椎管内修复臂丛神经损伤的解剖及临床应用研究

目的观察通过打开椎管找到残存的臂丛神经根并进行神经修复的可行性。方法甲醛溶液固定的成人尸体标本15具30侧，测量C5-T1，神经前根椎间孔段的直径、长度和有髓神经纤维计数。选择5例臂丛神经损伤患者，2例为椎孔处刀刺伤，3例为闭合性创伤。自受伤到椎管内探查的时间为3-6个月，平均4个月。CTM显示部分已损伤的神经根其椎管内神经前后根仍存在，而锁骨上臂丛神经探查在椎间孔外找不到相应的具有正常结构的神经根近端，通过打开椎管将椎管内残存的神经根用腓肠神经桥接进行神经修复。结果C5-T1，神经前根的有髓神经纤维数目为4000-6000根，椎间孔段的长度为11～14mm，外径为1．2～1．5mm。5例患者的椎管内均找到了具有正常结构的神经根近端，其中C5神经根3例，C5、C6神经根1例，C7神经根1例。C5修复肩胛上神经和C5神经远端各1例，C5修复正中神经内侧头1例，C7修复内侧束1例，C5、C6分别修复上干后股、肌皮神经1例。术后随访38--46个月，平均42个月。5例患者其修复神经所支配肌肉的肌力分别达3-4级。结论对于神经根在椎间孔处断裂的臂丛神经损伤，可通过打开椎管找到损伤神经根的近端，为臂丛神经根性损伤的修复提供理想的动力神经源，有利于臂丛神经治疗效果的提高。

The anatomical and clinical study of intradural repair of brachial plexus injury

Objective This study was to observe the feasibility of using the proximal spinal nerve root stumps which were ruptured at the level of intradural and exposed by laminectomy and partial facetectomy as donor sites for grafts to repair brachial plexus nerve injury. Methods The diameter, length and the amount of myelinated nerve fiber of the anterior spinal nerve roots of brachial plexus located at the intraforaminal portion were measured in 15 adult preserved cadavers. 5 clinical cases with brachial plexus injury including 2 cases injured close to the foraminal exit by knife and 3 cases caused by traumatic avulsion were diagnosed as at least one of the C 5 to C 7 nerve roots ruptured at the intraforaminal level proved by computer tomography myelography (CTM) examination preoperatively and classic supraclavicle exploring operation. The proximal spinal nerve root stumps ruptured at the level of intraforaminal were exposed and used as donor nerve, which was repaired by sural nerve graft to the recipient nerve. Results The diameter, length and the amount of myelin of the anterior spinal nerve roots of C 5 to T1 located at the intraforaminal portion were 1.2-1.5 mm, 11-14 mm and 4000-6000 respectively. The anterior nerve roots of C 5 were used as donor nerve to repair the suprascapular nerve in 1 case, to repair the distal of C 5 nerve root in 1 case and to repair the medial part of median nerve in 1 case; the anterior nerve roots of C 7 was used as donor nerve to repair the medial cord in 1 cases. The anterior nerve roots of C 5 and C 6 nerve were used as donor nerve to repair the posterior division of superior trunk and muscutaneous nerve respectively in 1 case. After 38-46 months with an average of 42 months follow up , the muscle strength of the target muscle recovered to 3-4 grade (MRC). Conclusion When the spinal nerve roots were ruptured at the level of intraforaminal in patients with brachial plexus injury, the proximal spinal nerve root stumps which were exposed by laminectomy and partial facetectomy can be used as donor nerves for grafts to repair the injured brachial plexus nerve.