腕管综合征内镜诊治新方法——改良奥津法(附11例报告)

目的:介绍应用改良内镜技术治疗腕管综合征,术前和术后应用肌电图检测,从腕管内直接切断腕管横韧带和屈肌支持带远侧纤维束,解除其对正中神经压迫的手术方法及技巧。方法:臂丛麻醉,不使用驱血带,皮肤1cm切口,应用USE系列,在内镜下切断腕管横韧带和屈肌支持带远侧纤维束,经肌电图验证,术后正中神经末端CMAP平均潜伏期较术前加快1ms。结果:临床应用11例腕管综合征病人,于术后第1,第3个月随访,结果据Kelly疗效评定标准,优9例;良2例;一般或差无。结论:与常规手术相比,皮肤切口小,组织创伤轻,手术时间短,术后不需石膏外固定,不残留手术瘢痕。术中注意减压彻底,在微创伤条件下,能与常规手术取得相同的疗效。     

经腕横韧带近侧切口显露拇长屈肌腱腕远侧断裂

拇长屈肌腱断裂后近端均有不同程度回缩,有时寻找极其困难.我们于1997年至今以经腕横韧带近侧切口肌腱向远侧递推法显露拇长屈肌腱近侧断端13例,效果满意,介绍如下.     

正确掌握与评估内镜松解治疗腕管综合征

1986年Okutsu首次在临床利用USE(universal subcutaneous endoscope)系统通过近腕部的小切口，切断腕横韧带，松解腕部正中神经卡压，取得满意效果。由于组织创伤轻，避免了手掌部痛性疤痕，能早日恢复日常生活与工作，此术式已在欧美不断普及与改良。     

简易微创减压法治疗腕管综合征

本术式介绍的方法,实质上是一种盲视下的小切口屈肌支持带切开术。单就屈肌支持带切开而言,此法应该是可行的。但由于是盲视,所以不可能对腕管内病变进行观察和处理,如果有神经粘连,肌腱滑膜增厚,腕管内占位等需要行切开时将发生漏诊,导致手术无效。同时,在盲视下切开的安全性值得研究。屈肌支持带松解不彻底是内窥镜松解屈肌支持带手术的最常见并发症,尸体解剖研究可达50%,临床报告为1~35%。血管、神经损伤是内窥镜手术的严重并发症,正中神经、尺神经、指神经、正中神经返支及掌皮支损伤,尺动脉、掌浅弓损伤等临床均有报道。镜视下况且如此,盲视下如何才能避免此类并发症的发生?在目前的技术条件下,要解决这些问题,本术式报告的方法显然不会优于内窥镜镜视下的手术术式。     

尺侧腕屈肌移位重建屈肘功能

１９８１年５月～１９９２年１１月，连续应用尺侧腕屈肌移位重建屈时功能２１例。经平均３．８年随访，肘关节屈伸活动度最小为７０°，最大为１２０°。肌力最小达Ⅲ级，最大达Ⅴ级。全部病人能满足日常生活工作需要。讨论了在屈时功能重建的同时，需从上肢整体功能考虑肩关节的稳定性及前臂旋转功能。分析了影响疗效的因素，包括肱三头肌肌力不足致伸肘障碍；尺侧腕屈肌肌力小于Ⅳ级者，重建的屈肘活动度较小；肩关节不稳定影响屈肘肌的力量；以及康复治疗的重要性等。提出了相应的提高疗效的措施。     

超声测量腕横韧带厚度辅助诊断腕管综合征的可行性研究

[目的]探讨超声测量腕横韧带厚度辅助诊断腕管综合征的可行性。[方法]对40例临床及电生理检测确诊为腕管综合征并进行腕管切开减压的患者,术前应用B超测量钩骨钩水平腕横韧带的厚度,并与术中同水平直接测量结果和24例正常腕管B超结果进行比较。[结果]B超检查腕管综合征组钩骨钩水平腕横韧带的平均厚度分别为(0.42±0.08)cm,术中同水平直接测量结果为(0.4±0.1)cm,正常人分别为(0.29±0.07)cm,腕管综合征组钩骨钩水平腕横韧带的厚度B超结果和术中直接测量结果均大于对照组,两组差异有统计学意义(P0.05),而CTS组钩骨钩水平腕横韧带的厚度B超结果和术中直接测量结果无统计学差异(P0.01)。[结论]超声测量腕横韧带厚度可作为辅助诊断腕管综合征的一种新的有价值的方法。     

