正中神经显微结构三维可视化研究

目的 将正中神经干全长作连续冰冻组织切片,采集系列切片的神经二维信息,开发3D Nerve可视化系统,实现正中神经内部显微结构的三维可视化.方法 取新鲜成人尸体正中神经标本,作好定位并标记、OCT包埋、采用连续冰冻组织切片、染色、用扫描仪获取切片染色前后的连续的正中神经断面二维信息数据库,开发并应用3D Nerve可视化系统.结果 通过3D Nerve可视化系统观察发现,在不同断面正中神经神经束的数量、位置以及神经束内神经纤维的性质变化较大.在该系统中可在任意断面放大的视野下观察正中神经的显微结构,追踪各神经束在正中神经内的立体行径;重建的正中神经能在空间位置上绕任意轴作任意角度旋转,便于从不同的角度对各神经束的形态、空间位置及相互毗邻关系进行观察,从而动态地展示正中神经内部的复杂结构.结论 正中神经3D Nerve可视化系统真实地再现正中神经干全长及其内部各神经束和束组的三维立体结构,可为临床修复正中神经损伤提供精确的断层解剖图像.     

人体尺神经显微结构三维可视化研究

目的 将人体尺神经行连续冰冻组织切片,经染色、扫描后获取尺神经连续断面二维图像信息,通过3D Nerve三维可视化软件系统勾画出完整的尺神经干三维解剖图谱.方法 取自愿捐献死亡3 h内38岁男性左侧尺神经全长(自臂丛内侧束至腕横韧带)标本1例,长约50cm,经定位、包埋、连续冰冻组织切片、乙酰胆碱脂酶组织化学染色,获取尺神经连续二维图像信息,应用3D Nerve三维可视化软件系统对尺神经内部结构进行三维重建.结果 尺神经在不同断面神经束的数量、位置及内部神经纤维的性质均有变化.应用尺神经3D Nerve三维可视化软件系统可在任意断面、任意角度观察尺神经内部的显微结构,追踪各神经束的立体行径,动态地展示尺神经内部神经束的复杂结构.结论 尺神经的3D Nerve三维可视化软件系统可真实地再现尺神经干全长及其内部各神经束的三维立体行径,为医学教学与临床修复尺神经损伤提供精确的神经任意断面三维立体解剖图像,有助于提高神经修复的疗效.     

Study of sensory and motor fascicles in brachial plexus and establishment of a digital three-dimensional graphic model

To investigate a 3-dimensional (3D) model of human brachial plexus including its topography of sensory and motor fascicles with the assistance of the computer technology, 2 brachial plexus were serially horizontally sliced. Each slice was stained by Karnovsky-Roots acetylcholinesterase histochemical method. The stained sections were scanned, and the image was put into the computer serially. At last, the 3D diagram of brachial plexus was made. The internal structure of the brachial plexus was found to be very complicated. The fascicles bifurcated and recombined with one another with no fixed rules. All fascicles were mixed sensory and motor fibers. Acetylcholinesterase histochemical staining from a serial tissue section is a useful technique to distinguish sensory fibers from motor ones. The 3D visualization of the brachial plexus may help to develop a computerized database of the fascicle topography to provide an anatomical reference in fascicular repair of brachial plexus.     

短段腓总神经功能束三维重建的初步研究

目的 基于组织学连续断层切片,利用计算机技术进行短段腓总神经功能束三维重建.方法 取自愿捐献的成人约5 cm长胭窝段腓总神经,连续横断冰冻切片,片厚10 μm,切片间距0.25 mm,共切取200张切片.采用乙酰胆碱酯酶组织化学染色,镜下观察神经束变化规律,通过数码摄像系统将染色切片转化为数字图像,图像拼接获取放大100倍的二维全景图像,人工判断功能束性质,图形处理软件配准分割后,利用Amira 3.1三维重建软件实现腓总神经功能束的三维重建.结果 (月国)窝段腓总神经内部功能束可划分为感觉神经束、运动神经束、混合神经束和以运动神经纤维为主的混合神经束.其中,腓深神经和腓浅神经间无神经束的交叉融合,神经束的交叉融合主要发生在腓深神经和腓浅神经内部的功能束间.三维重建结果能较真实地再现周围神经的三维立体结构及其内部功能束组的三维立体行径,重建结构能单独或搭配显示,还能任意角度显示.结论 基于组织学和计算机技术,可以三维重建短段腓总神经功能束,为长段周围神经功能束的三维重建提供可行性依据.     

