斜方肌神经支配的解剖学研究

目的 :通过解剖学研究 ,了解斜方肌神经支配方式对根治性颈清扫术术后肩功能可能产生的影响 ,根据神经支配的特点 ,探讨改进手术方法以改善根治性颈清扫术后肩功能的可能性 .方法 :解剖 16具成人尸体 2 2侧颈部 ,观察斜方肌的神经支配 .结果 :68.18%的副神经在胸锁乳突肌后缘前接受颈丛分支的交通 ,所有斜方肌均接受颈丛分支的支配 ,多来源于 C3、C4,其中 ,88.37%的分支在颈后三角位于椎前筋膜的浅面 ,颈丛均有肩胛提肌分支且位于椎前筋膜的深面 .结论 :斜方肌受副神经和颈丛的双重支配 ,大多数颈丛斜方肌支在根治性颈清扫术中会被切断 .通过颈清扫术中保留 C3、C4到斜方肌分支或用颈丛肩胛提肌支与副神经移位吻合来改善术后斜方肌功能具有解剖学上的依据 .     

功能性根治性颈淋巴清扫术中的副神经手术解剖及保留方法

目的：探讨功能性根治性颈淋巴结清扫术中的副神经解剖及保留方法。对33例口腔癌患者术前颈部淋巴结检查阴性者行三保留功能性根治性颈清扫术。介绍副神经的寻找及保留方法，记录副神经与周围结构关系、手术时间及术后淋巴结病理检查结果等。结果：82％（27／33）副神经穿过胸锁乳突肌，18％（6／33）在胸锁乳突肌深面行走；85％（28／33）副神经和颈神经根间存在吻合交通支；副神经在耳大神经出胸锁乳突肌后缘中点上方2cm范围内出该肌；70％（23／33）副神经在进入斜方肌前约2－3cm基本与该肌前缘平行下行后进入该肌；副神经游离；解剖时间约20－30min；术后病理证实27％（9／33）病例颈淋巴结转移。结论：在胸锁乳突肌前缘上份深面及后缘中点上易于寻找副神经，耳大神经出胸锁乳突肌后缘中点是协助寻找副神经的重要解剖标志。     

运用术中神经电图确定斜方肌神经支配的临床研究

目的：通过术中神经电图明确颈丛斜方肌支及副神经对斜方肌的动力支配作用。方法：在术中直接刺激暴露的副神经及C2-C4神经干,在斜方肌的上中下三部分分别记录肌肉收缩时产生的复合肌肉动作电位,以确定副神经及颈丛斜方肌支对斜方肌的支配作用及其范围。结果：副神经对斜方肌的各部分都具有动力支配作用,而一部分颈丛斜方肌支对斜方肌也存在不恒定的动力支配作用,其中C2主要是通过加入副神经的方式支配斜方肌的,C3、C4则多为独立支配斜方肌。结论：斜方肌接受副神经及颈丛斜方肌支的双重动力支配作用,如根治性颈清扫术中保护颈丛斜方肌支,则可能在一定程度上改善患者术后肩功能。     

改良根治性颈淋巴清扫术中两种副神经解剖方法比较

目的：比较改良根治性颈淋巴清扫术术中两种不同的副神经解剖方法的差异。方法：对我院81例术前判断cNo的口腔癌患者行功能性颈淋巴清扫术,副神经解剖方法分胸锁乳突肌前缘和斜方肌前缘两种,记录观察统计副神经与周围组织解剖关系,比较副神经解剖时间,术中误伤副神经几率及术后肩综合征发生情况。结果：胸锁乳突肌前缘解剖方法快速简便,受颈丛神经干扰少,不易误伤副神经,术后肩综合征发生率低,易于掌握,平均副神经解剖时间10~15 min;而斜方肌前缘解剖方法平均20~30 min,术中易受颈丛神经分支的干扰,容易误伤副神经。结论：胸锁乳突肌前缘解剖方法比斜方肌前缘解剖方法有较明显优越性。     

C3、C4颈丛斜方肌支对斜方肌中下部分支配作用的研究

目的:明确C3、C4颈丛斜方肌支对斜方肌中下部分的支配作用。方法:选择73例接受不同颈清术式的患者,其中18例保留副神经及颈丛斜方肌支(A组);11例仅保留副神经(B组);17例保留C3、C4斜方肌支(C组);27例切除副神经及C2-C4斜方肌支(D组),分别于术后2周、6个月、1年及2年检测各患者的肩功能和斜方肌肌电指标进行比较。结果:A组术后肩功能恢复最好;C组患者斜方肌中下部分的功能与B组无明显差异,且上部分功能优于D组。结论:C3、C4颈丛斜方肌支对斜方肌中下部分有支配作用,这种支配可使患者术后的部分肩功能得到明显改善,其改善程度不亚于仅保留副神经的患者。     

