周围神经损伤的再手术治疗

目的：探讨周围神经损伤的再手术治疗的方法和疗效。方法：对167例周围神经损伤手术疗效不佳的病人进行再手术治疗，手术方法包括单纯松解术，神经松解 部分吻合术，重新吻合术和神经移植术，根据英国医学研究院颁布的感觉，运动分级标准评定疗效。结果：本组125例获随访，随访时间10个月-7年，平均28个月，共142条神经中功能优52例，良45例，可23例，差22例，结论：对于初次吻合后疗效不佳的周围神经损伤，应尽早积极地再次手术探查，术中电生理监测对决定手术方式及预计术后神经功能的恢复情况有较大的帮助。     

髋臼后壁骨折伴髋关节后脱位与坐骨神经损伤的临床分析

目的 探讨髋臼后壁骨折伴髋关节后脱位合并坐骨神经损伤的创伤机制、类型和预后关系.方法 笔者收治髋臼后壁骨折伴髋关节后脱位合并坐骨神经损伤21例,在骨折内固定时,均行坐骨神经探查术,按MCRR标准评定神经功能恢复情况.结果 21例在术后24个月内,神经均有不同程度的功能恢复,优11例,良9例,可1例,优良率为95.2%.本组无一例出现医源性损伤.结论 髋臼后壁骨折伴髋关节后脱位常合并坐骨神经损伤者,在骨折内固定时应探查神经,结合损伤性质和程度,采取相应疗措施,有利于正确判断预后和恢复神经功能.     

髋臼骨折合并坐骨神经损伤的手术治疗

目的总结髋臼骨折合并坐骨神经损伤内固定和神经探查的手术治疗体会.方法对33例患者行重建钢板、拉力螺钉固定髋臼骨折,同时行坐骨神经探查术,神经损伤者予以神经松解减压或束膜吻合.结果髋臼骨折复位程度按Matta标准:解剖复位14例,满意复位16例,不满意复位3例.坐骨神经功能恢复按MCRR标准评定:优15例,良13例,可3例,差2例,优良率为84%.髋关节功能按修订的dAubigen-Postel髋关节评分标准:优13例,良13例,可5例,差2例,优良率为79%.结论手术复位内固定及坐骨神经探查术治疗髋臼骨折合并坐骨神经损伤可获得良好的效果.     

Surgical outcomes of 111 spinal accessory nerve injuries

OBJECTIVE: Iatrogenic injury to the spinal accessory nerve is not uncommon during neck surgery involving the posterior cervical triangle, because its superficial course here makes it susceptible. We review injury mechanisms, operative techniques, and surgical outcomes of 111 surgical repairs of the spinal accessory nerve. METHODS: This retrospective study examines clinical and surgical experience with spinal accessory nerve injuries at the Louisiana State University Health Sciences Center during a period of 23 years (1978-2000). Surgery was performed on the basis of anatomic and electrophysiological findings at the time of operation. Patients were followed up for an average of 25.6 months. RESULTS: The most frequent injury mechanism was iatrogenic (103 patients, 93%), and 82 (80%) of these injuries involved lymph node biopsies. Eight injuries were caused by stretch (five patients) and laceration (three patients). The most common procedures were graft repairs in 58 patients. End-to-end repair was used in 26 patients and neurolysis in 19 patients if the nerve was found in continuity with intraoperative electrical evidence of regeneration. Five neurotizations, two burials into muscle, and one removal of ligature material were also performed. More than 95% of patients treated by neurolysis supported by positive nerve action potential recordings improved to Grade 4 or higher. Of 84 patients with lesions repaired by graft or suture, 65 patients (77%) recovered to Grade 3 or higher. The average graft length was 1.5 inches. CONCLUSION: Surgical exploration and repair of spinal accessory nerve injuries is difficult. With perseverance, however, these patients with complete or severe deficits achieved favorable functional outcomes through operative exploration and repair.     

