健侧C7神经根移位至桡神经治疗全臂丛神经根性撕脱伤

目的观察健侧C7神经根移位至桡神经治疗全臂丛神经根性撕脱伤的临床疗效。方法1993～1999年,用健侧C7神经根移位至桡神经治疗全臂丛神经根性撕脱伤107例,36例获得2年以上随访。男31例,女5例;年龄7～44岁,平均27岁。受伤距第一次神经移位手术的时间为3～36个月,其中3～6个月4例,6～12个月29例,12～24个月2例,24～36个月1例,平均间隔时间9.4个月。整个手术过程分三期完成。第一期:锁骨上下臂丛神经探查,将膈神经移位至上干前股或通过神经桥接至肌皮神经;副神经移位至肩胛上神经;正中神经腋前区皮下预置。第二期:健侧C7神经根移位至用于桥接的尺神经。第三期:肋间神经移位至正中神经,肋间神经移位至胸背神经;尺神经与桡神经吻合术。36例患者随访时间为24～84个月,平均38个月。随访指标包括:桡神经支配肌肉运动改善情况,肌肉再生电位恢复情况,桡神经支配区皮肤感觉变化。结果运动功能改善者29例,占患者总数的80.6%;感觉功能改善者27例,占75.0%。结论健侧C7神经根移位至桡神经治疗全臂丛神经根性撕脱伤总体效果满意,但肱三头肌功能恢复欠佳。     

Treatment of brachial plexus injury with modified contralateral C7 transfer

Objective: To study the curative effects of different surgical methods using a contralateral C₇ transfer technique for treatment of brachial plexus injury induced by root avulsion. Methods: Sixty‐four patients with brachial plexus injury due to root avulsion were divided into two groups: 30 patients were included in Group A and 34 in Group B. In Group A, the contralateral C₇ roots were partially transected and anastomosed to one end of an ulnar nerve graft which had been removed from the affected limb. The other end of the ulnar nerve was divided into two parts and anastomosed to the distal ends of the recipient median and radial nerves, respectively. In Group B, the whole of the contralateral C₇ roots was transected and anastomosed to one side of an ulnar nerve graft, the other side of which was anastomosed eight months later to the distal ends of the recipient median and radial nerves. All subjects were followed up and the outcomes assessed. Results: Neurological deficit and recovery time of the donor limb in group A were less than those in group B. The nerve transfer procedure to the affected limb was easily completed in group A with less morbidity, and the tension of the stoma in group A was less than that in group B. However, there was no statistical difference between group A and B in the recovery of motor function and results of electrophysiological testing of the affected side (P > 0.05). Conclusions: The method of partial C₇ root transfer results in equally good motor function as does transfer of the whole root, while occurrence of motor and sensory damage is less than that which occurs with transfer of the whole root.     

全臂丛神经损伤健侧颈7移位术后大鱼际肌功能的远期随访

目的 随访全臂丛神经根性撕脱伤患者行健侧颈7移位术后手内在肌的远期功能恢复情况.方法 对5例行健侧颈7移位于正中神经的全臂丛神经损伤患者进行远期随访,随访时间24～ 118个月,了解患肢受体神经所支配肌肉的肌力及其支配区域皮肤感觉恢复、神经电生理检测结果等.结果 5例患者(2例儿童,3例成人),其患侧大鱼际肌均获得不同程度的恢复.拇短展肌肌力恢复达M2者为4例,M1者1例;电生理检测拇短展肌动作电位有2例为单纯相,3例为少量运动单位电位(MUP);感觉恢复达S3者4例,S2者1例.结论 健侧颈7移位术治疗全臂丛神经损伤可使大鱼际肌得到一定程度的恢复.     

