膈神经移位治疗产瘫节前损伤

目的 总结临床膈神经移位治疗产瘫节前损伤的疗效及其对肺功能的影响。方法 本组16例，皆在全麻下行膈神经移位修复撕脱的臂丛神经，术后观察膈神经移位后患儿上肢功能恢复及呼吸功能情况。结果 随访2～6年，按照Mallet评分标准评定膈神经移位功能恢复情况，优5例，良7例，可3例，差1例，优良率75％，3个月以内优良率80％。11例呼吸平稳；4例呼吸急促，术后1周平稳；1例发生肺炎，经治疗10余天后呼吸平稳。结论 早期膈神经移位治疗产瘫节前损伤疗效满意，肥胖及体弱新生儿膈神经移位时需慎重，切取一侧嗝神经对患儿呼吸功能无明显影响。     

早期神经移位移植治疗产瘫

目的：报告早期神经移位移植治疗产瘫的方法和疗效。方法：１９９５年５月～１９９６年８月，对１２例出生后３个月无肌力恢复的产瘫患儿进行手术治疗，上干不全损伤神经瘤形成者８例，上干完全断裂或根性撕脱４例，采用４种神经移位移植术修复上干。用Ｍａｌｅｔ评分评价疗效。结果：术后随访１６～２８个月，平均２０．８个月，肩肘功能完全恢复３例，达ＭａｌｅｔⅣ级６例，优良率７５％，膈神经移位优良率８３．３％，副神经移位优良率６６．７％。结论：早期神经移位移植治疗产瘫可获得满意疗效     

全长膈神经移位重建屈指功能的临床报告

目的 探讨在胸腔镜视下切取全长膈神经直接移位至正中神经内侧头重建全臂丛撕脱伤后屈指功能的可行性,为全臂丛根性撕脱伤后屈指功能的恢复提供新思路.方法 对3例全臂丛根性撕脱伤的患者,采用胸腔镜视下游离胸腔内的全长膈神经,于入膈肌处切断膈神经,将全长膈神经直接移位于正中神经内侧头,术后每3个月随访肺功能和临床功能恢复情况.结果 3例患者随访时间均超过3年,拇长屈肌及2～5指指浅屈肌肌力均恢复至3～4级,掌长肌肌力2例为2级,1例为1级;桡侧腕屈肌、旋前圆肌、鱼际肌肌力为0级.肺功能显示患者在术后6个月内有不同程度的肺功能降低,但在1年内都恢复到术前水平.结论 胸腔镜视下切取全长膈神经直接移位至正中神经内侧头重建全臂丛撕脱伤后的屈指功能是一种可行的新术式.     

臂丛神经产瘫的自然病程、显微外科修复与手术重建结果的比较

<正> 目的:本研究的目的是观察臂丛神经产瘫(BPBP)的自然病程(出生后6个月肱二头肌功能恢复的情况),评估6个月肱二头肌功能无恢复患儿行显微修复术的结果,比较后锯肌、大圆肌肌腱移位与肱骨旋转截骨的结果,并将肌腱移位术及截骨术与本病自然病程作比较。方法:观察66例(67侧)3月龄以内BPBP患儿肱二头肌功能恢复的时间及程度,每月记录一次。按肱二头肌恢复时的患儿月龄数分组。每月进行体格检查,并用Mallet功能标准进行评估,对6例出生后6个月肱二头肌功能无恢复的患儿行臂丛神经显微外科修复术。另一组27例患儿在他们6个月时被认为慢性神经病损,肩关节内旋挛缩或外旋功能差,其中9例行后锯肌和大     