Trapezius muscle innervation from the spinal accessory nerve and branches of the cervical plexus

The aim of this study was to demonstrate the extent of motor innervation of the trapezius muscle from the accessory nerve and branches of the cervical plexus using intraoperative electroneurography and histochemical staining. In 34 patients during radical neck dissection the accessory nerve and C2-C4 branches running to the trapezius were identified and stimulated. Potentials were registered under three conditions: intact accessory nerve, section of superior part of communication between the nerve and the cervical branches, and complete section of the nerve. Projections that did not elicit responses were analyzed for acetylcholinesterase activity. Before cutting the accessory nerve, its stimulation led to a recordable contraction in all parts of the trapezius muscle in all patients. C2 contributions were seen in 15, C3 in 21 and C4 in 20 patients. After sectioning of the upper half of the nerve, the results were similar. After the nerve was completely cut, C2 contributions were seen in only 2 patients, but C3 were seen in 20 patients and C4 in 19 patients. Histochemical staining revealed that the branches with no responses contained both motor and sensory axons. The accessory nerve provides the main motor input to the trapezius muscle, but preservation of the C2-C4 branches to the muscle during modified neck dissection should improve outcomes.     

The innervation of the trapezius muscle in connection with radical neck-dissection. An anatomical study

The accessory nerve, the cervical plexus, the sternocleidomastoid and trapezius muscles and neighbouring structures were examined in 47 corpses. Considerable inter- as well as intra-individual differences could be found both in the course and shape of the accessory nerve and in the participation of the cervical plexus in the innervation of the trapezius muscle. The great variation in the manifestation of the shoulder-arm-syndrome in patients after radical neck-dissection can thus be explained. Finally a new method of restoring the innervation of the trapezius muscle is proposed.     

颈神经丛的组织化学研究

目的　拟确定颈丛及其分支是否含有运动神经轴突 ,从而探讨根治性颈清扫术后肩 (胛 )综合征的发生机制 ,并提出改良颈清扫术术式 ,以保存术后正常的肩功能。方法　通过AchE组织化学染色法对颈丛C2～C4及其相关分支的神经纤维进行鉴定。结果　颈丛C2～C4均含运动神经轴突。 6 6 .6 7%的病例至少有 1根以上。颈丛近根部AchE染色呈阳性 ,4 5 .4 5 %颈丛斜方肌支含运动神经轴突 ,颈丛肩胛提肌支及头夹肌的分支均含有运动纤维。结论　颈丛可作为斜方肌的一个运动神经支配来源。颈清扫术中保留颈丛到斜方肌的支配和行颈丛肩胛提肌支副神经移位吻合可较好地恢复术后斜方肌的功能。     

Reinnervation of the trapezius muscle after radical neck dissection

Based on the observation, that the caudal parts of the trapezius muscle after radical neck dissection with complete loss of the spinal accessory nerve, are still innervated to an individually varying degree, and on recent anatomical findings relating to this fact, a method for completely reinnervating the trapezius muscle, despite uncompromising radicality of the dissection, is introduced. This procedure consists of identifying and dislodging a subfascial branch of the deep cervical plexus running to the caudal parts of the trapezius muscle in the lateral cervical triangle and anastomosing it to the distal stump of the accessory nerve, using microsurgical techniques, thereby connecting it to the whole innervation system of the muscle. Clinical and electromyographical examinations showed very good recovery of all three portions of the muscle, 15 months after the procedure, in 46 of 52 patients (85%), although these patients were preselected by temporarily blocking the accessory nerve prior to operation, as possessing very little additional nerve supply.     

副神经的解剖特点及其损伤在临床中的意义

副神经作为胸锁乳突肌、斜方肌等的支配神经,在颈肩运动中起重要作用,其解剖特点对颈淋巴清除、神经修复等临床手术有指导作用。下面就副神经的解剖特点、副神经损伤在临床中的意义作一综述。     

颈清扫术中改善术后肩功能方法的初步探讨

目的　观察并论证两种改进颈清扫术式的优越性及改善术后斜方肌功能的效果。方法　 2 4例需行颈清扫术的患者 ,每组 12例 ,分别在颈清扫术中保留颈丛斜方肌分支 (MRND1)或采用颈丛肩胛提肌支与副神经移位吻合 (MRND2 )。结果　手术 6月后 ,MRND1和 MRND2均可获得较大程度的斜方肌功能恢复 ,MRND1和MRND2的上肢平均最大外展角度分别为 96 .6 7°和 98.13°,5 0 %的患者可以外展上臂超过 90°。结论　 MRND1和MRND2均可较大程度地保存和恢复术后斜方肌的功能 ,改善传统颈清扫术 (RND)后的肩综合征 ,既不违反根治肿瘤的原则 ,同时具有简便、无联带运动、利于斜方肌神经再生、功能恢复等优点。临床上可以用来代替传统 RND,以提高患者的生存质量     

Shoulder-arm-syndrome after radical neck dissection: its relation with the innervation of the trapezius muscle.

