基于二次成像技术标志点获取和自动配准的长段周围神经功能束三维可视化关键技术研究

目的探讨四肢周围神经功能束三维可视化重建过程中的关键技术问题及解决方法,并验证其可行性。方法取自愿捐献新鲜成人尸体右上臂20cm尺神经标本。以4根成年女性头发作为标志线,连续横断面冰冻切片,厚15μm,层距0.5mm,共400张切片,行乙酰胆碱酯酶(acetylcholinesterase,AchE)染色;采用二次成像技术,以配置MSHTO MD90显微数码成像装置的Olympus Z61型体视显微镜于AchE染色前、后分别获取同一切片的2张全景图像,通过Photoshop图像处理软件图层叠加进行图像处理,获取含4个完整定位标志点的神经断面二维全景图像;以优化最小二乘支持向量机方法作为分类器自动识别处理图像,并利用空间变换方法实现自动配准,结合人工辅助获取功能束轮廓,通过Amira 4.1医学三维重建软件进行长段尺神经功能束三维重建,评估重建逆向还原效果。结果利用二次成像Photoshop图像处理软件处理同一张切片染色前、后的图像,图像轮廓吻合度良好,合成图像获得的标志点定位精确,操作简便快捷。优化最小二乘支持向量机方法识别精度高,误差率为8.250%;三维模型可直观观察神经内部不同性质功能束交叉融合的变化,其任意水平切割逆向还原基本吻合。结论基于二次成像技术和Photoshop图像处理软件图层处理技术的计算机自动配准可应用于长段周围神经的三维可视化重建,重建快捷,效果较好。     

臂丛神经显微结构的计算机三维重建

目的：重建臂丛神经的外轮廓及其内部神经束的精细三维行径，同时探索一种臂丛神经显微结构计算机三维重建的实用方法。方法：取健康成年尸体的臂丛神经标本2例(从神经根管出口至正中神经交叉处，平均长20cm)，作好标记，以女性头发作为定位线，采用连续组织切片后胆碱脂酶组织化学染色，高分辨率数码摄像系统获取二维数码信息后对臂丛神经显微结构进行三维重建。结果：三维重建真实地再现臂丛神经的三维立体结构及其内部各神经束的三维立体行径，并可显示臂丛神经中神经束的任意断面及其全长的解剖结构与相互关系，形象地展示臂丛神经内部神经束的复杂重组过程。重建结构均能单独或搭配显示，还能任意角度显示：在臂丛的五个根中，C6-C8内部神经束数目较C5、T1多。在C6-C8中，又以C7神经根内部神经束数目最多。结论：臂丛神经内部神经束结构相当复杂，相互间不断交叉重组，形成独特的神经束网络结构。臂丛神经显微结构三维重建由于采用了较为精确的定位材料和方法，三维图像显示效果较好，是一种较为实用的方法。     

周围神经功能束三维可视化中完整信息的二维全景图像获取

目的 探讨用于周围神经功能束三维可视化重建的带完整信息的神经断面二维全景图像获取的关键技术.方法 新鲜成人截肢腓总神经及尺神经标本各一段,以4根成年女性头发作为标志线,连续冰冻切片,乙酰胆碱酯酶组织化学染色:分别以100倍光学显微镜下分区摄影后拼接及光学扫描仪和体视全景数码成像仪一次性获取全景图像,观察染色前后人发标志点贴片情况,比较不同全景图像效果;以数码全景成像仪获取染色前、后同一切片的全景图像,通过Photoshop CS2处理获取含4个完整定位标志点的神经断面二维全景图像.结果 体视全景数码成像仪一次全景成像精确,功能束易于鉴别,基本具备高倍光学显微镜下拼接图像的特点,且获取简单快捷;二次成像Photoshop合成图像功能束轮廓吻合良好,标志点定位精确,操作简单快捷.结论 结合高像素体视全景数码成像装置一次性全景数码成像、二次成像技术和Photoshop图层处理技术,可用于海量获取带完整信息的神经断面二维全景图像进行三维重建,提高重建效率及精度,可为临床上周围神经损伤修复方式的选择以及组织工程神经的构建提供直观的解剖依据.     