肌电生物反馈治疗分娩性臂丛神经麻痹术后腕背伸功能的疗效分析

目的 初步评价肌电生物反馈电刺激对臂丛神经移位术后分娩性臂丛神经麻痹(产瘫)患儿腕背伸功能的疗效.方法 根据纳入标准,选取30例行臂丛神经移位术后的产瘫患儿,在服用神经营养药物治疗和康复训练的基础上,给予患侧桡侧腕长伸肌肌电生物反馈电刺激治疗.在治疗前和治疗4周后评定患儿腕背伸主动关节活动度和桡侧腕长伸肌自发肌电均值,进行统计分析.结果 30例患儿全部获得随访,腕背伸主动关节活动度治疗前为(0.00±14.20)°,治疗后为(24.57± 13.79)°,两组差异有统计学意义(P＜0.01).桡侧腕长伸肌自发肌电均值治疗前为(69.57±39.57)μV,治疗后为(529.30±293.17)μV,两组差异有统计学意义(P＜0.01).结论 肌电生物反馈电刺激有助于改善臂丛神经移位术后产瘫患儿的腕背伸功能.     

进胸膈神经全长切断后的肺功能变化观察

目的 研究全长膈神经移位术对肺功能的影响。方法 对15例行全长膈神经移位肌皮神经术的全臂丛根性撕脱伤病人的术后肺功能进行回顾性分析。11例共随访42～48个月，4例在随访过程中失访。结果 所有病例术后无呼吸功能障碍，胸部X线片中均出现不同程度的术侧膈肌麻痹和抬高（高1．0～1．5个肋间）。肺功能参数如肺活量、肺活量占预期值的百分比、残气量、肺总量、功能残余量、第1秒用力呼气量在术后1年均恢复到术前水平，但所有病例的最大吸气压值即使在术后4年仍比预期值有明显降低（平均降低20％）。结论 单侧膈神经完全切断后的肺功能参数均在术后1年内逐渐恢复到术前水平。     

膈神经移位术后肱肌及肱肌肌支恢复的实验研究

目的 观察两种膈神经移位术后肱肌及肱肌肌支功能恢复的情况,探讨修复后肱肌及肱肌肌支再利用的可能性.方法 取SD大鼠48只,体质量150～200 g,随机分为两组,膈神经通过移植神经移位至上干前股组(上干组),膈神经通过移植神经移位至肌皮神经组(移植组).分别于术后1、2、3个月取材进行大体观察、神经电生理学及组织学检测.结果 上干组于术后17～20 d出现与呼吸同步的屈肘运动,移植组于术后20～25 d出现与呼吸同步的屈肘运动.术后3个月切断肱肌肌支对两组大鼠的屈肘动作均无明显影响.两组肱肌复合肌肉运动电位最大波幅恢复率、肌湿重恢复率、肌纤维截面积恢复率于术后3个月差异均无统计学意义(P>0.05),肱肌肌支再生有髓神经纤维通过率于术后3个月差异有统计学意义(P<0.05),上干组优于移植组.结论 两种膈神经移位术均可使肱肌及肱肌肌支得到恢复,肱肌的远期恢复程度在两组间差异无统计学意义,肱肌肌支的远期恢复上干组优于移植组.     

膈神经移位术后肱肌及肱肌肌支恢复的实验研究

目的 观察两种膈神经移位术后肱肌及肱肌肌支功能恢复的情况,探讨修复后肱肌及肱肌肌支再利用的可能性.方法 取SD大鼠48只,体质量150～200 g,随机分为两组,膈神经通过移植神经移位至上干前股组(上干组),膈神经通过移植神经移位至肌皮神经组(移植组).分别于术后1、2、3个月取材进行大体观察、神经电生理学及组织学检测.结果 上干组于术后17～20 d出现与呼吸同步的屈肘运动,移植组于术后20～25 d出现与呼吸同步的屈肘运动.术后3个月切断肱肌肌支对两组大鼠的屈肘动作均无明显影响.两组肱肌复合肌肉运动电位最大波幅恢复率、肌湿重恢复率、肌纤维截面积恢复率于术后3个月差异均无统计学意义(P>0.05),肱肌肌支再生有髓神经纤维通过率于术后3个月差异有统计学意义(P<0.05),上干组优于移植组.结论 两种膈神经移位术均可使肱肌及肱肌肌支得到恢复,肱肌的远期恢复程度在两组间差异无统计学意义,肱肌肌支的远期恢复上干组优于移植组.     