坐骨神经霰弹枪伤的手术治疗

目的探讨霰弹枪致坐骨神经损伤的临床特点及手术治疗方法、效果。方法19例坐骨神经霰弹枪伤中,臀部损伤2例,大腿部损伤14例,胭窝部损伤3例。枪伤射击距离在0．5—9．0m之间,按霰弹枪的Shermen分型划分,I型4例,Ⅱ型11例,Ⅲ型4例。伤后至入院手术时间除1例为4h外,其余均为2～14个月。1例行清创、神经外膜对端吻合术,7例行神经全干移值术,6例行神经电缆式移植,4例行神经松解术,1例行踝关节融合术。结果19例患者随访0．8～3．5年、平均19个月,根据英国医学研究院神经外科学会制定的MCRR标准,坐骨神经损伤恢复的优良率为52．6％。结论坐骨神经霰弹枪伤的伤情复杂,常合并开放骨折、血管损伤、软组织缺损及感染;神经损伤的性质多为Sunderland分度中的4～5度损伤;手术治疗方法以神经移植为主,但预后不佳;神经损伤后应给予正确的初始治疗,在对损伤神经恢复状况认真的连续、动态观察的基础上,正确评估神经损伤性质,采取积极、恰当的手术治疗,同时注重神经营养药物、康复理疗等综合治疗,才能获得较好的手术效果。     

骨盆骨折致坐骨神经损伤机制及预后的相关因素

目的：探讨骨盆骨折所致坐骨神经损伤的创伤机制及影响预后的相关因素。方法：分析本组骨盆骨折所致的坐骨神经损伤共53例：39例行骨盆骨折复位内固定、坐骨神经探查松解手术治疗，14例保守治疗。结果：获得随访47例，随访12个月～6年，平均2年。根据MCRR标准，手术治疗组优19例、良10例、一般4例、差1例，保守治疗组优6例、良2例、一般3例、差2例。结论：骨盆骨折致坐骨神经损伤者宜早期行骨折复位内固定，坐骨神经探查松解减压或束膜吻合，可获得较好疗效。     

Hip and pelvic fractures and sciatic nerve injury

Objective:To investigate te influence of hip and pelvic fracture,especially acetanbular fracture complicated by sciatic nerve injury on clinical features and prognosis of sciatic nerve injury.Methods:From January 1987 to January 2000,17 patients(14 male and 3 female) who had hip and pelvic fractures complicated by sciatic nerve injury were treated with operative reduction and internal fixation and followed up from 10 months to 5 years.The average age was 38 years(ranging 23-56 years).The left extremities were involved in 11 patients and the right in 6.Twelve patients underwent primary exploration and neurolysis and 5 patients underwent secondary operation.Results:Preperativelys,8 patients were treated with large doses of oral narcotics to control their severe sciatic pain.Three of the 8 patients underwent patient-controlled analgesia and epidural analgesin.After operation,excellent and good rates of reduction and functional recovery of sciatic nerve were 94.1% and 88% respectively.Four patients still had sciatic pain and 2 patients failed to recover.Sciatic nerve function improved within 3-6 months after surgery in 11 patients.Conclusions:Hip and pelivic fractures can result in sciatic nerve injury,especially common peroneal nerve injury and prognosis is poor.Open reduction and internal fixation combined with nerve exploration and neurolysis should be used as early as possible for severe sciatic pain.     

髋臼后壁骨折的手术治疗

目的探讨手术治疗髋臼后壁骨折的临床疗效。方法从2001年1月．2003年6月，手术治疗有明显移位的髋臼后壁骨折89例，男67例，女22例，平均年龄34．2岁。伴有股骨头脱位62例；按Letournel分类，典型后壁骨折47例，后上骨折33例，后下骨折9例；原发性坐骨神经损伤5例。受伤至手术时间：1—93d，平均11．2d。手术全部采用Kocher—Langenbeck入路。结果平均手术时间87min，失血247mL。全部采用钢板加螺钉固定，手术一过性坐骨神经麻痹4例。平均随访55．6个月（37—66个月），按Matta的复位标准、x线评估标准和Matta改良的d’Aubigne和Postel临床标准进行评估。全部患者均达到解剖复位，x线评估结果：优71例，良16例，一般2例；临床评估结果：优67例，良14例，一般8例。2例坐骨神经高位分支、腓总神经支完全断裂虽经神经吻合，仍有拖行步态，另3例除腓骨长短肌力4级外，步态正常；无感染和股骨头坏死病例，异位骨化11例。结论髋臼后壁骨折行手术治疗可获得良好的临床疗效；合并股骨头脱位急诊复位后的后壁骨折并不增加股骨头坏死率；术前坐骨神经断裂与后壁有大骨折块及伴有坐骨神经盆内高位分支有关。     