人体正中神经内部显微结构的三维重建与可视化研究

[目的]探索应用计算机处理人体正中神经全长连续冰冻组织切片的二维图像信息,开发3DNerve神经三维可视化系统,重建人体正中神经内部显微结构并实现三维可视化.[方法]取新鲜人尸正中神经标本1例,以人长发为定位线、OCT包埋剂包埋、采用连续冰冻组织切片、乙酰胆碱脂酶组织化学法染色、高分辨率扫描仪获取二维数码信息后、应用3DNerve对正中神经显微结构进行三维重建.[结果]正中神经在不同断面神经束的数目、位置以及神经束内神经纤维的性质变化较大.连续断面观察显示各神经束均是混合束,未见有纯粹的感觉束或运动束的出现.通过3D Nerve可在任意断面放大的视野下观察正中神经的显微结构,追踪各神经束在正中神经内的立体行径.从而动态地展示正中神经内部神经束的复杂结构.[结论]重建的正中神经三维可视化真实地再现正中神经干全长及其内部各神经束和束组的三维立体结构,可为临床修复正中神经损伤提供精确的断层解剖图像.     

面神经的角神经三维可视化研究

目的 通过三维可视化技术,验证前期解剖学研究结果,并为失神经支配手术提供一定的理论依据.方法 取自愿捐献的甲醛固定的成人尸头,切取内眦角内侧全层软组织长3 cm、宽1 cm,以皮肤表面2平行刀痕为定位线,连续横断石蜡切片,片厚10 μm,切片间距0.25 mm,共切取120张切片.采用HE组织化学染色,高分辨率扫描仪获取二维数码图像后进行三维重建.结果 ①真实再现了角神经的三维立体结构及角神经与内眦动静脉的三维立体行径,且重建结构不但能单独或搭配显示,并可从任意角度显示.②证实了角神经显微解剖学研究的正确性.③角神经毗邻关系的三维重建技术可以应用到临床.结论 基于组织学和计算机技术,可以三维重建角神经的毗邻关系,为角神经的失神经支配手术提供更加准确的可行性依据.     

人体尺神经显微结构三维可视化研究

目的 将人体尺神经行连续冰冻组织切片,经染色、扫描后获取尺神经连续断面二维图像信息,通过3D Nerve三维可视化软件系统勾画出完整的尺神经干三维解剖图谱.方法 取自愿捐献死亡3 h内38岁男性左侧尺神经全长(自臂丛内侧束至腕横韧带)标本1例,长约50cm,经定位、包埋、连续冰冻组织切片、乙酰胆碱脂酶组织化学染色,获取尺神经连续二维图像信息,应用3D Nerve三维可视化软件系统对尺神经内部结构进行三维重建.结果 尺神经在不同断面神经束的数量、位置及内部神经纤维的性质均有变化.应用尺神经3D Nerve三维可视化软件系统可在任意断面、任意角度观察尺神经内部的显微结构,追踪各神经束的立体行径,动态地展示尺神经内部神经束的复杂结构.结论 尺神经的3D Nerve三维可视化软件系统可真实地再现尺神经干全长及其内部各神经束的三维立体行径,为医学教学与临床修复尺神经损伤提供精确的神经任意断面三维立体解剖图像,有助于提高神经修复的疗效.     

尺神经功能束组走行模式的三维重建

目的 在组织学切片基础上，应用计算机三维成像技术，重建尺神经功能束组走行的三维图象，以期指导临床臂丛与尺神经损伤后的显微修复，为臂丛神经根性撕脱伤后手内肌功能的恢复提供必要的形态学基础。方法 制作尺神经连续断面组织切片，AchE组织化学染色，将切片转化为数字图象，人工判断功能束组性质，图形处理软件配准后，采用体数据场轮廓线表面重建方法，应用VC语言编制三维图象存储构建程序，在程序中重建尺神经功能束组走行的三维图象。结果 在程序中实现了尺神经功能束组走行的三维重建。对重建的各神经功能束的外表面进行三维显示，实现人机交互的任意三维旋转、任意断面切割。通过对感兴趣的显示对象(神经干和各束组)的选择，可以在同一三维空间同时显示任意神经功能束组的立体结构，结果反映出它们的在空问位置上的结构、毗邻关系和走行。通过与显微解剖结果对照，发现其显示图象与解剖结果基本吻合。结论 构建的尺神经功能束组的三维图象，能较真实的反映束组的走行分布情况，对临床医生理解神经内部结构，设计手术方案和在术中对照束组的分布方位调整手术方法有积极的作用。     