膈神经移位术后肱肌及肱肌肌支恢复的实验研究

目的 观察两种膈神经移位术后肱肌及肱肌肌支功能恢复的情况,探讨修复后肱肌及肱肌肌支再利用的可能性.方法 取SD大鼠48只,体质量150～200 g,随机分为两组,膈神经通过移植神经移位至上干前股组(上干组),膈神经通过移植神经移位至肌皮神经组(移植组).分别于术后1、2、3个月取材进行大体观察、神经电生理学及组织学检测.结果 上干组于术后17～20 d出现与呼吸同步的屈肘运动,移植组于术后20～25 d出现与呼吸同步的屈肘运动.术后3个月切断肱肌肌支对两组大鼠的屈肘动作均无明显影响.两组肱肌复合肌肉运动电位最大波幅恢复率、肌湿重恢复率、肌纤维截面积恢复率于术后3个月差异均无统计学意义(P>0.05),肱肌肌支再生有髓神经纤维通过率于术后3个月差异有统计学意义(P<0.05),上干组优于移植组.结论 两种膈神经移位术均可使肱肌及肱肌肌支得到恢复,肱肌的远期恢复程度在两组间差异无统计学意义,肱肌肌支的远期恢复上干组优于移植组.     

产伤性臂丛神经上干神经瘤的早期治疗

目的：探讨产伤性臂丛神经上干神经瘤的手术方式及时机。方法：２６例中１０例为出生后３个月，上干支配肌无肌力恢复的产瘫，行神经移位或移植术。另１６例年龄１．１～１．８岁，其上干支配肌肌力均为２级，行神经松解术。两组术中均行电生理检测，并对其治疗效果进行分析。结果：术中电刺激上干处神经瘤两组均有传导性。出生后３个月组平均随访１６．３个月，疗效优良者７例，占７０％。晚期神经松解组平均随访１９．８个月，肌力均无明显恢复。结论：出生后３个月肱二头肌肌力未恢复者应立即手术，不管术中电刺激神经有无传导性，以神经移位或移植术为首选     

Intercostal nerve transfer in infants with obstetric brachial plexus palsy

The use of intercostal nerve (ICN) transfer to repair brachial plexus lesions associated with root avulsions is a well known procedure in adults. However, there is a paucity of reports on the use of ICN in infants with obstetrical brachial plexus palsy (OBPP). This study included 46 infants with obstetric brachial plexus palsy who underwent 62 neurotization procedures. Clinically, 2 cases had upper trunk injury, 19 had upper-middle trunk injury, 3 had lower trunk injury, and 22 had total palsy. The average age at surgery was 14 months. Twelve patients underwent surgery younger than 6 months of age, 11 patients at 6 to <9 months, 9 patients at 9-12 months, and 14 patients at >12 months. The average follow-up period was 49 months. ICN transfer resulted in 76% satisfactory (good and excellent) outcome, and was best for restoration of elbow flexion (93.5%). Functional results were best when the operation was done before the age of 9 months; however, the difference between age groups was statistically insignificant. Functional results were also independent of the extent of the original injury. Nine children had preoperative and postoperative CT chest scans. All the nine children developed basal pulmonary atelectasis postoperatively. Pulmonary atelectasis was mostly ipsilateral and was not correlated to the patient age (months), or the duration of anesthesia (in minutes). We conclude that, intercostals nerve transfer is an effective procedure for restoration of function in infants with OBPP and root avulsions. The procedure is associated with variable degree of ipsilateral pulmonary atelectasis.     

