副神经移位膈神经后膈肌运动诱发电位与病理学对照研究

[目的]探讨副神经移位膈神经重建高位颈髓损伤大鼠呼吸功能后膈肌的病理学变化及膈肌运动诱发电位(motion evoked potential,MEP)的特点。[方法]健康雄性SD大鼠60只。随机分为1～6个月6个时间组。取下颈部正中切口,将双侧副神经在锁骨下水平发出内、外侧支之前切断,移位缝接膈神经干起始部。术后第1～6个月各组样本取颈后正中切口,切除C3全椎板充分显露颈髓并于C3、4水平锐性横断。证实胫前肌MEP完全消失后,于两侧腋前线肋下缘作切口,显露该处膈肌腹腔侧。直视下将同心针电极于腋前线第9肋骨下缘垂直胸壁插入膈肌肋部,监测其MEP的变化。然后完整取出膈肌,于电子天平称重。并于右侧腋前线顺膈肌肌纤维方向切取2 mm宽肌条行HE染色。分析膈肌肌纤维截面积的变化。[结果]神经移位后随着时间延长,大鼠膈肌MEP潜伏期逐渐缩短,波幅逐渐增大。6个月组MEP波幅为(6.35±0.51)mV,潜伏期为(3.41±0.36)m s。同时,膈肌逐渐饱满,肌重逐渐恢复,6个月为正常对照组的(97.23±4.07)%。肌纤维截面积也逐渐增大,6个月组达(1 741±439)μm2为正常对照组(1 809±461)μm2的(98.28±3.65)%。6个月组的各数据与对照组比无显著差异(P>0.05)。[结论]从电生理及病理学来看副神经可作为运动神经移位膈神经重建高位颈髓损伤后呼吸功能。     

副神经移位膈神经后高位颈髓损伤大鼠血气分析指标变化特点研究

[目的]探讨副神经移位膈神经重建高位颈髓损伤大鼠呼吸功能时血气分析指标的变化特点.[方法]健康雄性SD大鼠60只.随机分为1、2、3、4、5、6个月6个时间组.取下颈部正中切口,将双侧副神经在锁骨下水平发出内、外侧支之前切断,移位缝接膈神经干起始部.术后第1、2、3、4、5、6个月各组样本取颈后正中切口,切除C3全椎板充分显露颈髓并于C3、4水平锐性横断.分别于横断C3、4脊髓后10、30 min于颈总动脉处插管抽取动脉血各0.2 ml.利用ABL50型血气分析仪(雷度公司,丹麦产)进行pH值、氧分压、二氧化碳分压及血氧饱和度的监测.此后,每30 min检测1次.同时测定10只正常SD大鼠血气指标作为对照.[结果]C3、4脊髓横断后10 min,第1、2个月组大鼠呼吸停止,血氧饱和度为0及(1.9±0.7)%.3个月组大鼠表现出严重呼吸性酸中毒,pH值为7.19±0.04,PCO2为(73.5±6.17)mmHg(1 mmHg=0.133 kPa),PO2为(32.7±4.26)mmHg,SO2为50.7%±8.93%,(18±5)min后呼吸停止.4个月组大鼠出现轻度CO2潴留,SO2为(88.6±4.02)%,30 min后为(57.1±6.27)%.5、6个月组大鼠血气分析指标正常,正常值维持时间第5个月组为(176.31±22.53)min,第6个月组为(58.70±12.62)h.[结论]从血气分析指标变化来观察,副神经移位膈神经可能是重建高位颈髓损伤后呼吸功能的一种治疗方法.     

Plication of the diaphragm for symptomatic phrenic nerve paralysis

Paralysis of the diaphragm in infants may produce severe respiratory difficulty because of the paradoxic motion of the affected diaphragm and shift of a mobile mediastinum to the contralateral side. Six infants with diaphragmatic paralysis and severe respiratory distress underwent plication of the diaphragm by a simple technique. Five of the six infants had significant improvement in respiratory effort and were ultimately weaned from ventilatory support. One patient with bilateral paralysis had only minimal improvement. Diaphragmatic function returned in two patients after plication. Plication of the diaphragm is a safe and useful procedure to improve ventilation in infants with a paralyzed diaphragm. Since this technique does not prevent return of diaphragmatic function, it should be employed prior to the development of sequelae of prolonged assisted ventilation and sooner if the phrenic nerve is permanently injured.     

