不同部位神经移位修复臂丛神经根性撕脱伤的疗效比较
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摘要
目的分析不同部位神经移位修复臂丛神经根性撕脱伤患者的疗效及影响手术效果的相关因素。方法选取2010年1月—2014年12月哈尔滨医科大学附属第四医院骨外科行膈神经移位术、肋间神经移位术及健侧C7神经移位术的臂丛神经根性撕脱伤患者47例作为研究对象,根据神经部位分为膈神经移位组16例、肋间神经移位组15例及健侧C7神经移位组16例。屈肘、屈指肌力恢复釆用BMRC分级系列进行评估,肘关节活动度采用中华医学会手外科学会上肢部分功能试用标准评定。结果 3组不同部位神经移位术后的肌力与肘关节功能恢复有效率比较差异无统计学意义(P>0.05)。影响膈神经移位术肌力恢复有效率的相关因素有患者年龄、神经移植长度、损伤至手术时间和功能锻炼时间(χ~2/t=-5.310、7.111、-5.536、3.400,P均<0.01);影响肋间神经移位术肌力恢复有效率的相关因素有年龄、神经移植长度和功能锻炼时间(χ~2/t=-3.883、8.182、3.067,P均<0.01),健侧C7神经移位术肌力恢复有效率的相关因素有年龄、损伤至手术时间及功能锻炼时间(χ~2/t=-2.423、-3.381、3.985,P<0.05或P<0.01)。影响膈神经移位术肘关节功能恢复有效率的相关因素有患者年龄、神经移植长度、损伤至手术时间和功能锻炼时间(χ~2/t=-2.340、4.752、-2.221、2.907,P<0.05或P<0.01);肋间神经移位术肘关节功能恢复有效率的相关因素有损伤部位、神经移植长度和功能锻炼时间(χ~2/t=5.000、5.000、2.582,P<0.05);健侧C7神经移位术肘关节功能恢复有效率的相关因素有年龄、神经移植长度、损伤至手术时间有关(χ~2/t=-2.571、4.752、-4.875,P<0.05)。结论 3种不同神经移植术后肌力与肘关节的功能恢复有效率存在差异,但无统计学意义;不同术式肌力与肘关节的功能恢复受不同因素影响。
Objective To analyze the curative effect of nerve transposition in different parts of brachial plexus for repairing brachial plexus root avulsion injury and the related factors affecting the surgical effect. Methods Forty-seven patients with brachial plexus root avulsion who underwent phrenic nerve transposition, intercostal nerve transposition and contralateral C7 nerve transposition from January 2010 to December 2014 in the Department of Orthopedics of the Fourth Affiliated Hospital of Harbin Medical University were selected as subjects. According to the nerve location, they were divided into 16 cases of phrenic nerve transposition group, 15 cases of intercostal nerve transposition group and 16 cases of contralateral C7 nerve transposition group. The recovery of flexor elbow and flexor finger muscle strength was assessed by BMRC grading series, and elbow motion was assessed by the trial criteria of upper limb function of Hand Surgery Society of Chinese Medical Association. Results There was no significant difference in the effective rate of muscle strength and elbow function recovery between the three groups at different sites(P>0.05). Factors affecting the effective recovery of muscle strength in sacral nerve transposition include age, nerve graft length, injury to surgery time, and functional exercise time(χ~2/t=-5.310, χ~2/t=7.111, χ~2/t=-5.536, χ~2/t=3.400,P<0.01); factors related to the effective recovery of muscle strength in intercostal nerve transposition include age, length of nerve transplantation and functional exercise time(χ~2/t=-3.883, χ~2/t= 8.182, χ~2/t=3.067,P<0.01), the factors related to the effective recovery of muscle strength in the contralateral C7 nerve transposition were age, injury to surgery time and functional exercise time(χ~2/t=-2.423, χ~2/t=-3.381, χ~2/t=3.985,P<0.05 or P<0.01). Factors affecting the recovery of elbow function in sacral nerve transposition include age, nerve graft length, injury to surgery time, and functional exercise time(χ~2/t=-2.340, χ~2/t=4.752, χ~2/t=-2.221, χ~2/t=2.907, P<0.05 or P<0.01); relevant factors for the effective recovery of elbow function in intercostal nerve transposition include injury site, nerve graft length and functional exercise time(χ~2/t=5.000, χ~2/t=5.000, χ~2/t=2.582, P<0.05); the relevant factors for the effective recovery of elbow joint function in the contralateral C7 nerve transposition were related to age, length of nerve graft, and injury to operation time(χ~2/t=-2.571, χ~2/t=4.752, χ~2/t=-4.875,P<0.05). Conclusion The effective rate of muscle strength and elbow joint function recovery after three kinds of nerve transplantation was different, but there was no statistical significance. The muscle strength and elbow joint function recovery of different surgical methods were affected by different factors.
