全长膈神经移位重建屈指功能的临床报告

目的 探讨在胸腔镜视下切取全长膈神经直接移位至正中神经内侧头重建全臂丛撕脱伤后屈指功能的可行性,为全臂丛根性撕脱伤后屈指功能的恢复提供新思路.方法 对3例全臂丛根性撕脱伤的患者,采用胸腔镜视下游离胸腔内的全长膈神经,于入膈肌处切断膈神经,将全长膈神经直接移位于正中神经内侧头,术后每3个月随访肺功能和临床功能恢复情况.结果 3例患者随访时间均超过3年,拇长屈肌及2～5指指浅屈肌肌力均恢复至3～4级,掌长肌肌力2例为2级,1例为1级;桡侧腕屈肌、旋前圆肌、鱼际肌肌力为0级.肺功能显示患者在术后6个月内有不同程度的肺功能降低,但在1年内都恢复到术前水平.结论 胸腔镜视下切取全长膈神经直接移位至正中神经内侧头重建全臂丛撕脱伤后的屈指功能是一种可行的新术式.     

全臂丛根性撕脱伤后神经移位联合早期股薄肌移植重建术

目的 探讨重建全臂丛根性撕脱伤后上肢主要功能的新方法。方法 8例全臂丛根性撕脱伤后2～4月一期行膈神经移位修复肩胛上神经,联合对侧股薄肌移植重建屈肘、伸指伸拇5例或屈拇屈指3例。前者其中2例二期再行同侧股薄肌移植重建屈拇屈指等。结果 一期手术1年以上5例,术后4～5月移植肌肉出现收缩,5～7月伸指伸拇或屈拇屈指、屈肘,12月屈肘60°～90°、肌力M_4,伸拇伸指或屈拇屈指M_3～M_4,肩外展30°～60°、M_3。二期手术的1例术后7月移植肌肉收缩,12月屈拇屈指M_4。重建屈拇屈指者可握持物品。结论 神经移位联合早期股薄肌移植,可在短时间内恢复全臂丛根性撕脱伤肢体的部分功能,初步重建手握持功能。     

全臂丛根性撕脱伤后神经移位联合早期股薄肌移植重建术

目的：探讨重建全臂丛根性撕脱伤后上肢主要功能的新方法。方法：8例全臂丛根性撕脱伤后2－4月一期行膈神经移位修复肩胛上神经,联合对侧股薄肌移植重建屈肘、伸指伸拇5例或屈拇屈指3例。前其中2例二期再行同侧股薄肌移植重建屈拇屈指等。结果：一期手术1年以上5例,术后4－5月移植肌肉出现收缩,5－7月伸指伸拇或屈拇屈指、屈肘,12月屈肘60°-90°、肌力M4,伸拇伸指或屈拇屈指M3－M4,肩外展30°-60°、M3。二期手术的1例术后7月移植肌肉收缩,12月屈拇屈指M4。重建屈拇屈指可握持物品。结论：神经移位联合早期股薄肌移植,可在短时间内恢复全臂丛根性撕脱伤肢体的部分功能,初步重建手握持功能。     

臂丛神经根性撕脱伤的治疗

神经移位术是治疗臂丛根性撕脱伤的主要方法。臂丛丛外移位神经包括肋间神经(Tsuyama1969)、副神经(Kotani1970)、颈丛运动支(Brunelli1977)、膈神经(顾玉东1970)、健侧颈7神经根(顾玉东1986)等。其中，健侧颈7根移位神经纤维数量最多，安全有效，已被国内外广泛应用。近年来，胸腔镜下超长切取膈神经，有效缩短了神经再生时间。对颈5、6根性撕脱伤，改良的Oberlin术式——臂丛丛内部分尺神经或正中神经移位修复肌皮神经肱二头肌支，手术简单，屈肘功能疗效肯定；同侧颈7根移位术有效且能恢复多组肌肉功能。对颈8胸1根性撕脱伤，肌皮神经肱肌肌支移位修复正中神经屈指肌束或骨间前神经以恢复屈指功能。对全臂丛根性撕脱伤，改良的Doi术式——双股薄肌移位联合神经移位较好恢复了手握持功能；肢体短缩，健侧颈7移位直接修复正中、尺神经，能恢复屈拇屈指功能，但手内肌功能仍无恢复。如何重建手内肌仍需作进一步探索。     