两点法内镜下治疗腕管综合征

腕管综合征常规手术是将皮肤与腕管横韧带之间的组织完全切断,直视下切开腕横韧带,然后行神经松解。开放性手术的缺点是手术创伤较大,术后手部功能恢复期较长,手的握力和捏力明显下降;手掌部的皮肤切开易损伤正中神经的掌皮支,形成神经瘤而产生疼痛;切口持续性疼痛,活动时加重;易发生弓弦状屈肌腱、神经与皮肤和肌腱粘连、外形不够美观等并发症。尽管开放手术的手术切口不断改良,但最终难免在手掌部残留有痛性或肥厚性瘢痕。日本Okutsu1986年首先应用内镜治疗腕管综合征,通过前臂1cm     

腕管综合征患者与正常人腕横韧带厚度的超声影像学研究

[目的]探讨超声测量腕横韧带厚度在腕管综合征(CTS)临床诊断中的应用价值.[方法]52侧(40例)腕管综合征(CTS)患者的手腕为CTS组,均经手术证实,术前均行超声检查,32侧(20例)正常人手腕为正常对照组,由同一人进行超声检查,测量豌豆骨水平和钩骨钩水平腕横韧带的厚度.[结果]CTS组钩骨钩水平腕横韧带厚度(0.41±0.10) cm,豌豆骨水平(0.35±0.11) cm,正常人组钩骨钩水平腕横韧带厚度(0.28±0.11) cm,豌豆骨水平(0.20±0.08) cm.CTS组与正常人组腕横韧带厚度在豌豆骨水平和钩骨钩水平均差异显著(P≤0.01).[结论]超声测量腕横韧带厚度是诊断CTS的一种新的有价值的方法,对治疗方式的选择有重要意义.     

内镜在腕管综合征治疗中的应用选择

目的探讨内镜治疗腕管综合征（carpal tunnel syndrome,CTS）的病例选择。方法2004年7月～2007年9月,用内镜技术治疗21例（24腕）CTS。手术在局麻下进行,距腕横纹近侧3cm处掌长肌腱尺侧横切口1cm,前臂筋膜深层分离将专用外套管置入腕管,在内镜监视下用专用钩刀切断腕横韧带。术后1、2、3、5个月随访。结果术后5个月时按Kelly法疗效评级：优11例;良6例;一般2例（3腕）;差2例。其中疗效差1例于内镜术后7个月行传统开放手术神经干束间松解而缓解,1例存在明显的手指皮肤痛觉过敏并皮肤干燥等交感神经症状而继续保守治疗。结论按如下原则选择内镜处理或开放手术治疗CTS：①特发性病例内镜处理;继发性病例开放手术,如类风湿关节炎所致的滑膜增生肿胀,腕内骨折后畸形,腕管内肿瘤、囊肿、炎症、痛风,神经干自身病变等。②拇指对掌功能有障碍及晚期CTS选择开放手术。③老年患者（〉60岁）优先考虑开放手术;年轻、有较高职业和外观要求的患者可以优先考虑内镜治疗。     

尺、桡侧腕屈肌内神经分布和血供特点的研究

目的研究人尺侧腕屈肌和桡侧腕屈肌内神经分布、血供模式及肌肉结构。探讨将其分成两个或两个以上具有独立神经和血管支配肌肉束的可能性,指导临床切取部分肌肉移植重建运动功能的应用。方法以解剖学、血管造影、肌内神经染色等方法,研究神经和血管在两肌内的分布特点;电刺激神经支,检测相应肌束可否具有独立收缩功能及正常血供;测量肌肉的生理横截面积和肌纤维长度,并与相关肌肉比较。结果支配和供应两肌肉的主要神经和血管均在肌腹的近、中1/3结合部入肌,神经在肌内分成2支,分别在肌中央腱两侧沿长轴走向远端,直至肌肉的末端,且与血管紧密伴行;电生理证实,沿中央腱将肌肉分成的两部分在功能上具有独立性;该两肌的尺侧部和桡侧部生理横截面积和肌纤维长度与支配手的有关肌肉相近。结论尺侧腕屈肌和桡侧腕屈肌都可分成两个具有独立的神经支配及血管供应、功能上相对独立的肌束,可用于转位移植重建运动功能,而且对供区的功能影响也较小。     

内窥镜Chow法治疗腕管综合征

目的探讨内窥镜镜视下Chow法行钩刀或推刀切断腕横韧带,解除正中神经压迫的手术方法和疗效。方法2004年5月-2009年8月,对76例（85侧）腕管综合征患者采用Chow法在内窥镜镜视下行腕横韧带切开术。结果经2～18月随访,伤口均一期愈合,无血管神经损伤,无手掌部疼痛,无伤口感染,多数患者术后夜麻即消失,术后4周桡侧三个半指感觉恢复正常,麻木、疼痛症状明显缓解,10周左右拇对掌功能恢复。Kelly分级评定：优（症状完全消失）58侧,良（明显缓解）21侧,一般（症状轻度减轻）5侧,差（症状不变或加重）1侧,优良率92．94％。结论Chow法内窥镜镜视下切开腕横韧带治疗腕管综合征是安全有效的微创手术。     