健侧C7移位至桡神经治疗全臂丛神经根性撕脱伤改良术的解剖学基础

目的寻求健侧C7神经根移位治疗全臂丛神经根性撕脱伤手术中尺神经与桡神经的最佳吻合部位。方法在10具20侧福尔马林固定的成人尸体上肢标本上观察桡神经及其肱三头肌肌支的解剖学特征;尺神经的解剖学特征;尺神经不同水平与对侧颈根部的距离。结果桡神经从后侧束发出部位到发出肱三头肌长头的第一支肌支之间的距离为(8.2±1.4)cm,从发出长头的第一个肌支部位到外侧头最后一个肌支发出部位之间的距离为(4.8±0.7)cm。尺神经肘部以上几乎无分支,尺神经在发出部位的直径为(6.7±0.6)mm;在肘部的直径为(6.3±0.5)mm;在腕部的直径为(4.0±0.4)mm;从锁骨下尺神经发出部位到肘部的长度为(29.0±2.6)cm;从锁骨下尺神经发出点到对侧颈根部的距离为(18.0±1.8)cm。结论健侧C7神经根移位修复桡神经,尺神经与桡神经的最佳吻合部位是锁骨下区,在此部位吻合不但能保证肱三头肌功能恢复,而且大大缩短桥接神经的长度。     

Reorganization in motor cortex after brachial plexus avulsion injury and repair with the contralateral C7 root transfer in rats

The purpose of our study was to establish the profile of cortical reorganization in whole BPAI on rats and evaluate changes of cortical reorganization after repair of the median nerve with the contralateral C7 root transfer. Forty adult SD rats underwent whole roots avulsion of left brachial plexus, among them 20 received contralateral C7 root transfer to the injured median nerve. Intracortical microstimulation was performed in primary motor cortex (M1) at intervals of 3, 5, 7, and 10 months, postoperatively. The maps of motor cortical responses were constructed. Five normal rats were used as the control. Results showed that stimulating right M1 elicited motion of left vibrissae, submaxilla, neck, back, and left hindlimb after left BPAI, among them neck representation area replaced the forelimb area throughout the reorganization process. The left forelimb representation area was found in the left motor cortex 5 months after the contralateral C7 root transfer and existed in both motor cortexes at 7th postoperative month. The left forelimb representation area was detected only in right motor cortex at 10th month, postoperatively. In conclusions, after the contralateral C7 root transfer for repair of the median nerve in BPAI, the cortical reorganization occurred in a time‐dependent reorganization. The findings from this study demonstrate that brain involves in the functional recovery after BPAI and repair with nerve transfer and suggest that efforts to improve the results from nerve repair should address the peripheral nerve as well as the brain. © 2010 Wiley‐Liss, Inc. Microsurgery 2010.     

The prespinal route in contralateral C7 nerve root transfer for brachial plexus avulsion injuries

Contralateral C7 nerve root transfer for brachial plexus injury is described, passing the nerve through a subcutaneous tunnel on the anterior surface of the neck and chest. We recommend passing the nerve graft through the retropharyngeal space. This route has the benefits of a simpler dissection, a shorter distance and protected placement of the graft. It has been used in one clinical case.     

改良式健侧颈7神经移位术治疗臂丛根性撕脱伤

目的研究探讨健侧颈7神经移位术不同术式及不同神经吻合方法的特点,并在一定程度上判断各方法对神经再生的影响及予后。方法本组64例臂丛神经根性撕脱伤的患者将其分成A,B两组。A组30例为实验组,将健侧颈7神经根部分切断,与患侧尺神经远端行部分端端吻合（尺神经自颈椎椎体前食管后穿过）;尺神经近端自然分成两束,分别与患侧正中神经、桡神经远端一期行端端吻合;B组34例为对照组,将健侧颈7神经根完全切断,与患侧尺神经远端行端端吻合（尺神经自颈前皮下穿过）,患侧尺神经近端于二期（术后8个月）与患侧正中神经或桡神经远端行端端吻合。术后定期观察随访并记录分析结果。结果术中神经吻合张力A组明显小于B组;术后健侧上肢短期感觉运动异常改变,A组较B组发生率低,且症状消失快,但电生理检查无显著差异（P〉0．05）。术后患肢功能恢复结果,A组较B组无显著差异（P〉0．05）。结论健侧颈7部分切开,术后减少了上肢感觉、运动异常的发生率,且症状消失快,同时吻合神经的直径相当,也减少了供区神经资源浪费;患侧尺神经自颈椎椎体前食管后穿过减少了神经吻合的张力;一期手术即可完成患侧上肢两条神经移植,患者痛苦小,病程短,费用低,易接受。因此A组改良的方法优于B组常规的方法。     

