正中神经部分束支移位重建屈肘功能的临床应用

目的:总结应用正中神经部分束支移位与肌皮神经肱二头肌肌支重建屈肘功能的治疗效果。方法:5例臂丛神经上干根性损伤者,采用正中神经部分束支移位与肌皮神经肱二头肌肌支缝合术。术中切取正中神经后内侧,横截面的1/6为移位束支。结果:术后对患肢正中神经功能的影响轻微;患者均出现手部麻木、疼痛等感觉异常,对手部肌力无明显影响。经1～3年的随访,5例患者均在10～12个月恢复了屈肘功能。根据肱二头肌肌力恢复情况及肘关节活动范围,优3例,可2例。结论:正中神经部分束支移位于肌皮神经肱二头肌肌支是治疗臂丛神经上干型根性撕脱伤、重建屈肘功能的一种简单有效、安全可靠的手术方法。     

母体神经移植桥接健侧患臂丛治疗小儿难治性产瘫的实验研究

目的:为臂丛根性撕脱伤的治疗提供一种新的有效手术方法。方法:将实验动物按手术方式分组如下,A组:母鼠提供的的神经移植体一端与子鼠健侧臂丛上干行端侧吻合,另一端与患侧已切断的锁骨下肌皮神经远端行端端吻合。B组:母鼠提供的神经移植体一端与子鼠健侧臂丛上干行端侧吻合,另一端与患侧已切断的锁骨上颈6远端行端端吻合。C组:母鼠提供的神经移植体桥接于子鼠患侧膈神经与锁骨下肌皮神经之间。D组:子鼠患侧膈神经直接与锁骨上颈6远端行端端吻合。术后采用电生理学、组织学及肌肉功能检测等指标定期进行各组疗效评价。结果:A组和D组术后肱二头肌的恢复无明显差异,但明显优于B组和C组。结论:A组,即该实验设计的手术方法与D组,即目前被公认为最好的膈神经移位的疗效相当。     

MICROSURGICAL TREATMENT OF BRACHIAL PLEXUS IRREVERSIBLE AVULSION

A new combined measure of nerve transfer, including antebrachial medial cutaneous nerve, and free musculocutaneous flap transfer was applied to the treatment of irreversible avulsion of the brachial plexus. 12 patients underwent this operation for restoring elbow and finger flexion. Good result was obtained in 71% for elbow and 60% for finger flexion restoration. The definition of irreversible avulsion and the methods, key points and value of the operation are described and discussed in detail.     

Root avulsion of brachial plexus in infants and children.

Twenty-one patients, under 6 years of age, with root avulsion of the brachial plexus were treated from 1975 to 1987. Among them, 9 had root avulsion of the upper trunk, 2 root avulsion of the lower trunk with middle trunk broken, and 10 root avulsion of the whole brachial plexus. Follow-up of 16 patients showed excellent results in 2 patients, good in 11, fair in 1 and poor in 2. It is suggested that good results can be obtained if multi-paired nerve transfer is adopted in treatment. We conclude that owing to anatomical and physiological characteristics of the respiratory system in children, it is harmful to perform phrenic nerve transfer concomitantly with intercostal nerve transfer. Advisably, two-stage operation is required, otherwise dyspnea and pneumonia are liable to occur. In addition, the time of the operation could be extended to 4-5 years after injury in children, but best results are obtained if the operation is performed within 1 year.

     

Semi-skeletonized Internal Mammary Grafts and Phrenic Nerve Injury： Cause-and-effect analysis

The topic of phrenic nerve injury (PNI) after cardiac surgery has been discussed over many years with rela- tively inconclusive results. Many factors have been im- plicated as contributing to an increased incidence of PNI, including the use of left internal mammary artery (LIMA)[1, 2], devascularization of the periphrenic nerve blood vessels[3], surgical manipulation[2, 4], clod injury[5-7] the low preoperative myocardial performance[1], chronic obstructive pulmonary disease (COPD)[8], di…     

灯盏花素对左心缺血再灌注致肺损伤家兔膈神经放电的影响

目的探讨灯盏花素对左心缺血再灌注致肺损伤的保护作用。方法 30只新西兰家兔随机分为假手术组、模型组和治疗组,每组10只,制备左心缺血再灌注肺损伤模型,并与BL-420生物信号采集分析系统相连;假手术组不做左冠状动脉的前降支结扎,其余同模型组。治疗组缺血10 min后静脉给予灯盏花素10 mg.kg-1。记录缺血30 min,再灌注20、40 min 3个时间点3组家兔膈神经放电曲线,测定放电幅度、放电持续时间和放电频率。结果与假手术组比较,模型组家兔各时间点膈神经放电幅度显著减小,放电持续时间缩短,放电频率增加,其差异均有统计学意义(P<0.05);与模型组比较,治疗组膈神经放电幅度显著增加,放电持续时间延长,膈神经放电频率降低,其差异亦均有统计学意义(P<0.05)。结论灯盏花素可改善左心缺血再灌注急性肺损伤家兔膈神经放电曲线参数,灯盏花素对左心缺血再灌注后的呼吸功能具有保护作用。     