双重股薄肌移植重建全臂丛根性撕脱伤后手握持功能

目的 探讨双重股薄肌移植重建全臂丛根性撕脱伤后手握持功能的疗效。方法 24例全臂丛根性撕脱伤患者,行吻合血管、神经的双重股薄肌移植,一期重建屈肘、伸指、伸拇,二期重建屈指、屈拇,以重建手握持功能。结果 随访16例二期手术后时间超过24月患者,最长62月,平均36月。16例均恢复屈肘、伸指、伸拇功能,屈肘90°～135°,肌力M_4(Highet法),伸指伸拇M_3～M_4。14例屈拇、屈指恢复,肌力M_3～M_4,可握持200～500g物品;2例屈拇屈指肌力M_1。结论 吻合血管、神经的双重股薄肌移植治疗全臂丛根性撕脱伤,可很好恢复屈肘、伸拇伸指功能,较好恢复屈指屈拇功能,初步重建手握持功能。     

健侧颈_7椎体前路移位直接修复下干联合股薄肌移植治疗臂丛根部撕脱伤

目的 探讨健侧颈7神经椎体前路移位直接修复下干联合功能性股薄肌移植重建术治疗全臂丛根部撕脱伤的手术设计及其临床疗效.方法 12例全臂丛根性撕脱伤患者,于伤后1～3个月行臂丛神经根干部探查,一期健侧颈,经椎体前路移位直接修复患侧C_8T_1-下干,同时行膈神经移位修复肩胛上神经9例.于一期术后4-8个月分别行二期吻合血管的股薄肌移植(以副神经斜方肌支为缝接神经)重建屈肘、伸指伸拇功能.结果 随访9～36个月.一期术后3个月12例患侧尺神经、正中神经Tinel征至上臂近段平面,术后6个月至肘关节与前臂近段平面,9个月至前臂远段与腕部.9例12个月Tinel征至手掌、手指部.7例术后9个月胸大肌胸肋部收缩,12个月肩内收可夹持物品;5例术后15-18个月手掌、手指与前臂内侧均有触痛觉恢复,尺侧腕屈肌和示、中、环、小指屈指肌收缩.3例术后24个月,拇指屈曲,1例鱼际肌出现收缩(M_1).二期股薄肌移植功能重建术后有7例于二期术后4～7个月移植肌肉收缩;9～12个月屈肘90°～120°(M_3),伸指伸拇M_3 .结论 健侧颈_7神经经椎体前路移位直接修复C_8T_1-下干术,联合二期股薄肌移植重建屈肘、伸指伸拇功能治疗全臂丛根部撕脱伤的手术设计具有可操作性,初步观察神经再生进程顺利,能恢复手腕、手指的屈曲与感觉功能,重建屈肘、伸指功能.     

健侧C7椎体前移位联合多组神经移位治疗全臂丛神经根性撕脱伤

目的：探讨健侧C7神经根椎体前移位并联合多组神经移位治疗全臂丛神经根性撕脱伤的方法和疗效。方法对20例全臂丛根性撕脱伤患者采用健侧C7神经根、膈神经、副神经及健侧C7修复患侧下干后形成新的动力神经：臂内侧皮神经、前臂内侧皮神经、下干后股移位修复患侧下干、肌皮神经、肩胛上神经、腋神经、桡神经、正中神经内侧头。并进行长期随访,观察肩外展、屈肘、屈指和伸腕伸指及手部感觉功能恢复的情况。结果20例中有17例获得随访,随访时间20～72个月（平均38个月）。肩外展平均39°,有效率（肌力M2以上）71%,优良率（肌力在M3以上）59％;屈肘平均77°,有效率83%,优良率53％;屈指、屈拇功能恢复：10例指屈肌力≥M2,有效率为59%（10/17）,其中7例肌力≥M3,优良率为42%;伸肘恢复有效率（肌力M2以上）59%,优良率42%;伸指有效率47%,优良率36%。结论健侧C7神经根椎体前移位并联合多组神经移位治疗全臂丛神经根性撕脱伤是有效的治疗方法之一。     