Objective To analyze the curative effect of nerve transposition in different parts of brachial plexus for repairing brachial plexus root avulsion injury and the related factors affecting the surgical effect. Methods Forty-seven patients with brachial plexus root avulsion who underwent phrenic nerve transposition, intercostal nerve transposition and contralateral C7 nerve transposition from January 2010 to December 2014 in the Department of Orthopedics of the Fourth Affiliated Hospital of Harbin Medical University were selected as subjects. According to the nerve location, they were divided into 16 cases of phrenic nerve transposition group, 15 cases of intercostal nerve transposition group and 16 cases of contralateral C7 nerve transposition group. The recovery of flexor elbow and flexor finger muscle strength was assessed by BMRC grading series, and elbow motion was assessed by the trial criteria of upper limb function of Hand Surgery Society of Chinese Medical Association. Results There was no significant difference in the effective rate of muscle strength and elbow function recovery between the three groups at different sites(P>0.05). Factors affecting the effective recovery of muscle strength in sacral nerve transposition include age, nerve graft length, injury to surgery time, and functional exercise time(χ~2/t=-5.310, χ~2/t=7.111, χ~2/t=-5.536, χ~2/t=3.400,P<0.01); factors related to the effective recovery of muscle strength in intercostal nerve transposition include age, length of nerve transplantation and functional exercise time(χ~2/t=-3.883, χ~2/t= 8.182, χ~2/t=3.067,P<0.01), the factors related to the effective recovery of muscle strength in the contralateral C7 nerve transposition were age, injury to surgery time and functional exercise time(χ~2/t=-2.423, χ~2/t=-3.381, χ~2/t=3.985,P<0.05 or P<0.01). Factors affecting the recovery of elbow function in sacral nerve transposition include age, nerve graft length, injury to surgery time, and functional exercise time(χ~2/t=-2.340, χ~2/t=4.752, χ~2/t=-2.221, χ~2/t=2.907, P<0.05 or P<0.01); relevant factors for the effective recovery of elbow function in intercostal nerve transposition include injury site, nerve graft length and functional exercise time(χ~2/t=5.000, χ~2/t=5.000, χ~2/t=2.582, P<0.05); the relevant factors for the effective recovery of elbow joint function in the contralateral C7 nerve transposition were related to age, length of nerve graft, and injury to operation time(χ~2/t=-2.571, χ~2/t=4.752, χ~2/t=-4.875,P<0.05). Conclusion The effective rate of muscle strength and elbow joint function recovery after three kinds of nerve transplantation was different, but there was no statistical significance. The muscle strength and elbow joint function recovery of different surgical methods were affected by different factors.
引文
[1] 刘宗宝,朱寅,陆剑锋,等.臂丛根性撕脱伤后肋间神经移位修复肩外展功能的疗效观察[J].中国实用神经疾病杂志,2015,18(23):121-123.doi:10.3969/j.issn.1673-5110.2015.23.080.
[2] Carolina K, Thomas C, Martin K, et al. Long-term outcome of brachial plexus reimplantation after complete brachial plexus avulsion injury[J]. World Neurosurg, 2017,103(1):28-36.DOI: 10.1016/j.wneu.2017.03.052.
