应用电生理检测肌皮神经肱肌肌支在神经根的定位

目的 探讨应用电生理检测肌皮神经肱肌肌支在神经根的定位,为肱肌肌支移位术的临床应用寻求理论依据.方法 选择30例臂丛神经损伤行健侧C7移位的患者,年龄16～50岁,平均[(28.9±7.7)岁,-x±s,下同],术中暴露健侧正常的臂丛神经,运用意大利ESAOTE的Reposer四道程肌电诱发电位仪,分别刺激C5～T1神经根,在肱肌记录诱发电位的潜伏期及波幅.结果 30例健侧C7移位者术中电生理检测,刺激臂丛神经根时,其中C529例、C630例、C728例记录到肱肌运动电位,而刺激C8、T1仅有6例记录到较小的肱肌运动电位.C5、6、7运动电位的潜伏期和波幅分别为(6.32±1.50)ms、(6.51±1.36)ms、(6.99±1.33)ms和(4.87±4.43)mV、(5.65±4.76)mV、(0.90±2.29)mV,其中以C6的波幅最大,C5次之,C7波幅较小,提示C5、6支配肱肌的神经纤维数可能最多.结论 肱肌主要接受来自C5、6神经纤维的支配,该肌支移位至正中神经(骨间前神经)是可行及有效的,同时该方法为今后临床研究周围神经的定位提供了检测手段.     

上中下三干后股对指总伸肌及肱三头肌长头交叉支配的电生理研究

目的通过术中电生理检测,在臂丛神经中找到指总伸肌支配神经的相对集中区,为神经移位重建伸指功能新术式的设计提供理论依据。方法2008年2月-2009年10月,17例臂丛神经撕脱伤行健侧C7神经根移位术。应用Keypoint型肌电图仪,术中分别对上、中、下三干后股进行电刺激,在指总伸肌及肱三头肌长头记录复合肌肉动作电位（compound muscle action potential,CMAP）。结果指总伸肌记录到的CMAP最大波幅有76．5％（13／17）为电刺激下干后股,17．6％（3／17）为电刺激中干后股,5．9％（1／17）为电刺激上干后股。电刺激上、中、下三干后股在指总伸肌记录到的CMAP波幅平均值分别为：0．75±1．16mV,1．64±1．54mV,5．32±4．58mV。在肱三头肌长头记录到的最大CMAP波幅有53％（9／17）为电刺激中干后股,47％（8／17）为电刺激下干后股。电刺激中干及下干后股在肱三头肌长头记录到的CMAP平均波幅分别为4．57±3．84mV,5．98±8．43mV。结论支配指总伸肌的神经纤维来自下千后股比C7后股的多,而下干后股亦是肱三头肌长头的主要支配神经。     

臂丛颈7神经根支配主要代表肌的电生理研究

目的 通过电生理检测分析臂丛颈,神经根的主要代表肌.方法 选择16例臂丛神经根性撕脱伤行健侧颈7神经根移位的患者,术中采用电生理检测,对颈7神经根支配肌的波幅进行分析,确定颈7神经根的主要代表肌.结果 电生理检测表明背阔肌与肱三头肌长头均可较好地代表颈7神经根的功能.尤其是肱三头肌长头在所有16例患者的检测中,刺激颈7神经根所得复合肌肉动作电位(CMAP)波幅值均明显大于其余神经根所得波幅值;而背阔肌有4例(占25.0%),在刺激颈6神经根时所得CMAP波幅值与颈,神经根接近.结论 将肱三头肌长头、背阔肌作为定位颈,神经根的代表肌更具有合理性与科学性.     

同侧C_7神经根移位后对其支配肌影响的初步观察

目的　观察C7神经移位后对C7神经根所支配肌肉功能的影响。方法　 1996年 2月至 2 0 0 0年 2月 ,对 7例臂丛上干或C5,6神经根损伤患者 ,均采用同侧C7神经根 (全部 )移位修复 ;并观察手术前、后背阔肌、肱三头肌及指总伸肌肌力及肌电的变化。术后 1周 7例 ,术后 4个月 6例 ,术后 1年 5例进行了肌力测定及肌电检查。结果　术后 1周背阔肌、肱三头肌及指总伸肌的肌力较术前均有所下降 ,下降幅度多在 1级以内。肌力的下降均呈可逆性 ,术后 4个月三块肌肉的肌力均已恢复正常。术后 3个时间组三块肌肉CMAP(复合肌肉动作电位 )的波幅、潜伏期和术前比无明显影响。结论　臂丛上干损伤采用同侧C7移位后 ,供区背阔肌肌力下降最明显 ,肱三头肌次之 ,指总伸肌最小。     

