用股后皮神经桥接下位胸神经与阴部神经治疗截瘫后大小便失禁

本研究设计了用股后皮神经、桥接下位胸神经与阴部神经治疗截瘫后大、小便失禁的新术式,并在34侧成人尸体标本上,对下位胸神经、股后皮神经和阴部神经进行了观测,提供手术时有关的数据。第十、十一肋间神经和肋下神经从骶棘肌外缘至分出外侧皮支间的长度分别为10.4cm、8.8cm 和6.6cm;至梨状肌下缘阴部神经出盆处的距离为31.2cm、27.3cm 和22.0cm。股后皮神经和阴部神经的横径4.5mm 和4.2mm。     

脊柱胸腰段左侧胸膜外腹膜后手术入路的解剖观察及临床意义

目的：研究脊柱胸腰段（T11-L2）左侧胸膜外腹膜后的手术入路解剖,为该部位手术提供层次解剖学基础。方法：用15例10％甲醛固定的成人尸体标本（男10例,女5例）,按脊柱胸腰段椎体病灶的左侧胸膜外腹膜后手术入路逐层解剖,观察T11～L2椎体前外侧面的器官、血管和神经等结构的位置及毗邻关系,重点观察肋膈窦、腹膜腔和膈肌之间解剖关系。结果：（1）经左侧胸膜外腹膜后入路显露胸腰段脊柱,经过皮肤、浅筋膜,背部浅、深层肌及腹壁肌层,肋、肋间隙,在膈上、下推开壁胸膜和壁腹膜,剪开部分膈肌避开椎前的血管、神经、食管和胸导管即可显露T11-L2椎体。（2）左肋膈窦底由后向前,先后与12肋、11肋间神经血管和11肋平齐,在T11～T12左椎间孔处第11肋间神经与左肋膈窦底的上下距离为（34．3±1．0）mm,在左竖脊肌外缘为（21．4±0．8）mm,在左腋前线至胸前外侧壁二者平齐,向前内行渐低于左肋膈窦底部。结论：左侧胸膜外腹膜后入路经膈肌与壁腹膜和膈胸膜之间隙可显露T11～L2椎体,第11肋间动静脉和肋间神经的走行可作为肋膈窦底的参考标志。     

多血管神经蒂腹内斜肌瓣修复面瘫的应用解剖

目的：为了探索晚期面瘫动力性修复中多神经支配的供区，提供多血管神经蒂腹内斜肌瓣的应用解剖学基础。方法：在２２侧红色乳胶灌注的成人尸体上，测量观察了腹内斜肌的神经支配及血供情况。结果：腹内斜肌主要接受第１１肋间神经和肋下神经支配的占９０．９％，接受第１０、１１肋间神经和肋下神经支配的占９．１％。第１１肋间神经入肌处至腋后线的平均长度为１２．７ｃｍ，肋下神经入肌处至腋后线的平均长度为１２．９ｃｍ，血供主要来源于第１１肋间动脉、肋下动脉和旋髂深动脉的腹壁肌支，在腹内斜肌和腹横肌筋膜之间有丰富的血管吻合。结论：可利用腹内斜肌多血管神经支配的特点，设计超长吻合多血管神经蒂的腹内斜肌瓣跨面移植治疗晚期面瘫的新术式。     

胸后壁胸膜腔穿刺安全区的定位

目的探究胸后壁第六至第九肋间隙肋间神经和肋间后血管的走行及位置关系,为临床在胸后壁行胸膜腔穿刺确定在肋间隙进针的安全区域。方法在32具成人尸体上,解剖胸后壁第六至第九肋间隙的肋间神经和肋间后血管,观察它们的走行及位置关系,测量肋间神经和肋间后动脉、静脉各自的分叉点及各自的下支与下位肋上缘交点距后正中线和肩胛线的距离,并进行统计学分析。结果肋间神经、血管在排列和分布上呈现一定的规律。结论根据肋间神经和肋间后血管在胸后壁的走行和位置状况可确定胸腔穿刺术的安全进针区。     

