5 cm～24 cm× 10cm的病例,根据软组织缺损的部位及大小应用股前外侧游离皮瓣修复18例,应用足背动脉游离皮瓣修复4例.游离皮瓣时,切取股前外侧皮瓣上的股外侧皮神经及足背动脉皮瓣上的腓浅神经,将皮神经与肢体创面周围的供体神经呈30°～45.角端侧吻合,术后2、4、8、16和24周检测皮瓣的感觉功能,感觉功能的评定按照英国医学研究会提出的标准进行. 结果 22例皮瓣全部成活,2例皮瓣部分裂开,1例皮瓣皮缘部分坏死,经换敷料或清创缝合后愈合,供区伤口均Ⅰ期愈合.随访6～24个月,供区瘢痕轻,其中足背供区植皮成活后未出现皮肤磨损等;受区功能恢复良好,术后4周起皮瓣痛触及两点辨别觉等感觉有恢复,术后16周起皮瓣的感觉均达S2以上,恢复了保护性感觉,自主神经功能有部分恢复,未影响供体神经功能. 结论 根据创面的部位及大小,选择合适的游离皮瓣进行修复,利用神经端侧吻合重建皮瓣的感觉功能,能达到较好的临床效果.     

神经端侧缝合术后远期疗效的临床观察

目的 探讨周围神经断伤行端侧缝合术后的远期疗效。方法 对12例周围神经断伤作端侧缝合术。其中，前臂尺神经长段缺损3例，远断端与邻近正中神经干作端侧缝合；腓肠神经小腿中下段缺损7例，远断端与邻近腓浅神经干作端侧缝合；腓总神经膝上长段缺损2例，远断端与胫神经干在膝部作端侧缝合。对照组6例，皆为腓肠神经小腿中下段的缺损，远断端未作处理。术后连续随访3～5年。结果 缺损神经支配区感觉功能有所恢复，而运动功能恢复不明显。结论 神经端侧缝合后感觉功能有一定的恢复，运动功能恢复差，临床应谨慎选择使用。     

应用神经转位重建足底感觉功能

[目的]探讨神经转位方法重建足底感觉功能的效果。[方法]对足踝以下感觉均丧失者，选用隐神经为供体神经：于小腿中上1／3内后缘作纵行切口长约10cm，于皮下分离出隐神经后切断。于胫骨内后缘分开小腿三头肌显露胫神经，切断部分神经纤维后将隐神经近断端植入其中后行束外膜联合缝合。对于足背及外侧感觉存在而足底足趾感觉丧失者，选用腓肠神经作为供体神经：于外踝后缘向远端行纵切口长约5cm，游离出腓肠神经切断。内踝后方作长约5cm弧形切口，显露胫神经，切开神经外膜并切断部分神经纤维。于跟腱前方间隙打通隧道，将腓肠神经经隧道引至胫神经切开处植入，行束外膜联合缝合。[结果]本组9例患者均得到术后1．5～2年（平均21个月）的随访，顺向电生理检测法测定胫神经感觉传导速度为36．1～41．2（平均38．3）m／s：波幅（峰-峰波幅）在7～15．3μV（平均11．2μV）。9例患者均恢复了足底部痛、触觉。3例患者的两点辨别觉恢复正常。所有患者对行走过程满意，基本无定位错觉等不适情况。所有患者的足部肌肉未出现萎缩。神经供区感觉缺失在腓肠神经者只出现在外踝下方足的外侧区，在隐神经者出现在踝前方的小片区域，对下肢的功能无影响。[结论]应用神经转位的方法可有效的重建足底感觉功能。     

肢体恶性肿瘤侵害周围神经干的临床与病理观察

目的观察受肿瘤侵害的神经干组织学形态,探讨肿瘤侵害神经干的发生机制。方法12例肢体恶性肿瘤伴有神经损害症状的截肢标本,解剖出受侵段神经干。大体观察及石蜡切片,HE染色、变色酸染色,显微镜下观察。结果12例中,7例神经受肿瘤挤压、推移,但神经外膜完好,无肿瘤细胞浸润。3例神经干一侧面受侵及,神经外膜不完整。肿瘤细胞侵及神经外膜,轴突增粗、空泡变及脱髓鞘。2例神经干完全受侵及,神经外膜完全破坏,肿瘤细胞侵及神经束膜。结论肢体恶性肿瘤早期对神经干以机械性压迫损害为主,随病程进展,肿瘤细胞侵及神经外膜,甚至神经束膜。     