Treatment for bilateral diaphragmatic dysfunction using phrenic nerve reconstruction and diaphragm pacemakers

 Open in a separate windowOBJECTIVESBilateral diaphragmatic dysfunction results in severe dyspnoea, usually requiring oxygen therapy and nocturnal ventilatory support. Although treatment options are limited, phrenic nerve reconstruction (PR) offers the opportunity to restore functional activity. This study aims to evaluate combination treatment with PR and placement of a diaphragm pacemaker (DP) compared to DP placement alone in patients with bilateral diaphragmatic dysfunction. METHODSPatients with bilateral diaphragmatic dysfunction were prospectively enrolled in the following treatment algorithm: Unilateral PR was performed on the more severely impacted side with bilateral DP implantation. Motor amplitudes, ultrasound measurements of diaphragm thickness, maximal inspiratory pressure, forced expiratory volume, forced vital capacity and subjective patient-reported outcomes were obtained for retrospective analysis following completion of the prospective database.RESULTSFourteen male patients with bilateral diaphragmatic dysfunction confirmed on chest fluoroscopy and electrodiagnostic testing were included. All 14 patients required nocturnal ventilator support, and 8/14 (57.1%) were oxygen-dependent. All patients reported subjective improvement, and all 8 oxygen-dependent patients were able to discontinue oxygen therapy following treatment. Improvements in maximal inspiratory pressure, forced vital capacity and forced expiratory volume were 68%, 47% and 53%, respectively. There was an average improvement of 180% in motor amplitude and a 50% increase in muscle thickness. Comparison of motor amplitude changes revealed significantly greater functional recovery on the PR + DP side.CONCLUSIONSPR and simultaneous implantation of a DP may restore functional activity and alleviate symptoms in patients with bilateral diaphragmatic dysfunction. PR plus diaphragm pacing appear to result in greater functional muscle recovery than pacing alone.     

副神经移位膈神经重建高位颈髓损伤患者呼吸功能的解剖学研究

目的 :探讨副神经移位膈神经重建高位颈髓损伤患者呼吸功能的解剖学可行性。方法 :选取经福尔马林固定的成人尸体30具,解剖分离颈部双侧膈神经及副神经共60侧,测量副神经主干终点(设定为副神经进入斜方肌处)及膈神经起始点的宽度及厚度、副神经出胸锁乳突肌外侧缘点至膈神经主干起始点及终点的距离、胸锁乳突肌外侧缘与斜方肌内侧缘之间的副神经长度,寻找副神经沿胸锁乳突肌外侧缘斜出的位置、副神经起始点与甲状软骨的位置关系及副神经入斜方肌内侧缘的位置与锁骨中线的关系。选取5具尸体(10侧)的副神经主干终点及膈神经起始点标本,进行切片、免疫组织化学染色,计数运动神经纤维含量。结果:副神经进入胸锁乳突肌后,5侧穿过胸锁乳突肌下行,55侧在胸锁乳突肌的深面继续向下外穿行,其在胸锁乳突肌后缘,距胸锁乳突肌锁骨止点85.2±5.9mm处浅出;在肩胛提肌表面,副神经越过颈后三角行至斜方肌前缘于锁骨中线内侧13.2±1.9mm处进入斜方肌,于斜方肌深面分为2~5支支配斜方肌。副神经主干终点的宽度为1.61±0.39mm,厚度为0.61±0.23mm,胸锁乳突肌外侧缘与斜方肌内侧缘之间的副神经长度为59.2±12.2mm。16侧膈神经起始点位于甲状软骨的中点水平,32侧位于甲状软骨上缘水平,6侧位于甲状软骨下缘水平,6侧位于甲状软骨上1/3水平。膈神经起始点处的宽度为1.43±0.27mm,厚度为0.60±0.26mm,副神经胸锁乳突肌外侧缘点至膈神经起始点的距离为26.9±6.0mm,至膈神经终点的距离为76.7±8.2mm。胸锁乳突肌外侧缘与斜方肌内侧缘间的副神经长度大于副神经胸锁乳突肌外侧缘至膈神经起始点的距离(P=0.000)。膈神经起始点的运动神经纤维含量为836±311条,副神经主干终点的运动神经纤维含量为1290±371条,两者比较差异有统计学意义(P=0.019)。结论:胸锁乳突肌外侧缘与斜方肌内侧缘之间的副神经长度明显大于副神经胸锁乳突肌外侧缘点至膈神经起始点的距离,从解剖学的角度证明了在不损伤胸锁乳突肌的情况下副神经可与膈神经起始点无张力直接吻合。     

