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     

颈淋巴清扫术后肩功能研究之现状

根治性颈淋巴清扫术由于切除了副神经等结构,常发生肩(胛)综合征。本文概述了根治性和功能性颈淋巴清扫术后的肩功能研究现状,肩综合征的可能发生机制,以及近年来解决根治性颈淋巴清扫术后肩综合征的一些办法。     

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。     

背阔肌皮瓣移植时吻合肋间神经皮克获得感觉

病人和方法 6名口腔鳞状细胞癌患者,平均年龄58岁,肿瘤分期T_4N_(2a)M_0,均行下颌骨部分切除术,同侧根治性颈淋巴清扫术和对侧舌骨上颈淋巴清扫术,拟用带肩胛骨的背阔肌游离皮瓣修复组织缺损。取瓣时,自肋间神经皮支穿出胸壁处开始分离,分离出长约6～7cm,然后切断之。皮瓣制备完成后,将胸背动脉     

颈淋巴清扫术中保留副神经的方法

目前,保留副神经的改良颈淋巴清扫术已被广泛采用,并公认是一种安全有效的方法。但是对颈淋巴清扫术中如何保留副神经,文献上却较少报道。作者报道一种逆行解剖分离副神经的方法,此法能最大限度地显露副神经的颈段全程,而甚少损伤神经。应用近200例,只1例发生神经损伤。方法胸锁乳突肌翻起后,首先辨认副神经的前上段,并确定副神经与颈静脉的关系以及副神经淋巴链有无转移,如肿瘤累及神经则无保留必要而应予切除。此后,在锁骨上缘上方3～5cm,颈后三角神经入斜方肌处寻找副神经,找到后用神经刺激器予以证实。另外,尚可在胸锁乳突肌后缘近Erb点处解剖副神经。用神经拉钩小心牵拉神经,用锐剪仔细将神经与周围组织分离,显露出斜方肌与胸锁乳突肌之间的副神经及其远端     

下颌骨部分切除术后移植前臂皮神经修复下齿槽神经

对象和方法 6名下颌牙龈鳞癌患者,行下颌骨部分切除术及根治性颈淋巴清扫术,用前臂皮瓣修复组织缺损。下颌骨部分切除后,以橡皮管切实保护好下齿槽神经近心端。待皮瓣的血管吻合完成,分离出前臂外侧皮神经,其长度应超过切除下齿     

保留颈外静脉，耳大神经和颈神经丛深支的根治性颈清扫术疗效评价

目的：评价保留颈外静脉,耳大神经和颈神经丛深支的根治性颈清扫术疗效。方法：2001年6月至2003年12月住院的口腔癌初诊患者40例,均经病理确诊,其中男23例,女17例,年龄31—60岁,平均年龄48岁,中位年龄50岁,舌癌16例,颊癌15例,口底癌5例,下牙龈癌4例。所有患者分为两组,分别行经典的根治性颈淋巴清扫术和保留颈外静脉,耳大神经和颈神经丛深支的根治性颈清扫术。结果：术后切口均I期愈合,与经典的根治性颈淋巴清扫术相比,保留颈外静脉,耳大神经和颈神经丛深支的根治性颈清扫术在功能保留方面明显优于经典的根治性颈淋巴清扫术（P〈0．05）,而术后颈部复发率与经典的根治性颈淋巴清扫术无显著差异。结论：保留颈外静脉,耳大神经和颈神经丛深支的根治性颈清扫术可作为口腔癌颈清扫术的常规术式,并易于临床推广。     