胸腔镜下切取膈神经移位重建全臂丛根性撕脱伤手部功能初步报告

目的探讨胸腔镜下膈神经超长切取、移位重建全臂丛根性撕脱伤手部功能的可行性。方法全臂丛根性撕脱伤3例,胸腔镜下于邻膈肌处切断膈神经,逆行游离胸腔内全长膈神经及其血管组织蒂,并由第二肋间引出,经胸大肌下移位至上臂上内侧,分别与尺神经前内侧部吻合2例,与移植股薄肌之闭孔神经前支吻合1例。结果2例膈神经联合第3～6肋间神经运动支移位修复尺神经者,结合短期免疫抑制剂FK506口服治疗,术后12个月手内肌肌电图检测均出现再生电位,1例随访15个月出现手内肌收缩。1例用以重建屈肘、屈指屈拇的移植股薄肌术后7月出现肌肉收缩,随访12个月肌力达M3。结论胸腔镜下全长切取膈神经,作为运动性动力神经移位应用于全臂丛根性撕脱伤的治疗,可在短时间内有效重建屈指屈拇功能,并有使手内肌神经再支配、开始恢复手内肌收缩功能的迹象。     

分娩性臂丛神经损伤的早期显微外科治疗

目的 探讨分娩性臂丛神经损伤的手术治疗时机与方法。方法 1997年10月～2001年4月对32例分娩性臂丛神经损伤进行早期显徽手术治疗，术时年龄3个月～2岁，平均10个月，6个月以内19例，大于6个月13例。手术方法：臂丛神经松解12例，臂丛神经瘤切除端端缝合或神经桥接移植7例，膈神经移植于上干前股或肌皮神经7例，肋间神经移植于肌皮神经(经神经移植)6例。神经松解及神经吻合均应用显微器械操作，用7／0或9／0无损伤缝合线缝合。结果 术后30例患儿获随访1-3年5个月，平均1．9年。疗效评定标准：肱二头肌肌力达4级以上为优14例；3级者为良9例12级以下者为差或无效7例。优良率为76．7％，其中年龄小于6个月的19例为84．2％(16／19)；大于6个月的11例为63．6％(7／11)。结论 分娩性臂丛神经损伤患儿，出生后3～6个月无明显屈肘功能恢复者即应行显微手术治疗，神经松解和神经吻合效果优于神经移植术，根据术中探查的具体情况选择恰当的术式是提高疗效的关键。     

Diaphragmatic paralysis and eventration in infants

Twenty-six children with eventration (congenital in 10, resulting from birth trauma in four, and resulting from operative phrenic nerve injury in 12) under 15 months of age were evaluated at a single institution in a 5 year period. There was a high incidence of significant associated anomalies and prematurity. All operative phrenic nerve injuries occurred in patients under 3 months of age, and they were most common in patients undergoing Blalock-Taussig shunt. Plication (12 thoracic, nine abdominal) was performed in 21 patients, 19 of whom had respiratory distress or were ventilator dependent. Repeat plication was required in four patients. All long-term survivors were extubated within 1 week of plication. Of 21 patients undergoing plication, 14 (67%) died. Death was attributed directly to complications of eventration in three patients and was a contributing factor in nine patients. We reached the following conclusions: The incidence of operative phrenic nerve injury in infants undergoing lateral thoracotomy, particularly for Blalock-Taussig shunt, is higher than generally appreciated; plication is a safe procedure as performed by either an abdominal or thoracic approach; failure to achieve extubation within a week of plication is an ominous prognostic sign; mortality in patients with eventration in the presence of major associated conditions may be high despite plication.     

膈神经移位治疗臂丛损伤的临床应用和早期疗效

目的探讨膈神经移位至肌皮神经重建屈肘功能的临床应用及早期疗效。方法对8例臂丛根性撕脱伤行膈神经移位术，膈神经与上干前股的肌皮神经束直接吻合5例，膈神经通过神经移植桥接至肌皮神经3例，术后随访评定其屈肘功能。结果8例经10月-2年随访，肱二头肌肌力在2级以上5例，有效率62．5％。结论膈神经移位术是治疗臂丛根性撕脱伤的理想术式，重视术前和术中膈神经功能的评估、神经移位时吻合方法的合理选择和术后综合康复锻炼是提高手术疗效关键。     