膈肌损伤诊断与治疗的探讨

目的探讨膈肌损伤的诊断与治疗方法。方法对12例膈肌损伤病人临床资料进行回顾性分析,其中11例为闭合性损伤,1例为穿透性损伤,均合并其他脏器损伤,予手术治疗,经胸手术1例,经腹手术7例,经胸腹切口手术4例,术前确诊10例,术中应用胸腔镜辅助治疗12例。结果12例均治愈,无并发症。结论胸部X线及胸腹CT检查是最可靠的诊断方法,并对手术入路选择最有帮助。手术是治疗膈肌损伤的惟一方法,手术入路要视胸、腹部损伤情况而定。     

Sudden severe postoperative dyspnea following shoulder surgery: Remember inadvertent phrenic nerve block due to interscalene brachial plexus block

Advanced imaging techniques, improved operative techniques, and instrumentation combined with better patient awareness and expectations have resulted in an exponential increase in upper limb surgical procedures during recent times. Surgical teams expect superior analgesia and regional blocks have matched these expectations quite often resulting in improved patient satisfaction and early rehabilitation to achieve best results. Ultrasound-guided interscalene brachial plexus block (ISB) is commonly used to provide analgesia for procedures involving shoulder girdle. We report a case of symptomatic hemi-diaphragmatic paresis (HDP) due to the phrenic nerve block following ISB for arthroscopic sub-acromial decompression of the shoulder presenting as severe postoperative dyspnea. There is strong evidence of HDP following ISB in anesthetic literature, but not reported in related surgical specialties such as orthopedics. We wish to inform upper-limb surgeons and educate junior doctors and other ancillary staff working in upper-limb units to be aware of this serious but reversible complication.     

Inhibition of phrenic nerve activity during positive-pressure ventilation at high and low frequencies

A study was made to determine whether the ventilatory pattern, in terms of ventilatory frequency, insufflation period and end-expiratory pressure, influences the arterial blood gas level at which central inspiratory activity is inhibited, and whether further expansion of the lung changes this activity. This was accomplished by measuring arterial pH and blood gases, and intratracheal, intrapleural and transpulmonary pressures, at the setting of positive-pressure ventilation causing inhibition of phrenic nerve activity in chloralose-anaesthetized cats. Spontaneous breathing movements were prevented by muscle relaxation. Ventilatory frequencies of 15-120 breaths per minute (b.p.m.) were studied at at least two different insufflation times. A volume-controlled ventilator with a large compressible volume was used in the frequency range 15-45 b.p.m. and a constant flow respirator with a low-compressible volume in the range 45-120 b.p.m. A much lower PCO2 was needed for phrenic nerve activity to be inhibited at a ventilatory frequency of 15 b.p.m. than at higher frequencies. At ventilatory frequencies between 30 and 120 b.p.m. inhibition could be achieved at a higher PCO2, within the normal range. The inhibition of phrenic nerve activity tended to be less stable when PEEP was added during ventilation with a long insufflation period, but PEEP did not influence the arterial blood gas level at which inhibition occurred. In the lower frequency range of 15-30 b.p.m., inspiratory activity was observed with bursts at the same rate as the insufflations given by the ventilator. The intratracheal peak pressures at ventilation causing inhibition of phrenic nerve activity decreased with increasing ventilatory frequencies.(ABSTRACT TRUNCATED AT 250 WORDS)     

Anatomical variations of the phrenic nerve and its clinical implication for supraclavicular block

This paper reports a case of simultaneous diaphragmatic andbrachial plexus stimulation followed by a successful nerve blockusing the supraclavicular approach. An explanation for the qualitativedifferences in phrenic nerve block between interscalene andsupraclavicular block is postulated, based on known anatomicalvariations. Br J Anaesth 2003; 91: 916--17     