前锯肌间隙阻滞的解剖学观察及其临床意义

目的　观察测量前锯肌间隙美兰溶液扩散范围及神经分布, 为该间隙神经阻滞提供解剖学依据。 方法　选用4具尸体,应用超声引导技术,采用Blanco穿刺入路,在胸壁两侧腋中线4、5肋间,注入含美兰染料的液体（0.4 ml/kg）至前锯肌间隙,约10 min后逐层分离至该间隙,观察美兰液体的扩散范围、染料沉积后界限以及该范围内的神经分布。 结果　观察8侧前锯肌,逐层掀开胸大肌和胸小肌后,清晰显露前锯肌间隙的蓝染区域及区域内蓝染的2~6肋间神经的外侧皮支、胸长神经和胸背神经。中位数M(P25, P75)描述8个前锯肌筋膜间隙注射扩散范围测量结果,腋前线11.35（10.45,12.15）cm,腋中线12.6(12.12,13.15)cm,腋后线11.1(10.70,12.05)cm,平乳头线9.8(9.12,10.65)cm。头侧扩散至第2肋腋前线占75%,腋中线占87.5%,腋后线占87.5%;扩散至第3肋腋前线占25%,腋中线占12.5%,腋后线占12.5%。 结论　前锯肌间隙美兰溶液扩散范围解剖测量研究提示临床应用此方法进行前锯肌间隙神经阻滞,可阻滞前锯肌间隙内的2~6肋间神经外侧皮支、胸长神经和胸背神经,满足胸前外侧壁手术的麻醉和镇痛。     

A study on the communication between the pectoral nerve and the extramural nerve branches of the intercostal nerves]

Kumaki et al. (1979) defined the extramural nerve as the rudimentary sensory nerve which appeared on the upper thoracic wall; it branched off the root of the lateral cutaneous nerve of the second, third or fourth intercostal nerve, ran inferomedially adhering to the fascia of the intercostalis externus muscle and ended supplying the membrane covering the adjacent rib. They also stated that the extramural nerve (Rxm) occasionally became a cutaneous nerve which pierced the pectoralis muscles and supplied the skin covering the thoracic wall similar to the lateral cutaneous nerve (Rcl) or the anterior cutaneous nerve (Rca). Further, they proposed that the muscular nerves to the obliquus externus abdominis muscle which are usually situated below the fifth rib might be considered a part of this Rxm series. Although the definition of Rxm is still not widely accepted, Rxm is thought to be a key morphological factor influencing the variations of peripheral nerve arrangement on the thoracic wall. In the student course of gross anatomy dissection at Iwate Medical University School of Medicine during the years 1987-1991, three cases of Rxm communicating with the pectoral nerve and supplying the pectoralis major muscle were observed. Some cases have been reported in which Rcl innervates part of the pectoral muscles. However, the communication between the pectoral nerve and Rxm has not yet been discussed. Therefore, to clarify the morphological significance of the communication between Rxm and the pectoral nerve, the branching pattern and the distribution of the pectoral nerves were extensively investigated and the intramuscular nerve supply of some pectoral nerves, especially the pectoral nerves which communicated with Rxm, was examined in detail under a stereomicroscope. The results are summarized as follows: 1. In the first case, Rxm of the second intercostal nerve originated from Rcl, ran inferomedially adhering to the fascia of the intercostalis externus muscle and pierced the origin of the pectoralis minor muscle at the third intercostal space. Then Rxm turned superolaterally to communicate with a pectoral nerve which originated from the loop composed of the lateral and medial pectoral nerves and passed inferior to the pectoralis minor muscle. After communication, the pectoral nerve with Rxm supplied the caudalmost part of the sternocostal portion of the pectoralis major muscle. In the second case, a similar branch of Rxm of the second intercostal nerve passed inferior to the pectoralis minor muscle.(ABSTRACT TRUNCATED AT 400 WORDS)     