Cervical nerve root transfer from the healthy side in the treatment of brachial plexus root avulsion

Cervical nerve root transfer from the healthy side for treatment of obstinate brachial plexus root avulsion was designed in August, 1986. Up to the present, we have performed the operation in 50 cases. Preliminary effective rate reached 70% in 1-2 years follow-up studies. The anatomical basis of the operation and the rationality of C7 nerve root transfer from the healthy side are discussed in detail in this paper. Long term follow-up studies showed that C7 nerve root transfer from the healthy side does not affect the functions of the healthy side. The authors believe that bridging C7 nerve root of the healthy side with the ulnar nerve of the affected side yields better results than bridging it free or vascular pedicle sural nerve. Factors affecting the results of C7 nerve root transfer from the healthy side are analyzed in this paper.     

彩色多普勒超声对PRGD复合神经导管修复周围神经缺损的评价

目的探讨彩色多普勒超声（color Doppler ultrasound,CDUS）在神经导管桥接修复缺损神经再生临床评价的可行性。方法对10例周围神经缺损患者进行神经导管桥接修复术,并在术后采用超声连续动态观察缺失神经再生生长状况。结果术后每3个月超声检查,密切观察导管内缺失段神经变化;6个月后神经导管内壁上见神经纤维束细线状爬行生长显示明显;12个月后神经导管管壁逐渐模糊、断续,提示导管材料发生降解,导管内缺损处再生神经纤维束排列逐渐规则、尚均匀;同时观察导管内神经血流情况。结论超声在临床评价神经导管桥接修复缺损神经的方面具有潜在应用价值。     

心脏术后胸骨骨髓炎和纵隔炎使用腹直肌带蒂肌皮瓣修复创面

目的观察心脏术后胸骨骨髓炎和纵隔炎患者使用腹直肌带蒂肌皮瓣修复胸骨缺损的疗效。方法2002年1月-2006年1月收治6例心脏术后胸骨骨髓炎和纵隔炎患者,行胸骨及部分肋骨切除,用腹直肌带蒂肌皮瓣转移修复创面。结果术后所有肌皮瓣均成活良好,无坏死,肌皮瓣成活率达100%。无胸骨骨髓炎复发,肌皮瓣有效地修复了手术清创后的胸骨及周围组织缺损,封闭了创面,修复区形态满意。术后未发生反常呼吸等情况,循环及呼吸功能正常,也未见腹部取材区域相关并发症。1例行动-静脉吻合的患者在出院前再次行血管造影检查,吻合口通畅,与周围组织有良好的血管网状吻合。所有患者术后均随访2年以上,皮瓣愈合情况均良好,无感染。结论心脏术后胸骨骨髓炎和纵隔炎使用腹直肌带蒂肌皮瓣修复胸骨缺损安全、有效。     

臂丛神经上干损伤的屈肘功能重建体会

目的:探讨臂丛神经上干根性撕脱伤后重建屈肘功能的方法。方法:对7例臂丛上干根性撕脱伤,术前EMG、MRI及全面的理学检查确诊后,或者通过术中神经探查及术中肌电检测确诊后,施行新的神经移位术:尺神经部分神经束移位至肌皮神经的肱二头肌肌支(经典的Oberlin手术),正中神经部分神经束移位至肌皮神经的肱肌肌支,施行双重移位,重建屈肘功能。术中运用电生理技术,增加手术的准确性和合理性,术后早期行理疗、功能锻炼及神经营养药物等综合措施。结果:经过术后6～28个月的随访,屈肘功能恢复满意。5例随访超过1年的患者,目标肌力均达M3以上,随访少于8个月的2例患者,目标肌力也达M1～2。结论:对臂丛上干根性撕脱伤确诊后,尺神经及正中神经部分神经束双重移位是重建屈肘功能有效的、合理的治疗方法,较之单一的尺神经部分束移位(即为传统的Oberlin术式),增加了屈肘功能的恢复效率。     