Thoracoscopic intercostal to phrenic nerve transfer for diaphragmatic reanimation in a child with tetraplegia

Context: To describe for the first time a novel technique of thoracoscopic intercostal nerve mobilization and intercostal to phrenic nerve transfer in the setting of tetraplegia with the goal of reanimating the diaphragm and decreasing ventilator dependence.Findings: A 5-year-old female on 24 h ventilator support secondary to traumatic tetraplegia was evaluated for possible phrenic nerve pacing. Left-sided phrenic nerve stimulation did not result in diaphragmatic contraction indicating a lower motor neuron injury. The patient underwent thoracoscopic mobilization of the left phrenic nerve and 10th intercostal nerve while positioned in the left lateral decubitus position using four 5 mm trocars. The mobilized intercostal nerve was transected close to its distal anterior termination and coapted without tension to the cut end of the terminal phrenic nerve using fibrin sealant. Lastly, phrenic nerve pacer leads and battery were implanted in the chest wall and connected to the electrode placed on the intercostal nerve. One year following the procedure, the patient was tolerating phrenic pacing during the day while requiring ventilation overnight. Currently, the patient is 2 years post-operative from this procedure and does not require ventilator support.Conclusion/clinical relevance: We have shown for the first time a novel approach of thoracoscopic nerve mobilization and phrenic to intercostal nerve transposition to be both safe and effective for restoring innervation of the diaphragm in a child. This minimally invasive procedure is recommended as the preferred approach to reanimate the diaphragm.     

单纯钩骨钩骨折致尺神经深支损伤的临床研究

目的探讨单纯钩骨钩骨折致尺神经深支损伤的致病机理。方法采用16侧甲醛固定和4侧新鲜成人尸体标本。以钩骨钩中点为O,过O点作一条水平线及垂线,水平线与尺神经深支的交点为A点,与钩骨钩基底尺侧交点为B点,垂线与尺神经的交点为C点,分别测量OA、OB、OC、AB长度,并进行统计学分析;对1996年4月~2009年6月5例单纯钩骨钩骨折合并尺神经深支损伤进行回顾分析。结果尺神经深支绕过钩骨钩的基底部进入掌深间隙,OA的长度为(4.96±0.11)mm、OB的长度(3.69±0.12)mm、OC的长度(10.55±1.07)mm、AB的长度为(1.27±0.15)mm;5例根据中华医学会手外科学会上肢周围神经功能评定试用标准:优4例,良1例。结论单纯钩骨钩骨折可致尺神经深支损伤但临床容易漏诊,早期正确诊治是神经功能得以恢复的关键。     

Effects of sevoflurane on respiratory activities in the phrenic nerve of decerebrate cats

Although the depressive effect of sevoflurane on ventilation has been reported, its potency and mode of action on the neural respiratory activity is still unclear. Therefore, the effects of sevoflurane on the phrenic nerve discharge and the respiratory timing were compared with those of halothane.
The efferent activity of the phrenic nerve was recorded from decerebrate, un-anesthetized and artificially ventilated cats, and its power spectrum was calculated. The inspiratory and expiratory periods were measured. Sevoflurane and halothane of the doses of 0.5–1.5 MAC were inhaled for 15 min.
With 0.5 MAC, sevoflurane decreased the total power and two dominant spectral components of the high-frequency oscillation and medium-frequency oscillation in the power spectrum. With the same MAC dose, halothane had a greater depressive effect in a normocapnic condition with the vagus nerves being intact. In a state of hypercapnia or after vagotomy, the effect of halothane was considerably attenuated whereas that of sevoflurane remained unaltered. Halothane increased the neural respiratory rate much more than sevoflurane in both normocapme and hypercapnic states. Vagotomy significantly weakened the effect of halothane to increase the respiratory rate but did not modify the effect of sevoflurane. With 1.0–1.5 MAC, both anesthetics severely decreased the phrenic power spectra and the potency difference became indistinct.
The present findings demonstrate that sevoflurane has a weaker depressive effect on the respiratory nerve discharge and a smaller effect on the neural respiratory rate than halothane when the effects of 0.5 MAC were compared. This may be due to the lesser effect of sevoflurane on the vagal mediated and CO₂-related mechanisms which modulate the global outputs of the central respiratory control system.     