保存颈内静脉的改良根治性颈淋巴清扫术的临床评价

目的 :对口腔癌及口咽癌颈淋巴清扫术中保存颈内静脉术式的临床效果进行评价。方法 :回顾分析本院近 10年内所行的根治性颈淋巴清扫术和保存颈内静脉的改良根治性颈淋巴清扫术病例资料。比较 2种术式的术后面部水肿和颅内高压持续时间及程度、2组患者的术后局部复发情况和生存时间。结果 :保存颈内静脉的改良根治性颈淋巴清扫术的术后颌面部水肿和头晕症状程度轻于根治性颈淋巴清扫术 ,持续时间缩短。改良根治性颈淋巴清扫术 3年和 5年生存率分别是 72 .6%和 5 3 .3 % ,局部复发率 5 .1% ;而根治性颈淋巴清扫术 3年和 5年生存率分别是 75 .2 %和 5 7.8% ,局部复发率 4.8%。二者 3组指标差异均无显著性 (P >0 .0 5 )。结论 :保存颈内静脉的改良根治性颈淋巴清扫术和经典的根治性颈淋巴清扫术临床疗效相近 ,术后并发症轻 ,且能保存颈内静脉 ,为可能的再次手术治疗创造了条件 ,值得临床推广。     

合理的根治性颈淋巴清扫术的临床应用评价

目的:评价保留颈外静脉、耳大神经和颈神经丛深支的新型改良根治性颈淋巴清扫术(或称合理的根治性颈淋巴清扫术)在治疗口腔癌颈淋巴转移灶中的临床应用价值。方法:TNM分期在T2N1M0~T4N3M0之间的口腔鳞癌初诊患者45例,随机分为2组(RND组和RRND组),RND组行传统根治性颈淋巴清扫术(22例),RRND组行合理的根治性颈淋巴清扫术(23例),比较2种手术方式的颈淋巴结术后复发率和并发症。结果:RRND组术后患者面部水肿及头晕、头痛症状显著低于RND组(P<0.05);术后6个月复查,RRND组患者耳廓和肩部麻木感显著低于RND组,耳廓皮肤感觉功能和肩运动功能显著高于RND组(P<0.05);随访3年,RRND组和RND组术后颈淋巴结复发率分别为8.70%、4.55%,差别无统计学意义(P>0.05)。结论:合理的根治性颈淋巴清扫术与传统根治性颈淋巴清扫术相比,不会增加术后颈淋巴结复发率,但极大地提高了患者术后的生存质量。     

保留颈外静脉、颈神经丛深支和耳大神经的根治性颈淋巴清扫术疗效评价

目的：探索一种保证口腔癌颈淋巴结转移手术彻底性和避免并发症，最大限度保存患者术后生存质量和机体功能的最佳颈清扫术式。方法：通过对182例颈淋巴清扫术的回顾性研究，对保留颈外静脉、颈神经丛深支和耳大神经的颈淋巴清扫术式的根治效果、术中并发症和术后功能障碍进行评价，所得数据进行X^2检验。结果：与常规根治性颈淋巴清扫术相比，保留颈外静脉和颈神经丛深支的根治性颈淋巴清扫术在维持术中较平稳的生命体征、术后恢复等方面具有明显的优势，尤其是接受双侧根治性颈清扫术的病例，保留颈外静脉将降低手术风险和术后护理难度，并有利于患者的尽早恢复，其术后肩功能和耳郭和（或）耳后区皮肤感觉功能明显优于根治性颈清术式（P〈0．05）．而术后颈部复发率与根治性颈淋巴清扫术无显著差异（P〉0．05）。结论：保留颈外静脉和颈神经丛深支的根治性颈淋巴清扫术是一种比较合理的术式，在保证颈清扫根治性的前提下，减轻和避免了术中、术后的颅内高压并发症和肩功能损伤及耳部感觉障碍。本术式适应证广泛，可作为口腔癌颈淋巴结转移和cN0选择性颈清扫术的常规术式。     

颈清扫术不同术式对cN0口腔鳞状细胞癌患者肩功能的影响

目的比较颈清扫术（ND）不同术式对口腔鳞状细胞癌患者术后肩功能的影响.方法将66例临床颈部淋巴结阴性（cN0）口腔鳞状细胞癌患者按接受ND的术式分为根治性颈清扫术（RND）组、改良根治性颈清扫术（MRND）组和择区性颈清扫术（SND）组,采用Constant＇s肩功能量表和ND损伤指数量表对术后肩功能进行评价.结果保留副神经组的患侧肩功能优于RND组（P＜0.01）.在保留副神经组中,SND组的肩功能优于MRND组（P＜0.01）.SND术后的肩部疼痛和功能障碍轻微.结论SND对术后肩功能影响轻微,优于RND和MRND.     