正中神经显微结构三维可视化研究

目的 将正中神经干全长作连续冰冻组织切片,采集系列切片的神经二维信息,开发3D Nerve可视化系统,实现正中神经内部显微结构的三维可视化.方法 取新鲜成人尸体正中神经标本,作好定位并标记、OCT包埋、采用连续冰冻组织切片、染色、用扫描仪获取切片染色前后的连续的正中神经断面二维信息数据库,开发并应用3D Nerve可视化系统.结果 通过3D Nerve可视化系统观察发现,在不同断面正中神经神经束的数量、位置以及神经束内神经纤维的性质变化较大.在该系统中可在任意断面放大的视野下观察正中神经的显微结构,追踪各神经束在正中神经内的立体行径;重建的正中神经能在空间位置上绕任意轴作任意角度旋转,便于从不同的角度对各神经束的形态、空间位置及相互毗邻关系进行观察,从而动态地展示正中神经内部的复杂结构.结论 正中神经3D Nerve可视化系统真实地再现正中神经干全长及其内部各神经束和束组的三维立体结构,可为临床修复正中神经损伤提供精确的断层解剖图像.     

胫神经近端肌支转位修复腓深神经的可行性研究

目的探讨胫神经近端肌支转位修复腓深神经的可行性,为手术治疗高位腓总神经损伤提供解剖学依据。方法取8具新鲜冷冻尸体双下肢标本以及由3例高位截肢术患者自愿捐赠的新鲜下肢标本(左侧2具、右侧1具),解剖腘窝部各神经,测量胫神经3条运动分支(比目鱼肌支和腓肠肌内、外侧头肌支)长度、直径及其发出点至腓总神经分支点的距离,腓深神经无损伤分离束长度及直径,评价各条运动支与腓深神经束行无张力吻合的可行性。切取以上神经分支行HE及乙酰胆碱酯酶染色观察,计数神经纤维。结果大体解剖观察示,腓肠肌内、外侧头肌支及比目鱼肌支发出点至腓总神经分支点之间的距离分别为:(71.44±2.76)、(75.66±3.20)、(67.50±3.22)mm;以上各分支以及腓深神经无损伤分离束长度分别为(31.09±2.01)、(38.44±2.38)、(59.18±2.72)、(66.44±2.85)mm,直径分别为(1.72±0.08)、(1.88±0.08)、(2.10±0.10)、(2.14±0.12)mm。组织学观察示腓肠肌内、外侧头肌支、比目鱼肌支、腓深神经无损伤分离束运动神经纤维数分别为(2 032±58)、(2 186±24)、(3 102±85)、(3 512±112)根。比目鱼肌支直径以及运动神经纤维数与腓深神经无损伤分离束相似(P0.05),腓肠肌内、外侧头肌支以上指标均显著低于腓深神经无损伤分离束(P0.05)。结论胫神经腘窝部3条运动神经分支均可直接转位吻合腓深神经无损伤分离束修复高位腓总神经束损伤,其中比目鱼肌支为首选供体神经。     

应用micro-CT实现兔坐骨神经显微三维结构可视化研究

目的探讨通过micro-CT扫描新西兰大白兔坐骨神经标本,利用三维可视化软件Mimics17.0重建兔坐骨神经内部显微三维结构。方法取6只成年新西兰大白兔坐骨神经组织标本分成A、B组(n=3),分别用1%、5%Lugol液对两组标本染色,于染色0.5、1.0、1.5、2.0、2.5、3.0、3.5 h时,行光镜及micro-CT观察两组标本的显像变化,将显像良好的micro-CT图像序列导入Mimics软件,采用三维重建工具重建兔坐骨神经神经显微三维结构。结果 A组标本在染色2.5 h、B组标本在染色1.5 h时,经光镜及micro-CT观察可获得较为清晰的显微三维结构图像。图像显示新西兰大白兔的坐骨神经主要分3组神经束,且各神经束立体行径相对固定,Mimics软件测量各神经束横截面积分别为(0.425±0.013)、(0.038±0.007)、(0.242±0.026)mm~2,生成的数字化三维模型可在任意横断面观察坐骨神经内部显微结构。结论应用micro-CT可清晰真实显示兔坐骨神经显微三维结构,为建立大样本量周围神经显微解剖学数据库提供了可靠方法。     

鼻唇部连续组织切片的计算机三维重建

目的:通过获取鼻唇部连续组织切片图像,初步建立可视化虚拟三维唇鼻模型。方法:将鼻唇部组织标本行连续切片,染色后用数码相机获取切片图像数据,进行三维重建及重建后可视化应用。结果:成功探索大块组织标本石蜡切片的制作方法,重建出的鼻唇部数字化模型有良好的展示特性并可进行简单的可视化应用。结论:运用三维重建软件将连续组织切片进行三维重建及可视化应用是可行的。     

