面神经修复手术中影响疗效的相关因素分析

目的 通过对38例面神经修复手术临床资料的回顾,探讨影响面神经功能恢复的可能的相关因素.方法 对38例患者的临床资料进行采集.依据Sunny-Brook量表中面部神经动态功能的评价表,对所有患者手术前后的动态影像资料进行评价.依据神经受损的不同情况,分为颞支组(7例)、颧支组(8例)、颊支组(18例)、下颌缘支组(4例)、面神经总干组(7例)和颅内神经损伤组(6例).手术方法有神经直接吻合、神经移植、跨面神经移植和寄养.各个组中,分别对性别、瘫痪时间、神经移植、瘢痕和神经损伤位置等因素对结果的影响进行分析,并用S PSSl 3.0软件来进行统计学分析.结果 颞、颧和颊支经手术修复后功能改善明显,而下颌缘支的功能恢复较差;同侧3 cm内的神经移植对疗效无不利影响;神经入肌处和面神经出颅区域的瘢痕会对最终的功能恢复带来不良的影响;在面神经总干位置损伤后的修复疗效不及分支处损伤后的修复效果;咬肌神经作为寄养的神经,可以明显提高面部功能的恢复.结论 健康的神经两端,无张力的神经移植修复,以及咬肌神经的寄养将会给疗效的提高带来帮助.     

跨面神经结构胸小肌游离移植修复晚期面瘫畸形

报告家兔横跨面神经移植实验研究及吻合血管神经的胸小肌游离移植治疗晚期面瘫畸形的临床实践，结果表明，横跨面部神经移植用以支配对侧表情肌是可行的，不吻合血管与吻合血管的跨面神经移植结果对比无显著差异性，提示跨面神经移植勿需强调血管吻合，腓肠神经，胸小肌游离移植是治疗晚期面瘫畸形的一种较好方法。     

跨面神经结合胸小肌游离移植修复晚期面瘫畸形

报告家兔横跨面部神经移植实验研究及吻合血管神经的胸小肌游离移植治疗晚期面瘫畸形的临床实践。结果表明：横跨面部神经移植用以支配对侧表情肌是可行的。不吻合血管与吻合血管的跨面神经移植结果对比无显著差异性，提示跨面神经移植勿需强调血管吻合。腓肠神经、胸小肌游离移植是治疗晚期面瘫畸形的一种较好方法。     

面神经调控术修复面瘫后面肌联动的初步报告

目的 为了改善面瘫后遗症中面部表情肌联动、误动,及健侧面肌肌力偏强,口角歪斜,无法微笑,表情怪诞的症状,设计通过跨面神经移植来调控健侧的肌力并让患侧联动面肌的动作分离,使误动的面肌的收缩活动与健侧同步,从而恢复自然对称的微笑表情.方法 高选择的切断健侧面神经的分支,将健侧的神经动力通过跨面的神经移植,转移至患侧,然后高选择地将患侧联动面神经分支切断分离,将分支的远侧断端与健侧转移来的移植神经吻合,由健侧神经提供动力来支配患侧的部分面肌,使该面肌获得与健侧同步的动作.结果 2003年至今共有6例接受面神经调控手术.术后随访病例的口角同步活动都有不同程度的恢复.结论 精确设计的面神经调控术对修复面瘫后面肌联动症有效.     

面神经腮腺外分支的解剖学研究及其临床意义

目的 准确地描述面神经腮腺外段的分支,走行等情况,为颌面外科、头颈部整形与美容外科提供重要的形态学资料.方法 20具(40侧)新鲜成人头颈部标本,在手术显微镜下解剖观察并记录照相;利用上述形态学资料作为各种面神经损伤的诊断依据,指导相关手术的设计、分离和寻找面神经分支.结果 ①五组神经的分支数个体差异很大,平均颞支3.2支,颧支2.2支,颊支3.6支,下颌缘支1.3支,颈支恒为1支.②面神经急诊损伤探查缝合术12例,均成功.二级吻合前的损伤才具有神经缝合的条件,而二级(集中)吻合后的分支极其细小,探查、缝合基本不可能.③做面神经解剖术或者其他手术需辨清面神经各支时,颞中筋膜和咬肌筋膜是重要的标志.腮腺混合瘤切除面神经解剖术4例,跨面神经移植术2例,SMAS-颈阔肌除皱术千余例.这些手术中,发生明确的医源性面神经颧支损伤2例.结论 ①除颈支或单支的下颌缘支外,各组神经支可以被损伤或切断1～2支而不至于造成严重、永久的瘫痪;②在手术中,颞中筋膜与咬肌筋膜既是重要的保护结构,又是明确的辨别寻找标志.     