腹外斜肌的神经入肌点定位与肌内神经分布研究

目的　对人腹外斜肌的神经入肌点定位和肌内神经染色观察，为其临床应用提供形态学资料。 方法　成尸11具定位神经入肌点和5具行Sihler’s 肌内神经染色。 结果　腹外斜肌受下8对肋间神经外侧肌支支配，各个肌齿的神经入肌点距离相应肌齿起端中点(1.54±0.33)cm，位于锁骨中线与第5肋下缘的交界处至腋后线与第11肋下缘交界处的连线上。Sihler’s染色显示支配腹外斜肌的肋间神经外侧肌支入肌后分出小分支分布到各肌齿的起端1/3，然后约在各肌齿的近、中1/3交界处分出2支二级神经分支，即上支与下支，它们分出小分支分布到各肌齿的中间1/3，相邻两个肌齿的上支与下支在各肌齿中远部形成“U”形吻合，从“U”形吻合弓上分出小分支分布到各肌齿的止端1/3。在腹外斜肌上半部，各肌齿的神经分支分布到相应的肌齿，但在腹外斜肌下半部，上一肌齿的远侧下份是由下一肌齿的神经分支(上支)分布。 结论　①为临床上腹壁局部麻醉和术后切口疼痛的神经阻滞提供指导意义；②腹外斜肌中远部从上至下形成“波浪形”的神经分支密集区；③腹部手术切口建议不要超过四个肌齿。     

多血管神经蒂腹内斜肌瓣修复面瘫的解剖学基础

目的：为多血管神经蒂腹内斜肌瓣修复晚期面瘫提供解剖学基础。方法：在３６侧成尸标本上,对腹内斜肌的形态、血供及神经支配进行解剖观测。结果：腹内斜肌中部上１／２肌腹主要由第１１肋间神经支配,下１／２肌腹主要由肋下神经支配。上１／２肌腹的血供６６．７％来自第１１肋间后动脉,３３．３％来自旋髂深动脉的髂嵴支;下１／２肌腹的血供主要来自旋髂深动脉的腹壁肌支。第１１肋间神经、肋下神经在腋后线横径分别为２．２ｍｍ和２．４ｍｍ,入肌点距腋后线长分别为１３．３ｃｍ和１３．８ｃｍ。第１１肋间后动脉在腋后线外径为１．７ｍｍ,入肌点距腋后线长为１３．１ｃｍ;旋髂深动脉腹壁肌支和髂嵴支的起始外径分别为１．３ｍｍ和１．８ｍｍ,入肌点至起点长分别为５．１ｃｍ和８．６ｃｍ。结论：吻合多血管神经腹内斜肌瓣移植可全面修复晚期面瘫     

Case 5

A 53-year-old man with a heavy exposure to asbestos 25 years earlier was admitted to the East Orange Veterans Administration Medical Center with a rapidly enlarging chest wall mass of 4-5 weeks duration.

The mass, overlying the ninth and tenth ribs in the infraaxillary area, was firm. On X-ray the ribs appeared eroded and the mass was seen to extend into the pleural space. A chest wall resection was performed, and the tumor was sharply dissected from the diaphragm to which it was firmly adherent. Grossly, it measured 7.5 X 5.0 X 3.0 cm and was yellow-tan with homogeneous and nodular areas The inferior aspect of the ninth rib was obviously involved and the tumor extended between the pleura and intercostal muscle.

The patient did not receive further therapy and was asymptomatic 7 months after surgery.     

A proposed method of dissection of the anterolateral abdominal wall -- applied features

The dissection described allows the segmental nerve supply of the rectus abdominis to be seen in its continuity, namely: intercostal nerves seven to eleven, the subcostal and occasionally the iliohypogastric nerve as shown in Fig. 1. The advantages of transverse or interneural incisions are obvious. The medial retraction of the lower rectus after incision of the anterior part of the rectus sheath, exposing the femoral ring and pectineal ligament is a suitable approach of femoral hernia repair. The posterior part of the dissection shows the relation of subcostal nerve and the ventral ramus of the first lumbar nerve and/or its iliohypogastric and ilioinguinal branches to the superior lumbar triangle, which is of consequence in posterior approaches to the kidney. A lateral cutaneous branch, which normally comes off the iliohypogastric nerve also crosses the field. Brief mention is made concerning the anatomy of local anesthesia for inguinal hernia repair.     