Intraneural Ganglion of the Superficial Peroneal Nerve: A Case Report

Ganglia affecting the peripheral nerves of the foot and ankle are rare. The most frequent location of occurrence is the common peroneal nerve at the level of the fibular neck. We report the case of an intraneural ganglion of the superficial peroneal nerve and its branches. Although there have been many previous reports of intraneural ganglion involvement with the common peroneal nerve, deep peroneal nerve, sural nerve, and the posterior tibial nerve, to our knowledge, this is the first reported occurrence of an intraneural ganglion distinctly localized to the superficial peroneal nerve and its branches. The presumptive diagnosis was made preoperatively using magnetic resonance imaging, and then confirmed postoperatively by pathologic examination. Despite the use of operative magnification, it was impossible to remove all of the cyst elements within the nerve trunk, because the nerve fascicles were intimately intertwined. Therefore, complete resection of the common trunk of the superficial peroneal nerve and its terminal branches was performed, and the proximal stump was buried in a hole in the distal fibula. Two years after the surgery, the patient was pain free and asymptomatic except for cutaneous anesthesia in the distribution of the superficial peroneal nerve.     

Successful management of foot drop by nerve transfers to the deep peroneal nerve

Traumatic damage to the common peroneal nerve due to sharp injury, gunshot wound, sciatic nerve tumor, radiculopathy, or hip replacement surgery may result in foot drop. We present an alternative strategy for reanimation of foot drop following deep peroneal nerve palsy, successfully restoring voluntary movement. Fourteen consecutive patients with deep peroneal nerve injuries resulting in foot drop underwent nerve transfer of functional fascicles of either the superficial peroneal nerve or of the tibial nerve as donor for deep peroneal-innervated muscle groups. Eleven cases had successful restoration of British motor grade 3+ to 4+/5 ankle dorsiflexion, one case had restoration of grade 3 ankle dorsiflexion, and two cases had no restoration of dorsiflexion. Nerve transfer to the deep peroneal nerve is a feasible and effective method of treating deep peroneal nerve injuries of less than 1-year duration.     

Structural and functional regeneration of muscle-related axons after transection and repair of the rat sciatic nerve using nonvascularized autologous fascia as a barrier between tibial and peroneal nerve fascicles

Aberrant reinnervation of target organs caused by misdirected axonal growth at the repair site is a major reason for the poor functional outcome usually seen after peripheral nerve transection and repair. This study investigates whether the criss-crossing of regenerating rat sciatic nerve axons between tibial and peroneal nerve fascicles can be reduced by using non-vascularized autologous fascia as a barrier. The left sciatic nerve was transected and repaired at midthigh as follows: epineurialy sutures (Group A); fascicular repair of tibial and peroneal nerve fascicles (Group B); fascicular repair of tibial and peroneal nerve fascicles separating the two fascicles by non-vascularized autologous fascia (Group C). In the control Group D, only the left tibial fascicle was transected and repaired. Five months postoperatively, the outcome of regeneration was evaluated by histology, by retrograde tracing, and by assessment of the contraction force of the gastrocnemius and tibial anterior muscles. The tracing experiments showed that muscle reinnervation was less abnormal in Group C than in Groups A and B. However, muscle contraction force was not better in Group C than in Groups A and B. With respect to the peroneal nerve innervated muscle, the contraction force in Group C was significantly lower than in Group B. The histologic picture indicated that this inferior result in Group C was due to nerve compression caused by fibrotic scar tissue at the site of the fascia graft. Results of this study show that a non-vascularized autologous fascial graft used as a barrier between two sutured nerve fascicles in adjacency reduces criss-crossing of regenerating axons between the fascicles, but causes significant nerve compression.     

Three‐dimensional reconstruction and visualization of the median nerve from serial tissue sections

The purpose of this study was to definitively implement the three‐dimensional visualization of sensory and motor fascicles in the human median nerve by means of acetylcholinesterase (AChe) histochemical staining and under the assistance of the computer technology. One fresh human median nerve was harvested from a male adult cadaver. The median nerve was fixed at a special holder. Then, the whole holder was embedded and rapidly frozen in the liquid nitrogen. The processed median nerve was then cut coronally every 100 μm at a 20 μm thickness along its long axis in a sliding freezing microtome. The total number of sections was 4,650 slices. All sections were stained with the AChe histochemical method. The stained sections were scanned and saved as Joint Photographic Experts Group files. These images with positively and negatively stained sections were acquired to an Intel dual Pentium computer. The Adobe Photoshop CS2 software was used to compare the reference points of images before and after staining. The two‐dimensional intraneural microstructure database of median nerve was then acquired. A software of 3D nerve visualization system was developed. With the 3D nerve visualization system, the 3D visualization result of intraneural microstructure of median nerve was created. The findings may provide more accurate and detailed anatomic information for nerve repairs, specifically for the fascicular nerve repairs. The 3D nerve visualization technique may have potential for future studies of topography of peripheral nerve. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Peroneal intraneural ganglia: the importance of the articular branch. A unifying theory