[3] James MA. Use of the Medical Research Council muscle strength grading system in the upper extremity [J]. J Hand Surg Am, 2007,3(2): 154-156.DOI: 10.1016/j.jhsa.2006.11.008.
[4] 潘达德,顾玉东,侍德,等.中华医学会手外科学会上肢部分功能评定试用标准[J].中华手外科杂志,2000,16(3):130-135.DOI: 10.3760/cma.j.issn.1005-054X.2000.03.003.
[5] Madura T, Doi K, Hattori Y, et al. Free functioning gracilis transfer for reanimation of elbow and hand in total traumatic brachial plexopathy in children[J]. J Hand Surg Eur Vol, 2018,43(6):596-608.DOI: 10.1177/1753193418762950.
[6] 顾玉东,王澍寰,侍德.手外科手术学[M].上海:复旦大学出版社,2010:333.
[7] H Lin, C Hou, A Chen, et al. Transfer of the phrenic nerve to the posterior division of the lower trunk to recover thumb and finger extension in brachial plexus palsy[J]. Journal of Neurosurgery, 2011,114(1):212-216.DOI: 10.3171/2010.7.JNS091748.
[8] 魏建伟, 董忠根. 臂丛神经损伤的治疗进展[J].中国现代手术学杂志,2018,22(3):236-240.DOI:10.16260/j.cnki.1009-2188.2018.03.018.
[9] 阿不地合比尔·阿不拉,李平,依力哈木江·吾斯曼,等. 膈神经与肋间神经移位修复臂丛神经根性撕脱伤[J].中国组织工程研究,2016,20(51):7660-7665.DOI: 10.3969/j.issn.2095-4344.2016.51.009.
[10] Madura T,Doi K,Hattori Y.et al. Free functioning gracilis transfer for reanimation of elbow and hand in total traumatic brachial plexopathy in children[J].J Hand Surg Eur Vol,2018, 43(6):596-608. DOI: 10.1177/1753193418762950.
[11] 刘宗宝,朱寅,陆剑锋,等. 肋间神经移位肌皮神经治疗臂丛神经根性撕脱伤的疗效观察[J]. 中华手外科杂志,2014,30(6):442-444.DOI:10.3760/cma.j.issn.1005-054X.2014.06.016.
[12] Maldonado AA, Romero-Brufau S, Kircher MF, et al.Free functioning gracilis muscle transfer for elbow flexion reconstruction after traumatic adult brachial pan-plexus injury: Where is the optimal distal tendon attachment for elbow flexion[J]. Plastic and Reconstructive Surgery, 2017,139(1):128-136.DOI: 10.1097/PRS.0000000000002864.
[13] 李君. 肋间神经移位肌皮神经治疗臂丛神经根性撕脱伤的疗效观察[J]. 中国伤残医学,2016,(2):47-48. DOI:10.13214/j.cnki.cjotadm.2016.02.032.
[14] Yang G,Kate W,Chang C,et al. A Systematic Review of Contralateral C7 Transfer for the Treatment of Traumatic Brachial Plexus Injury: Part 1. Overall Outcomes[J] . Plastic and Reconstructive Surgery, 2015,136(4):794-809. DOI: 10.1097/PRS.0000000000001494.
[15] Hoang D, Chen VW, Seruya M. Recovery of Elbow Flexion after Nerve Reconstruction versus Free Functional Muscle Transfer for Late, Traumatic Brachial Plexus Palsy: A Systematic Review[J].Plast Reconstr Surg, 2018,141(4):949-959. DOI: 10.1097/PRS.0000000000004229.
[16] Rui J, Xu YL, Zhao X, et al. Phrenic and intercostal nerves with rhythmic discharge can promote early nerve regeneration after brachial plexus repair in rats[J]. Neural Regeneration Research,2018,13(5)862-868.DOI: 10.4103/1673-5374.232482.
