颌面部神经爆炸性创伤的实验研究
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摘要
随着武器的发展，战争中爆炸性武器的使用不断增多，爆炸伤也逐渐成为战伤中的主要类型。颌面部位置暴露，不易防护，因而颌面部战伤在历次战争中都有较高的发生率，对颌面部战伤的研究也一直是战创伤研究中的重点问题。面部神经分布密集，在颌面部爆炸伤中几乎不可避免受到累及。特别是面神经，位置表浅，受伤后易导致面瘫，对患者的生理、心理和生活影响很大。而周围神经的火器性创伤由于神经损伤范围广、伤口污染严重，本身处理就比较困难，同时颌面部解剖结构复杂，腔窦多，所以对面部神经火器伤的处理比较困难。以往对颌面部神经火器伤的研究多集中在枪弹致伤方面，对颌面部神经爆炸伤的研究少，而爆炸作为一种剧烈的致伤因素，所引起的损伤有别于枪弹伤，因此对面部神经爆炸伤的过程尤其是面神经爆炸性损伤的特点值得研究。
国内外过去的神经爆炸伤研究多从临床经验出发，分析在某次战争或爆炸性事故中各种伤情的比例和致伤原因，缺乏前瞻性研究。因此，我们在实验室条件下通过严格控制致伤因素对颌面部特定部位进行致伤，观察该部位神经损伤特点并尝试相应救治方法。
本研究的主要内容包括：
1，面神经爆炸伤模型的建立
第回罩匡大学协士学位恰工
没计并建立了一种模拟面神经爆炸伤的动物模型。通过对比不同致
伤条件下动物的伤情，摸索出适合用于研究面神经创伤救治和预后的模
型。同时，对面神经的枪弹伤和爆炸伤的特点进行了比较。
2，颌面颈部神经爆炸伤后的病理变化
观察面神经爆炸伤后病理变化和恢复过程，并采用免疫组化等方法
对面神经的恢复过程与下颌神经和迷走神经进行比较，分析由神经自身
因素及周围解剖关系不同而引起的创伤过程的差异。
3，颈部迷走神经损伤程度对爆炸伤后急性创伤反应的影响
通过前瞻性随机化的动物实验分析了迷走神经损伤程度对爆炸伤后
的机体急性创伤反应，尤其是创伤性休克的影响，结果表明迷走神经在
爆炸伤后急性循环呼吸系统反应中起重要作用。
4，面神经爆炸救治的研究
探讨在面神经爆炸伤后初期处理中可以采取的措施以利于面神经的
恢复，减少遗留面神经功能障碍。对面神经爆炸伤后采用皮瓣修复创面，
避免面神经长期暴露，可以促进面神经的恢复。通过面神经外膜切开减
轻神经干内部压力也有助于神经功能的恢复。
总之，本研究设计并建立了一种模拟面神经爆炸伤的动物模型，观察了
颌面颈部神经爆炸伤后的特点并进行对比，对面神经爆炸伤后的早期救治提
出新的思路。
With the development of armament, the explosive weapon was applied more often than ever in the war, and the blast injury became the majority of war wounds. The maxillofacial region was exposed and not easy to be protected in usual. As a result, the maxillofacial war injury was reported high incidence rate in all the past wars, and the responsible research was all along an important item in the field of battle surgery. The nerves were distributed intensively in the head and neck region and involved inevitably in the blast injury of this part. In particular, the facial nerve was prone to facial paralysis after injury, which had great effect on the patient's physiologic and mental health. The treatment of facial nerve firearm injury was difficult because of the wide damage coverage, contamination of wounds and complicated anatomy in the facial region. The previous study was mainly concentrated on gunshot injury. However, the facial nerve blast injury is different from the gunshot injury for the different woundi
ng causes. Therefore, it is necessary to research the blast injury of nerves in the facial region, especially the facial nerve blast injury. The past reports on peripheral blast injury were mainly according to clinical
Department of Oral & Maxillofacial Surgery .
experience to analyze the wound types and reasons in wars or explosive accidents, in which little prospective research had been undertaken. And this study was a prospectively randomized, controlled animal study to observe the feature of the nerve blast injury in the maxillofacial region as well as the treatment.
