【作者】 刘叶；

【导师】 贺长清；

【作者基本信息】 郑州大学 ， 骨科学， 2003， 硕士

【摘要】 臂丛是上肢神经的总起源，一旦损伤，致残率高。特别是臂丛根性撕脱伤或近椎孔的节后损伤，损伤部位接近脊髓或位于脊髓表面，这种损伤不仅易使神经元死亡或因胞浆内尼氏体、线粒体的减少而致其功能低下，而且损伤后无法进行对端吻接，故预后更差。对这类损伤目前较好的治疗方法是利用健康的动力神经移位于损伤神经的远断端以重建其功能。膈神经由于含运动纤维多以及有日夜不息的高频率大振幅的自发性电活动而被公认为是最佳可供移位的神经。 臂丛神经损伤后，患肢肘关节的控制应放在修复的首位。肱二头肌是屈肘的主要肌肉，它主要受肌皮神经的支配，故目前临床上多用膈神经移位至肌皮神经以恢复患者的屈肘功能。常规的移位方法是将膈神经通过一段移植神经桥接到肌皮神经主干。由于神经移植不仅使手术繁琐复杂，而且其对神经轴索再生会产生不良影响，从而使肱二头肌功能恢复不佳。为了提高手术疗效，一些学者开始对肌皮神经在臂丛干股部的位置进行解剖及免疫组化研究，证实在臂丛上干前股，肌皮神经较为集中于其前外侧束，认为将膈神经移位于此位置对恢复患者的屈肘功能是可行的。由于此种方法使神经移位距离缩短，故不再需要移植神经的桥接。这种新的膈神经移位方式临床应用少，对其尚缺乏全面的认识。我科近年来开始将本术式应用于临床。 目的：通过观察膈神经移位至臂丛上干前股术的疗效，并将其与常规的膈神经桥接移位术的疗效进行对比，探讨这种新的膈神经移位术式的优点并分析影响郑州大学2003年硕士毕业论文肠神经移位至臂丛上干前股治疗臂丛神经损伤的临床研究其疗效的可能因素，为该术式的临床应用提供可靠的依据，从而有助于提高臂丛神经损伤的治疗效果。 方法:自1996年8月一2003年3月我科分别采用两种隔神经移位方式治疗55例臂丛损伤患者，其中隔神经移位至臂丛上干前股24例，隔神经通过移植神经桥接于肌皮神经主干31例。将随访在15个月以上的共35例患者按手术方法的不同分为两组:隔神经移位于臂丛上干前股14例(简称直接移位组)，隔神经通过皮神经桥接于肌皮神经主干21例(简称桥接移位组)。对两组患者的手术切口长度、术中出血量及手术时间分别进行记录;术后平均随访20个月(巧一42个月)，电生理检测肌皮神经有无新生电位及其变化;记录患者胧二头肌最早出现收缩的时间;观察患者肪二头肌肌力及肘关节屈曲功能的恢复情况。按中华医学会手外科学会制定的上肢周围神经功能评定的试用标准对肌皮神经的功能恢复进行评价，并计算其优良率;以肌皮神经肌电检查无新生电位及潜伏期不能测出术后无效的客观标准。统计学处理:所有资料应用spss for Windows n.o软件分析处理，以。=0 .05作为检验水准。 结果:(1)直接移位组手术切口小，出血少，手术时间短。(2)直接移位组胧二头肌最早出现收缩的时间为术后【(9 .45士1 .56)月，X士s1;桥接移位组胧二头肌收缩最早出现的时间为术后【(12.50士1.33)月，X士sl;两组相比具有显著性差异(p<0.05)。(3)直接移位组肌皮神经恢复的优良率为71.43%，桥接移位组的优良率为33.33%，两组对比有显著性差异(p<0.05)。(4)两组各有两例患者术后无效。 结论:1隔神经移位至臂丛上干前股术具有以下优点:(1)术后肌皮神经功能恢复快，优良率高。(2)手术创伤小，操作简单，适宜在临床推广应用。2影响隔神经移位至臂丛上千前股术疗效的主要因素有臂丛神经的多节段损伤、变异、隔神经的错向生长以及神经吻合口的张力，提示手术时应注意适应证的选择。更多还原

【Abstract】 Brachial plexus is the general origin of peripheral nerve at upper limbs. Its injury is one common disease that can cause severe disabled. The prognosis of these injuries are usually poor, especially when brachial plexus roots avulsion or post-ganglionic root lesion closed to spinal cord is involved. For hi these cases, The nerve cells are easily being hurted and it is almost impossible to anastomose the scathing nerve root. Currently the best way to restore the brachial plexus in these situations is depending on healthy nerve transfer. Phrenic nerve is acknowledged as the best healthy nerve for transfer, for it possesses such advantages as unceasing electrical impulsion and more nerve fiber.The restoration of elbow flexion should be given priority in those patients with brachial plexus injuries. Biceps brachii muscle is the primary muscle for elbow flexion and it is controlled by musculocutaneous nerve. So it become a common way to use healthy phrenic nerve transfer to musculocutaneous nerve to restore elbow flexion in those patients with brachial plexus injuries. The conventional way is using nerve graft to connect phrenic nerve with musculocutaneous nerve. It was found that nerve regeneration were severely disturbed by nerve graft, and the outcome of the transfer were unsatisfactory. In order to improve curative effect, some doctors attempted to transfer the phrenic nerve to anterior division of the upper trunk of brachial plexus. Bythis way, the transfer distance became short enough to make it possible for anastomosis the scathing nerve root directly. There are few cases of clinical application of this new surgical procedure reported up to now. The indication and contraindication of this new surgical procedure are not roundly clear and need further study in order to avoid disappointment. In this study, the clinical data and follow-up results of the brachial plexus injuries treated in our department in recent years were retrospectively analyzed. These injuries had been respectively performed by two procedures with phrenic nerve transfer to musculocutaneous nerve.Objective: Based on the contrast of the fellow-up results of two surgical procedures, we can make clear the advantages of the new surgical procedure and can summarized some possible causes that greatly influenced its curative effect, with which we can provide reliable evidence for its clinical application and can expect a better curative effect.Methods: 55 patients have been carried out operations with two phrenic nerve transfer procedures respectively from Aug. 1996 to Mar.2003. This study involves 35 patients who have been followed up over 15 months. They were divided into two groups according to different nerve transfer procedures. In the group one, the phrenic nerve had been transferred to anterior division of the upper trunk in 14 cases, and to the musculocutaneous nerve with nerve graft in 21 cases in the group two. The relief of the strain at nerve commissure was attempted in the group one. The operation index of two groups such as blood loss, operation time and incision length were reviewed. The average period of follow-up studies is 20 months (15~42months). Recovery state of musculocutaneous nerve was measured with Nerve-Electrophysiological instrument. The earliest time of the appearance of biceps muscle contraction was recorded. The function of musculocutaneous nerve was evaluated according to the probation criterions established by The Hand Surgery Institute of Chinese Medical Association, and its good rate were calculated. The results were analyzed by SPSS for windows 11.0 statistical software, and a value equal to 0.05 was considered as test standard.Results: 1). In the group of phrenic nerve transfer to upper trunk of brachial plexus,the length of operation incision and the operation time were short, and the blood loss was relatively little. 2). The earliest time of appearance of biceps muscle contraction of phrenic nerve transfer to the anterior division of the upper trunk and to themusculocutaneous ner更多还原