小针刀治疗上肢周围神经双卡综合征

目的：评价小针刀对近端颈神经根受压合并远端神经卡压（上肢周围神经双卡综合征）的临床疗效。方法：本组近端颈神经根受压合并远端神经卡压48例，男27例，女21例；年龄32～73岁，平均48．6岁。左上肢15例，右上肢33例。48例均利用针刀进行治疗，根据术后症状及体征改善程度分析小针刀治疗上肢周围神经卡压的治疗效果。结果：所有患者平均随访16个月，根据术后症状、体征改善的程度分优、良、中和差4级。本组优22例，良18例，中5例，差3例，共计40例治疗后疗效优良，占83．3％。结论：采用小针刀治疗颈神经根受压合并远端神经卡压的双卡综合征，具有微创、恢复快、操作简便、安全经济和疗效可靠等优点。正确及时的诊断及选择合适的适应证是保证疗效的关键。     

神经根型颈椎病伴有周围神经卡压的诊断和治疗

目的：研究29例双卡综合征的诊断和治疗。方法：从1997年以来同时诊断为神经根型颈椎病与周围神经卡压的病例中选出29例患者，诊断标准为：(1)影像学上存在神经根在椎管内受压的证据；(2)有临床和(或)电生理的证据表明存在周围神经受到卡压；(3)周围神经的Tine1征阳性。对其中5例行保守治疗，24例行手术治疗，即神经松解术。平均随访12个月，根据术后症状、体征改善的程度分优、良、可和无效4级。结果：25例治疗后疗效优良，占86％。结论：神经根型颈椎病伴有周围神经卡压的双卡综合征并不罕见，正确认识双卡综合征，对诜择正确的治疗方案和估计愈后有重要意义．一旦确诊．应采取手术或非手术相结合的方法，可以达到满意的效果。     

双神经卡压综合征

目的：研究双神经卡压征的病因及手术治疗方法。方法：分析了自１９８８年以来同时诊断为腕管综合征和肘管综合征２６例３４侧的临床资料。全部患者均作两处神经松解术，平均随访１７个月。疗效评定标准，根据术后症状、体征的改善程度分优、良、可和无效四级。结果：２５侧术后疗效优良，占７３．６％（２５／３４）。结论：双神经卡压征手术治疗效果较好。当双神经卡压同时合并颈部神经卡压时，建议优先考虑远端的神经减压。当远端神经减压后未能改善近端神经卡压症状时，才考虑近端神经减压     

颈椎管内外神经双卡综合征

1973年,Upton和McComas[1]首次提出周围神经双卡综合征( double crush syndrome)的假说,即神经近端受压后会导致其远端另一部位对压迫的敏感性增加,从而产生远端神经卡压症状.尽管此后该假说得到了部分基础及临床研究的支持,但对于其诊断及治疗原则,仍存在较大争议.本文就双卡综合征的研究进展做一综述.     

腕尺管综合征的解剖特点及显微外科治疗

目的 探讨腕尺管综合征尺神经卡压的解剖特点、临床表现、治疗方法和疗效。方法 对1993年以来收治的24例腕尺管综合征患的病因、症状与体征、解剖特点及采用显微外科技术治疗的结果进行分析和总结。结果 本组尺神经在Guyon管近侧受压9例，占38％；在远侧端受压15例，占62％。术后随访3个月～8年6个月，尺神经术后功能恢复优良率75％。结论 腕尺管综合症尺神经的卡压多在Guyon管的远端，因此诊断一经确立应立即应用显微外科手术治疗，术中应对Guyon管和尺神经全面探查，必要时对尺神经行外膜及束膜松解。     

胸廓出口综合征合并颈椎病的治疗疗效分析

[目的]探讨应用常规臂丛神经松解术治疗胸廓出口综合征（thorasis outlet syndrome，TOS）合并颈椎病的疗效。[方法]对经过肌电图证实为胸廓出口综合征与X线片证实为颈椎病的16例病人进行了前、中斜角肌切断、神经松解术，术后配合理疗及神经营养药物治疗。[结果]所有病例均在术后得到随访。按陈履平等疗效评定标椎，随访22个月时，优5例，良4例，可3例，差4例。[结论]合并颈椎病的胸廓出口综合征的病人必须首先治疗颈椎对神经根的压迫，才能保证手术治疗胸廓出口综合征的疗效。     