创伤性全臂丛撕脱伤上肢整体功能重建的临床研究

 目的 观察采用多组神经移位术结合后期手功能重建恢复全臂丛神经撕脱伤患者主动拾物功能的疗效。方法 33例全臂丛神经撕脱伤患者,一期手术均采用多组神经移位术,即副神经移位修复肩胛上神经恢复肩外展,健侧C7神经经椎体前通路移位与患侧下干直接吻合重建屈指、屈腕功能,同时将下干发出的前臂内侧皮神经移位修复肌皮神经恢复屈肘功能,膈神经与下干后股直接吻合同时重建伸肘、伸指功能。术后选择肌力获得有效恢复(肩外展恢复到30°或以上, 伸肘、伸指肌力达到3级或以上,屈肘、屈腕、屈指肌力达到4级或以上)的患者进行二期手功能重建恢复患手的主动抓握功能。主要包括腕关节固定术、拇外展功能重建及掌板紧缩术等。结果 一期神经移位术后平均41±7.7(36~73)个月。10例患者的肌力恢复达到二期手功能重建的条件,其中8例已进行二期手功能重建。6例患者恢复了部分主动拾物功能,1例因爪形指纠正失败,另1例因腕融合术后伸指肌腱粘连致伸指功能丧失。结论 新设计的多组神经移位术可同时恢复全臂丛撕脱伤患者的肩外展、屈肘、屈腕、屈指及伸肘、伸指的有效肌力,在此基础上通过后期手功能重建,可成功重建患侧上肢的部分主动拾物功能。     

膈神经移位治疗臂丛损伤的临床应用和早期疗效

目的探讨膈神经移位至肌皮神经重建屈肘功能的临床应用及早期疗效。方法对8例臂丛根性撕脱伤行膈神经移位术，膈神经与上干前股的肌皮神经束直接吻合5例，膈神经通过神经移植桥接至肌皮神经3例，术后随访评定其屈肘功能。结果8例经10月-2年随访，肱二头肌肌力在2级以上5例，有效率62．5％。结论膈神经移位术是治疗臂丛根性撕脱伤的理想术式，重视术前和术中膈神经功能的评估、神经移位时吻合方法的合理选择和术后综合康复锻炼是提高手术疗效关键。     

肌皮神经肱肌支在股薄肌移植治疗下臂丛损伤中的解剖学研究及临床应用

目的通过解剖学研究，设计选择性肌皮神经肱肌支移位联合股薄肌移植术重建屈拇屈指功能术式，验证该术式在下臂丛神经损伤治疗中的安全性和有效性。方法30侧甲醛固定的成年国人上肢标本，经逐层解剖，观察肌皮神经肱肌支的走行，测量肱肌支的长度、直径。对2例创伤性下臂丛损伤上肢功能障碍患者进行选择性肌皮神经肱肌支移位联合股薄肌移植术重建屈拇屈指功能术式。术后观察屈拇屈指功能及手握持功能恢复情况。结果在30侧标本中，肌皮神经肱肌支分型：单支型25侧，占83．33％，粗细两支型1侧，多支型4侧，未见变异及异常发出。肌皮神经肱肌支长度平均为（52．66±6．45）mm，横径平均为（1．39±0．09）mm。肌皮神经肱肌支神经束平均为（2．83±0．46）束。2例患者术后4～6个月出现股薄肌收缩，恢复屈拇屈指功能。其中1例术后6个月屈拇屈指肌力达M4，可握持200g物品；术后12个月可握持500g物品，初步恢复手握持功能。结论以肌皮神经肱肌支为缝接神经的股薄肌移植治疗下臂丛根性撕脱伤可较好地恢复屈指屈拇功能，初步重建手握持功能。肌皮神经肱肌支可作为股薄肌移植治疗下臂丛神经损伤移位神经较理想的供体。     

Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus

Recent interest in reconstruction of the upper limb following brachial plexus injuries has focused on the restoration of prehension following complete avulsion of the brachial plexus. The authors use free muscle transfers for reconstruction of the upper limb to resolve the difficult problems in complete avulsion of the brachial plexus. This article describes the authors' updated technique--the double free muscle procedure. Reconstruction of prehension to achieve independent voluntary finger and elbow flexion and extension by the use of double free muscle and multiple nerve transfers following complete avulsion of the brachial plexus (nerve roots C5 to T1) is presented. The procedure involves transferring the first free muscle, neurotized by the spinal accessory nerve for elbow flexion and finger extension, a second free muscle transfer reinnervated by the fifth and sixth intercostal nerves for finger flexion, and neurotization of the triceps brachii via its motor nerve by the third and fourth intercostal motor nerves to extend and stabilize the elbow. Restoration of hand sensibility is obtained via the suturing of sensory rami from the intercostal nerves to the median nerve. Secondary reconstruction, including arthrodesis of the carpometacarpal joint of the thumb and glenohumeral joint, and tenolysis of the transferred muscle and distal tendons, improve the functional outcome. Based on the long-term result, selection of the patient, donor muscle, and donor motor nerve were indicated. Most patients were able to achieve prehensile functions such as holding a can and lifting a heavy box. This double free muscle transfer has provided prehension for patients with complete avulsion of the brachial plexus and has given them new hope to be able to use their otherwise useless limbs.     

膈神经移位修复下干后股重建臂丛撕脱伤伸肘及伸指功能的中期随访

 目的 观察膈神经移位修复下干后股重建臂丛神经撕脱伤伸肘、伸指、伸拇功能的效果。方法 2005年6月至2008年12月采用膈神经移位修复下干后股重建43例臂丛神经撕脱伤患者的伸肘及伸指功能,男36例,女7例;年龄4~44岁,平均(23.5±9.9)岁。受伤至手术时间1~12个月,平均(3.7±1.9)个月。其中全臂丛神经撕脱伤32例,中下干撕脱伴上干部分损伤或正常5例,C6~T1神经根撕脱伴C5椎孔外断裂或部分损伤6例。取锁骨上、下臂丛神经探查联合切口,显露下干后股,向近端干支分离后切断。将后侧束、桡神经向远端游离,切断后侧束的其他分支。将下干后股、后侧束及桡神经上提,膈神经在胸廓上口内切断,将膈神经与下干后股吻合。膈神经与下干后股直接吻合33例,通过腓肠神经桥接10例。结果 全部病例获得随访,随访时间36~73个月,平均(39.7±7.1)个月。伸肘、伸指、伸拇肌力达到3或以上的比例分别为81.6%、41.9%、39.5%。结论 膈神经移位修复下干后股,其伸肘功能恢复满意,伸指、伸拇功能的恢复仍需进一步改善。     

Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long-term results

BACKGROUND: Recent interest in reconstruction of the upper limb following brachial plexus injuries has focused on the restoration of prehension following complete avulsion of the brachial plexus. METHODS: Double free muscle transfer was performed in patients who had complete avulsion of the brachial plexus. After initial exploration of the brachial plexus and (if possible) repair of the fifth cervical nerve root, the first free muscle, used to restore elbow flexion and finger extension, is transferred and reinnervated by the spinal accessory nerve. The second free muscle, transferred to restore finger flexion, is reinnervated by the fifth and sixth intercostal nerves. The motor branch of the triceps brachii is reinnervated by the third and fourth intercostal nerves to restore elbow extension. Hand sensibility is restored by suturing of the sensory rami of the intercostal nerves to the median nerve or the ulnar nerve component of the medial cord. Secondary reconstructive procedures, such as arthrodesis of the carpometacarpal joint of the thumb, shoulder arthrodesis, and tenolysis of the transferred muscle and the distal tendons, may be required to improve the functional outcome. RESULTS: The early results were evaluated in thirty-two patients who had had reconstruction with use of the double free muscle procedure. Twenty-six of these patients were followed for at least twenty-four months (mean duration, thirty-nine months) after the second free muscle transfer, and they were assessed with regard to the long-term outcome as well. Satisfactory (excellent or good) elbow flexion was restored in twenty-five (96 percent) of the twenty-six patients and satisfactory prehension (more than 30 degrees of total active motion of the fingers), in seventeen (65 percent). Fourteen patients (54 percent) could position the hand in space, negating simultaneous flexion of the elbow, while moving the fingers at least 30 degrees and could use the reconstructed hand for activities requiring the use of two hands, such as holding a bottle while opening a cap and lifting a heavy object. The results were analyzed to identify factors affecting the outcome. CONCLUSIONS: The double free muscle procedure can provide reliable and useful prehensile function for patients with complete avulsion of the brachial plexus.     

