根据肌内神经分布定位髂腰肌和腰方肌痉挛的阻滞靶点
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摘要
目的通过探索髂腰肌和腰方肌的肌内神经分布模式,定位其肌痉挛时肉毒毒素A的阻滞靶点。方法 12具24侧中国成人尸体髂腰肌和腰方肌。改良的Sihler’s染色法显示肌内神经分布。结果髂腰肌和腰方肌的神经支配源于T_(12)和L_1～L_4脊神经分支。腰大肌肌腹上1/2区内有一神经分支密集区,位于肌长的(12.10±0.65)%～(43.20±1.17)%水平,其中心点在肌长(23.90±0.82)%水平,向内平对第三腰椎体中部;髂肌中央有一与髂嵴平行的蚕豆形神经密集区,其中心点位于髂腰肌肌长的(58.0±1.61)%水平,向外平对髂结节;腰方肌的内上和下1/3部各存在1个肌内神经密集区,其中心点分别平对第一和第三腰椎体下部。结论这些肌内神经密集区及中心的定位研究能指导临床医生注射肉毒毒素A接近其作用部位。
Objective To localize the blocking targets for botulinum toxin A injection in iliopsoas and quadratus lumborum muscles by exploring the intramuscular nerve distribution pattern. Methods Iliopsoas and quadratus lumborum muscles of 12 adult cadavers were collected from both sides. Modified Sihler's staining was used to reveal intramuscular nerve distribution. Results The innervation of the iliopsoas and quadratus lumborum originated from the branches of T_(12) and L_1～L_4 spinal nerves. There was a nerve branch dense region in the upper 1/2 of psoas major muscle. It was located about(12.1±0.65)%～(43.2±1.17)% of muscle length with a central point at(23.90±0.82)% of muscle length corresponding medially to the middle of L_3 vertebral body. There was a broad bean-shaped nerve dense region parallel to the iliac crest in the center of the iliacus muscle. The central point of this region was at(58.0 ± 1.61)% of iliopsoas muscle length corresponding laterally to iliac tubercle. There was an intramuscular nerve dense region in the superomedial 1/3 and inferior 1/3 of the quadratus lumborum muscle respectively, each having a central point medially corresponding to the lower part of the L_1 and L_3 vertebral bodies. Conclusion The localization study of these intramuscular nerve dense regions and centers of the iliopsoas and quadratus lumborum muscle can allow the clinician to inject BTX-A close to its site of action.
Objective To localize the blocking targets for botulinum toxin A injection in iliopsoas and quadratus lumborum muscles by exploring the intramuscular nerve distribution pattern. Methods Iliopsoas and quadratus lumborum muscles of 12 adult cadavers were collected from both sides. Modified Sihler's staining was used to reveal intramuscular nerve distribution. Results The innervation of the iliopsoas and quadratus lumborum originated from the branches of T_(12) and L_1～L_4 spinal nerves. There was a nerve branch dense region in the upper 1/2 of psoas major muscle. It was located about(12.1±0.65)%～(43.2±1.17)% of muscle length with a central point at(23.90±0.82)% of muscle length corresponding medially to the middle of L_3 vertebral body. There was a broad bean-shaped nerve dense region parallel to the iliac crest in the center of the iliacus muscle. The central point of this region was at(58.0 ± 1.61)% of iliopsoas muscle length corresponding laterally to iliac tubercle. There was an intramuscular nerve dense region in the superomedial 1/3 and inferior 1/3 of the quadratus lumborum muscle respectively, each having a central point medially corresponding to the lower part of the L_1 and L_3 vertebral bodies. Conclusion The localization study of these intramuscular nerve dense regions and centers of the iliopsoas and quadratus lumborum muscle can allow the clinician to inject BTX-A close to its site of action.
引文
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[10]Amirali A,Mu L,Gracies JM,et al.Anatomical localization of motor endplate bands in the human biceps brachii[J].J Clin Neuromuscul Dis,2007,9(2):306-312.
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[12]侯树勋,吴叶.腰痛治疗的选择[J].中国疼痛医学杂志,2011,17(3):129-130.
[13]Van Campenhout A,Hubens G,Fagard K,et al.Localization of motor nerve branches of the human psoas muscle[J].Muscle Nerve,2010,42(2):202-207.
[14]刘臻,苏清伦,刘多,等.在B超引导下注射A型肉毒素的疗效观察[J].中国康复理论与实践,2008,14(1):67-68.
[15]徐开寿,燕铁斌,麦坚凝.不同定位技术引导肉毒毒素治疗脑瘫患儿踝跖屈肌群痉挛的对照研究[J].中华物理医药与康复杂志,2006,28(9):607-610.