Hemi-contralateral C7 transfer to median nerve in the treatment of root avulsion brachial plexus injury

Because of the poor clinical results in achieving hand function in patients with complete brachial plexus root avulsion with other nerve transfers, we evaluated 111 patients prospectively to evaluate the technique of the hemi-contralateral C7 transfer to the median nerve. The transfer was performed as a primary procedure in 62 patients and as a secondary procedure in additional 49 patients. Twenty-one of the 62 patients in the primary group had sufficient follow-up (at least 3 years) to assess the motor and sensory recovery in the median nerve. The adverse effects of the operation were also analyzed in all 111 patients. Six of the 21 (29%) patients obtained M3 and 4 (19%) experienced M2 recovery of the wrist and finger flexors. Ten (48%) patients obtained S3 and 7 (33%) had S2 recovery in the median nerve area. The rate of the advancing Tinel's sign was markedly different between those achieving M3 function and the remaining patients. Although the age of the patient did not correlate with outcome, patients aged 18 and younger had the best motor recovery (ie, achieving M3 function in 3 of 6 cases). There was no correlation between the timing of the surgery after the initial injury, medical comorbidities, and clinical outcome. After surgery 108 of 111 (97%) patients experienced temporary paresthesia in the median nerve area, which resolved by an average of 2.8 months. Three (3%) patients had motor weakness of the donor limb; this resolved completely in 2 patients and left a mild deficit in wrist extension in 1 patient.     

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。     

健侧C7神经经椎体后通路治疗臂丛神经根性撕脱伤的解剖学研究

目的通过解剖学研究,探讨健侧C7神经经椎体后通路移位治疗对侧臂丛神经根性撕脱伤的可行性。方法取10具甲醛固定的成人尸体标本,其中男7具,女3具,标本均无明显畸形,组织无缺损,颈部中立位。模拟臂从神经损伤手术探查方式,将C₇神经根的前、后股向远端行干支分离使其长度增加后再切断,同时测量C₇神经根自椎间孔发出至分股处长度及其前、后股长度;模拟颈椎后路手术入路,充分暴露C₇颈椎及T₁棘突,并于其间靠近椎体侧钻孔,测最经椎体后通路达对侧臂丛神经上干与下干距离。结果 C₇神经根长度为（58.62±8.70）mm,加后股长度为（65.15±9.11）mm,加前股长度为（70.03±10.79）mm。经椎体后通路C₇神经根至对侧臂丛神经上干距离为（72.12±10.22）mm,至对侧臂丛神经下干距离为（95.21±12.50）mm。结论健侧C₇神经可以经椎体后通路移位至对侧,不需要或仅需一小段桥接神经,该通路能有效避免经椎体前路损伤血管、神经等并发症,可能成为治疗臂丛神经根性撕脱伤的有效入路。     