用带胸锁乳突肌瓣的耳大神经重建腮腺癌根治术缺损的面神经

目的探讨腮腺癌根治术造成面神经缺损的修复方法和临床效果。方法对腮腺癌根治术并造成面神经缺损的病例，应用带蒂胸锁乳突肌瓣的耳大神经移植修复，肌瓣修复创面同时在手术显微镜下进行面神经与耳大神经吻合，即刻修复面神经。结果临床修复8例，术后随访3～6个月，面瘫症状均有改善，面神经功能恢复达Ⅱ级6例，Ⅲ级2例。结论带胸锁乳突肌瓣的耳大神经瓣移植修复面神经，为神经修复提供了良好的血运，能有效的恢复面神经的功能。     

腮腺区肿物切除后面神经缺损的手术修复

目的 探讨腮腺癌、面神经肿物切除后面神经缺损修复方法的可行性,并对各种面神经缺损修复方法进行评价.方法 对腮腺恶性肿物侵袭面神经扩大切除及发生在面神经的神经源性肿物切除后面神经缺损的32例患者进行了神经移植修复.其中单纯采用耳大神经移植19例,神经长度1～2 cm;朐锁乳突肌携带耳大神经5例,修复腮腺恶性肿瘤扩大切除后骨面暴露的面神经缺损;携带筋膜面神经颈支修复下颌缘支缺损5例,携带筋膜面神经上颊支修复颧支缺损3例.所有手术均在双人双目手术显微镜下进行,用9-0及11-0无损伤缝合线吻合神经.结果 面神经恢复标准按照刘世勋面神经损伤修复评价标准进行评价.采用单纯耳大神经移植修复面神经缺损19例,术后恢复时间为6～18个月,恢复程度多数为部分功能恢复;胸锁乳突肌携带耳大神经移植修复面神经缺损5例,术后恢复时间为6～12个月,恢复效果比较理想;携带筋膜面神经颈支、上颊支修复下颌缘支、颧支缺损8例,术后恢复时间为6个月左右,恢复效果均比较理想.结论 几种神经移植修复面神经缺损,均是可行的.但采用面神经次要神经修复主要神经,修复效果比较理想.对于腮腺癌扩大切除后局部骨面外露者,采用胸锁乳突肌携带耳大神经移植修复是一种比较理想的修复方法.     

双神经转位恢复面部功能

不可逆的永久性面瘫会导致严重的后遗症,例如角膜溃疡、视力减退、口腔功能不全和面部不对称,给患者带来严重的社会心理压力。传统上可通过舌下神经或咬肌神经转位来修复不可逆性面瘫,这两种术式各有其优点和缺点:舌下神经转位能有效的恢复瘫痪侧面部的静息张力,然而在微笑时提供的口角偏移却是有限的;咬肌神经转位可以有效的恢复面部微笑,但提供给脸部的静息张力却很小。最近,美国斯坦福大学医学中心的Pepper博士介绍了将上述两种术式合二为一的双神经转位技术,通过将咬肌神经转位至面神经颊支来恢复面部的微笑表情,舌下神经转位至面神经第二膝区(介于面神经鼓室段与乳突段之间)来恢复面部张力。     