肱三头肌及指总伸肌电生理支配权重分析在同侧C7神经根移位术中的临床意义

目的 分析在健侧C7神经根移位术中得出的臂丛神经各干对肱三头肌/指总伸肌的电生理支配权重,推断其对于同侧C7神经根移位术的影响,为探讨其安全性和适应证提供电生理依据.方法 随机选择2007年8月-2007年10月15例全臂丛神经根性撕脱伤,行健侧C7神经根移位的患者.男13例,女2例:年龄18～49岁,平均28岁.致伤原因:坠落伤1例,压砸伤2例,余均为车祸伤.左侧8例,右侧7例.术中依次刺激健侧臂丛神经上、中、下干,于肱三头肌/指总伸肌记录复合肌肉动作电位(compound muscle action potential,CMAP),比较各干的CMAP波幅所占百分比,确定臂丛神经各干对肱三头肌,指总伸肌的电生理支配权重.术后6个月内随访肱三头肌/指总伸肌肌力,并复查肌电图了解其自发电活动和主动募集反应情况.结果 15例患者均获随访6个月.肱三头肌的电生理支配权重:上中干型3例(20%),中下干型3例(20%),全干型7例(47%),中干型2例(13%);指总伸肌:中下干型3例(20%),全干型10例(67%),下干型2例(13%).肱三头肌:术后1个月,2例出现肱三头肌肌力4级,募集反应单纯相,至术后3个月恢复正常.余患者术后1个月肌力均达5级,募集反应单纯混合相或混合相.指总伸肌:术后1个月,患者肌力及募集反应均恢复正常.结论 对于各种电生理支配权重的患者,C7神经根的切取均不会造成肱三头肌和指总伸肌的实质性损害,同侧C7神经根移位术是安全可行的;但对于中干支配权重高的患者,采用同侧C7神经根全干移位应慎重,有可能造成肱三头肌短期内的肌力下降.     

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.     

同侧C7神经根移位后对其支配肌影响的初步观察

目的：观察C7神经移位后对C7神经根所支配肌肉功能的影响。方法：1996年2月至2000年2月,对7例臂丛上干或C5,6神经根损伤患者,均采用同侧C7神经根（全部）移位修复,并观测手术前、后背阔肌、肱三头肌及指总伸肌肌力及肌电的变化。术后1周7例,术后4个月6例,术后1年5例进行了肌力测定及肌电检查。结果：术后1周背阔肌、肱三头肌及指总伸肌的肌力较术前均有所下降,下降幅度多在1级以内。肌力的下降均呈可逆性,术后4个月三块肌肉的肌力均已恢复正常。术后3个时间组三块肌肉CMAP(复合肌肉动作电位）的波幅、潜伏期和术前比无明显影响。结论：臂丛上干损伤采用同侧C7移位后,供区背阔肌肌力下降最明显,肱三头肌次之,指总伸肌最小。     

背阔肌电生理支配权重分析在同侧C7神经根移位术中的临床意义

目的 通过比较健侧G移位术中背阔肌上、中、下份复合肌肉动作电位（compound muscle action potential，CMAP）波幅的差异，了解臂丛神经根对背阔肌的支配权重，从而为同侧G移位术的应用提供电生理依据。方法于健侧G移位术中依次刺激臂丛神经上、中、下干，分别于背阔肌上、中、下份记录CMAP，比较CMAP波幅差异，确定各臂丛神经对背阔肌的支配权重。术后4周随访背阔肌肌力。结果CMAP波幅提示背阔肌上份主要受臂丛中干和上中干支配占60％，受上干支配仅10％；中份受中干支配占70％，受上干支配占15％；下份受中、下干和中干支配占70％，无单独上干支配。综合背阔肌上中下份分析显示由上干主要支配仅占8％、由中干主要支配占33％、由下干主要支配占10％、中下干支配占23％、上中下干支配占8％。术后4周随访背阔肌功能无明显影响。结论通过术中对背阔肌所受臂丛神经支配的电生理权重的研究，证实了同侧G神经根移位术的安全性。     

Avulsion of the peripheral nerve of the trigeminal nerve

There are variety of surgical methods in treating trigeminal neuralgia. They can all be devided in two large groups: less invasive procedures and decopmressive procedures in the region of pontocerebelar angle. Peripheral neurectomy, exeresis or avulsion of peripheral branches of trigeminal nerv are methods for elderly patients with serious cardiopulmonal disturbances. We performed avulsion of peripheral branches at 58 patients, all older than 60 years. In 32 patients we did avulsion of only one of three branches of trigeminal nerv, while in 26 patients the combined avulsion of two branches was performed. There were no postoperative complications.     