[16]Molenaers G,Eyssen M,Desloovere K,et al.A multilevel approach to botulinum toxin A treatment of the(ilio)psoas in spasticity in cerebral palsy[J].Eur J Neurol,1999,6(Suppl 4):59-62.
[17]Willenborg MJ,Shilt JS,Smith BP,et al.Technique for iliopsoas ultrasound-guided active electromyography-directed botulinum A toxin injection in cerebral palsy[J].J Pediatr Orthop.2002,22(2):165-168.
[18]Westhoff B,Seller K,Wild A,et al.Ultrasound-guided botulinum toxin injection technique for the iliopsoas muscle[J].Dev Med Child Neurol,2003,45(12):829-832.
[19]Ward AB.Botulinum toxin A treatment of hip and thigh spasticity:a technique for injection of psoas major muscle[J].Eur J Neurol,1999,6(Suppl 4):91-93.
[2]杨远滨,金爽.痉挛状态与疼痛[J].中国康复医学杂志,2011,26(3):292-295.
[3]张雪非,刘宗良,任中杰.腰方肌腰髂肋肌痉挛型脑瘫的临床征候及手术治疗[J].中国矫形外科杂志,2012,20(7):668-671.
[4]Alvisi E,Serrao M,Conte C,et al.Botulinum toxin A modifies nociceptive withdrawal reflex in subacute stroke patients[J].Brain Behav,2018,e01069.
[5]Li J,Zhang R,Cui BL,et al.Therapeutic efficacy and safety of various botulinum toxin A doses and concentrations in spastic foot after stroke:a randomized controlled trial[J].Neural Regen Res,2017,12(9):1451-1457.
[6]刘建军,纪树荣,吴卫红,等.A型肉毒毒素对脑性瘫痪患儿髂腰肌痉挛的疗效观察[J].中国康复理论与实践,2013,19(10):956-959.
[7]Ueshima H,Otake H,Lin JA.Ultrasound-guided quadratus lumborum block:an updated review of anatomy and techniques[J].Biomed Res Int,2017,2017:2752876.
[8]Tang S,Zhang MX,Yang S.Localization of center of intramuscular nerve dense regions in adult anterior brachial muscles:a guide for botulinum toxin A injection to treat muscle spasticity[J].Am J Transl Res,2018,10(4):1220-1228.
[9]Yang S,Hu S,Li B,et al.Localization of nerve entry point and intramuscular nerve-dense regions as targets to block brachioradialis muscle spasticity[J].Int J Clin Exp Med,2017,10(8):11912-11920.
[10]Amirali A,Mu L,Gracies JM,et al.Anatomical localization of motor endplate bands in the human biceps brachii[J].J Clin Neuromuscul Dis,2007,9(2):306-312.
[11]杨胜波,李季蓉,薛黔,等.家兔胸大肌肌内神经、运动终板与肌梭的分布[J].解剖学杂志,2004,27(2):195-198.
[12]侯树勋,吴叶.腰痛治疗的选择[J].中国疼痛医学杂志,2011,17(3):129-130.
[13]Van Campenhout A,Hubens G,Fagard K,et al.Localization of motor nerve branches of the human psoas muscle[J].Muscle Nerve,2010,42(2):202-207.
[14]刘臻,苏清伦,刘多,等.在B超引导下注射A型肉毒素的疗效观察[J].中国康复理论与实践,2008,14(1):67-68.
[15]徐开寿,燕铁斌,麦坚凝.不同定位技术引导肉毒毒素治疗脑瘫患儿踝跖屈肌群痉挛的对照研究[J].中华物理医药与康复杂志,2006,28(9):607-610.
[16]Molenaers G,Eyssen M,Desloovere K,et al.A multilevel approach to botulinum toxin A treatment of the(ilio)psoas in spasticity in cerebral palsy[J].Eur J Neurol,1999,6(Suppl 4):59-62.
[17]Willenborg MJ,Shilt JS,Smith BP,et al.Technique for iliopsoas ultrasound-guided active electromyography-directed botulinum A toxin injection in cerebral palsy[J].J Pediatr Orthop.2002,22(2):165-168.
[18]Westhoff B,Seller K,Wild A,et al.Ultrasound-guided botulinum toxin injection technique for the iliopsoas muscle[J].Dev Med Child Neurol,2003,45(12):829-832.
[19]Ward AB.Botulinum toxin A treatment of hip and thigh spasticity:a technique for injection of psoas major muscle[J].Eur J Neurol,1999,6(Suppl 4):91-93.