胸廓出口综合征的诊疗体会

目的探讨胸廓出口综合征(TOS)的诊断和手术治疗。方法我院自1997-2003年诊断和手术治疗胸廓出口综合征23例24侧，诊断为臂丛上千型TOS2例，下千型17例18侧，全臂丛型1例，血管型2例，混合型1例。手术切除颈肋及过长的横突，同时作臂丛神经外膜松解术。术中发现23例有纤维束带压迫臂丛神经，均切断前斜角肌，松解臂丛神经及受压的锁骨下血管，如果发现中、小斜角肌压迫臂丛神经血管，则予切断。术后当天行颈肩部活动。结果按Ross的疗效评定标准评定疗效，本组优10例11例，良9例，可2例，差2例，优良率83.33％。结论胸廓出口综合征应早期手术探查，彻底松解臂丛神经血管。     

神经松动术配合微波及牵引治疗神经根型颈椎病

目的观察神经松动术配合微波及牵引治疗神经根型颈椎病的临床疗效。方法将神经根型颈椎病患者52例随机分为观察组和对照组,每组26例,观察组采用神经松动术手法配合颈椎牵引治疗,对照组采用传统颈椎推拿手法配合微波及牵引治疗。2组均于治疗前、治疗后分别采用视觉模拟评分法（VAS）、颈椎病临床评价量表（Clinical Assessment Scale for Cervical Spondylosis,CASCS）评价颈椎的疼痛及整体功能改善情况以及治疗后临床疗效评定。结果治疗前2组患者间VAS及CASCS评分差异无统计学意义（P〉0.05）;2组治疗后VAS及CASCS评分明显改善（P〈0.01）,且观察组显著优于对照组,差异有统计学意义（P〈0.05）。结论神经松动术配合微波及牵引治疗神经根型颈椎病具有显著的临床疗效,值得推广应用。     

神经电生理检查对神经根型颈椎病与肘管综合征的鉴别诊断价值

目的：探讨神经电生理检查对神经根型颈椎病与肘管综合征的鉴别诊断价值。方法：对14例以手部内在肌萎缩为主要临床表现的患者进行双上肢体感诱发电位（somatosensory evoked potential，SEP）、双侧正中神经和尺神经传导速度（nerve conduction velocity，NCV）、双侧第一背侧骨间肌和尺侧腕屈肌肌电罔（electromyogram，EMG）检查。结果：3例以尺神经肘上-肘下段传导速度减慢大于10m／s及第一背侧骨间肌神经源性损害为主，诊断为肘管综合征；4例以SEP颈髓至外周电位（N9-N13）峰间潜伏期延长和尺侧腕屈肌、第一背侧骨间肌神经源性损害为主，诊断为神经根型颈椎病；7例为尺侧腕屈肌及第一背侧骨间肌神经源性损害、尺神经肘上-肘下段传导速度减慢大于10m／s、SEPN9-N13峰间潜伏期延长，诊断为二者合并存在。手术治疗10例，术中所见均与神经电生理检查结果相符。结论：神经电生理检查在神经根型颈椎病与肘管综合征的鉴别诊断中具有重要提示意义。     

桡骨远端骨折合并腕部尺神经损伤的诊断与治疗

目的总结桡骨远端骨折合并腕部尺神经损伤的发病机制、临床表现和治疗方法。方法对桡骨远端骨折合并尺神经支配区单纯掌侧感觉、运动或感觉和运动同时改变的7例患者，进行腕尺管探查尺神经松解术。结果术后随访时间为6～12个月，按中华医学会手外科学会上肢部分功能评定试用标准评定：优5例，良1例，可1例。结论部分伸直型桡骨远端骨折可合并腕部尺神经卡压，一经明确诊断即应早期行尺神经松解手术。     

同期手术治疗胸廓出口综合征合并远端神经卡压的疗效

目的探讨远近端同期手术治疗胸廓出口综合征合并远端神经卡压的疗效。方法对8例胸廓出口综合征合并远端神经卡压者,一期同时手术松解臂丛神经及远端神经卡压,并消除了全部卡压因素。结果按成效敏等的评定标准评价优3例,良4例,差1例。结论对晚期已出现肌萎缩的胸廓出口综合征合并远端神经卡压患者,应选择一期远近端神经同时松解术,以改善疗效、提高治愈率。     

