创伤继发臂丛神经急性卡压征

目的　总结创伤继发臂丛神经急性卡压征的病因、症状与体征、治疗及预后。方法　 12例因创伤引起肩锁区肿胀、瘀血、压痛、畸形外 ,肩锁区存在搏动感及血管杂音 ;臂丛下干支配区感觉及 /或功能障碍。伴肋骨、锁骨、多处骨折 7例 ;锁骨下血管损伤 (破裂、假性动脉瘤、动静脉瘘 ) 9例 ,血肿 3例。诊断为创伤继发臂丛神经急性卡压征。采用假性动脉瘤切除动脉直接缝合或静脉移植 3例 ,血管吻合、修补术 4例 ,血管结扎 2例 ,血肿去除 3例。骨折切开复位内固定 8例 ,臂丛神经松解术 12例。结果　 12例术后平均随访 2 6个月 ,患侧的桡动脉搏动良好 ,肩胛带骨折已骨性愈合。臂丛神经功能恢复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[1] :优 11例 ,可 1例。结论　创伤继发臂丛神经急性卡压的病例起病急 ,在伤后 2～ 3h或 1～ 2d内发生。除有臂丛神经损伤症状外 ,还伴有肩胛带骨折及锁骨下血管损伤。早期手术预后较好。     

锁骨下血管合并臂丛损伤的处理

目的 探讨锁骨下动脉合并臂丛神经损伤的诊断和处理。方法 5例锁骨下动脉损伤合并臂丛损伤，其中锁骨下动脉第一段损伤1例，第三段损伤4例；2例合并动脉瘤，1例动脉瘤加动静脉瘘．2例血管纤维化自行闭塞。根据锁骨下动脉损伤性质，分别采用静脉移植、直接缝合、血管结扎处理，损伤臂丛神经采取直接缝合、神经松解。结果 3例开放性损伤患者早期手术修复动脉和神经，术后伤肢无疼痛，神经功能有不同程度恢复；2例闭合钝器伤晚期患者，1例行血管、神经松解术，仅疼痛减轻，1例血管臂丛神经广泛粘连，神经松解术后无任何恢复。结论 除原发性损伤外，进行性增大的血肿或假性动脉瘤压迫可加重臂丛神经损害．如能早期处理血肿或动脉瘤，解除压迫，可减轻神经损害，有利于臂丛神经功能恢复。     

小切口治疗臂丛神经血管受压征

目的研究小于5cm的臂丛神经血管受压征的手术切口。方法对11例患者用该切口,成功地切断了前、中小斜角肌的腱性部分,手术时间为1h左右。该切口为最终用内窥镜治疗臂丛神经血管受压征打下了基础。结果10例的近期疗效良好,感觉有明显改善,肌力增加;1例颈部疼痛不适同术前。结论采用5cm及小于5cm的臂丛神经血管受压征切口,可切断前、中小斜角肌,达到手术治疗臂丛神经血管受压征的目的。     

臂丛神经合并上肢大血管损伤的手术时机与方法的选择

目的 总结臂丛神经合并上肢大血管损伤的手术治疗结果,探讨最佳手术时机与方法的选择.方法 2005年6月至2011年6月,对4例臂丛合并上肢大血管损伤患者进行手术治疗.4例患者中,2例臂丛根性损伤合并锁骨下动脉损伤,2例臂丛束支部损伤合并肱动脉损伤.根据患者创伤程度与类型的不同,分别采用神经直接缝合、神经移植与神经移位修复臂丛损伤.采用血管直接吻合、血管移植与血管搭桥修复血管损伤.其中1例神经血管急诊一期修复;1例神经血管亚急诊一期修复;2例急诊一期修复血管,二期修复神经.结果 术后随访28 ～ 44个月,平均37个月.修复的血管通畅,患肢血供良好,修复的神经功能均有不同程度的恢复.结论 臂丛合并上肢大血管损伤应争取一期同时修复血管与神经,二期修复神经会明显增加手术的难度与风险.     