Bifid Rib: Anatomical Considerations in Three Cases

The present study involved a detailed investigation of 3 cases of bifid rib, focusing on anatomical features, and classified them into 2 types. The bifid ribs were in the right fourth rib of all 3 male cadavers. The upper intercostal spaces of the fourth bifid rib were considerably narrowed, whereas the lower intercostal spaces were widened. Although the size and shape of the bifid space between the upper and lower divisions of the bifid rib were different, the intercostal muscles were present in the bifid space in all cases. The third anterior intercostal artery from the internal thoracic artery supplied the bifid space in all cases. In 2 cases, the fourth intercostal nerve ran along the inferior margin of the fourth bifid rib and innervated the muscles of the bifid space. In the third case, there was another branch from the third intercostal nerve supplying the muscles of the bifid space as well as the fourth intercostal nerve. The bifid ribs are associated with other diseases or develop accidentally or sporadically. Knowledge of this malformation is needed for the differential diagnosis with other diseases, such as a chest wall tumor or costal fracture.     

The gross anatomy of the extrathoracic course of the intercostobrachial nerve

Recent reports emphasize the importance of preserving the intercostobrachial nerve (ICBN) during surgical procedures (i.e., mastectomy, axillary clearance). However, a limited number of scientific reports explore the surgical anatomy of this nerve. We dissected 100 adult human formalin-fixed cadavers (200 axillae). In all the cadavers the ICBN was present with variant contributions from intercostal nerves T1, T2, T3, and T4. The arrangements of the ICBN were typed as I through VIII. The components of Type I (45% or 90 of our specimens) included a branch to the posterior antebrachial cutaneous nerve, a branch to the anterior and lateral parts of the axilla, a branch to the medial side of the arm, and a branch to the medial antebrachial cutaneous nerve. Type II (25%) describes the ICBN arising from T2 and giving off a branch to the brachial plexus. In Type III (10%), lateral cutaneous branches of T2 and T3 fuse as a common trunk and then split immediately after exiting the intercostal space to form an ICBN. In type IV (5%), T2 and T3 join distally to form an ICBN that ends as its terminal branches. Type V (5%): T3 joins T2 from the same intercostal space proximally, with Type VI (3%) showing a very proximal branching of the sensory terminal nerves. Type VII (5%) displayed a contribution from T3 and a branch to the brachial plexus with multiple terminating branches. A contribution from T3 and T4 and a branch to the brachial plexus with multiple branches of termination comprised Type VIII (2%).     

The pecs anesthetic blockade: A correlation between magnetic resonance imaging,ultrasound imaging,reconstructed cross‐sectional anatomy and cross‐sectional histology

The interfascial thoracic wall blockades Pecs I and Pecs II are increasingly applied in breast and axillary surgery. Despite the clear anatomical demarcations depicted at their introduction, the clinical outcome is more variable than would be expected based upon the described anatomy. In order to elucidate factors that explain this variability, we evaluated the spread of each injection—medial Pecs I, lateral Pecs I, the deep injection of the Pecs II—separately. A correlation of in vivo landmarks and ultrasound images with ex vivo ultrasound, reconstructed anatomical planes, histology and magnetic resonance imaging. The medial Pecs I, similar to the sagittal infraclavicular block positioning with needle position medial to the pectoral branch of the thoracoacromial artery, reaches the medial and lateral pectoral nerves. The lateral Pecs I, below the lateral third of the clavicle at the level of the third rib with needle position lateral to the pectoral branch of the thoracoacromial artery, additionally spreads to the axilla and reaches the intercostobrachial nerve. The deep Pecs II injection spreads to the lateral cutaneous part of the III–VI intercostal nerves and reaches the long thoracic nerve. The variability of the Pecs anesthetic blockades is driven by the selected Pecs I approach as only the lateral approach stains the intercostobrachial nerve. The pectoral branch of the thoracoacromial artery can serve as the landmark to differentiate the needle position of the medial and lateral Pecs I block. Clin. Anat. 32:421–429, 2019. © 2019 Wiley Periodicals, Inc.     