1. The establishment of an animal model on facial nerve blast injury
An animal model of blast-fragment combined injuries was designed and founded to imitate the facial nerve injury of explosion. The local wound of different explosive condition was compared in detail to explore the appropriate pattern for the research of facial nerve injury and recovery. The features between gunshot and blast nerve injury were also compared in this part as well.
2. The pathology of the nerve blast injury in the maxillofacial and cervical region
The pathology of facial nerve blast injury was observed and the recovering process of facial nerve was compared to the process of mandibular and vagus nerve to analyze the difference of wounding effect caused by the different nervous types and local anatomy.
3. The influence of vagal injury in acute cardiorespiratory responses to blast exposure
The influence of vagal injury in acute response to blast exposure was analyzed by the prospectively randomized animal study, and our data implicates that the vagus nerve play an important role in the acute cardiorespiratory responses such as traumatic shock seen immediately after blast injury.
4. The treatment of facial nerve blast injury
Two experiments was designed to investigate the possible early management of facial nerve blast injury. Repairing the facial blast wounds or depression of the facial nerve at the early stage after injury could promote the recovery of the facial nerves.
Department of Oral &. Maxillofacial Surgery
In summary, an animal model was designed and established in this study to imitate the real facial nerve blast injury. The blast injury of nerves in the maxillofacial and cervical region was observed and compared among them. And the early treatment of facial nerve blast injury was preliminarily studied.
国内外过去的神经爆炸伤研究多从临床经验出发，分析在某次战争或爆炸性事故中各种伤情的比例和致伤原因，缺乏前瞻性研究。因此，我们在实验室条件下通过严格控制致伤因素对颌面部特定部位进行致伤，观察该部位神经损伤特点并尝试相应救治方法。
本研究的主要内容包括：
1，面神经爆炸伤模型的建立
第回罩匡大学协士学位恰工
没计并建立了一种模拟面神经爆炸伤的动物模型。通过对比不同致
伤条件下动物的伤情，摸索出适合用于研究面神经创伤救治和预后的模
型。同时，对面神经的枪弹伤和爆炸伤的特点进行了比较。
2，颌面颈部神经爆炸伤后的病理变化
观察面神经爆炸伤后病理变化和恢复过程，并采用免疫组化等方法
对面神经的恢复过程与下颌神经和迷走神经进行比较，分析由神经自身
因素及周围解剖关系不同而引起的创伤过程的差异。
3，颈部迷走神经损伤程度对爆炸伤后急性创伤反应的影响
通过前瞻性随机化的动物实验分析了迷走神经损伤程度对爆炸伤后
的机体急性创伤反应，尤其是创伤性休克的影响，结果表明迷走神经在
爆炸伤后急性循环呼吸系统反应中起重要作用。
4，面神经爆炸救治的研究
探讨在面神经爆炸伤后初期处理中可以采取的措施以利于面神经的
恢复，减少遗留面神经功能障碍。对面神经爆炸伤后采用皮瓣修复创面，
避免面神经长期暴露，可以促进面神经的恢复。通过面神经外膜切开减
轻神经干内部压力也有助于神经功能的恢复。
总之，本研究设计并建立了一种模拟面神经爆炸伤的动物模型，观察了
颌面颈部神经爆炸伤后的特点并进行对比，对面神经爆炸伤后的早期救治提
出新的思路。
With the development of armament, the explosive weapon was applied more often than ever in the war, and the blast injury became the majority of war wounds. The maxillofacial region was exposed and not easy to be protected in usual. As a result, the maxillofacial war injury was reported high incidence rate in all the past wars, and the responsible research was all along an important item in the field of battle surgery. The nerves were distributed intensively in the head and neck region and involved inevitably in the blast injury of this part. In particular, the facial nerve was prone to facial paralysis after injury, which had great effect on the patient's physiologic and mental health. The treatment of facial nerve firearm injury was difficult because of the wide damage coverage, contamination of wounds and complicated anatomy in the facial region. The previous study was mainly concentrated on gunshot injury. However, the facial nerve blast injury is different from the gunshot injury for the different woundi
ng causes. Therefore, it is necessary to research the blast injury of nerves in the facial region, especially the facial nerve blast injury. The past reports on peripheral blast injury were mainly according to clinical
Department of Oral & Maxillofacial Surgery .