手术治疗臂丛神经血管受压征106例

目的观察不同类型臂丛神经血管受压征手术后的疗效，探讨手术指征和手术时机的选择。方法对106例诊断为各型臂丛神经血管受压征的患者，均施行臂丛神经松解手术治疗，术后跟踪随访2年以上，以观察临床疗效。结果99例患者术后随访2年，优75例，良11例，可8例，差5例，优良率86.8％。结论对于临床确诊为臂丛神经血管受压征的患者应早期手术治疗，疗效可靠。     

锁骨下动脉损伤的外科处理

目的 探讨锁骨下动脉损伤的外科治疗特点。方法 1990年7月～2006年1月，对12例锁骨下动脉损伤患者，取锁骨上下联合切口，充分显露锁骨下动脉全段，分别采用动脉破口修补、包裹修复、血管吻合及人造血管移植修复重建损伤动脉。均为男性，年龄18～36岁，平均22.6岁。损伤部位：锁骨下动脉第1段1例，第2段4例，第3段7例。损伤类型：均为不完全断裂及破损，其中动脉破损区小于动脉周径1／3者4例，小于动脉周径2／3者5例，大于动脉周径2／3者3例。伴全臂丛神经损伤1例，神经干缺损5cm；部分臂丛神经损伤3例，其中2例仅前束损伤，神经缺损分别为4cm和6cm；正中神经完全损伤及尺神经不完全损伤1例，神经缺损4cm。损伤至手术时间3h～1.5个月。结果 术后无死亡及肢体坏死。获随访2个月～12年，平均5年2个月。10例桡动脉搏动恢复良好，2例桡动脉搏动不明显，均为动脉直接吻合者。4例合并臂丛神经损伤患者，前束损伤者术后肢体功能基本恢复正常，屈肘肌力Ⅳ级；全臂丛神经完全损伤者术后上肢功能基本无改善。结论 锁骨下动脉解剖位置特殊，动脉损伤后显露、修复均较困难。锁骨上下联合切口可在直视下显露动脉全段，修复重建安全可靠。     

手术治疗无骨性异常的臂丛神经血管受压征

目的 观察9例无骨性异常的臂丛神经血管受压征的手术疗效。方法 对9例无骨性异常的臂丛神经血管受压征进行手术，其中1例为全臂丛型，8例为臂丛下干型。采用前、中、小斜角肌切断并解除一切压迫臂丛神经的纤维束带。结果 术后平均随访2年9个月(1年6个月—3年7个月)，以患者的主观感觉评价疗效，6例对手术结果满意，2例对手术结果基本满意，1例对手术不满意。结论 斜角肌切断及纤维束带切除术是治疗无骨性异常的臂丛神经血管受压征的一种简单、有效的方法。     

胸廓出口综合征手术治疗中对前中小斜角肌的处理

目的随访35例胸廓出口综合征手术治疗的疗效。方法手术治疗35例37侧胸廓出口综合征患者,其中上干型5例,下干型28例30侧,全臂丛型2例。X线片示颈肋1例,第七颈椎横突过长3例。手术切除增长的骨组织和颈肋,术中发现35例均有纤维束带压迫臂丛神经,均作前、中、小前斜角肌切断术。术后随访1年～3年6个月。结果术后症状明显改善26例27侧,部分改善5例6侧,无效4例。结论斜角肌是引起臂丛神经血管受压征的主要因素,手术探查时应常规切断前、中斜角肌及小斜角肌。     

锁骨及第一肋骨骨折致臂丛不完全性损伤的特点及处理

目的报道锁骨与第一肋骨骨折致臂丛不完全性损伤的特点。方法观察总结锁骨与第一肋骨骨折致臂丛不完全性损伤主要表现及体征。经神经松解手术治疗分别在术后半年、1年进行随访。结果术后平均随访1．5年，26例臂丛不完全损伤患者，均有明显恢复。结论及时、准确的诊断锁骨与第一肋骨骨折致臂丛不完全性损伤，早期行神经松解术预后较好。     

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。     

Brachial plexus injuries. Management and results

At the time of accident the brachial plexus can be repaired primarily if there is a clean transection. In case of a clavicular fracture and/or of a severe bleeding by rupture of the subclavian artery, the hematoma has to be evacuated to avoid compression of the brachial plexus. For the same reason, the fracture should be stabilized as soon as possible and the artery repaired. The reconstruction of the brachial plexus is performed as a secondary procedure. In case of a closed injury all efforts should be directed to clarify the diagnosis and to exclude cases with good chances of spontaneous recovery. The remaining cases are subject to direct repair. According to the amount of damage, external or internal neurolysis, neurorrhaphy, nerve grafting, or neurotization by nerve transfer is performed. Direct surgery is followed by a period of intensive physiotherapy. Social and psychologic care are extremely important. Patients should start to work as soon as possible. If they are not able to resume their original profession, they have to be prepared for another job that they can perform with one arm and one hand. The whole treatment is planned and supervised by the surgeon. After a sufficiently long period, usually one-and-a half years following direct repair, the amount of functional return is analyzed. Decisions are made to perform adequate palliative surgery, in order to make maximum use of the returned function.     