In a clinical and electromyographic follow-up of 54 patients who underwent radical neck dissection, vast differences in the individual severity of the shoulder-arm-syndrome were found: 31% experienced severe limitations of shoulder mobility combined with severe pain, whereas 41% suffered only mild discomfort and 28% were free of complaints. These clinical findings were compared to recent anatomical observations concerning individual patterns of innervation of the trapezius muscle. It could be shown that the role of the cervical plexus in the innervation of the trapezius muscle is of great importance and that its subfascial branches are able to maintain the motor supply following radical neck dissection in about 2/3 of patients.     

保留颈外静脉及颈丛神经深支颈淋巴清扫术式的相关基础研究

目的　研究保留颈外静脉及颈丛神经深支对颈淋巴清扫术的安全性、彻底性及术后颅内和面部静脉回流的影响。方法　20例口腔鳞癌患者均采用联合根治术并保留颈神经丛深支。按保留颈外静脉与否将患者随机分为两组,每组10例。检测患者术前、术后的面部组织间质压,免疫组织化学技术染色淋巴管并计数其密度,观察记录患者的术后主观症状。结果　保留颈外静脉组术后面部组织间质压的升高及持续时间均低于不保留组。颈部不同结构淋巴管密度的均值由高至低依次为:颈内静脉、胸锁乳突肌、副神经、颈外静脉和颈丛深支。结论　保留颈外静脉及颈丛神经深支不影响颈淋巴清扫术的安全性及彻底性,并可有效改善患者术后颅内和面部的静脉回流,保存肩功能。     

High division of the accessory nerve: a rare anatomical variation as a possible pitfall during neck dissection surgery.

A rare clinical variant found during neck dissection surgery is reported in which the spinal accessory nerve divided at a high level in the neck, before entering the sternocleidomastoid muscle. This case documents the need for meticulous technique in identification and dissection of the spinal accessory nerve in order to reduce the risk of postoperative morbidity.     

Sternocleidomastoid myocutaneous flap for intraoral reconstruction after resection of oral squamous cell carcinoma.

PURPOSE: The sternocleidomastoid (SCM) myocutaneous flap remains an important tool in head and neck reconstruction. This article retrospectively reviews 40 consecutive SCM myocutaneous flaps used for the reconstruction after resection of oral squamous cell carcinoma with respect to reliability and complications. PATIENTS: From 1987 to 1997, 40 patients underwent SCM myocutaneous flap reconstruction of the oral cavity. The age and gender of the patients, site of primary tumor TNM stage, type of associated operation, and clinical course were analyzed. RESULTS: In 8 cases, partial epithelial loss over the skin paddle occurred with survival of the muscle and at least some of the dermis. Unilateral supraomohyoid neck dissection (SND) was performed in 11 cases, and unilateral functional neck dissection, which preserves SCM and/or internal jugular vein and/or accessory nerve, in 16 cases. Pathologically positive nodes were recognized in 14 of these 27 neck dissection cases; in 11 of these 14 cases, the neck lesion was controlled. CONCLUSION: The SCM myocutaneous flap appears to be simple to use and useful for reconstruction of the defect after resection of oral carcinoma, and the indications for this flap will be extended in accordance with the recent increases in the number of supraomohyoid and functional neck dissection cases.     

Stability of the sternoclavicular joint. A retrospective study

Enlargement of the sternoclavicular joint is a well-documented but little recognised complication of radical neck dissection [AJR 3 (1971) 584]. We examined the stability of the sternoclavicular joint in 61 patients who had had radical neck dissection, functional neck dissection or sternomastoid division in the treatment of torticollis. Our findings support the hypothesis that postoperative stability of the sternoclavicular joint depends on the integrity of the accessory nerve and probably the proprioceptive branches of C3 and C4 of the cervical plexus. We conclude that in patients who require surgical section of the sternomastoid muscle in the treatment of torticollis, or for venous access in microvascular reconstruction, enlargement of the sternoclavicular joint should not occur as a postoperative complication, unlike those patients who have radical neck dissection with resection of the accessory nerve.     