A case of schwannoma of intrathoracic right phrenic nerve

A 22-year old man was admitted because of an abnormal shadow on his chest X-ray film. Radiographic findings revealed that the tumor was located in the right middle mediastinum. At operation a smooth round tumor was found arising from the right phrenic nerve. The tumor was removed with phrenic nerve. Pathohistological examination revealed this tumor was benign schwannoma. Intrathoracic schwannoma usually arise from intercostal and sympathetic nerve and that arising from phrenic nerve is very rare. We removed the tumor by means of cutting his right phrenic nerve because of complete resection. Postoperatively he did well without any respiratory distress. And his respiratory function studies recovered normal 9 months after the operation. We think that schwannoma arising from phrenic nerve should be removed completely and in such a case cutting of the one side phrenic nerve is at ease if the patient have normal respiratory function.     

Restoration of shoulder abduction in brachial plexus injury with phrenic nerve transfer

BACKGROUND: Shoulder abduction is one of the most essential functions in reconstruction of the brachial plexus following injury. In the literature there are few reports on phrenic nerve transfer, especially in relation to restoration of shoulder function. The purpose of the present study was to evaluate the clinical effectiveness and safety of phrenic nerve transfer. METHODS: A study was made of 10 cases of phrenic nerve transfer to the suprascapular nerve. RESULTS: The average shoulder abduction was 41 degrees (range: 20-60 degrees). The average degree of shoulder abduction in patients with C5 or C6 root avulsions was slightly more than that in the patients with total root avulsions. There was no clinically significant respiratory insufficiency in any patient. CONCLUSIONS: Phrenic nerve transfer to the suprascapular nerve is an effective, reliable and safe method of shoulder abduction restoration in brachial plexus injury.     

Topical cooling for myocardial protection: the results of a prospective randomized study of the "shallow technique"

INTRODUCTION AND BACKGROUND: Respiratory distress following cardiac surgery is a troublesome complication. In several cases it is associated to cool-related phrenic nerve injury (PNI) after adoption of iced slush or hypothermic cardiopulmonary bypass. We compare two different strategies for myocardial protection: the "shallow technique" (ST) (dripping and prompt removal of cold saline solution from the epicardial surface) plus normothermic cardiopulmonary bypass, versus mild hypothermic cardiopulmonary bypass plus iced slush. METHODS: Two hundred forty-nine patients undergoing elective cardiac surgery were randomly assigned to receive either ST (Group A) or iced slush (Group B). Occurrence of postoperative PNI (abnormal diaphragmatic movement plus alteration of nerve conduction) was evaluated. Multivariate analysis was performed for identification of factors associated to PNI. Patients had a 6-month follow-up. RESULTS: PNI and failure of extubation occurred more frequently in Group B (p = 0.009 and p = 0.034, respectively), but there was no statistically significant difference in mean intensive care unit stay. Diabetes and the use of iced slush were independent predictors of phrenic dysfunction, while internal thoracic artery (ITA) harvest was a significant risk factor only among Group B patients. Abnormal diaphragmatic movement was persistent at 6 months only in 30% of Group B individuals who suffered this complication in the early postoperative. CONCLUSIONS: ST likely reduces the incidence of postoperative PNI and might be protective mainly in the event of ITA harvest. It should be considered as a valuable tool for myocardial protection protocols.     

Eventration of the diaphragm in children

Diaphragmatic plication is a safe, well tolerated procedure for congenital diaphragmatic eventration. It is the treatment of choice in neonates with respiratory distress following phrenic nerve injury. The abdominal approach is as good as the thoracic and may be safer in cases with central eventration and when the diagnosis of congenital diaphragmatic hernia cannot be excluded with confidence. However, in phrenic nerve paralysis the thoracic approach is superior in showing the anatomical distribution of the phrenic nerve. Experience with eight paediatric patients treated for diaphragmatic eventration is reported. Five had congenital eventration of the diaphragm and three had acquired eventration. All patients except one required surgical plication of the diaphragm. Three patients developed minor postoperative complications and all patients were alive and well on follow-up. It appears that diaphragmatic plication is a safe and well tolerated procedure for symptomatic diaphragmatic eventration.