Morphology of peripheral nerves, their sheaths, and their vascularization

This review aims to update our understanding of peripheral nerves, including the nature and function of their sheaths and, finally, their vascularization. The peripheral nervous system is made up of nerves whose function is to gather stimuli from the periphery as well as to transport the motor, secretory or vegetative responses that are triggered to the periphery. The connective tissue surrounding peripheral nerves all along their extension is made up of endoneurial, perineurial and epineurial. The endoneurium surrounds individual axons, which are grouped in fasciculi, each of which is surrounded by the perineurium and finally, the group of fasciculi that comprise all the axons present in this nerve are surrounded by the epineurium. Axons form an intraneural plexus such that they occupy positions in the various fasciculi along the trajectory of the plexus. The number and size of fasciculi vary along the trajectory of a nerve as a result of the plexus positioning of the axons. Peripheral nerves are richly vascularized throughout their length, with multiple anastomoses forming the intraneural vascular network, which is made up mainly of arterioles, capillaries, postcapillary venules and venules. Regarding the blood-nerve barrier and the existence of capillary permeability: endoneural capillaries have junctions that are stronger than those of the endothelial cells of vessels in the epineurium and perineurium. Two distinct lymph channels networks are present in the peripheral nerve stems and are separated by the perineural barrier. The nervi-nervorum are special nerves of a sympathetic and sensory nature that arise from the nerve itself and the perivascular plexuses.     

Electron microscopy evaluation of block needle‐related trauma to the tibial nerve

Background: Direct puncture by a needle is a risk factor for nerve damage. This investigation used scanning electron microscopy (SEM) to attempt to visualize the damage caused by different needles. Method: A 15 cm section of the tibial nerve was removed from the ankle of a patient undergoing below‐the‐knee amputation. The nerve specimen was punctured perpendicular to the fibers once by each of four needles: an insulated 22 G short‐beveled (30°), a 25 G long‐beveled Quincke spinal needle, an 18 G Tuohy, and a 25 G Whitacre pencil point. The distal and proximal ends on either side of the needles were marked and the nerve was sectioned into 0.5 cm pieces. Each sample was preserved and then prepared for SEM. The needle tract was observed for evidence of mechanical damage at magnifications between × 47 and × 102 using SEM. Results: The epineurium, perineurium, fascicles, endoneurium, and vessels were identified in each sample. In both the short‐beveled and the Whitacre samples, all fascicles along with the surrounding perineurium were intact. In both the Tuohy and the Quincke samples, obvious transection of fascicles and disruption of the perineurium were observed. Conclusions: This investigation suggests that both the Tuohy and the Quincke needles may be more likely to cause trauma to the tibial nerve than either the short‐beveled or the Whitacre needles.     

带血供尺神经转位重建截瘫患者下肢功能

目的:探讨应用带血供的尺神经转位与股神经吻合重建完全性截瘫患者下肢功能的方法及效果。方法:1996年6月～2004年12月共收治19例陈旧性完全性脊髓损伤后截瘫患者,损伤平面T2～T8,Frankel分级均为A级,受伤时间至本次手术时间1.1～3.5年,平均1.65年。采用自体一侧尺神经作为供体神经,自皮下隧道转位至腹股沟区,尺神经主干与股神经深支缝接,尺神经手背支与股神经浅支缝接,用尺侧屈腕肌支和指深屈肌支与闭孔神经缝接。随访观察治疗效果。结果:术后随访2～7年,按照周围神经损伤修复术后功能评价标准进行评定,髂腰肌肌力恢复至3级以上者达46%;股四头肌肌力恢复至3级以上者达75%;下肢深感觉均有恢复。在供区有16例(占95%)患者维持其正常的手内肌功能。结论:保留血供的尺神经转位与股神经吻合可有效重建陈旧性胸段脊髓完全性横断伤患者的部分下肢功能。     

Carpal tunnel syndrome due to fibrolipomatous hamartoma of the median nerve

Nervous lipofibromatous hamartoma is a rare tumor-like condition involving the peripheral nerves, whereby the epineurium and perineurium are enlarged and distorted by excess of fatty and fibrous tissues that infiltrate between and around nerve boundaries. The median nerve is much more likely to develop a hamartoma than other nerves with a predilection for the carpal tunnel. We present a case of carpal tunnel syndrome in an adult caused by fibrolipomatous hamartoma of the median nerve, successfully removed by excision of the fibrolipomatous tissue and decompression.     

Primary repair of crush nerve injuries by means of biological tubulization with muscle-vein-combined grafts

Despite extensive research and surgical innovation, the treatment of peripheral nerve injuries remains a complex issue, particularly in nonsharp lesions. The aim of this study was to assess the clinical outcome in a group of 16 patients who underwent, in emergency, a primary repair for crush injury of sensory and mixed nerves of the upper limb with biological tubulization, namely, the muscle-vein-combined graft. The segments involved were sensory digital nerves in eight cases and mixed nerves in another eight cases (four median nerves and four ulnar nerves). The length of nerve defect ranged from 0.5 to 4 cm (mean 1.9 cm). Fifteen of 16 patients showed some degree of functional recovery. Six patients showed diminished light touch (3.61), six had protective sensation (4.31), and three showed loss of protective sensation (4.56) using Semmes-Weinstein monofilament test. All the patients who underwent digital nerve repair had favorable results graded as S4 in one case, S3+ in six cases, and S3 in one case. With respect to mixed nerve repair, we observed two S4, two S3+, two S3, one S2, and one S0 sensory recovery. Less favorable results were observed for motor function with three M4, one M3, two M2, and two M0 recoveries. Altogether, the results of this retrospective study demonstrates that tubulization nerve repair in emergency, in case of short nerve gaps, may restore the continuity of the nerve avoiding secondary nerve grafting. This technique preserves donor nerve and, in case of failure, does not preclude a delayed repair with a nerve graft.     