面神经颊支和下颌缘支的解剖学研究及应用

目的 观察面神经颊支与下颌缘支肌外、肌内走行分布情况，为面瘫整复术中受区神经的选择和预防神经支损伤提供依据。方法 在24侧头部标本中，分别观测颊支和下颌缘支的分支数目、吻合情况、走行中的层次、颊支与腮腺导管以及下颌缘支与下颌骨下缘、面血管的关系，结合Sihler’s肌内神经染色，明确其支配肌肉和在肌内的分布规律；并在40例面瘫手术患者受区面神经分支的寻找和选择中进行验证。结果 腮腺导管体表投影较恒定，面神经颊支以2～3支为主，占87．5％，多数分布在导管上方10．7mm和下方9．3mm的范围内，支配中面部表情肌。下颌缘支以1～2支为主，占95．9％，多数分布在下颌骨下缘上方13．4mm和下方4．8mm的范围内，跨面动脉浅面，支配下唇诸肌。结论 面神经颊支与腮腺导管、下颌缘支与面动脉及下颌骨下缘有着紧密的关系。应用改良Sihler法，可以更为清晰的显示人面部表情肌的肌内神经分布情况。     

阿曲库铵对耳外科手术面神经监测的影响

目的探讨肌松剂阿曲库铵对面神经监测的影响。方法选择因慢性中耳炎须在全麻下行乳突根治术的患者20例，全麻诱导均采用舒芬太尼0．4μg／kg，利多卡因0．5—1mg／kg，丙泊酚2mglkg，氯化琥珀胆碱1．5mg／kg依次静注，气管插管后接麻醉机行机械通气，用TOF-GUARD肌松监测仪行右手拇内收肌肌松监测，用Medtronic多功能神经监测仪行面神经功能监测。术中刺激面神经引出面肌收缩肌电图之前不用肌松剂，而以舒芬太尼和丙泊酚静注维持麻醉。记录神经肌肉接头完全不被阻滞时的刺激电流阈值，术中刺激面神经成功引出面肌收缩肌电图信号之后，再给予阿曲库铵0．5mg／kg，神经肌肉接头达100％阻滞后再次刺激面神经，记录能够引出肌电图信号的刺激电流闷值。结果术中给予阿曲库铵前后均能维持患者麻醉平稳，安静不动；阿曲库钱应用后达到100％神经肌肉接头阻滞时，刺激面神经时面部肌肉收缩的肌电图信号依然能够引出，但刺激电流阈值从（0．224-0．09）mA增大至（0．394-0．17）mA（t=-8＋643，P=0．000）。结论阿曲库铵应用后周围神经肌肉阻滞达100％时依然可以进行面神经监测，但刺激电流阌值显著增大；可以在不用肌松剂的情况下，只用丙泊酚和舒芬太尼维持乳突根治手术的麻醉平稳。     

兔面神经外伤性损伤后恢复的实验研究

目的通过比较兔压榨性损伤组与正常组的面神经功能与组织学差异,研究面神经的损伤及其修复过程,为临床治疗周围性面瘫寻找合适的干预时机。方法15只普通级成年新西兰兔,分别对其左侧颞外面神经主干施以压榨性损伤,分别于损伤后2周、4周、6周取材,通过电生理测定、显微结构观测及相应的组织学量化分析等方法,比较实验组与对照组间的差异。结果损伤后2周时,大部分轴突颗粒状变性,髓鞘松解;4周时,部分轴突恢复正常;6周后,压迫组基本恢复正常结构,其电生理功能与形态学相符。损伤4周后,总体轴突密度为68.88%;6周后,总体轴突密度恢复至88.63%,与正常组比较均有统计学差异。结论兔面神经损伤2周后部分神经功能开始恢复,至6周时功能基本恢复。     

Nerve fiber transfer by end-to-side coaptation

To bring some light into the ongoing controversy concerning end-to-side coaptation in brachial plexus surgery, the authors organized a symposium in 2006 titled How To Improve Peripheral Nerve Surgery. The authors sought the participation of experienced surgeons and researchers who had made personal contributions to the field. This article contains information collected at this symposium and presents the authors' clinical results and ideas illustrating the potential of nerve fiber transfer by end-to-side coaptation.     

Contribution of the Proximal Nerve Stump in End-to-side Nerve Repair: In a Rat Model

Background

The aim of this study was to evaluate the contribution of the proximal nerve stump, in end-to-side nerve repair, to functional recovery, by modifying the classic end-to-side neurorrhaphy and suturing the proximal nerve stump to a donor nerve in a rat model of a severed median nerve.