健侧C7神经根移位治疗臂丛神经根性撕脱伤的疗效观察

目的观察健侧C7神经根移位修复臂丛神经根性撕脱伤术后患侧肢体运动、感觉功能恢复情况,以及该术式对健侧肢体的影响。方法 2008年8月-2010年11月,采用健侧C7神经根移位修复全臂丛神经根性撕脱伤22例。患者均为男性;年龄14～47岁,平均33.3岁。术前临床检查及电生理检测均确诊为全臂丛神经根性撕脱伤。其中修复正中神经16例,桡神经3例,肌皮神经3例;一期手术2例,二期手术20例。观察手术前、后患侧肢体运动、感觉功能恢复情况。结果 21例患者获随访,随访时间7～25个月,平均18.4个月。健侧C7神经根修复正中神经:屈腕肌肌力达3级或以上10例,屈指肌肌力达3级或以上7例;感觉恢复达S3或以上11例。健侧C7神经根修复肌皮神经:屈肘肌肌力达3级或以上2例;前臂外侧皮肤感觉达3级2例。健侧C7神经根修复桡神经(失访1例)伸腕肌肌力达3级1例;感觉恢复达S3 1例。结论健侧C7神经根全干移位修复全臂丛神经根性撕脱伤效果较好,分期手术是提高疗效的重要因素。     

健侧C_7神经联合多组神经移位治疗全臂丛神经根性撕脱伤正中神经功能随访

目的探讨健侧C7神经联合多组神经移位治疗全臂丛神经根性撕脱伤后正中神经功能的恢复情况。方法自2005-06—2010-06诊治40例全臂丛神经根性撕脱伤,首先行臂丛神经探查和健侧C7移位术一期。间隔4~8个月后完成健侧C7移位术二期及附加其他神经移位,按附加手术的不同分为3组,其中第1组10例健侧C7神经根移位于正中神经附加膈神经移位肌皮神经;第2组15例健侧C7神经根移位于正中神经附加肋间神经移位肌皮神经;第3组15例健侧C7神经根分2股分别移位于正中神经和肌皮神经附加副神经移位肩胛上神经。结果 40例获得随访3年余,1、2、3组有效率分别达50%、60%、73.3%。3组间差异无统计学意义(P0.05)。结论健侧C7神经根联合多组神经移位治疗全臂丛神经根性撕脱伤可获得较好的疗效,但不同附加术式未见明显疗效差异。     

健侧C7神经根移位治疗上干根性撕脱伤性产瘫

分娩性臂丛神经麻痹简称产瘫，主要是指在分娩过程中胎儿的一侧或双侧臂丛神经因受到头肩分离暴力作用而发生的牵拉性损伤。其中上千根性撕脱伤是产瘫中较常见的一种类型。2002年3月～2004年6月，我们用健侧C7神经根移位治疗12例上干根性撕脱伤性产瘫患儿，取得了较满意的疗效。[第一段]     

健侧C7神经经椎体前通路移位的并发症及防治对策

目的 分析健侧C7神经经椎体前通路移位修复臂丛神经损伤相关并发症的发生原因,并提出防治方法 .方法 自2002年2月至2009年8月,共完成425例健侧C7神经经椎体前通路移位术,男379例,女46例;年龄3个月～56岁,平均21岁.创伤性臂丛神经损伤401例,分娩性臂丛神经损伤24例.健侧C7神经自干平面切断15例,将前后股向远端做干支分离后在其远端切断410例.将并发症分为与椎体前通路制备、与健侧C7神经切取及围手术期其他严重并发症.结果 并发症发生率为5.18%(22/425).与椎体前通路制备相关的并发症:椎动脉损伤0.47%(2/425),喉返神经牵拉伤致声音嘶哑1.18%(5/425),进食时健侧上肢麻木与疼痛0.94%(4/425).与健侧C7神经切取相关的并发症:健侧伸指、伸拇功能障碍0.94%(4/425),健侧上肢术后出现严重疼痛0.71%(3/425),健侧出现Horner征0.47%(2/425),C7神经根错切0.24%(1/425).其他围手术期严重并发症0.24%(1/425),1例患者术后第2天出现脑干栓塞症状,逐渐出现呼吸、循环衰竭,术后第38天死亡.结论 健侧C7神经经椎体前通路移位安全.椎动脉损伤的发生率虽然很低,但其是椎体前通路移位的严重并发症,显露椎动脉起始段后,直视下进行操作是防止此并发症的有效方法.     