End-to-side neurotization with the phrenic nerve in restoring the function of toe extension: an experimental study in a rat model

The phrenic nerve being transferred to the posterior division of the lower trunk with end-to-end neurorrhaphy is reported to be effective in restoring the function of digit extension in literature. However, the phrenic nerve is extremely important in respiration. We designed an animal experiment to discover whether the phrenic nerve being transferred to the posterior division of the lower trunk with end-to-side neurotization was feasible and provided the theoretical basis. A sum of 36 Sprague-Dawley rats was randomly assigned to one of two groups. In Group A, the phrenic nerve was transferred to the posterior division of the lower trunk with end-to-side neurotization. In Group B, the posterior division of the lower trunk was directly sutured. The results of behavioral assessment, electrophysiology, histology and nerve fiber count and muscle weight at 12 weeks postoperatively were recorded. In Group A, none of the rats experienced tachypnea. The motion of slight toe extension was observed. The results of electrophysiology, histology and nerve fiber count and muscle weight in Group A were not as well as those of Group B, but gradually improved with time. The phrenic nerve being transferred to the posterior division of lower trunk with end-to-side neurotization can partially restore the function of toe extension in a rat model. Whether the function of digit extension can be restored by the phrenic nerve with end-to-side neurotization in humans still needs more practice in clinic.     

Eventration of the diaphragm

Eventration of the diaphragm was noted in 69 children over a 20-yr period. The origin of the eventration was congenital in 48, acquired in 21.Nonoperative treatment was successful in most patients with symptomatic congenital eventration. Fourteen children with congenital eventration had operative plication. Three patients with gastric volvulus and total eventration of the left diaphragm were among those operated upon. There was one mortality in the medically treated group and two deaths in those treated surgically.All symptomatic patients with acquired eventration were managed non-operatively. The elevated, paralyzed diaphragm resulted from either birth or intraoperative trauma in all cases. There was one death among the 21 children with acquired eventration.     

A randomised,controlled, double‐blind trial of ultrasound‐guided phrenic nerve block to prevent shoulder pain after thoracic surgery

Moderate to severe ipsilateral shoulder pain is a common complaint following thoracic surgery. In this prospective, parallel‐group study at Odense University Hospital, 76 patients (aged > 18 years) scheduled for lobectomy or pneumonectomy were randomised 1:1 using a computer‐generated list to receive an ultrasound‐guided supraclavicular phrenic nerve block with 10 ml ropivacaine or 10 ml saline (placebo) immediately following surgery. A nerve catheter was subsequently inserted and treatment continued for 3 days. The study drug was pharmaceutically pre‐packed in sequentially numbered identical vials assuring that all participants, healthcare providers and data collectors were blinded. The primary outcome was the incidence of unilateral shoulder pain within the first 6 h after surgery. Pain was evaluated using a numeric rating scale. Nine of 38 patients in the ropivacaine group and 26 of 38 patients in the placebo group experienced shoulder pain during the first 6 h after surgery (absolute risk reduction 44% (95% CI 22–67%), relative risk reduction 65% (95% CI 41–80%); p = 0.00009). No major complications, including respiratory compromise or nerve injury, were observed. We conclude that ultrasound‐guided supraclavicular phrenic nerve block is an effective technique for reducing the incidence of ipsilateral shoulder pain after thoracic surgery.     

Assessment of diaphragm function after stellate ganglion block using magnetic stimulation

Stellate ganglion block is a procedure frequently used for the management of patients with chronic sympathetically mediated pain affecting the arm, neck or head. We studied the effect of stellate ganglion block on ipsilateral phrenic nerve function, and hence diaphragmatic strength, in 11 adult patients with chronic sympathetically mediated pain. Pre- and post-block forced vital capacity (FVC) measurements were recorded using a pneumotachograph and a Magstim nerve stimulator was used to generate pre- and post-block twitch mouth pressures (P(TWM)). This device can be used to stimulate the phrenic nerves and hence the diaphragm. The resulting change in airway pressure was measured at the mouth and has previously been shown to reflect diaphragm strength. There was no statistically significant difference in FVC or P(TWM) pre- or post stellate ganglion block. In conclusion, a stellate ganglion block has no adverse effect on ipsilateral phrenic nerve function or diaphragm strength in healthy adult patients.