Methods

Three experimental groups were studied: a modified end-to-side neurorrhaphy with suturing of the proximal nerve stump (double end-to-side neurorrhaphy, Group I), a classic end-to-side neurorrhaphy (Group II) and a control group without neurorrhaphy (Group III). Twenty weeks after surgery, grasping testing, muscle contractility testing, and histological studies were performed.

Results

The grasping strength, muscle contraction force and nerve fiber count were significantly higher in group I than in group II, and there was no evidence of nerve recovery in group III.

Conclusions

The contribution from the proximal nerve stump in double end-to-side nerve repair might improve axonal sprouting from the donor nerve and help achieve a better functional recovery in an end-to-side coaptation model.     

Endoscopic Anterior Transposition of Ulnar Nerve (EATUN) for Treatment of Tardy Ulnar Nerve Palsy

BackgroundTardy ulnar nerve palsy is the development of late onset ulnar nerve dysfunction and is usually treated by open anterior transposition of ulnar nerve. Open technique is done using a longitudinal incision about 6–8 inch. in length with chances of development of medial antebrachial cutaneous nerve neuromas.PurposeIn this study, we describe the technique of Endoscopic Anterior Transposition of Ulnar Nerve (EATUN procedure) to treat tardy ulnar nerve palsy and analyze the results.MethodsSeven patients diagnosed to have tardy ulnar nerve palsy was treated by EATUN. The humerus-elbow-wrist angle (HEW), pre- and post-operative intrinsic muscle power and sensory assessment, Dellon scores, and the Q-DASH was analyzed.ResultsThe minimum follow-up was 12 months (Mean 27.4 months, Range 12–36 months). Improvement in Dellon and Q-DASH scores following EATUN procedure was statistically significant. There was objective improvement of intrinsic muscle power and sensation on follow-up, though not statistically significant. No instance of neuroma of the medial cutaneous nerve of forearm was noted.ConclusionsThe endoscopic anterior transposition of the ulnar nerve is a good option in surgical management of tardy ulnar nerve palsy.Level of evidenceTherapeutic Level IV.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43465-021-00366-w.     

神经移植合并双端侧神经吻合修复双侧指固有神经陈旧性损伤

目的介绍一种修复双侧指固有神经陈旧性损伤的方法。方法自2000年11月至2009年10月,共收治40例陈旧性双侧指固有神经损伤患者,分为A、B、C三组。A组15例,行双侧神经桥接端侧缝合;B组13例,行单侧神经桥接端侧缝合;C组12例,行神经桥接断端缝合。结果术后随访6～8个月,A组患者伤指麻木、疼痛完全消失,指腹饱满、弹性佳,感觉测定为S4～S4+级,两点分辨觉为5.0～6.0 mm;B组患者伤指感觉恢复不同步,且缝合侧感觉明显,感觉测定为S1～S3级,两点分辨觉为7.0～7.6 mm;C组患者伤指感觉测定为S3～S3+级,指腹为SI级甚至盲区,两点分辨觉为7.5～8.5 mm。结论移植神经、双端侧神经缝合对于二期修复双侧指固有神经损伤是一种可行的方法。     

周围神经断裂减张缝合术

目的 介绍并评价３种新的修复周围神经断裂减张缝合方法。方法 治疗周围断裂８９６例,１０３条神经,其中正中神经２０条,桡神经３９条,尺神经４４条。分别采用外膜－外膜法,神经瘤外膜－外膜法,外膜－神经床法等３种方法,使神经断端在无张力下缝合。结果 手术优良率８４．４％。结论 神经减张缝合术效果确切,利于神经的再生。     

外伤性面瘫的早期手术治疗

目的 探讨外伤性面瘫手术时机和手术方法的选择。强调神经外瘢痕松解切除和严格遵守显微外科无创原则,结合神经损伤的形态特点。针对性选择优选用吻合神经方法的重要性。方法 1993年12月-1997年11月,收治外伤性面瘫病人7例。于伤后3-4个月采用显微外科技术进行面神经吻合及腓肠神经眼轮匝肌植入术进行修复。结果 术后随访6个月-2年,均获得了比较满意的面肌功能恢复。结论 外伤性面瘫,争取早日手术是成功的关键。方法宜首选面神经吻合,神经移植肌肉内植入术,对整复某些外伤后面瘫有其临床应用价值和适应证。     