Management and outcomes in 353 surgically treated sciatic nerve lesions

OBJECT: This is a retrospective analysis of 353 surgically treated sciatic nerve lesions in which injury mechanisms, location, time to surgical repair, surgical techniques, and functional outcomes are reported. Results are presented to provide guidelines for management of these injuries. METHODS: One hundred seventy-five patients with buttock-level and 178 with thigh-level sciatic nerve injury were surgically treated at the Louisiana State University Health Sciences Center between 1968 and 1999. Buttock-level injury mechanisms included injection in 64 patients, hip fracture/dislocation in 26, contusion in 22, compression in 19, gunshot wound (GSW) in 17, hip arthroplasty in 15, and laceration in 12; at the thigh level, GSW was the cause in 62 patients, femoral fracture in 34, laceration in 32, contusion in 28, compression in 12, and iatrogenic injury in 10. Patients with sciatic nerve divisions in which positive intraoperative nerve action potentials (NAPs) were found underwent neurolysis and attained at least Grade 3 functional outcomes in 108 (87%) of 124 and in 91 (96%) of 95 buttock- and thigh-level tibial divisions, respectively, compared with 84 (71%) of 119 and 75 (79%) of 95, respectively, in the peroneal divisions. For suture repair, recovery to at least Grade 3 occurred in eight (73%) of 11 buttock-level and in 27 (93%) of 29 thigh-level tibial division injuries, and in three (30%) of 10 buttock-level and 20 (69%) of 29 thigh-level peroneal division lesions. For graft repair, good recovery occurred in 21 (62%) of 34 and in 43 (80%) of 54 buttock- and thigh-level tibial divisions, respectively, even in proximal repairs requiring long grafts, and in only nine (24%) of 37 and 22 (45%) of 49 buttock- and thigh-level peroneal division lesions, respectively. CONCLUSIONS: Surgical exploration and neurolysis after positive NAP readings, or repair with sutures or grafts after negative NAP results are worthwhile in selected cases.     

髋臼骨折合并坐骨神经损伤的治疗(附20例报告)

目的　探讨髋臼骨折合并坐骨神经损伤的创伤机制及治疗。方法　分析本组髋臼骨折合并坐骨神经损伤共 2 0例 ,均行肌电图检查。 4例采用患肢持续股骨髁上牵引非手术治疗 ;16例采用髋臼骨折切开复位内固定手术治疗 ,术中视坐骨神经损伤程度作神经外膜松解或束间松解。结果　坐骨神经恢复情况 :优 7例 ,良 6例 ,可 4例 ,差 3例。结论　应根据临床检查 ,X线及CT所示骨折移位情况和有无髋关节后脱位 ,作电生理检查 ,结合临床有无造成神经严重损伤的因素而决定是否探查坐骨神经 ;术中肉眼观察坐骨神经损伤程度对指导手术和判断预后有一定意义 ,神经的恢复情况与术中所见损伤程度有关     

臀部外伤性坐骨神经损伤的手术治疗

目的探讨臀部外伤性坐骨神经损伤手术治疗的指征及效果. 方法对21例外伤性臀部坐骨神经损伤者进行手术治疗,方法包括神经探查、松解、减压、路径清理及神经吻合. 结果平均随访2.98年,坐骨神经恢复优良率为57.1%. 结论臀部外伤性坐骨神经损伤以腓神经较多见,且预后不佳;伤后应早期手术治疗,术中应注意判断坐骨神经的行径、损伤或严重情况,避免漏治.     