Post-traumatic distal nerve entrapment syndrome

Eleven patients with paralysis of muscle groups in the upper or lower extremity were clinically diagnosed after previous proximal direct trauma to the corresponding peripheral nerves, without complete nerve disruption. Patients were seen within an average of 8 months after trauma (minimum 3 months and maximum 2 years after). Nerve lesions were caused either by gunshot, motor-vehicle accident, and other direct trauma or, in one case, after tumor excision. All patients presented with complete sensory and motor loss distal to the trauma site, but demonstrated a positive Tinel sign and pain on testing over the "classic" (distal) anatomic nerve entrapment sites only. After surgical release through decompression of the nerve compression site distal to the trauma, a recovery of sensory function was achieved after surgery in all cases. Good-to-excellent restoration of motor function (M4/M5) was achieved in 63 percent of all cases. Twenty-five percent had no or only poor improvement in motor function, despite a good sensory recovery. Those patients in whom nerve compression sites were surgically released before 6 months after trauma had an improvement in almost all neural functions, compared to those patients who underwent surgery later than 9 months post trauma. A possible explanation of traumatically caused neurogenic paralysis with subsequent distal nerve compressions is provided, using the "double crush syndrome" hypothesis.     

单开门椎管扩大成形术后颈椎曲度与C_5神经根麻痹的关系

目的探讨单开门椎管扩大成形术后颈椎曲度与C5神经根麻痹发生率的关系。方法对254例颈椎病患者采取3种不同术式治疗:A组(126例)行颈椎单开门椎管成形术;B组(70例)行颈椎单开门椎管成形+未明显改变颈椎曲度的后路内固定术;C组(58例)行颈椎单开门椎管成形+明显改变颈椎曲度的后路内固定术。结果患者均获得随访,时间12~18个月。X线、MRI和CT检查显示:3组患者脊髓均有不同程度的向后漂移,侧块螺钉均没有进入椎间孔和椎管内,椎板没有再关门,椎板合页处没有向内陷入椎管,亦没有明显压迫硬膜脊髓的硬膜外血肿。A组颈椎曲度无改变;B组颈椎曲度无显著性改变;C组颈椎曲度改善明显,曲度增加值为5.3 mm±2.7 mm。18例术后发生C_5神经根麻痹,其中A组2例(1.59%)、B组4例(5.71%)、C组12例(20.69%);A、B两组比较差异无统计学意义(P0.05),A、B组与C组比较差异均有统计学意义(P0.017);脊髓型组5例(3.09%),混合型组13例(14.13%),两组比较差异有统计学意义(P0.05)。18例C_5神经根麻痹患者于术后2~4 d出现颈肩痛或原有颈肩痛加重,其中12例随后迅速出现肌力下降,而感觉减退不明显。18例均给予保守治疗,术后2~3周患者颈肩部麻痛消失;术后4~24周12例肌力下降中11例完全康复,1年后另1例C_5神经支配区肌力恢复至4+级。结论颈椎单开门椎管扩大成形术后可发生C_5神经根麻痹,无内固定时发生率最低,在颈椎生理曲度明显改变时发生率最高;术后混合型较脊髓型更易出现C_5神经根麻痹,其损伤机制可能与脊髓漂移有关。     

An experimental study of nerve bypass graft

Objective： To study the use of a nerve ＂bypass＂ graft as a possible alternative to neurolysis or segmental resection with interposition grafting in the treatment of neuroma-in-continuity. Methods： A sciatic nerve crush injury model was established in the Sprague-Dawley rat by compression with a straight hemostatic forceps. Epineurial windows were created proximal and distal to the injury site. An 8-mm segment of radial nerve was harvested and coaptated to the sciatic nerve at the epineurial window sites proximal and distal to the compressed segment （bypass group）. A sciatic nerve crush injury without bypass served as a control. Nerve conduction studies were performed over an 8-week period. Sciatic nerves were then harvested and studied under transmission electron microscopy. Myelinated axon counts were obtained. Results： Nerve conduction velocity was significantly faster in the bypass group than in the control group at 8 weeks （63.57 m/s±5.83 m/s vs. 54.88 m/s±4.79m/s, P〈0.01）. Myelinated axon counts in distal segments were found more in the experimental sciatic nerve than in the control sciatic nerve. Significant axonal growth was noted in the bypass nerve segment itself. Conclusion： Nerve bypass may serve to augment peripheral axonal growth while avoiding further loss of the native nerve.     