experience to analyze the wound types and reasons in wars or explosive accidents, in which little prospective research had been undertaken. And this study was a prospectively randomized, controlled animal study to observe the feature of the nerve blast injury in the maxillofacial region as well as the treatment.
1. The establishment of an animal model on facial nerve blast injury
An animal model of blast-fragment combined injuries was designed and founded to imitate the facial nerve injury of explosion. The local wound of different explosive condition was compared in detail to explore the appropriate pattern for the research of facial nerve injury and recovery. The features between gunshot and blast nerve injury were also compared in this part as well.
2. The pathology of the nerve blast injury in the maxillofacial and cervical region
The pathology of facial nerve blast injury was observed and the recovering process of facial nerve was compared to the process of mandibular and vagus nerve to analyze the difference of wounding effect caused by the different nervous types and local anatomy.
3. The influence of vagal injury in acute cardiorespiratory responses to blast exposure
The influence of vagal injury in acute response to blast exposure was analyzed by the prospectively randomized animal study, and our data implicates that the vagus nerve play an important role in the acute cardiorespiratory responses such as traumatic shock seen immediately after blast injury.
4. The treatment of facial nerve blast injury
Two experiments was designed to investigate the possible early management of facial nerve blast injury. Repairing the facial blast wounds or depression of the facial nerve at the early stage after injury could promote the recovery of the facial nerves.
Department of Oral &. Maxillofacial Surgery
In summary, an animal model was designed and established in this study to imitate the real facial nerve blast injury. The blast injury of nerves in the maxillofacial and cervical region was observed and compared among them. And the early treatment of facial nerve blast injury was preliminarily studied.
引文
1.Roganovic Z, Savic M, Minic L, et al. Peripheral nerve injuries during the 1991-1993 war period. Vojnosanit Pregl 1995;52(5):455-460
2.Bajec J, Gang RK, Lari AR. Post Gulf war explosive injuries in liberated Kuwait. Injury. 1993 Sep;24(8):517-520.
3.Vrebalov-Cindro V, Reic P, Ognjenovic M, et al. Peripheral nerve war injuries. Military Medicine 1999;164(5):351-352
4.Cujic M. Rehabilitation of war injuries associated with peripheral nerve lesions. Med Pregl 1996;49(11-12):469-472
5.Henigsberg N, Lagerkvist B, Matek Z, et al. War victims in need of physical rehabilitation in Croatia. Scand J Soc Med 1997;25(3):202-206
6.Mallonee, S, Shariat, S, Stennies G, et al. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA 1996;276(5):382-387
7.Dubuisson A, Kline DG. Indications for periphral nerve and brachial plexus surgery. Neurosurg Clin 1992;10:935-951
8.Mahapatra AK. Bilateral optic nerve injury. Neurol India. 1999 Jun;47(2):92-93
9.Kline DG. Civilian gunshot wounds to the brachial plexus. J Neurosurg 1989;70(2):166-174
10.Miroslav MS, Lukas GR, Danica MG. Gunshot injuries to the brachial plexus. J Trauma 1997;43(4):645-649
11.Gousheh J. The treatment of war injuries of the brachial plexus. J Hand Surgery 1995;20A(3):568-576
12.Danic D, Prgomet D, Milicic D, et al. War injuries to the head and neck. Mil Med 1998 Feb;163(2):117-119
13.Flores AJ, Lavernia C J, Owens PW. Anatomy and physiology of peripheral nerve injury and repair. Am J Orthop 2000;29(3):167-173. Review.