移位髋臼骨折的手术治疗

目的探讨移位髋臼骨折的手术方法。方法对22例髋臼骨折按不同类型、不同手术入路分别用加压螺钉、重建钢板等予以内固定治疗。结果平均随访14个月(5~30个月)。术后发生1例伤口感染和1例坐骨神经牵拉伤,未发生血管损伤及深静脉栓塞。复位情况按Judet方法评估,达到解剖复位者18例,复位满意者4例。按美国矫形外科研究院标准评估疗效,优14例,良5例,可2例,差1例。结论重建钢板内固定治疗移位髋臼骨折是有效的方法,正确的骨折分型、手术切口的选择是复位成功的关键。     

Improvement in motor function after brachial plexus surgery

Motor functional recovery of 52 patients with brachial plexus surgery followed up for more than 2 years was evaluated. Fifty-eight surgical procedures were done, including autologous nerve grafting (38 cases), neurolysis (14 cases), and neurotization (6 cases). Overall results, evaluated according to the 0 to 5 formula of the Medical Research Council, were as follows: good, 58%; fair, 15%; and poor, 27%. Good results were evident in 58% of patients with nerve grafts and in 64% of those with neurolysis. In patients with neurotization, no good recovery and only one fair recovery were seen. Patients with open injuries showed good recovery, whereas the group with closed injury showed good recovery in only 48%. Patients with closed injuries caused by traffic accidents showed a worse recovery than those caused by other means. Patients with closed injuries and nerve grafting done within 3 months of injury or neurolysis within 6 months showed better recovery.     

The Effect of Aprotinin on Extraneural Scarring in Peripheral Nerve Surgery: An Experimental Study

Summary  Extraneural scarring is one of the factors negatively influencing the result of peripheral nerve surgery. Many organic materials have been used to prevent fibrosis. The effect of aprotinin on peripheral nerve scarring in rats was investigated in this study. Three types of surgical intervention were carried out; namely external neurolysis (I), abrasive injury (II), and anastomosis (III). The coded samples which consisted of pure collagen fibers soaked with aprotinin or phosphate-buffered saline were applied around the left sciatic nerves of rats whereas only sham operations were performed on the right sciatic nerves. Animals were sacrificed after 4 or 6 weeks. Neurological examination, gross evaluation of extraneural fibrosis, and histological study were undertaken. The results have demonstrated that aprotinin is a promising agent in the prevention of extraneural scarring.     

Surgical management and results of 135 tibial nerve lesions at the Louisiana State University Health Sciences Center

OBJECTIVE: This retrospective study presents 33 years of clinical and surgical experience with 135 tibial nerve lesions to review operative techniques and their results and to provide management guidelines for the proper selection of surgical candidates. METHODS: Between 1967 and 1999, 135 patients with tibial nerve lesions at the knee level or below were managed surgically at the Louisiana State University Health Sciences Center. We reviewed these cases. RESULTS: Of the 135 cases, traumatic injury accounted for 71, tarsal tunnel syndrome for 46, and nerve sheath tumor for 18. Of 22 lesions not in continuity, functional recovery of Grade 3 or better was achieved in 4 (67%) of 6 patients who required end-to-end suture repair and 11 (69%) of 16 patients who required graft repair. One hundred thirteen tibial nerve lesions in continuity underwent primarily external or internal neurolysis or resection of the lesions. A few received end-to-end suture or graft repair. Direct intraoperative recording of nerve action potentials guided case management decisions. Among the 113 patients with lesions in continuity, 76 (81%) of 94 patients receiving neurolysis, 5 (83%) of 6 receiving suture repair, and 11 (85%) of 13 receiving graft repair recovered function to Grade 3 or better. Repair results were best in patients with recordable nerve action potentials treated by external neurolysis. Results were poor in a few patients with very lengthy lesions in continuity and in reoperated patients with tarsal tunnel syndrome. CONCLUSION: Surgical exploration and repair of tibial nerve lesions, including nerve sheath tumors and tarsal tunnel syndromes, achieved excellent outcomes.     