Anatomical variations in the relationship between the spinal accessory nerve and internal jugular vein: a systematic review and meta-analysis

The relationship between the spinal accessory nerve and internal jugular vein is important for modified neck dissection surgery. Therefore, the aim of this review was to investigate variations in this relationship. Through a search of the PubMed, Scopus, Web of Science, LILACS, and SciELO databases, the review authors collected anatomical data for inclusion in a meta-analysis, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Four relationship patterns were identified and classified: type 1, the nerve lies superficial to the vein; type 2, the nerve lies deep to the vein; type 3, the nerve crosses the branches of the vein; type 4, the nerve splits and its branches pass around the vein. The last pattern was not included in the meta-analysis. Eighteen studies were included (useful sample of 1491 hemi-necks). Type 1 variation had a prevalence of 79.7% (95% CI 77.6–81.7%), type 2 had a prevalence of 19.6% (95% CI 17.7–21.7%), and the type 3 had a prevalence of 0.7% (95% CI 0.0–1.4%). Significant differences were found among geographical subgroups. Normally, the spinal accessory nerve passes superficial to the internal jugular vein, but anatomical variations are common and there is a geographical influence. These findings are important for the safety of modified radical neck dissections.     

功能性与根治性颈淋巴清扫术在早期口腔鳞状细胞癌治疗中的疗效比较

目的:探讨功能性颈淋巴清扫术(functional neck dissection,FND)与根治性颈淋巴清扫术(radical neckdissection,RND)在口腔鳞状细胞癌中的临床疗效.方法:63例口腔鳞状细胞癌患者,分为FND组(n=30)和RND组(n=33),FND组保留胸锁乳突肌、副神经、颈内静脉及耳大神经,术后随访2组患者的肩外展功能、耳大神经功能、颈部是否明显凹陷及颈部复发率.应用SPSS 18.0软件包对数据进行单因素x2检验、两独立样本均数t检验,以及Fisher确切概率检验.结果:FND与RND组之间在年龄、性别、肿瘤部位、T分期、N分期、组织学分化程度、病理学类型、术前化疗及术后化疗等方面无显著差异(P＞0.05).所有患者均为N0或N1期,FND组术后肩关节活动度、耳垂感觉麻木及颈部凹陷改善程度显著优于RND组(P＜0.05);术后随访2年,FND组的颈部复发率与RND组无显著差异(P=1.000).结论:对于N0或N1期口腔鳞状细胞癌患者,FND与RND相比,患者颈部复发率无显著差异,但其并发症显著减少,可明显提高患者术后的生活质量.     

Variations in the Anatomy of Spinal Accessory Nerve and its Landmarks for Identification in Neck Dissection: A Clinical Study

PurposeTo assess the anatomy of the spinal accessory nerve (SAN), its variations and the landmark of level II B lymph nodes.MethodsProspective study included 50 patients from 2016 to 2018.The predictor variables were drawn from demographic details of the patients; SAN was analyzed intraoperatively with the parameters like the nerve relationship with the IJV, SCM muscle, contributions of cervical plexus and a new parameter of length from midpoint of clavicle to entry of nerve in the trapezius muscle in the lower part of neck which was studied for the first time and forms the prime identification landmark to preserve the nerve. Outcome variables were details of anatomic variations and branches and utility of these landmarks in prevention of nerve injury.ResultsSample consisted of 38 (76%) male and 12 (24%) female patients. The SAN with respect to the IJV was dorsal in 42% patients and ventral in 58%. In 54% cases, SAN gave a branch to the SCM without penetrating the muscle and in 46% gave a branch to the SCM penetrating the muscle. SAN received contributions from the C2 root of the cervical plexus in 68%, both C2 and C3 in 54% and C3 in 50% cases. Mean length from measurements recorded between mid-line of clavicle to insertion of SAN to trapezius muscle and entry of SAN into trapezius muscle was 59 mm with variations recorded in gender and short/long neck.ConclusionThe result of this study suggests that parameters used are simple clinical tools for identification of the SAN and its variations resulting in no nerve injury. It is prudent for the surgeon to have knowledge of sound anatomical landmarks with the variations in the SAN course which avoids morbidity and improves the quality of life.     

胸锁乳突肌-耳大神经瓣修复颈清扫术中缺损的副神经

目的　总结颈清扫术中用胸锁乳突肌 耳大神经瓣修复副神经缺损的一种方法。方法　将 34例需行传统根治性颈清扫术患者分为单纯颈清扫术组 ( 19例 )及副神经重建组 ( 15例 ) ,副神经重建组缺损副神经用新修复方法处理 ,比较两组病例术后肩功能恢复状况。结果　副神经重建组的术后肩部疼痛、肩臂活动能力及臂外展角度均明显优于单纯颈清扫术组。结论　利用胸锁乳突肌 耳大神经瓣修复缺损副神经是一种简单、有效、充分利用组织和不会带来并发症的可靠方法