肋间后血管下支的解剖学观测及意义

目的　为人类体质学调查补充新的资料 ,为临床胸膜腔穿刺提供新的参考标准。方法　在 4 0侧成人标本上对标准肋间隙 (第 3～ 10肋间隙 )的肋间后血管的下支进行解剖学观测。结果　下支的起始处在胸后壁的体表投影点距后正中线的平均距离为 (5 0± 0 4 )cm。结论　临床医生行胸膜腔穿刺可在第 7～ 9肋间隙距后正中线 7 0cm以外进行     

The human musculus obliquus externus abdominis innervated by ramus muscularis externus of intercostal nerves

Each of the uppermost slips of the bilateral M. obliquus externus abdominis originated from the fifth rib and was innervated from its inner surface by the Ramus muscularis externus of the fifth intercostal nerve, in one corpse. Furthermore, the slip originating from the sixth rib of the right M. obliquus externus abdominis was innervated not only by the lateral cutaneous branches of the sixth and seventh intercostal nerves from its outer surface, but also by the Ramus muscularis externus of the sixth intercostal nerve from its inner surface. The slip originating from the fifth rib was given us an aspect in appearance as if it were the uppermost slip of origin of this muscle, but its true nature is considered to be the M. obliquus abdominis externus profundus from the viewpoint of its innervating nerve and pattern. In addition, the slip originating from the sixth rib is considered to be a substance formed by the dorsal adhesion of the M. obliquus abdominis externus profundus originating from the sixth rib to the slip of the M. obliquus externus abdominis originating from the same rib.     

Medial and lateral pectoral nerves: course and branches

During modified radical mastectomy or cosmetic surgery, denervation of the lower part of the pectoralis major frequently occurs and may reduce muscle spasm, with consequent better reconstruction of the breast. The aim of this study was to determine the relationship between the pectoral nerves and the pectoral muscles. Eight unembalmed female cadavers were dissected and vascular and radiologic studies performed. The lateral pectoral nerves showed a constant course, parallel to the thoraco-acromial vessels. They coursed for 55 +/- 7 mm inferomedially on the deep surface of pectoralis major, under its fascia. The medial pectoral nerves showed two main patterns of branching, which correlated with the extent of the costal attachments of the pectoralis minor muscles. In pattern A (56%), associated with costal attachments narrower than 6.0 cm, the nerve pierced the deep aspect of the pectoralis minor as a single trunk, ramified in the muscle, and gave some branches that appeared on the superficial aspect to enter the pectoralis major. In pattern B (44%), associated with costal attachments wider than 6.6 cm, the nerve divided before entering pectoralis minor and its branches passed through the muscle or round its lower border to reach pectoralis major. The most medial branch of the medial pectoral nerve directed to the pectoralis major muscle emerged from pectoralis minor at the third intercostal space in the midclavicular line, a mean of 10.3 cm lateral to the margin of the sternum. Knowledge of the relationship between the extent of the costal attachment of pectoralis minor and the two patterns of branching of the medial pectoral nerve may be useful when performing elective denervation of the major pectoralis muscle.     

The distribution of sensory and motor axons of the intercostal nerves and their branches (author's transl)]

As it is well established that motor axons in general display a higher acetylcholinesterase-activity than sensory axons do, the histochemical method of KARNOVSKY and ROOTS (1964) was used for the differentiation of motor and sensory fibres in the intercostal nerves and their branches. In the paravertebral sections of the intercostal nerves of the upper segments 30--35% of the nerve fibres show a high enzyme activity and therefore were classified as motoric. The percentage of the motor fibres in comparable zones of the lower segments increases to 45%. Only 15% of the nerve fibres proved to be motoric in the parasternal sections of the intercostal nerves. In a histogram of the acetylcholinesterase-positive intercostal nerve fibres 2 peaks can be seen: one in the alpha-calibre class, the second in the gamma-class. There are more motor axons in the lateral cutaneous branch of the lower intercostal nerve than in upper ones. This may be explained by the participation of these nerve branches in the innervation of the abdominal muscles. In 2 cases nerve branches of the intercostal nerve to the diaphragm were found containing 15--25% motor axons.