Shoulder complaints after neck dissection; is the spinal accessory nerve involved?

The purpose of the current study was to investigate the relation between shoulder morbidity (pain and range of motion), and the function of the spinal accessory nerve after neck dissection. Identifying dysfunction of the nerve gives insight in the mechanisms of post-operative shoulder complaints. In total 112 patients after neck dissection (73 males/39 females), mean (SD) age 61 (13) years, participated in the study. The mean duration of follow up was 3 (2) years. Five patients had radical, 43 modified radical, 48 supraomohyoid, and 16 posterolateral neck dissection. Thirty-nine complained of shoulder pain of whom 20 (51%) had dysfunction of the spinal accessory nerve, and 19 (49%) did not. In total 29 patients (26%) had dysfunction of the spinal accessory nerve of whom 20 (69%) had shoulder pain. Shoulder pain was significantly related to dysfunction of the nerve (P < 0.001). Twenty-three patients had a difference in active range of motion in shoulder abduction of > or =40 degrees, of whom 22 (96%) had dysfunction of the nerve. A difference in active shoulder abduction of > or =40 degrees was significantly related to loss of function of the spinal accessory nerve (P < 0.001). CONCLUSION: Shoulder pain after neck dissection can only be attributed to dysfunction of the spinal accessory nerve in about 50%. If patients experience shoulder pain after neck dissection examination of the trapezius muscle and active bilateral abduction of the shoulder should be made to find out if the spinal accessory nerve is involved.     

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.     

A simple method of identifying the spinal accessory nerve in modified radical neck dissection: anatomic study and clinical implications for resident training

Purpose

The major complication of neck dissection and surgery at the posterior triangle of the neck is the shoulder syndrome, which results from spinal accessory nerve injury. Erb’s point (the great auricular nerve) and the point where the spinal accessory nerve enters the trapezius muscle are used to identify the spinal accessory nerve in the posterior nerve triangle.

Materials and methods

Measurements were made during unilateral neck dissections in 30 patients to identify the relationship between the spinal accessory nerve and great auricular nerve and the distance between the entrance of the accessory nerve in the trapezious and clavicle.

Results

The distance between the spinal accessory nerve and Erb’s point was ranging from 0 to 3.8 cm (mean 1.53 cm). The distance between the spinal accessory nerve entering the trapezious muscle and the clavicle was between 2.5 and 7.3 cm (mean 4.8 cm).

Conclusions

Since the great auricular nerve (Erb’s point) represents a constantly identifiable landmark, it allows simple and reliable identification of the course of the spinal accessory nerve. Also useful, but of secondary importance in our opinion, is identifying the nerve at the point where it enters the trapezius muscle.     

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。     

Anatomical study of accessory nerve innervation relating to functional neck dissection.

PURPOSE: The present study sought to clarify correlations of accessory nerve innervation in the neck region and innervation of the sternocleidomastoid and trapezius muscles with postoperative dysfunction after functional neck dissection by macroscopic observation. MATERIALS AND METHODS: The materials used in this study were 35 cadavers provided for anatomical practice to the Department of Anatomy, Tokyo Dental College. The accessory nerve was identified at the anterior margin of the trapezius muscle, and its innervation in the posterior triangle of the neck was examined in detail. RESULTS: The superficial cervical vein vascularizes the anterior margin of the trapezius muscle near an area where the main trunk of the accessory nerve innervates the trapezius muscle. The results showed 3 types of accessory nerve innervation of the sternocleidomastoid muscle: Type A, the not penetrating type; Type B, the partially penetrating type; and Type C, the completely penetrating type. In addition, 5 types of innervation of the trapezius muscle by the main trunk and branches of the accessory nerve were apparent, with the number of branches innervating the muscle ranging from 0 to 4. CONCLUSIONS: Dysfunction after functional neck dissection can thus be avoided by paying attention to not only the main trunk of the accessory nerve, but also the branches. Moreover, when identifying accessory nerve innervation of the trapezius muscle, the superficial cervical vein may offer a useful surgical landmark.     

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。     

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.