Spontaneous brachial plexus hemorrhage-case report

BACKGROUND: Shoulder hemorrhage resulting in brachial plexus neuropathy is a rare occurrence most often seen in cases of traumatic injury or anticoagulation therapy. We report a unique case of spontaneous brachial plexus hemorrhage. CASE DESCRIPTION: This is the first report of a spontaneous shoulder hemorrhage in which a 48-year-old jackhammer operator presented to the emergency department with a sudden onset of right shoulder pain and upper extremity pain and numbness. Imaging studies revealed a hematoma in the right axilla and chest wall. Without evidence of active bleeding or worsening neurologic deficit, this patient was treated conservatively with pain control and observation and eventually experienced a full recovery. Had there been persistent neurologic deficit, however, surgical evacuation would have been indicated. CONCLUSIONS: Cases of nerve compression caused by a hematoma should be analyzed on the basis of the severity of the neurologic deficit and not on the underlying cause of bleeding. Conservative treatment may be indicated in cases of mild or improving neurologic deficit, but regardless of its etiology, a hematoma that results in severe or worsening neurologic symptoms must be surgically evacuated to prevent permanent nerve damage.     

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。     

四肢周围神经鞘瘤40例临床回顾

目的：分析40例周围神经鞘瘤的临床特点，诊断和手术要点。方法：40例神经鞘瘤，其中臂丛神经5例，上肢神经21例，下肢神经14例，单发者38例，多发者2例（同一肢体2个肿瘤），8例肿块位于颈部及上臂近端者术前作MRI检查，证实5例的肿瘤起源于臂丛神经，2例为颈部肿瘤，1例为肺尖部肿瘤。33例行肿瘤完整切除；1例C8神经根肿瘤因邻近胸膜顶及锁骨下动静脉，很难分离，故只能行肿瘤包膜内切除，6例曾在其它医院误将肿瘤与神经干一同切除，行神经修复术。结果：33例术后神经功能正常，随访6个月，－28年未见复发。1例包膜内切除者术后出现手内肌功能部队障碍，出院时已有大部分恢复，仍在随访中，结论：神经鞘瘤能够完整切除者疗效满意。对起源于神经根的肿瘤可行包膜内切除。     

Stretching of the brachial plexus in rabbits

The brachial plexus of rabbits was stretched until mechanical failure. The level and site of rupture varied according to the direction of the stretching force. Upward and lateral traction of the forelimbs caused spinal nerve-root avulsions combined with nerve-trunk ruptures distal to the dorsal root ganglions. In such tractions the C5 nerves consistently exhibited postganglionic nerve-trunk rupture. The C6, C7, and C8 nerves had root avulsions. The T1 nerve was avulsed from the spinal cord in 7 cases out of 10; the other 3 cases had postganglionic nerve-trunk rupture. Downward traction of the forelimbs caused nerve avulsions from the scapulohumeral muscles innervated by the terminal branches of the brachial plexus and peripheral nerve ruptures in the course of the arm. The force producing trunk rupture of the C6 nerve was twice as great as that for root avulsion. The required stain was similar for nerve trunk rupture and root avulsion.     

Stretching of the brachial plexus in rabbits

The brachial plexus of rabbits was stretched until mechanical failure. The level and site of rupture varied according to the direction of the stretching force. Upward and lateral traction of the forelimbs caused spinal nerve-root avulsions combined with nerve-trunk ruptures distal to the dorsal root ganglions. In such tractions the C5 nerves consistently exhibited postganglionic nerve-trunk rupture. The C6, C7, and C8 nerves had root avulsions. The T1 nerve was avulsed from the spinal cord in 7 cases out of 10; the other 3 cases had postganglionic nerve-trunk rupture. Downward traction of the forelimbs caused nerve avulsions from the scapulohumeral muscles innervated by the terminal branches of the brachial plexus and peripheral nerve ruptures in the course of the arm. The force producing trunk rupture of the C6 nerve was twice as great as that for root avulsion. The required stain was similar for nerve trunk rupture and root avulsion.