周围神经虚拟三维重建中神经束功能及形态定位的组织化学染色方法研究

目的探索周围神经虚拟三维重建中不同性质神经纤维与功能束的组织学水平的形态学定位方法。方法取自愿捐献新鲜成人尸体右侧正中神经作为样本进行连续冰冻切片,取形态完整标本切片30个,首先采用单纯Karnovsky-Roots法对神经切片染色(A组,n=30),再依次行甲苯胺蓝染色(B组,n=28)以及丽春红2R染色(C组,n=21)。每种染色完成后即于光学显微镜下分区显微摄影(×100)并拼接成全景图像,比较不同染色方法下全景图像的纹理特征、乙酰胆碱酯酶活性部位数量及平均灰度;并对比计算机自动获取神经束轮廓结果,以确立获取理想图像的染色方案。结果 A、B、C组乙酰胆碱酯酶活性位点数量分别为(21.63±4.06)×102、(20.64±3.51)×102、(20.54±5.71)×102个;平均灰度分别为(1.41±0.06)×102、(1.10±0.05)×102、(1.14±0.07)×102。各组间乙酰胆碱酯酶活性位点数量差异无统计学意义(F=0.64,P=0.54);与A组比较,B、C组平均灰度均较低,差异有统计学意义(P<0.001)。A组仅乙酰胆碱酯酶活性部位着色;B组髓鞘显示不满意;C组可同时显示神经纤维轴突及髓鞘染色,神经束和不同性质神经纤维纹理特征最显著,神经束边界轮廓最清晰,计算机处理时假阳性容易去除,图像分割最精确。结论 Karnovsky-Roots-甲苯胺蓝-丽春红2R三重复染方法不影响神经纤维乙酰胆碱酯酶阳性位点的表达,图像纹理清晰,较符合周围神经虚拟三维重建时在组织学水平分辨及获取神经束功能状态二维图像的相关要求,有望解决周围神经组织形态学表达方式这一技术难题。     

Rho-inhibition by local application of c3-toxin for enhancement of axonal sprouting in a rat end-to-side nerve repair model

Introduction: The aim of the presented study was to investigate nerve regeneration after application of C3‐Toxin, a Rho‐GTPase inhibitor and to correlate morphometry, neurophysiology, and function in an end‐to‐side peroneal/tibial nerve repair model of the rat. Materials and methods: Twenty rats with a peroneal to tibial end‐to‐side neurorrhaphy were divided into two groups: 1) control group, 2) C3 fusion toxin group with intrafascicular application of 1 μg/100 μl C3 fusion toxin. Survival time was 8 weeks. Nerve conduction velocities and motor function were analyzed and histomorphological evaluation consisting of measurement of intraneural collagen level, axon count, total nerve area, myelination index, and N‐ratio followed. Results: Evaluation of motor function and nerve conduction did not show any statistical differences. Histological analysis revealed higher axon count, thicker myelin sheaths, and higher myelination index in the C3 fusion toxin group (P < 0.001). Comparison of N‐ratio and intraneural collagen level were without statistical significance. Conclusion: The current study shows that application of C3 fusion toxin leads to higher myelination and increases axonal sprouting. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

臂丛神经显微结构的计算机三维重建

目的：重建臂丛神经的外轮廓及其内部神经束的精细三维行径，同时探索一种臂丛神经显微结构计算机三维重建的实用方法。方法：取健康成年尸体的臂丛神经标本2例(从神经根管出口至正中神经交叉处，平均长20cm)，作好标记，以女性头发作为定位线，采用连续组织切片后胆碱脂酶组织化学染色，高分辨率数码摄像系统获取二维数码信息后对臂丛神经显微结构进行三维重建。结果：三维重建真实地再现臂丛神经的三维立体结构及其内部各神经束的三维立体行径，并可显示臂丛神经中神经束的任意断面及其全长的解剖结构与相互关系，形象地展示臂丛神经内部神经束的复杂重组过程。重建结构均能单独或搭配显示，还能任意角度显示：在臂丛的五个根中，C6-C8内部神经束数目较C5、T1多。在C6-C8中，又以C7神经根内部神经束数目最多。结论：臂丛神经内部神经束结构相当复杂，相互间不断交叉重组，形成独特的神经束网络结构。臂丛神经显微结构三维重建由于采用了较为精确的定位材料和方法，三维图像显示效果较好，是一种较为实用的方法。     