OBJECT: Based on a large multicenter experience and a review of the literature, the authors propose a unifying theory to explain an articular origin of peroneal intraneural ganglia. They believe that this unifying theory explains certain intriguing, but poorly understood findings in the literature, including the proximity of the cyst to the joint, the unusual preferential deep peroneal nerve (DPN) deficit, the absence of a pure superficial peroneal nerve (SPN) involvement, the finding of a pedicle in 40% of cases, and the high (10-20%) recurrence rate. METHODS: The authors believe that peroneal intraneural lesions are derived from the superior tibiofibular joint and communicate from it via a one-way valve. Given access to the articular branch, the cyst typically dissects proximally by the path of least resistance within the epineurium and up the DPN and the DPN component of the common peroneal nerve (CPN) before compressing nearby SPN fascicles. The authors present objective evidence based on anatomical, clinical, imaging, operative, and histological data that support this unifying theory. CONCLUSIONS: The predictable clinical presentation, electrical studies, imaging characteristics, operative observations, and histological findings regarding peroneal intraneural ganglia can be understood in terms of their origin from the superior tibiofibular joint, the anatomy of the articular branch, and the internal topography of the peroneal nerve that the cyst invades. Understanding the controversial pathogenesis of these cysts will enable surgeons to perform operations based on the pathoanatomy of the articular branch of the CPN and the superior tibiofibular joint, which will ultimately improve clinical results.     

Histochemical staining of nerve endings as an aid to free muscle transplantation.

Histochemical staining techniques that identify intact motor nerve fascicles are available to aid free muscle transplantation. Cholinesterase activity of myelinated axons can be identified by Karnovsky and Roots's technique. Axon viability can be assessed based on the presence of axoplasmic enzyme activity. By reacting serial sections for cholinesterase activity and carbonic anhydrase activity, which labels sensory axons, an accurate cross-sectional map of regenerating or functional sensory and motor nerve fibers can be constructed. Resolving the motor and sensory identities of fascicles in a mixed peripheral nerve should lead to more precise coaptation of recipient motor fibers to the motor nerve of the transferred muscle and enhance reinnervation.     

The effect of polypropylene mesh on ilioinguinal nerve in open mesh repair of groin hernia

OBJECTIVES: Repair of groin hernia is one of the most common operations performed by general surgeons, and mesh repair methods have gained wide acceptance. Chronic pain is the most serious long-term complication that can occur after repair of groin hernia. The development of chronic pain after herniorraphy has been attributed to several mechanisms, including damage to sensory nerves and mesh inguinodynia. MATERIAL AND METHODS: Twenty-four rabbits underwent bilateral inguinal dissection and synthetic polypropylene mesh laid on one side. Bilateral inguinal dissection was performed again after 3 months, and samples of nerve tissue were taken from both sides for histological examination. RESULTS: Light microscopic examination of the sections of control group peripheral nerves were in normal appearance, but the nerve fascicles in experimental group operated with mesh showed axonal dilation and mild-to-severe loss of myelinated axons. Examination of semi-thin and ultra-thin sections in control group peripheral nerve fascicles showed normal morphology. Ultrastructural nerve morphology in experimental group operated with mesh exhibited endoneurinal edema with thickening of both endoneurium and perineurium, causing separation of nerve fibers. Myelin sheaths of fibers showed an ondulation toward the axoplasm and the endoneurium. Separation of myelin layers from each other as a prominent feature of myelin degeneration in nerve fibers was also observed. Axoplasms exhibited edema and crystallization. CONCLUSIONS: The light microscopic and ultrastructural changes seen in peripheral nerves in experimental group operated with mesh suggested that mechanical compression of peripheral nerves is associated with myelin degeneration, endoneurinal and perineurial edema, fibrosis, axonal loss, and edema that may cause peripheral neuropathy. Chronic groin pain after hernia repair can be possibly caused by the entrapment of peripheral nerves in the scar tissue formed by the mesh.