改良的尺神经桥接健侧C7治疗臂丛神经撕脱伤

目的 探讨肘上段尺神经桥接健侧C7神经修复正中神经，治疗臂丛神经撕脱伤的可行性。方法 尺神经在进入肘管前切断，然后将近端分离至内侧束，将尺神经经胸大肌的深面穿出，经胸前及颈部皮下隧道牵至健侧颈部切口与C7神经根缝合，二期修复正中神经。术中观察尺神经远端的血供并测量长度。结果 本组全臂丛神经撕脱伤13例，中、下干撕脱伤2例，均为男性，年龄14～45岁，平均27岁；受伤时间：1．5～11个月，平均5个月。肘上段尺神经翻转与健侧C7神经根缝合12例；肘上段尺神经及前臂内侧皮神经一起翻转与健侧C7神经根缝合3例。肘上段尺神经的长度21cm～-27cm，平均24．7cm，15例尺神经远端血供均良好。尺神经自穿出胸大肌处至健侧C7的距离15cm～2cm，平均17．8cm。结论 肘上段尺神经桥接健侧C7神经修复正中神经治疗臂丛神经撕脱伤较传统的手术方法简便、易行。     

健侧颈7神经根经椎体前路移位修复臂丛神经根性撕脱伤的疗效观察

目的探讨健侧颈，神经根经椎体前路移位修复臂丛神经撕脱伤的最短通路及其安全性，并分析其应用指征和临床疗效。方法将健侧颈。神经根白干股交界处或锁骨后束部起始部切断，近端游离至椎间孔，将前斜角肌切断，经椎体前食管后间隙，通过5～7股皮神经桥接或直接吻合，修复患侧上干或锁骨下外侧束和后束。临床修复8例，5例为全臂丛神经根性撕脱伤，3例为臂丛上中干根性撕脱伤伴下干部分损伤。结果5例患者术后1周内在咳嗽、进食时有轻度健侧手指麻木感，随后逐渐消失；2～3个月后患侧颈部扣击健侧手指出现麻木感，SSEP在术后3个月时均能引出，7个月时能引出支配肌CMAP，12个月时恢复了肩肘功能。结论切断双侧前斜角肌不仅可以缩短移植神经的长度，而且颈，神经根翻转通路更通畅、安全，有利于神经再生和患肢功能恢复。锁骨上修复主要重建上干前股、上干后股、肩胛上神经功能；锁骨下修复时，主要重建外侧束加后束。     

健侧颈7神经根移位治疗臂丛损伤的疗效观察

目的 观察健侧颈，神经根移位术后患侧肢体的功能恢复及对健侧颈7神经根所支配区运动、感觉的影响。方法 对25例全臂丛神经根性撕脱伤患者，均采用健侧颈7神经根（全部10例，后股15例）移位修复，其中修复上千6例，正中神经13例，桡神经3例，肌皮神经3例；并观察手术前、后健侧颈，神经根所支配肌肉功能和感觉的变化及患侧肢体的功能恢复。术后5～28个月随访到24例。结果 对健侧肢体的影响：10例健侧颈，神经根全部切断者，术后均出现不同程度的感觉运动障碍，主要表现为桡侧1～3指感觉减退、肢体酸胀、痛和不同程度的肢体无力，术后1年完全恢复正常。1例出现伸拇、伸指不能，1年半后仍无明显恢复。15例健侧颈，神经后股切断者，其中1例失访。术后2例无明显感觉障碍，但伸腕、伸指无力，3周后恢复正常。12例出现示、中指感觉异常，8例于术后3～4周后逐渐恢复正常，4例于6个月后症状消失。患肢功能恢复：术后随访至12～18个月，受区神经支配的部分肌肉获得不同程度的功能恢复。结论 健侧颈7神经根移位术后健侧肢体运动感觉功能不遗留明显的远期损害，但也偶有解剖因素导致其支配区功能的无法恢复。颈7后股移位能为受区神经提供足够的运动纤维，同时也减少了对健侧肢体感觉的影响。