Restoration of Elbow Flexion by Transfer of the Phrenic Nerve to Musculocutaneous Nerve after Brachial Plexus Injuries

Traumatic brachial plexus injuries are a devastating injury that results in partial or total denervation of the muscles of the upper extremity. Treatment options that include neurolysis, nerve grafting, or neurotization (nerve transfer) has become an important procedure in the restoration of function in patients with irreparable preganglionic lesions. Restoration of elbow flexion is the primary goal in treating patients with severe brachial plexus injuries. Nerve transfers are used when spinal roots are avulsed, and proximal stumps are not available. In the present study, we analyze the results obtained in 20 patients treated with phrenic–musculocutaneous nerve transfer to restore elbow flexion after brachial plexus injuries. A consecutive series of 25 adult patients (21 men and 4 women) with a brachial plexus traction/crush lesion were treated with phrenic–musculocutaneous nerve transfer, but only 20 patients (18 men and 2 women) were followed and evaluated for at least 2 years postoperatively. All patients had been referred from other institutions. At the initial evaluation, eight patients received a diagnosis of C5-6 brachial plexus nerve injury, and in the other 12 patients, a complete brachial plexus injury was identified. Reconstruction was undertaken if no clinical or electrical evidence of biceps muscle function was seen by 3 months post injury. Functional elbow flexion was obtained in the majority of cases by phrenic–musculocutaneous nerve transfer (14/20, 70%). At the final follow-up evaluation, elbow flexion strength was a Medical Research Council Grade 5 in two patients, Grade 4 in four patients, Grade 3 in eight patients, and Grade 2 or less in six patients. Transfer involving the phrenic nerve to restore elbow flexion seems to be an appropriate approach for the treatment of brachial plexus root avulsion. Traumatic brachial plexus injury is a devastating injury that result in partial or total denervation of the muscles of the upper extremity. Treatment options include neurolysis, nerve grafting, or neurotization (nerve transfer). Neurotization is the transfer of a functional but less important nerve to a denervated more important nerve. It has become an important procedure in the restoration of function in patients with irreparable preganglionic lesions. Restoration of elbow flexion is the primary goal in treating patients with severe brachial plexus injuries. Nerve transfers are used when spinal roots are avulsed, and proximal stumps are not available. Newer extraplexal sources include the ipsilateral phrenic nerve as reported by Gu et al. (Chin Med J 103:267–270, 1990) and contralateral C7 as reported by Gu et al. (J Hand Surg [Br] 17(B):518–521, 1992) and Songcharoen et al. (J Hand Surg [Am] 26(A):1058–1064, 2001). These nerve transfers have been introduced to expand on the limited donors. The phrenic nerve and its anatomic position directly within the surgical field makes it a tempting source for nerve transfer. Although not always, in cases of complete brachial plexus avulsion, the phrenic nerve is functioning as a result of its C3 and C4 major contributions. In the present study, we analyze the results obtained in 20 patients treated with phrenic–musculocutaneous nerve transfer to restore elbow flexion after brachial plexus injuries.     

Healing,Inflammation, and Fibrosis: Peripheral Nerve Healing: So Near and Yet So Far

Peripheral nerve injuries represent a considerable portion of chronic disability that especially affects the younger population. Prerequisites of proper peripheral nerve injury treatment include in-depth knowledge of the anatomy, pathophysiology, and options in surgical reconstruction. Our greater appreciation of nerve healing mechanisms and the development of different microsurgical techniques have significantly refined the outcomes in treatment for the past four decades. This work reviews the peripheral nerve regeneration process after an injury, provides an overview of various coaptation methods, and compares other available treatments such as autologous nerve graft, acellular nerve allograft, and synthetic nerve conduits. Furthermore, the formation of neuromas as well as their latest treatment options are discussed.