掌部小切口治疗腕管综合征

目的介绍应用新型掌部小切口行腕管松解术。方法对确诊为腕管综合征的68例(89侧)患者采用新型掌部小切口行腕管松解术,该切口为纵行、位于鱼际纹尺侧2～3mm、长约2.0～2.5cm,近端不超过远侧腕横纹。结果经术后6个月随访,所有患者症状均消失,拇短展肌肌力、握力、捏力、皮肤感觉功能均明显改善,术前术后差异在统计学极具显著意义(P<0.001)。本组无任何神经血管并发症,无1例出现腕掌部瘢痕疼痛。结论本切口具有安全、损伤小、直视下松解腕管并同时可行正中神经内松解和尺管松解、手术瘢痕小等诸多优点,是腕管松解术的一种新型、可靠的手术入路。     

内窥镜辅助下治疗腕管综合征的方法

目的报告在内窥镜辅助下治疗腕管综合征的方法及长期疗效的随访分析。方法2002年4月-2003年4月，对14例18侧患腕管综合征的患者，在局部或臂丛神经阻滞麻醉下，腕部作1cm长小切口，在正中神经前方置入“V”形槽，内窥镜辅助观察下，确认屈肌支持带后用推刀予以切断。结果术后第1天，8例患者表示手部原麻木感已消失，6例手部原麻木感明显改善；无明显并发症发生。术后随访2～4年，平均3．4年。按照Kelly分级标准评定，优良率为100％。腕部瘢痕小，患者对手术疗效十分满意。结论利用“V”形槽在内窥镜辅助下手术治疗腕管综合征的方法，其创伤小，术后恢复快，无明显并发症且长期疗效满意。     

Endoscopic versus open carpal tunnel release: A short-term comparative study

Objective:

To compare the results of endoscopic carpal tunnel release (CTR) with open CTR in patients with idiopathic Carpal tunnel syndrome (CTS).

Materials and Methods:

Seventy-one patients with CTS were enrolled in a prospective randomized study from May 2003 to December 2005. All patients had clinical signs or symptoms and electro-diagnostic findings consistent with carpal tunnel syndrome and had not responded to nonoperative management. Sixty-one cases were available for follow-up. Endoscopic CTR was performed in 30 CTS patients and open CTR was performed in 31 wrists (30 patients). Various parameters were evaluated, including each patient''s symptom amelioration, complications, operation time, time needed to resume normal lifestyle and the frequency of revision surgery. All the patients were followed up for six months.

Results:

During the initial months after surgery, the patients treated with the endoscopic method were better symptomatically and functionally. Local wound problems in terms of scarring or scar tenderness were significantly more pronounced in patients undergoing open CTR compared to patients undergoing endoscopic CTR. Average delay to return to normal activity was appreciably less in group undergoing endoscopic CTR. No significant difference was observed between the endoscopic CTR group and open CTR group in regard to symptom amelioration, electromyographic testing and complications at the end of six months.

Conclusion:

Short-term results were better with the endoscopic method as there was no scar tenderness. Results at six months were comparable in both groups.     

Chow法内窥镜下治疗腕管综合征的临床经验

目的：介绍腕管综合征内窥镜Chow法治疗的方法和经验。方法：25例30腕腕管综合征，在内窥镜指导下切开腕管。结果：术后随访1月～12月。18例20腕术后4周～6周桡侧三指半感觉恢复正常。7例lO腕大鱼际肌萎缩、拇对掌功能障碍术后8周～12周恢复正常。无并发症。结论：Chow法操作简单，容易掌握，皮肤切口小，组织创伤轻，术后恢复快，是一种安全有效的微创手术方法。     

探讨腕管综合征术中电生理检测指标与预后的关系

目的探讨腕管综合征术中正中神经远端运动电位潜伏期（distal motor latency，DML）与临床恢复预后的关系。方法对31例44侧临床诊断为腕管综合征的患者，根据术中DML检测结果分为三组。第1组：DML〈4．0ms，第2组：DML〉4．0～〈6．0ms，第3组：DML〉6．0ms。于术后2周、4周、3个月和6个月分别测定DML和息手握力及示指指腹两点分辨觉，并进行比较分析。结果术后6个月，患手握力与DML测定结果，第1、2组恢复明显优于第3组，两点分辨觉三组均基本恢复正常。结论腕管综合征术中DML测定可作为CTS术后的预后恢复参考指标之一。     