Intraneural median nerve pressure in carpal tunnel syndrome

In order to determine whether endoscopic carpal tunnel release decompresses the median nerve, we measured the intraneural median nerve pressure pre- and postoperatively in 55 hands. The median nerve pressure was significantly reduced postoperatively.     

Traumatic rupture of median artery an unusual cause for acute median nerve compression

Previous case reports of haemorrhage into the carpal tunnel causing median nerve compression were extraneural and usually associated with a blood dyscrasia although Watson Jones reported one due to direct trauma and Hayden recorded spontaneous intraneural haemorrhage not associated with trauma. We describe a case of intraneural haemorrhage, involving the median nerve in the carpal tunnel, due to indirect trauma and not associated with a blood dyscrasia. The condition required intraneural decompression to obtain relief.     

Histochemical study of estradiol receptors and morphologic parameters in breast cancer

We present our experience with the use of estradiol - bovine serum albumin (BSA) - fluorescein isothiocyanate (FITC) employed by LEE to localize estradiol receptors on frozen sections of breast carcinomas. 41 cases were studied on parallel sections with both conventional staining and a histochemical procedure. Heterogeneity of the cell population was usually found; however the histochemical result was influenced by morphological parameters. As far as histopathological types were concerned, invasive lobular carcinomas (3 cases) manifested a bright cytoplasmic fluorescence, while medullary carcinomas (3 cases) were poorly or non stained. Among infiltrating ductal carcinomas, well differentiated cases were composed of strongly fluorescent tubules, while poorly differentiated ones classified in BLOOM'S grade III were poorly stained. In most of the cases, the amount of stroma, mucus and carcinomatous or hyperplastic ductal components has to be taken in account to evaluate the fluorescence pattern of each microscopic field.     

Subchronic Stimulation Performance of Transverse Intrafascicular Multichannel Electrodes in the Median Nerve of the Göttingen Minipig

This work evaluated the subchronic stimulation performance of an intraneural multichannel electrode (transverse intrafascicular multichannel electrode, TIME) in a large human‐sized nerve. One or two TIMEs were implanted in the right median nerve above the elbow joint in four pigs for a period of 32 to 37 days (six TIMEs in total). The ability of the contact sites to recruit five muscles in the forelimb was assessed via their evoked electromyographic responses. Based on these responses, a selectivity index was defined. Four TIMEs were able to selectively recruit a subset of muscles throughout the implantation period. The required recruitment current significantly increased, while there was a tendency for the recruitment selectivity to decrease over time. Histological assessment showed that all TIMEs remained inside the nerve and that they were located between fascicles. The average thickness of the encapsulation of the electrode was estimated to be 115.4 ± 51.5 μm (mean ± SD). This study demonstrates the feasibility of keeping the TIME electrodes fixed and functional inside a large polyfascicular human‐sized nerve in a subchronic setting.     

Case report: Neurological deficit associated with intraneural needle placement without injection

Purpose

Recent reports of painless intraneural injection of low volumes of local anesthetic without subsequent neurological deficit have led to the suggestion that deliberate subepineural injection may be a safe and therefore acceptable practice.

Clinical features

This report describes a case where a venous cannulation needle inadvertently penetrated a patient’s median nerve. Sudden onset severe lancinating pain occurred in the median nerve sensory distribution. A subsequent thorough ultrasound examination showed the median nerve to be located immediately posterior to the targeted median cubital vein. New onset sensory symptoms (numbness, tingling, pain, and altered sensation to touch) in the distribution of the penetrated median nerve persisted for >6 weeks.

Conclusion

This report highlights the hazards of intraneural needle placement irrespective of an associated injection.     