Sporadic malignant nerve sheath tumour of the oculomotor nerve

Malignant peripheral nerve sheath tumours (MPNST) are exceedingly rare in an intracranial location. In this report clinical and pathological evidence for the diagnosis of a MPNST arising from of the oclumotor nerve is presented. To our knowledge this is the first such case reported in the medical literature.     

移植神经长度对膈神经移位肌皮神经疗效的影响

目的 探讨移植神经长度对膈神经移位肌皮神经治疗臂丛神经根性撕脱伤疗效的影响.方法 对2007年至2010年于我院行膈神经移位肌皮神经治疗臂丛损伤的患者进行临床随访,其中17例需要做神经移植.通过检测肱二头肌肌力与体重指数(BMI)评定手术疗效.结果 17例患者的总体有效率82.4％,移植神经长度以及BMI与屈肘功能恢复无明显相关性.结论 臂丛损伤患者尤其是全臂丛损伤患者中,膈神经移位肌皮神经的临床疗效不受移植神经长度以及BMI的影响.     

Anterior interosseous nerve transfer to the motor branch of the ulnar nerve for high ulnar nerve injuries

Primary repair of a high ulnar nerve injury results in a uniformly poor outcome as a result of the great distance between the site of injury and the innervated muscles. In this study the authors present two cases of high ulnar nerve injuries in adults. Reconstruction was performed using the distal branch of the anterior interosseous nerve, which was transferred to the distal motor branch of the ulnar nerve. This resulted in timely return of function to the ulnar-innervated intrinsic muscles of the hand, which was documented further by electromyography. For high ulnar nerve injuries, this type of nerve transfer is a much better approach than the traditional primary neurorrhaphy.     

Variant location of the musculocutaneous nerve during axillary nerve block

We present the case of a 56-year-old man who underwent axillary nerve block for a wrist arthroscopy procedure, with real-time ultrasound and peripheral nerve stimulator guidance. The ulnar nerve and radial nerve were located medial and posterior to the brachial artery, respectively. A large complex structure was noted in the position typically occupied by the median nerve. Contact of this structure with the stimulating needle produced strong biceps contraction, and slight adjustment of the needle resulted in forearm pronation. After injection of 10 mL of local anesthetic near this structure, it appeared to consist of two separate components on ultrasound. We believe that these components represented the median and musculocutaneous nerves lying together, lateral to the artery. Radial, median, ulnar, and musculocutaneous nerve block ensued, and wrist arthroscopy was carried out uneventfully. Knowledge of this anatomical variation may improve anesthesiologists' ability to provide effective axillary block.     

Numbering of the dorsal spinal nerve roots in man from the 12th thoracic nerve to the coccygeal nerve

A bilateral study for locating the dorsal root filaments of specific nerves was accomplished from the twelfth thoracic to the coccygeal level and this using 26 fetal and 8 adult specimens. After laminectomy from the thoracic to coccygeal levels, incision of the dural sac permitted visualisation of the dorsal root filaments, the successive rootlets corresponding to each segmental level (T12 to Co1 ) were counted with the aid of a binocular microscope where they penetrated the spinal medulla at the posterior sulcus. Statistical evaluation shows that for each dorsal nerve the average number of root filaments is greater on the right compared with the left. Numbering the dorsal nerve root filaments in the cephalo -caudal direction allows to assert with 99% probability up to the L5 level and with 95% probability up to the S1 level that one is at a given spinal level of the respective segmental range; caudal-cephalic direction numbering permits to affirm with 99% probability up to the S1 level and 95% probability up to the L4 level that one is at a given spinal level of the respective segmental range.     

Digital nerve grafting using the dorsal sensory branch of the ulnar nerve

The dorsal sensory branch of the ulnar nerve has been found to have the appropriate size and sufficient length for use as a digital nerve graft. This donor nerve was utilised fifteen times in twelve patients for the bridging of defects in thirteen digital nerves of the fingers. After an average follow-up of 23.2 months, only one patient failed to achieve any two point discrimination in the area supplied by the involved digital nerve. The other eleven patients had an average two point discrimination of 9.5 mm with a range of 5 to 18 mm. Painful neuroma formation or loss of hand function related to the use of the dorsal sensory branch of the ulnar nerve as a donor for digital nerve grafts was not encountered.