[2] Carolina K, Thomas C, Martin K, et al. Long-term outcome of brachial plexus reimplantation after complete brachial plexus avulsion injury[J]. World Neurosurg, 2017,103(1):28-36.DOI: 10.1016/j.wneu.2017.03.052.
[3] James MA. Use of the Medical Research Council muscle strength grading system in the upper extremity [J]. J Hand Surg Am, 2007,3(2): 154-156.DOI: 10.1016/j.jhsa.2006.11.008.
[4] 潘达德,顾玉东,侍德,等.中华医学会手外科学会上肢部分功能评定试用标准[J].中华手外科杂志,2000,16(3):130-135.DOI: 10.3760/cma.j.issn.1005-054X.2000.03.003.
[5] Madura T, Doi K, Hattori Y, et al. Free functioning gracilis transfer for reanimation of elbow and hand in total traumatic brachial plexopathy in children[J]. J Hand Surg Eur Vol, 2018,43(6):596-608.DOI: 10.1177/1753193418762950.
[6] 顾玉东,王澍寰,侍德.手外科手术学[M].上海:复旦大学出版社,2010:333.
[7] H Lin, C Hou, A Chen, et al. Transfer of the phrenic nerve to the posterior division of the lower trunk to recover thumb and finger extension in brachial plexus palsy[J]. Journal of Neurosurgery, 2011,114(1):212-216.DOI: 10.3171/2010.7.JNS091748.
[8] 魏建伟, 董忠根. 臂丛神经损伤的治疗进展[J].中国现代手术学杂志,2018,22(3):236-240.DOI:10.16260/j.cnki.1009-2188.2018.03.018.
[9] 阿不地合比尔·阿不拉,李平,依力哈木江·吾斯曼,等. 膈神经与肋间神经移位修复臂丛神经根性撕脱伤[J].中国组织工程研究,2016,20(51):7660-7665.DOI: 10.3969/j.issn.2095-4344.2016.51.009.
[10] Madura T,Doi K,Hattori Y.et al. Free functioning gracilis transfer for reanimation of elbow and hand in total traumatic brachial plexopathy in children[J].J Hand Surg Eur Vol,2018, 43(6):596-608. DOI: 10.1177/1753193418762950.
[11] 刘宗宝,朱寅,陆剑锋,等. 肋间神经移位肌皮神经治疗臂丛神经根性撕脱伤的疗效观察[J]. 中华手外科杂志,2014,30(6):442-444.DOI:10.3760/cma.j.issn.1005-054X.2014.06.016.
[12] Maldonado AA, Romero-Brufau S, Kircher MF, et al.Free functioning gracilis muscle transfer for elbow flexion reconstruction after traumatic adult brachial pan-plexus injury: Where is the optimal distal tendon attachment for elbow flexion[J]. Plastic and Reconstructive Surgery, 2017,139(1):128-136.DOI: 10.1097/PRS.0000000000002864.
[13] 李君. 肋间神经移位肌皮神经治疗臂丛神经根性撕脱伤的疗效观察[J]. 中国伤残医学,2016,(2):47-48. DOI:10.13214/j.cnki.cjotadm.2016.02.032.
[14] Yang G,Kate W,Chang C,et al. A Systematic Review of Contralateral C7 Transfer for the Treatment of Traumatic Brachial Plexus Injury: Part 1. Overall Outcomes[J] . Plastic and Reconstructive Surgery, 2015,136(4):794-809. DOI: 10.1097/PRS.0000000000001494.
[15] Hoang D, Chen VW, Seruya M. Recovery of Elbow Flexion after Nerve Reconstruction versus Free Functional Muscle Transfer for Late, Traumatic Brachial Plexus Palsy: A Systematic Review[J].Plast Reconstr Surg, 2018,141(4):949-959. DOI: 10.1097/PRS.0000000000004229.
[16] Rui J, Xu YL, Zhao X, et al. Phrenic and intercostal nerves with rhythmic discharge can promote early nerve regeneration after brachial plexus repair in rats[J]. Neural Regeneration Research,2018,13(5)862-868.DOI: 10.4103/1673-5374.232482.