Nerve perforation with pencil point or short bevelled needles: histological outcome

Background: In the case of needle nerve contact during peripheral blocks, pencil point needles are considered less traumatic compared with bevelled needles. However, there are not enough data to prove this notion. Therefore, the aim of this study was to challenge the hypothesis that nerve perforation with short bevelled needles is associated with major nerve damage compared with pencil point needles. Methods: In five anaesthetised pigs, the brachial plexus was exposed bilaterally. Up to eight nerves underwent needle nerve perforation using a pencil point needles cannula or an short bevelled needle. After 48 h, the nerves were resected. The specimens were processed for visual examination and the detection of inflammatory cells (haematoxylin–eosin, i.e. CD68‐immunohistochemistry to detect macrophages), myelin damage (Kluver–Barrera staining) and intraneural haematoma. The grade of nerve injury was characterised by an objective score ranging from 0 (no injury) to 4 (severe injury). Results: Fifty nerves were examined. According to the injury score applied, there was no significant difference between the pencil point needles [median (inter‐quartile range) 2.0 (2.0–2.0)] and the short bevelled‐needle group [median 2.0 (2.0–2.0) P=0.23]. No myelin damage was observed. Signs of post‐traumatic inflammation were equally distributed among both groups. Conclusions: In the present study, the magnitude of nerve injury after needle nerve perforation was not related to one of the applied needle types. Post‐traumatic inflammation rather than structural damage of nerve tissue is the only notable sign of nerve injury after needle nerve perforation with either needle type. However, neither the pencil point‐ nor the short bevelled needle can be designated a less traumatic device.     

Carbonic anhydrase activity of human peripheral nerves: a possible histochemical aid to nerve repair

The return of usable function after injury of peripheral nerves depends upon the appropriate regeneration of axons to their end organs. Debridement trimmings of severed nerves harvested during surgery were stained to demonstrate carbonic anhydrase activity. This histochemical method can be accomplished within 3 to 4 hours of receiving the tissue. Nerve fascicles were readily discriminated from one another by the individual staining patterns of their constituent axons. Axoplasmic staining was predominantly a feature of sensory fibers, and myelin staining was characteristic of skeletal motor axons. Carbonic anhydrase histochemistry may provide a means of accurately matching fascicles in cut nerve ends.     

腺病毒介导的LacZ基因靶向性导入脊髓及示踪周围神经的动态过程

目的由损伤的周围神经靶向性导入腺病毒介导的LacZ基因(AdLacZ)至脊髓，动态观察病毒裁体逆行输送到脊髓前角运动神经元、脊髓后根神经节(dorsal root ganglia，DRGs)感觉神经元及基因产物顺行标记周围神经的全过程和特点。方法分别将AdLacZ转染大鼠正中神经和胫神经近断端，然后以10-0无创线吻合神经。在转染后9周内的24个不同时间点取出正中神经组的C5～T1脊髓节段、DRGs连同臂丛，胫神经组的L2～L6脊髓节段、DRGs连同骶丛。将脊髓和DRGs的50μm横切片行X—gal染色和免疫组织化学染色，臂丛和骶丛的整个标本分别行X—gal染色。计数阳性脊髓前角运动神经元、DRGs神经元及周围神经轴突数，研究转基因表达在脊髓前角运动神经元、DRGs神经元及正中神经、胫神经的最早时间、高峰时间和持续时间。结果LacZ基因能特异性、高效表达在损伤周围神经的感觉和运动神经元。转基因在脊髓和周围神经的表达严格限于感染神经的同侧。正中神经组标本各部位的转基因表达均早于胫神经组。胫神经组被标记的运动神经元和感觉神经元数均高于正中神经组。表达持续的时间在运动神经元最短，然后是感觉神经元，在周围神经持续时间最长。在同一组内，转基因表达在DRGs神经元最早．然后是运动神经元，最后是周围神经干，而且被标记的感觉神经元数多于运动神经元数。结论由损伤的周围神经导入的AdLacZ不但在靶神经元高效特异性表达，而且能高效顺行标记神经元突起、周围神经直至吻合口远端的再生轴突。这对周围神经损伤的基因治疗和神经示踪研究有实用价值。     

Intraneural lipomatous tumor of the median nerve: Three case reports with a review of literature

