不同术式治疗臂丛上干根性撕脱伤的临床疗效比较
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摘要
目的目前临床上对臂丛神经上干(C56)根性撕脱伤较多采用两种术式:即Oberlin手术+副神经移位至肩胛上神经+桡神经肱三头肌长头肌支移位至腋神经前支(Oberlin等手术)及同侧C7移位修复上干+副神经移位于肩胛上神经。本文通过对比两者的手术疗效,希望能找到治疗C56损伤的最佳手术方案。
方法2000年12月～2008年2月,我们对21例C56损伤患者分别采用Oberlin等手术或同侧C7移位修复上干这两种手术方案。根据术式将其分为两组:接受Oberlin等手术的患者(Oberlin等手术组)13例,男11例,女2例;年龄17～52岁,平均年龄32.9岁。病因:颈部刀具切割伤1例,车祸伤9例,机器伤1例,重物坠肩伤1例,手术误伤1例。受伤到手术时间平均113天。接受同侧C7移位术的患者(同侧颈C7组)8例,皆为男性;年龄20～49岁,平均年龄29岁。病因:颈部刀具切割伤3例,车祸伤5例。受伤到手术时间平均52天。术后随访此21例患者肩外展、肩外旋的角度,并记录三角肌、冈下肌、屈肘肌肌力。
结果Oberlin等手术组:接受Oberlin等手术的13例患者,平均随访时间1.5年。肩外展20°-175°,平均75°,三角肌肌力达M4(MRC)者2/13例(15.4%),M3者3/13例(23.1%),其余8人为M2或以下;肩外旋0°-160°,平均59°(无效肩外旋为0°),冈下肌肌力达M4者3/13例(23.1%),M3者1/13例(7.7%),其余9人为M2或以下;肱二头肌肌力达M4以上者6/13例(46.2%),M3者6/13例(46.2%),1人为M2。所有患者术后未出现尺神经支配区感觉与肌肉的麻痹,肱三头肌肌力同术前相比无明显改变。
同侧C7组:接受同侧C7移位术的8例患者,平均随访时间1.8年。肩外展5°-180°,平均60°,三角肌肌力达M4者1/8例(12.5%),M3者1/8例(12.5%),其余6人为M2或以下;肩外旋0°-120°,平均27°(无效肩外旋为0°),冈下肌肌力达M4者1/8例(12.5%),M3者1/8例(12.5%),其余6人为M2或以下;屈肘肌肌力达M4者3/8例(37.5%),M3者2/8例(25%),其余3人为M2或以下。术前背阔肌功能与术后疗效的相互关系:4例术前背阔肌肌力正常者,在行同侧C7移位术后,屈肘肌力M4者3例,M3者1例;而4例术前背阔肌肌力减退者,仅1例屈肘肌力达到M3,其余3人为M2或以下。
结论两种手术方案均能取得较好的疗效;如能通过术前、术中检查确认患者C7功能良好,则同侧C7移位术由于切口较少,便于手术操作等优势,应被作为首选。
Objective To compare the clinical treatment outcome at patients with incomplete injury of upper trunk of brachial plexus repaired by two kinds of nerve transfer operation,in order to find the better one for C56 injury.
Methods 21 patients with C5～C6 preganglionic injury were involved between December 2000 and February 2008.13 of them had nerve transfers:a part of the ulnar nerve to the biceps motor branch(Oberlin's operation),spinal accessory nerve to the suprascapular nerve,and the nerve to the long head of the triceps to the anterior branch of the axillary nerve(Oberlin group),and the others have been undertaken transfer of ipsilateral C7 root(ipsilateral C7 group).Patients were evaluated with regard to elbow flexion,shoulder abduction,and shoulder external rotation.
Results Oberlin group:The mean shoulder abduction was 75°(20°-175°).The strength of deltoid muscle was detected:2/13(15.4%) scored M4(MRC),3/13(23.1%) scored M3,8≤M2.The range of motion of external rotation that was measured from full internal rotation averaged 59°(0°-160°).The strength of infraspinous muscle was detected:3/13(23.1%) scored M4,1/13(7.7%) scored M3,9≤M2.12/13 patients had recovered full elbow flexion:6 scored M4 and 6 scored M3,and the others scored M2. Ipsilateral C7 group:The mean shoulder abduction was 60°(5°-180°).The strength of deltoid muscle was detected:1/8(12.5%) scored M4,1/8(12.5%) scored M3,6≤M2. The range of motion of external rotation that was measured from full internal rotation averaged 27°(0°-120°).The strength of infraspinous muscle was detected:1/8(12.5%) scored M4,1/8(12.5%) scored M3,6≤M2.5/8 patients had recovered full elbow flexion:3 scored M4 and 2 scored M3,and the others scored M2.For 4 patients with normal muscle strength of latissimus dorsi muscle before operation,restoration of elbow flexion was obtained after transfer of ipsilateral C7 root to the upper trunk.However,for the other 4 patients with decrease in absent for muscle power of latissimus dorsi,1 patient was found recovey of elbow flexion after operation.