Comparison of neuropathic pain and neuronal apoptosis following nerve root or spinal nerve compression

Altered dorsal root ganglion (DRG) function is associated with neuropathic pain following spinal nerve injury. However, compression of the cauda equina and dorsal rhizotomy proximal to the DRG do not induce significant pain, whereas in the spinal nerve and peripheral nerve, injury distal to the DRG does induce neuropathic pain. Caspase signaling induces apoptosis, and caspase inhibitors prevent pain-related behavior. The degree of DRG neuronal apoptosis is thought to play a role in pain behavior. We suggest that differences in pain behavior according to the injury sites within the DRG may be related to imbalances in apoptotic injuries. The aim of this study was to determine which compression injury was more painful and to compare behavior with expression of tumor necrosis factor (TNF)-alpha in DRG and apoptosis in the DRG following crush injury to the L5 nerve root or L5 spinal nerve. Sprague–Dawley rats received a crush injury to the L5 spinal nerve (distal to the DRG), crush injury to the L5 nerve root (proximal to the DRG), or no crush injury (sham). Mechanical allodynia was determined by the von Frey test. Expression of TNF-alpha was compared among three groups using immunoblot findings. Furthermore, we compared the percentage of neurons injured in the DRG using immunostaining for apoptotic cells and localization of activated caspase 3. Mechanical allodynia was observed in both crush injury groups. The duration of mechanical allodynia in the distal crush group was significantly longer than in the proximal crush group (P < 0.05). TNF-alpha expression was increased in DRG neurons following injury. DRG apoptosis in the distal crush group was significantly higher than in the proximal group at each time point (P < 0.05). This study suggests that spinal nerve crush injuries produce a greater degree of DRG apoptosis than do corresponding nerve root crush injuries, and that the former injuries are associated with longer lasting mechanical allodynia. Thus, differences in the time course of mechanical allodynia might be associated with an imbalance in DRG apoptosis.     

Motor nerve conduction analysis of double crush syndrome in a rabbit model

 The double crush syndrome was proposed by Upton and McComas in 1973, but there are still many unclear points regarding its mechanism. We propose a model that enables electrophysiological study of the same nerve from the same individual over time. We employed 29 rabbits and used their sciatic nerves. (Four rabbits died from infection, and in nine rabbits we could not record the M-wave because the electrodes were off during the course of the study.) Sixteen rabbits were grouped into six experimental groups and one control group. Bipolar stimulus electrodes were buried at three locations in their sciatic nerves. The two areas between the proximal and intermediate electrodes and between the intermediate and distal electrodes were defined as the “nerve proximal part” and “nerve distal part,” respectively. An electrical stimulus was applied via each electrode, and the muscle action potential (M-wave) was recorded from the gastrocnemius. A narrow tube was inserted in the nerve proximal part and a wide tube in the nerve distal part. A decrease in the motor nerve conduction velocity (MCV) was observed in the nerve proximal part (narrow tube) followed by a decrease in MCV in the nerve distal part (wide tube). A wide tube was then inserted in the nerve proximal part and a narrow tube in the nerve distal part. A decrease in MCV was observed in the nerve distal part (narrow tube) followed by a decrease in MCV in the nerve proximal part (wide tube). We believe that these results are important findings in regard to the double crush syndrome (DCS) hypothesis and the reversed DCS hypothesis. Received: November 2, 2001 / Accepted: August 22, 2002 Offprint requests to: Y. Suzuki     

Double-crush nerve compression in thoracic-outlet syndrome

We studied 165 cases of thoracic-outlet syndrome in 142 patients in whom resection of the first rib had been performed. In seventy-three cases (44 per cent), there was compression of a nerve distally, as shown by electromyography and conduction studies. The most common secondary compression was carpal tunnel syndrome (forty-one cases). Thirteen patients needed an operation at three sites or more. Our results show that proximal compression of a nerve lessens its ability to withstand more distal compression. Once the diagnosis of thoracic-outlet syndrome has been made, the possibility of an additional distal compression neuropathy should be investigated.