Elongated muscle belly of the flexor digitorum superficial causing carpal tunnel syndrome

Background

Carpal tunnel syndrome (CTS) is by far the most common entrapment neuropathy (Adams et al. Am J Ind Med 25:527–536, 1994; Cheadle et al. Am J Public Health 84:190–196, 1994; Stevens et al. Neurology 38:134–138, 1988). A combination of described symptoms, clinical findings and electrophysiological testing is used to confirm the diagnosis. Several studies have suggested that in patients with a clinical diagnosis of CTS, the accuracy of nerve sonography is similar to that for electromyography (Chen et al. BMC Med Imaging 11:22, 2011; Guan et al. Neurol Res 33:970–953, 2011; Kele et al. Neurology 61:389–391, 2003; Tai et al. Ultrasound Med Biol 38:1121–1128, 2012). In special cases though, the nerve sonography can reveal the cause of the median entrapment neuropathy (Fumière et al. JBR-BTR 85:1–3, 2002; Kele et al. J Neurosurg 97:471–473, 2002; Kele et al. Neurology 61:389–391, 2003; Zamora et al. J Clin Ultrasound 39:44–47, 2011).

Methods

A 43-year-old farmer was admitted to our department with 1 year of intermittent pain in the left hand and numbness of the thumb, index and middle finger. The pain and the numbness could be reproduced by extension of the wrist and fingers. The electrophysiological testing revealed signs of an entrapment median neuropathy in carpal tunnel.

Results

The high-resolution sonography (18 MHz) revealed signs of entrapment neuropathy with increased cross-sectional area, disturbed echostructure of the nerve and pathological wrist-to-forearm ratio, confirming the results from a similar study (Kele et al. Neurology 61:389–391, 2003). In addition, an elongated muscle belly of the flexor digitorum superficialis in the carpal tunnel could be identified. During the extension of the wrist and fingers, a greater protrusion of the muscle belly could be demonstrated causing compression of the median nerve.

Conclusions

We present a video case report of the sonographic findings of a patient diagnosed with carpal tunnel syndrome due to an elongated muscle belly of the flexor digitorum superficialis in the carpal tunnel. Our case highlights the importance of nerve sonography in the differential diagnosis of the cause of a carpal tunnel syndrome. With the aid of ultrasonography, it is possible to obtain very important information concerning different aspects of this case. First, in showing the presence of the elongated muscle belly of the flexor digitorum superficialis, the cause of the symptoms could be explained. Second, it was possible through the ultrasound study to explain the atypical clinical appearance in this case, demonstrating the compression neuropathy only after extension of the wrist and fingers. There have been no previous reports in which authors described an elongated muscle belly as cause of a CTS. Third, and perhaps most important, ultrasonography had a direct influence on our selection of therapeutical strategy and approach. As a result, we recommended in this patient a surgical therapy to completely solve the problem, but the patient declined this option and preferred a conservative therapy with a hand orthosis to prevent wrist extension. In conclusion we recommend ultrasonography as a very useful method in the diagnostic evaluation of carpal tunnel syndrome. We have clearly demonstrated that ultrasonography can be used to discover the cause of median nerve compression, especially in cases with an atypical clinical presentation.

Electronic supplementary material

The online version of this article (doi:10.1007/s11552-012-9435-z) contains supplementary material, which is available to authorized users.     

Hand numbness and carpal tunnel syndrome after volar plating of distal radius fracture

We report the incidence of late onset post-operative carpal tunnel syndrome (late carpal tunnel syndrome) and late median nerve neuropathy after volar plating of distal radius fracture by conducting a retrospective study on volar plating for distal radius fracture performed during 2002 to 2006. Two hundred eighty-two volar plating were performed for acute distal radius fracture after exclusion. Post-operative hand numbness occurred in 24 patients of which nine had carpal tunnel syndrome. Thus, the incidence of late carpal tunnel syndrome was 3.2% (9/282). Of the eight (8/24, 33%) patients with post-operative hand numbness that failed to respond to conservative treatment, five had carpal tunnel release and three had neurolysis of median nerve at distal forearm. All had clinical improvement except in one patient. The incidence of late carpal tunnel syndrome after volar plating of distal radius in the present series is similar to the prevalence of carpal tunnel syndrome in general population. The incidence is low compared with other series, regardless of treatment method (conservative treatment, volar or dorsal plating). The outcome of post-operative hand numbness is generally favourable.     

腕管切开松解减压术

腕管切开松解减压术一直被认为是外科治疗腕管综合征的经典方法，于1913年由Marie和Foix最先提出。其术式甚多，优、缺点各异，操作也有简有繁。现结合腕部神经解剖特点，将每一种术式归纳复述如下。