Conclusions Two kinds of operations can both reach good results;however,if C7 root could be confirmed fine,transfer of ipsilateral C7 root should be preferred because it only requests one incision and is more convenient for operator.
方法2000年12月～2008年2月,我们对21例C56损伤患者分别采用Oberlin等手术或同侧C7移位修复上干这两种手术方案。根据术式将其分为两组:接受Oberlin等手术的患者(Oberlin等手术组)13例,男11例,女2例;年龄17～52岁,平均年龄32.9岁。病因:颈部刀具切割伤1例,车祸伤9例,机器伤1例,重物坠肩伤1例,手术误伤1例。受伤到手术时间平均113天。接受同侧C7移位术的患者(同侧颈C7组)8例,皆为男性;年龄20～49岁,平均年龄29岁。病因:颈部刀具切割伤3例,车祸伤5例。受伤到手术时间平均52天。术后随访此21例患者肩外展、肩外旋的角度,并记录三角肌、冈下肌、屈肘肌肌力。
结果Oberlin等手术组:接受Oberlin等手术的13例患者,平均随访时间1.5年。肩外展20°-175°,平均75°,三角肌肌力达M4(MRC)者2/13例(15.4%),M3者3/13例(23.1%),其余8人为M2或以下;肩外旋0°-160°,平均59°(无效肩外旋为0°),冈下肌肌力达M4者3/13例(23.1%),M3者1/13例(7.7%),其余9人为M2或以下;肱二头肌肌力达M4以上者6/13例(46.2%),M3者6/13例(46.2%),1人为M2。所有患者术后未出现尺神经支配区感觉与肌肉的麻痹,肱三头肌肌力同术前相比无明显改变。
同侧C7组:接受同侧C7移位术的8例患者,平均随访时间1.8年。肩外展5°-180°,平均60°,三角肌肌力达M4者1/8例(12.5%),M3者1/8例(12.5%),其余6人为M2或以下;肩外旋0°-120°,平均27°(无效肩外旋为0°),冈下肌肌力达M4者1/8例(12.5%),M3者1/8例(12.5%),其余6人为M2或以下;屈肘肌肌力达M4者3/8例(37.5%),M3者2/8例(25%),其余3人为M2或以下。术前背阔肌功能与术后疗效的相互关系:4例术前背阔肌肌力正常者,在行同侧C7移位术后,屈肘肌力M4者3例,M3者1例;而4例术前背阔肌肌力减退者,仅1例屈肘肌力达到M3,其余3人为M2或以下。
结论两种手术方案均能取得较好的疗效;如能通过术前、术中检查确认患者C7功能良好,则同侧C7移位术由于切口较少,便于手术操作等优势,应被作为首选。
Objective To compare the clinical treatment outcome at patients with incomplete injury of upper trunk of brachial plexus repaired by two kinds of nerve transfer operation,in order to find the better one for C56 injury.
Methods 21 patients with C5～C6 preganglionic injury were involved between December 2000 and February 2008.13 of them had nerve transfers:a part of the ulnar nerve to the biceps motor branch(Oberlin's operation),spinal accessory nerve to the suprascapular nerve,and the nerve to the long head of the triceps to the anterior branch of the axillary nerve(Oberlin group),and the others have been undertaken transfer of ipsilateral C7 root(ipsilateral C7 group).Patients were evaluated with regard to elbow flexion,shoulder abduction,and shoulder external rotation.
Results Oberlin group:The mean shoulder abduction was 75°(20°-175°).The strength of deltoid muscle was detected:2/13(15.4%) scored M4(MRC),3/13(23.1%) scored M3,8≤M2.The range of motion of external rotation that was measured from full internal rotation averaged 59°(0°-160°).The strength of infraspinous muscle was detected:3/13(23.1%) scored M4,1/13(7.7%) scored M3,9≤M2.12/13 patients had recovered full elbow flexion:6 scored M4 and 6 scored M3,and the others scored M2. Ipsilateral C7 group:The mean shoulder abduction was 60°(5°-180°).The strength of deltoid muscle was detected:1/8(12.5%) scored M4,1/8(12.5%) scored M3,6≤M2. The range of motion of external rotation that was measured from full internal rotation averaged 27°(0°-120°).The strength of infraspinous muscle was detected:1/8(12.5%) scored M4,1/8(12.5%) scored M3,6≤M2.5/8 patients had recovered full elbow flexion:3 scored M4 and 2 scored M3,and the others scored M2.For 4 patients with normal muscle strength of latissimus dorsi muscle before operation,restoration of elbow flexion was obtained after transfer of ipsilateral C7 root to the upper trunk.However,for the other 4 patients with decrease in absent for muscle power of latissimus dorsi,1 patient was found recovey of elbow flexion after operation.