胸腔镜视下切取膈神经移位治疗臂丛神经损伤的临床应用报告

目的 首创在胸腔镜视下切断膈神经远端移接于肌皮神经的新术式。方法 临床应用５例。在胸腔镜视下于人膈肌近端切断膈神经,游离在胸腔内的膈神经全长。膈神经自锁骨上抽出经皮下引至肌皮神经３例,于锁骨下自第二肋间引起移位于肌皮神经２例。移接于肌皮神经主干２例,移接于肌皮神经肌支３例。首例于术后１１０ｄ,检测肱二头肥肥电图出现再生电位。结论 胸腔镜视下切并游离胸腔内膈神经全长,是膈神经移位术中切取膈神经的最佳     

儿童创伤性臂丛神经撕脱伤的屈指功能重建

目的 观察健侧C_7,经椎体前通路移位与下干直接吻合,重建儿童创伤性臂从神经撕脱伤屈指功能的效果.方法 健侧C_7,在其前后股的远端切断,向近端游离至椎间孔,经椎体前通路牵至患侧.游离患侧臂丛下干及内侧束,切断下干后股及胸前内侧神经.将正中神经、尺神经及前臂内侧皮神经自内侧束的起始处一直游离到上臂中段.息肩前屈、内收至0°位,肘关节屈曲90°,上提患侧下干并与健侧C_7,直接吻合.2004年8月至2008年3月对20例患儿进行了健侧C_7,与患侧下干或内侧束直接吻合术.其中男16例,女4例;年龄5-18岁,平均13岁;伤后到手术时间1-11个月,平均4.6个月.全臂丛撕脱伤13例,中、下干撕脱伤7例.为减少吻合口张力,11例进行了肱骨短缩,短缩长度2.5-4.5 cm,平均(3.1±0.7)cm.结果 术后患者随访时间12-51个月,平均 27.4个月.屈指肌力4级18例,2级2例;屈拇长肌力4级10例、3级8例、2级2例.小指展肌肌力3级l例,2级1例;拇短展肌肌力3级1例.结论 健侧C_7,与患侧下干直接吻合,由于只有一个吻 合口及缩短了神经再生的距离,其重建屈指、屈拇功能的效果满意,并可恢复手内在肌的部分功能.     

Comparative study of phrenic nerve transfers with and without nerve graft for elbow flexion after global brachial plexus injury

Background

Nerve transfer is a valuable surgical technique in peripheral nerve reconstruction, especially in brachial plexus injuries. Phrenic nerve transfer for elbow flexion was proved to be one of the optimal procedures in the treatment of brachial plexus injuries in the study of Gu et al.

Objective

The aim of this study was to compare phrenic nerve transfers with and without nerve graft for elbow flexion after brachial plexus injury.

Methods

A retrospective review of 33 patients treated with phrenic nerve transfer for elbow flexion in posttraumatic global root avulsion brachial plexus injury was carried out. All the 33 patients were confirmed to have global root avulsion brachial plexus injury by preoperative and intraoperative electromyography (EMG), physical examination and especially by intraoperative exploration. There were two types of phrenic nerve transfers: type1 – the phrenic nerve to anterolateral bundle of anterior division of upper trunk (14 patients); type 2 – the phrenic nerve via nerve graft to anterolateral bundle of musculocutaneous nerve (19 patients). Motor function and EMG evaluation were performed at least 3 years after surgery.

Results

The efficiency of motor function in type 1 was 86%, while it was 84% in type 2. The two groups were not statistically different in terms of Medical Research Council (MRC) grade (p = 1.000) and EMG results (p = 1.000). There were seven patients with more than 4 month's delay of surgery, among whom only three patients regained biceps power to M3 strength or above (43%). A total of 26 patients had reconstruction done within 4 months, among whom 25 patients recovered to M3 strength or above (96%). There was a statistically significant difference of motor function between the delay of surgery within 4 months and more than 4 months (p = 0.008).

Conclusion

Phrenic nerve transfers with and without nerve graft for elbow flexion after brachial plexus injury had no significant difference for biceps reinnervation according to MRC grading and EMG. A delay of the surgery after the 4 months might imply a bad prognosis for the recovery of the function.