INTRODUCTIONIntraneural lipoma and fibrolipomatous hamartoma of the nerve are rare soft tissue tumors that most commonly occur in the forearm and the wrist, and particularly within the median nerve. When the lesions are large enough, they may cause progressive compression neuropathy. They are distinct entities each other with different clinical and radiological findings and thereby need different surgical treatments.PRESENTATION OF CASEWe report here 3 cases of intraneural lipomatous tumors of the median nerve (1 case of intraneural lipoma and 2 cases of fibrolipomatous hamartoma).DISCUSSIONAll patients were surgically treated successfully with complete excision for intraneural lipoma and with carpal tunnel releases for the both fibrolipomatous hamartomas.CONCLUSIONA careful preoperative planning is necessary for the optimal treatment by distinguishing whether it is a resectable or non-resectable tumor based on the clinical and radiological findings, because they have characteristic findings each other.     

Intraneural anatomy of the median nerve provides "third web space" donor nerve graft.

To determine the feasibility of using the fascicular group to the third web space as a source of nerve graft material for bridging of median nerve gaps, a study of the intraneural anatomy of the median nerve was carried out in 23 fresh cadaver specimens. The pattern of plexus formation between the third web-space group and the remainder of the median nerve was determined. The average length of the third web-space fascicular group that could be separated from the median nerve proper prior to plexus intermingling was 24.5 cm. Cross-sectional areas of the graft and the remaining nerve were 4.43 mm2 and 13.76 mm2, respectively. The number of nerve fibers in the third web-space group was 4,847 and in the remaining median nerve, 13,486. Between February, 1989 and October, 1991, this technique has been used on 11 patients to provide donor nerve material for nerve gaps of 3 to 6 cm in the median nerve.     

Histochemical discrimination of fibers in regenerating rat infraorbital nerve.

In rat dorsal root ganglia, histochemical staining of carbonic anhydrase (CA) and cholinesterase (CE) yields a reciprocal pattern of activity: Sensory processes are CA positive and CE negative, whereas motor processes are CA negative and CE positive. In rat infraorbital nerve (a sensory peripheral nerve), we saw extensive CA staining of nearly 100% of the myelinated axons. Although CE reactivity in myelinated axons was extremely rare, we did observe CE staining of unmyelinated autonomic fibers. Four weeks after transection of infraorbital nerves, CA-stained longitudinal sections of the proximal stump demonstrated 3 distinct morphological zones. A fraction of the viable axons retained CA activity to within 2 mm of the distal extent of the stump, and the stain is capable of resolving growth sprouts being regenerated from these fibers. Staining of unmyelinated autonomic fibers in serial sections shows that CE activity was not retained as far distally as is the CA sensory staining.     

Evaluación del área de sección del nervio mediano tras la inyección intraneural o perineural

Introduction

To recognise the relationship between the needle tip and the median nerve during peripheral nerve block is of interest to avoid neural damage. However, signs of intraneural injection are not clearly established. The aim of this study was to define the changes observed in the peripheral nerve after the intraneural or perineural administration of 1 ml of solution.

Measurement of carpal canal and median nerve pressure in patients with carpal tunnel syndrome

Carpal tunnel syndrome is a compression neuropathy wherein the median nerve is compressed inside of the carpal canal. Its diagnosis is made clinically, electrophysiologically, and sometimes by carpal canal pressure measurement. The objective of surgical management of this condition is the decompression of the median nerve. We usually measure carpal canal pressure preoperatively and postoperatively using a continuous infusion technique for diagnoses as well as for postoperative evaluation of decompression following our Universal Subcutaneous Endoscope system procedure. To evaluate whether our procedure effectively decompressed the median nerve, we measured intraneural pressure preoperatively and postoperatively in the resting position, with active power grip, and in the Okutsu test position. Correlation between the carpal canal pressure and intraneural median nerve pressure was statistically analyzed using the Kendall rank correlation coefficient (n = 157 hands). A significant correlation was present preoperatively in resting position and postoperatively with active power grip and in the Okutsu test position. Because of this correlation, we conclude that our endoscopic operative procedure effectively decompresses the median nerve and that simple carpal canal pressure measurement is sufficient to confirm diagnoses and to evaluate the status of postoperative decompression.