肺叶切除术中行膈神经压扎对肺功能的影响

目的 探讨肺叶切除术中膈神经压扎对肺功能的影响.方法 40例行肺叶切除的患者,其中20例在行肺叶切除后加行膈神经压扎,另外20例未行膈神经压扎,分别测定其膈肌活动度、肺功能及术后发生并发症情况.结果 两组患者比较,膈神经压扎组患者的膈肌活动度及肺功能均较未压扎组差,膈肌活动度分别为(1.17+0.41)cm和(2.11±0.42)cm(P＜0.05);肺功能方面,压扎组患者肺活量、最大分钟通气量及第1秒用力呼气量分别为(70.25±5.25)%、(71.42±7.15)%和(65.50±4.51)%,未压扎组分别为(81.24±4.78)%、(80.87±8.65)%和(76.97±6.26)%,两组比较差异均有统计学意义(P＜0.05).但术后并发症的发生率.两组之间并无差别.结论 肺叶切除时行膈神经压扎将进一步降低患者的肺功能,膈神经压扎在肺叶切除术中并非绝对必要.     

膈神经冷冻术的实验研究

目的：观察膈神经在一定冷冻温度下（-65℃）的变化及其特征,并探讨冷冻时间与神经损伤和修复的关系,以确定膈神经冷冻术的安全性。方法：冷冻治疗机温度设定为-65℃。实验动物为山羊,实验中取右侧8肋间切口入右胸,在下腔静脉外侧游离膈神经,分别行30 s、60 s、90 s及120 s膈神经冷冻术。术后60 d再次开右胸,在不同时间再分别行膈神经冷冻术,取材进行病理学检查。结果：冷冻当天镜下可见：冷冻90 s和120 s组出现明显神经变性和神经纤维断裂;30 s和60 s组表现为神经外膜、束膜及髓鞘轻度水肿;术后60 d标本不同冷冻时间肉眼观察与正常膈神经均无明显区别,镜下神经基本恢复正常,但仍有增生性改变。结论：膈神经在-65℃下,随冷冻时间延长,神经损伤逐渐加重。冷冻90 s以上,神经损伤明显。冷冻120 s仍可修复,证明膈神经冷冻术是安全的。     

带血管蒂拇展肌肌皮瓣局部转位术的临床应用

目的 根据应用解剖学基础，采用带血管蒂Mu展肌肌皮瓣局部转位术治疗踩足部疾患。方法 对11例患者实施带血管蒂Mu展肌肌皮瓣局部转位术，其中内踝慢性骨髓炎5例，足跟部溃疡3例，跟腱部复合组织缺损2例，足背软组织缺损l例。结果 术后随访6～11个月，肌皮瓣全部成活，且皮肤感觉恢复良好，无l例发生皮肤破溃。结论 该肌皮瓣血供丰富，有多组血管蒂可选择，转位灵活，操作简便，可修复踝足部组织缺损。     

桡神经肱三头肌支移位修复肌皮神经损伤的解剖学研究

解剖观测了30例成人桡神经和肌皮神经。结果表明，桡神经肱三头肌支各分支数为8～10支，多数可分离长度为48．2－121．1mm，横径为0．5－0．9mm。据此解剖学研究，我们提出了一种以桡神经肱三头肌支移位修复肌皮神经损伤的新的手术方式的设计。     

超声引导神经刺激器定位腋入路臂丛神经肌皮神经解剖变异的研究

目的本研究以超声引导和神经刺激器定位技术观察记录腋入路臂丛神经阻滞时肌皮神经对应的解剖位置及变异。方法选择251例行手、前臂及上肢远端手术的患者,麻醉方法为腋入路臂丛神经阻滞。将超声探头垂直于胸大肌和肱二头肌交界部位放置,采集横断面图像,包括腋动脉、腋静脉、尺神经、桡神经、正中神经、肌皮神经,联合应用神经刺激器定位并记录每根神经的位置。结果肌皮神经大部分（84.5%）分布在喙肱肌和肱二头肌之间,有33例（13.1%）肌皮神经位于腋鞘内,在腋动脉的外侧,有6例（2.4%）患者在腋窝处未找到肌皮神经,将探头沿长轴向远端滑动,可以在稍远的地方看到支配喙肱肌的神经。正中神经、尺神经、桡神经均靠近腋动脉,分布在神经血管束中。结论肌皮神经一般不在腋鞘内,应在喙肱肌中单独阻滞。由于神经分布在腋动脉周围的位置不同,为获得所有终末神经的完善阻滞,最好使用神经刺激器定位每支神经。     