The effects of experimental neurolysis on ectopic firing in a rat chronic constriction nerve injury model

PURPOSE: We studied the effects of experimental neurolysis on ectopic firing in a rat chronic constriction nerve injury (CCI) model. METHODS: Sixteen Wistar rats were used as CCI models; 8 in a neurolysis group and 8 in a sham operation group. Eight additional Wistar rats were used in a normal control group. The CCI model was created by loosely ligating the sciatic nerve with 4-0 chromic gut sutures. Seven days after surgery the same portion of the sciatic nerve, now embedded in scar tissue, was exposed. For the neurolysis group all sutures and scar tissue around the nerve were removed, and for the sham operation group only exposure of the sciatic nerve embedded in scar tissue was performed. Fourteen days after the first surgery the spinal cords of all animals in the 3 groups were transeated at the most rostral level of the spinal cord and ectopic firing was recorded antidromically from the sural nerve. The spontaneous ectopic firing frequency and the firing pattern at rest and the ectopic firing frequency under a hypoxic condition were analyzed. RESULTS: The ectopic firing frequency in the neurolysis group was significantly lower than that of the sham operation group but higher than that of the normal control group. Also the appearance rate of an on-off pattern was 0% in the neurolysis and normal control groups and 38% in the sham operation group. Finally the accumulated number of ectopic firings under a hypoxic condition was significantly smaller in the neurolysis and normal control groups than that of the sham operation group. CONCLUSIONS: Experimental neurolysis significantly improved the abnormal ectopic firing frequency and on-off firing pattern in the injured nerve of the CCI model. These findings may explain the efficacy of neurolysis on sensory symptoms such as numbness or spontaneous pain in chronic compression neuropathy.     

Surgical management of trapezius palsy

BACKGROUND: Injury to the spinal accessory nerve in the posterior cervical triangle leads to paralysis of the trapezius muscle. The aim of this study was to determine the indications for nerve repair or reconstructive surgery according to the etiology, the duration of the preoperative delay, and specific patient characteristics. METHODS: Of twenty-seven patients with a trapezius palsy, twenty were treated with neurolysis or surgical repair (direct or with a graft) of the spinal accessory nerve and seven were treated with the Eden-Lange muscle transfer procedure. Lymph node biopsy was the main cause of the nerve injury. The nerve repairs were performed at an average of seven months after the injury, and the reconstructive procedures were done at an average of twenty-eight months. Nerve repair was performed for iatrogenic injuries of the spinal accessory nerve, within twenty months after the onset of symptoms, and in one patient with spontaneous palsy. Reconstructive surgery was performed for cases of trapezius palsy secondary to radical neck dissection, for spontaneous palsies, and after failure of nerve repair or neurolysis. The mean follow-up period was thirty-five months. The functional outcome was assessed clinically on the basis of active shoulder abduction, pain, strength of the trapezius on manual muscle-testing, and level of subjective patient satisfaction. RESULTS: The results were good or excellent in sixteen of the twenty patients treated with nerve repair and in four of the seven patients treated with the Eden-Lange procedure. Poor results were seen in older patients and in patients with a previous radical neck dissection. CONCLUSIONS: Good results can be expected from a repair of the spinal accessory nerve if it is performed within twenty months after the injury, as the nerve is basically a purely motor nerve and the distance from the injury to the motor end plates is short. Muscle transfer should be performed in patients with spontaneous trapezius palsy, when previous nerve surgery has failed, or when the time from the injury to treatment is over twenty months. Treatment is less likely to succeed when the patient is older than fifty years of age or the palsy was due to a radical neck dissection, penetrating injury, or spontaneous palsy.     

Hyaluronic acid prevents peripheral nerve adhesion.