Contralateral C7 transfer for the treatment of brachial plexus root avulsions in children - a report of 12 cases

PURPOSE: To retrospectively determine the risks and benefits of contralateral C7 nerve root transfer in infants and children. METHODS: In 12 infants and children with brachial plexus root avulsions from birth injury or other trauma, the common trunk of the contralateral C7 root was transferred to the trunk, division, cord, or nerve branch(es) on the affected side with 2 different types of interposition grafts. The surgery was performed in 1 stage for 5 patients and in 2 stages for 7 patients. RESULTS: Patients were followed up for a mean of 42 months, with a minimum of 21 months. Noteworthy function (> or = M2+, modified British Medical Research Council grading system) was gained in 10 of 12 patients and sensory function (> or = S3, British Medical Research Council grading system) was gained in all patients. Improvements in strength and sensation were accompanied by little synchronous motion and sensibility changes in the donor limb in 7 children, to whom the repaired nerves were those innervating the shoulder and/or elbow or both the musculocutaneous and median nerves. In addition to slight damage to the sensory function of the median nerve, 2 infants also had temporarily reduced shoulder abduction on the healthy side. CONCLUSIONS: For contralateral C7 transfer in infants and children with brachial plexus root avulsions, the deficit created by the procedure is minimal and motor and sensory function is gained. Transfer of the contralateral C7 root to different nerves for a child may improve the quality of functional recovery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Nerve repair using freezing and fibrin glue: Immediate histologic improvement of axonal coaptation

Despite the fine microsurgical techniques available, injuries to peripheral nerves are still a surgical problem. Sutures placed in the epineurium or perineurium cause compression, brushing, and misdirection of endoneural tissue. A technique of nerve repair using freezing to trim the nerve and fibrin glue to coat it before thawing is described. The entire surgical repair procedure is carried out with the nerve stumps frozen. The observed axonal alignment with this technique was much better than that obtained by microsuture alone. © 1993 Wiley-Liss Inc.     

大鼠脊髓损伤后膀胱生理反射弧重建的实验研究

目的 探讨利用截瘫平面以上健存的神经根,与硬脊膜内骶神经前后根分别吻合,建立人工膀胱反射通路,重建膀胱生理反射弧的有效性.方法 取3月龄雄性SD大鼠20只,体重250～300 g;右侧为实验侧,左侧为对照侧.将大鼠右侧L5前根近端与右侧S2前根远端,L5后根近端与S2后根远端在硬脊膜囊内分别行显微缝合,同时修复重建膀胱的感觉与运动功能,建立人工膀胱生理反射弧.左侧不作任何处理.于术后5个月,在破坏L6～S4节段脊髓制备完全性截瘫前后,分别进行电生理检查及膀胱内压测定.结果 18只大鼠存活至术后5个月,9只大鼠成功分离出吻合的神经根,获得实验结果.实验侧截瘫前后,单相方波(3mA、0.3ms)刺激S2后根吻合口远端,均可记录到膀胱神经丛动作电位,波幅分别为(0.10±0.02)mV和(0.11±0.03)mV,差异无统计学意义(P>0.05);串刺激(3mA、20Hz、5 s)S2后根,均可记录到膀胱平滑肌复合肌肉动作电位,其波幅分别为(0.11±0.02)mV和(0.11±0.03)mV,差异无统计学意义(P>0.05).刺激S2后根吻合口远端,经新建的人工膀胱反射弧引出的膀胱内压分别为(6.55±1.33)cmH2O和(6.11±2.01)cmH2O,差异无统计学意义(P>0.05).对照侧截瘫前刺激S2后根,引出的膀胱神经丛动作电位波幅为(0.144±0.02)mV,膀胱平滑肌复合肌肉动作电位波幅为(0.17±0.02)mV,膀胱内压为(10.77±1.78)cmH2O,均大于实验侧截瘫前后(P<0.01).而电刺激对照侧截瘫后S2后根,不能引出膀胱神经丛动作电位、平滑肌复合肌肉动作电位,膀胱内压无变化.结论 利用截瘫平面以上健存的神经根,通过与硬脊膜内骶神经前后根分别吻合,可建立完整的人工膀胱反射弧,有望实现截瘫患者自主性排尿.