心内直视术后膈肌麻痹原因分析

目的 :探讨体外循环心内直视术后膈肌麻痹的原因和防治对策。方法 :对 1 1 7例心脏手术病人进行回顾性分析。结果 :膈肌麻痹发生率为 1 1 .1 % ( 1 3/1 1 7) ,均为左侧膈肌麻痹 ,病人年龄为 1 6～ 5 4岁。小于 1 6岁的无膈肌麻痹发生。膈肌麻痹多发生在手术时间长、阻断时间长、需多次灌注冷晶体液和多次心包内放置冰泥的病人。结论 :膈肌麻痹与术中心包内放置冰泥 ,导致膈神经冻伤有关。避免冰泥直接接触膈神经 ,可降低膈肌麻痹发生率     

Long- term outcome of contralateral C7 transfer: a report of 32 cases

Objective To observe long- term functional recovery after contralateral C7 transfer. Methods From August 1986 to July 2000, 224 patients with brachial plexus avulsion injuries were treated with contralateral C7 transfer in our department Thirty- two patients were followed up for over 2 years for evaluation of the following items: ① influence on healthy limb function; ② sensory and motor recovery of the recipient nerves in the affected limb; and ③ coordination between the healthy and affected limbs.Results There was no impairment of healthy limb function. Functional recovery of the recipient area reached ≥M3 in 8 patients (8/10, 80%) after musculocutaneous nerve neurotization, ≥M3 in 4 patients (4/6, 66%) after radial nerve neurotization, ≥M3 in 7 patients (7/14, 50%) and ≥S3 in 12 patients (85.7%) after median nerve neurotization, and ≥M3 in 1 patients (1/2, 50%) after thoracodorsal nerve neurotization. Synchronic contraction of the affected limb with the healthy limb occurred within 2-3 years in 12 patients, within 5 years in 13 patients, and over 5 years in 7 patients.Conclusion Contralateral C7 transfer is an ideal procedure for the treatment of brachial plexus root avulsion injury. Selection of the whole root or the posterior division as neurotizer and a staged operation are the major factors influencing treatment outcome.     

LOWER LEG LATERAL SKIN FLAP REPORT OF 7 CASES

Lower leg lateral skin flaps were used in 7 patients since January 1983. Satisfactory results were obtained. The blood supply of the flap was based on the peroneal artery, which gives rise to cutaneous or musculocutaneous branches to nourish the flap. The venous blood of the flap was drained by the venae comites accompanying these cutaneous or musculocutaneous branches. In clinical practice, the beginning portion of the peroneal artery and the vein arising from the posterior tibial vein are used for vascular anastomosis. The caliber of the peroneal artery is 2.5-3.0 mm, and that of the peroneal vein is 3-4 mm. The vascular pedicle is 8-12 cm long. In 4 0f these patients, the flaps were freely transferred using a microvascular tech- nique; in the remaining 3, a reversed transfer for treating defects over the foot was used.     

双侧C7神经根与下肢神经吻合治疗外伤性完全截瘫

目的探索双侧C7神经根与下肢神经吻合治疗外伤性完全截瘫。方法第一期手术：双侧C7神经根与胫神经吻合,第二期手术：切断C7神经根-胫神经-坐骨神经链,第三期手术：神经链与腰2、3、4神经根吻合。结果本组6例病人,5例进行了完整的手术,病人下肢屈伸髋关节肌力可以达到2级,整个下肢都能恢复本体感觉,有3例病人同时也恢复了浅感觉,有2例病人恢复了浅感觉的触觉,而痛、温觉未恢复。结论双侧C7神经根与下肢神经吻合治疗外伤性完全截瘫,手术周期长,手术难度大,可以取得一定的疗效。     

吻合血管神经足展肌游离移植治疗晚期面瘫的远期疗效评价

目的:评价吻合血管神经足罡母展肌游离移植治疗晚期面瘫的远期疗效.方法:对1990年3月至2006年11月接受该术式的患者共28例进行术后随访1～16年,中位随访时间4年,分析患者手术前后标准头正位照片,采用多伦多评价系统(T-FGS)和面神经功能指数(FNFI)评价面神经功能,并对移植肌存活状况、面宽、瘢痕、供足功能等情况加以分析比较.结呆:所有患者术后均获得理想的静态对称.随访发现所有患者均有移植肌的随意收缩运动,其中22例获理想的微笑.与术前相比,患者术后T-FGS得分提高了(27 7.2)分,FNFI值提高了(57±10.7)%,差异有统计学意义(P＜0.05);术后患者瘢痕隐蔽,供足无遗留功能障碍.结论:吻合血管神经足罡母展肌游离移植治疗晚期面瘫术后远期效果理想,供区无任何功能障碍,值得推广.