The purpose of this study was to clarify the effectiveness of hyaluronic acid (HA) in the prevention of scar formation after neurolysis using a rabbit model. In the first stage, the left sciatic nerve was exposed and elevated along a 3 cm section. Then, the surface of the neural bed was coagulated using a bipolar coagulator. Finally, the sciatic nerve was replaced and fixed to the neural bed with 8/0 nylon sutures, and the wound was closed. In the second stage, the adherent sciatic nerve was re-exposed after 6 weeks. In the neurolysis group, a simple neurolysis was performed. In the HA group, the neurolysis was performed in a surgical field coated with HA from the beginning to the end of the operation. In the steroid group, methyl prednisolone acetate was infiltrated at the end of the neurolysis. In the third stage, electrophysiological, histological and biomechanical measurements were taken 6 weeks after the second stage. While there was no significant difference between the HA and the steroid groups, the electrophysiological functions of the HA and steroid groups were significantly better than that of the neurolysis group. Histology showed that the formation of intraneural and extraneural scar tissue was lowest in the HA group, followed by the steroid and neurolysis groups. The tensile strength required to strip the sciatic nerve from the neural bed of the HA group was significantly less than that of the neurolysis group. However, there was no significant difference between the steroid and neurolysis groups. In conclusion, HA effectively reduced scar formation after neurolysis.     

Recovery of sciatic nerve injuries in association with total hip arthroplasty in 27 patients

We analyzed 27 sciatic nerve injuries associated with total hip arthroplasty (THA). The patients were 23 women and 4 men, and their median age was 55 years (range, 28-75 years). In 1987 to 1995, 4,339 THAs were performed. Primary arthroplasties accounted for 3,471 and 868 were revisions. Nine patients had developmental dysplasia of the hip. Six operations were revisions. Radiologic lengthening was median 1.4 cm (range, -1 to 4.1 cm); in 8 cases, lengthening was greater than 2 cm. The median follow-up period was 58 months (range, 24-110 months). Eight patients recovered fully, the recovery of 7 patients was fair, and 12 patients had a considerable permanent disability. The risk of nerve injury was not related to the extent of lengthening. The recovery of the nerve injury was only weakly correlated to its primary postoperative extent. The sciatic nerve injury rate was 0.6%.     

髋臼骨折手术治疗后髋关节功能恢复的影响因素分析

背景：髋臼骨折多为高能量损伤所致,属于关节内骨折,手术是最佳治疗方式。但骨折类型、手术入路、复位质量、年龄、手术时机等会对治疗效果产生影响。因此,分析影响手术效果的关键因素十分必要。目的：探讨手术治疗髋臼骨折后影响髋关节功能恢复的因素。方法方法：选择2010年1月至2013年10月手术治疗且随访资料完整的髋臼骨折患者42例,18例采用Kocher-Langenbeck入路,14例采用髂腹股沟入路,10例采用前后联合入路。术后采用Matta标准评定骨折复位情况。采用改良的Merled＇Aubigne-Postel评分系统评价患者髋关节功能。对可能影响手术疗效的指标（如性别、年龄、手术时机、骨折类型、手术入路、复位质量等）进行单因素及多因素Logistic回归分析,筛查影响手术疗效的危险因素。结果：术后14例达到解剖复位,20例良好复位,8例一般复位。切口均甲级愈合,未出现感染。全部患者术后随访12-26个月,平均19个月。X线检查示骨折于术后10-18周愈合,平均14周。术后出现坐骨神经损伤4例,创伤性关节炎2例,股骨头缺血坏死2例,异位骨化7例。术后6个月时髋关节功能评定为优13例,良21例,可5例,差3例,优良率为81%。单因素分析结果显示性别、年龄、手术入路、髋关节脱位与手术疗效无明显关系（P〉0.05）,而手术时机、骨折类型、复位质量、异位骨化与手术疗效有关（P〈0.05）。多因素分析显示骨折类型、手术时机、复位质量是影响手术效果的独立因素（P〈0.05）。结论：骨折类型、手术时机和复位质量是影响髋臼骨折手术疗效的独立因素,而后两者是相对可控的因素,治疗时要选择合适时机、尽量达到解剖复位,以期获得良好的临床结局。