Conclusions Two kinds of operations can both reach good results;however,if C7 root could be confirmed fine,transfer of ipsilateral C7 root should be preferred because it only requests one incision and is more convenient for operator.
引文
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[2]Leechavengvongs S,Witoonchart K,Uerpairojkit C,Thuvasethakul P,Malungpaishrope K.Combined nerve transfers for C5 and C6 brachial plexus avulsion injury.J Hand Surg[Am].2006 Feb;31(2):183-9.
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[4]徐建光,沈丽英,胡韶楠.不同术式切断C7神经根后对神经支配肌影响的实验研究.中华手外科杂志,1999,15:245-247.
[5]Oberlin C,Beal D,Leechavengvongs S,Salon A,Dauge MC,Sarcy JJ.Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6avulsion of the brachial plexus:anatomical study and report of four cases.J Hand Surg[Am].1994;19:232-7.
[6]Sungpet A,Suphachatwong C,Kawinwonggowit V,Patradul A.Transfer of a single fascicle from the ulnar nerve to the biceps muscle after avulsions of upper roots of the brachial plexus.J Hand Surg[Br].2000Aug;25(4):325-8.
[7]Allieu Y,Privat JM,Bonnel F:[Neurotization with the spinal nerve (nervus accessorius) in avulsions of roots of the brachialplexus.]Neurochirurgie 28:115-120,1982(Fre)
[8]Suzuki K,Doi K,Hattori Y,Pagsaligan JM.Long-term results of spinal accessory nerve transfer to the suprascapular nerve in upper-type paralysis of brachial plexus injury.J Reconstr Microsurg.2007Aug;23(6):295-9.
[9]Venkatramani H,Bhardwaj P,Faruquee SR,Sabapathy RS.Functional outcome of nerve transfer for restoration of shoulder and elbow function in upper brachial plexus injury.J Brachial Plex Peripher Nerve Inj.2008May 27;3(1):15.
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[2]Leechavengvongs S,Witoonchart K,Uerpairojkit C,Thuvasethakul P,Malungpaishrope K.Combined nerve transfers for C5 and C6 brachial plexus avulsion injury.J Hand Surg[Am].2006 Feb;31(2):183-9.
[3]Gu YD,Cai PQ,Xu F,et al.Clinical application of ipsilateral C7nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus.Microsurgery,2003,23(2):105-108.
[4]徐建光,沈丽英,胡韶楠.不同术式切断C7神经根后对神经支配肌影响的实验研究.中华手外科杂志,1999,15:245-247.
[5]Oberlin C,Beal D,Leechavengvongs S,Salon A,Dauge MC,Sarcy JJ.Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6avulsion of the brachial plexus:anatomical study and report of four cases.J Hand Surg[Am].1994;19:232-7.
[6]Sungpet A,Suphachatwong C,Kawinwonggowit V,Patradul A.Transfer of a single fascicle from the ulnar nerve to the biceps muscle after avulsions of upper roots of the brachial plexus.J Hand Surg[Br].2000Aug;25(4):325-8.
[7]Allieu Y,Privat JM,Bonnel F:[Neurotization with the spinal nerve (nervus accessorius) in avulsions of roots of the brachialplexus.]Neurochirurgie 28:115-120,1982(Fre)
[8]Suzuki K,Doi K,Hattori Y,Pagsaligan JM.Long-term results of spinal accessory nerve transfer to the suprascapular nerve in upper-type paralysis of brachial plexus injury.J Reconstr Microsurg.2007Aug;23(6):295-9.
[9]Venkatramani H,Bhardwaj P,Faruquee SR,Sabapathy RS.Functional outcome of nerve transfer for restoration of shoulder and elbow function in upper brachial plexus injury.J Brachial Plex Peripher Nerve Inj.2008May 27;3(1):15.
[10]Witoonchart K,Leechavengvongs S,Uerpairojkit C,Thuvasethakul P,Wongnopsuwan V.Nerve transfer to deltoid muscle using the nerve to the long head of the triceps,part Ⅰ:an anatomic feasibility study.J Hand Surg[Am].2003 Jul;28(4):628-32.
[11]T(o|¨)t(o|¨)sy de Zepetnek JE,Zung HV,Erdebil S,Gordon T.Innervation ratio is an important determinant of force in normal and reinnervated rat tibialis anterior muscles.J Neurophysiol.1992 May;67(5):1385-403.
[12]Leechavengvongs S,Witoonchart K,Uerpairojkit C,Thuvasethakul P.Nerve transfer to deltoid muscle using the nerve to the long head of the triceps,part Ⅱ:a report of 7 cases.J Hand Surg[Am].2003Jul;28(4):633-8.
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