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。

A preliminary report on full length phrenic nerve harvesting under thoracoscope and the phrenic nerve transfer for hand function reconstruction in total root avulsion of brachial plexus

Objective To explore the possibility to harvest full length phrenic nerve under thoracoscope and the effects of phrenic nerve transfer on hand function reconstruction in the total root avulsion of brachial plexus. Methods Phrenic nerve transfer was applied in 3 cases of the total root avulsion of brachial plexus. Full length phrenic nerve was mobilized with its vascular tissue pedicle in the thoracic cavity under thoracoscope and harvested till the phrenic nerve end near the phrenic muscle. 13 to 22cm phrenic nerves were withdrawn out of the second intercostal space to the proximal level of arm. In two cases, transfered phrenic nerve was anastomosed with the anteromedial part of the ulnar as motor drive nerve. In one case, phrenic nerve was transfered to be anastomosed with the obturator nerve anterior branch of the translated gracilis muscle for reconstruction of finger and thumb flexion. Results Two patients with the phrenic nerve and the motor branch of third to sixth intercostal nerves transfered to the ulnar nerve, accepted the oral administration of immunosuppresant FK506. The hand intrinsic muscles were examined by electromyogram and regenerated electric potentials were found by the 12 months postoperatively. In one of them, the hand intrinsic muscle contraction started by the 15 months after the phrenic nerve transfer. In another female case, contraction of the translated gracilis muscles for reconstruction of finger and thumb flexion started by 7 months after the phrenic nerve transfer. She was followed up 12 months and her muscle strength was M3. Conclusions The full length phrenic nerve harvested under thoracoscope can be applied as motor drive nerve transfer in the treatment of total root avulsion of brachial plexus. The function of the finger and thumb flexion can be reconstructed effectively in a short time. There are signs that the hand intrinsic muscle may also be reinnervated and start restoring its contraction function.