14.Barisic N, Perovic D, Mitrovic Z, et al. Assessment of war and accidental nerve injuries in children. Pediatr Neurol 1999;21(1):450-455
15．李主一，徐永清，翁龙江等．四肢战伤修复与功能重建的研究．中国修复重建外科杂志 1997；11(4)：233-235
16．丁自海，蔡锦方．张力性神经伤的基础研究进展．前卫医药杂志 1997；14(2)：128-129
17．卢世璧，朱盛修，张伯勋等．自体神经束间游离移植治疗火器性周围神经损伤．中华外科杂志 1982；21(11)：646-649
18.Stanec S, Tonkovic I, Stanec Z, et al. Treatment of upper limb nerve war injuries associated with vascular trauma. Injury 1997;28(7):463-468
19．朱盛修，刘郑生，卢世壁等．枪弹震荡后坐骨神经内液压＼氧分压及超微结构观察．中华外科杂志 1986；24(2)：87-90
20．万芪，刘荫秋．高速投射物的压力波致伤效应．国外医学军事医学分册 1990；36(3)：100-103
21．许小珊，袁本利，沈菊英等．周围神经枪击震荡伤的病理观察．解放军医学杂志 1984；9(6)：414-416
22．陈革，赖西南．周围神经火器震荡伤的实验研究．解放军医学杂志 1992；17(1)：31-33
23.Samardzic MM, Rasulic LG, Vuckovic CD. Missile injuries of the sciatic nerve. Injury 1999;30(1):15-20
24.Micovic V, Stancic M, Eskina N, et al. Prognostic validity of different classifications in assessment of war inflicted nerve injury. Acta Med Croatica 1996;50(3):129-132
25.Seddon H. Surgical disorders of the peripheral nerves. 2nd ed. Edinburgh. London. New York: Churchill Livingstone, 1975;139-153
26．朱盛修．周围神经束膜减压术治疗灼性神经痛及其机理探讨．中华外科杂志 1984；10(2)：85-87
27．姚建祥，朱盛修，周中英等．火器性周围神经伤合并刺激性神经痛．北京医学 1988；10(2)：85-87．
28.Roganovic Z. Factors influencing the outcome of nerve repair. Vojnosanit Pregl 1998;55(2):119-131
29.Roganovic Z, Antic B, Petkovic S, et al. Post-gunshot wound lesions of the peripheral nerves which may be prevented with adequate primary surgical wound care. Vojnosanit Pregl 1996;53(1):11-17
30.Guelinckx PJ, Sinsel NK. The "Eve" procedure: the transfer of vascularized seventh rib, fascia, cartilage, and serratus muscle to reconstruct difficult defects. Plast Reconstr Surg. 1996;97(3):527-535.
31.Safak T, Akyurek M. Primary one-stage reconstruction of cheek defect after a shotgun blast to the face: use of the latissimus dorsi musculocutaneous free flap for soft-tissue repair and facial reanimation. Ann Plast Surg. 2001;47(4):438-441.
32．李建生，陈立龙，刘德诚．24例火器性周围神经损伤的手术治疗及疗效观察．解放军医学杂志 1983；8(1)：36-37
33.Motamedi MH, Behnia H. Experience with regional flaps in the comprehensive treatment of maxillofacial soft-tissue injuries in war victims. J Craniomaxillofac Surg. 1999;27(4):256-265.
34.Jorgenson DS, Antoine GA. Advances in the treatment of lower extremity wounds applied to military casualties. Ann Plast Surg. 1995;34(3):298-301; discussion 301-303.
35.Yim KK, Hui KC, Ramos D, et al. Use of intercostal nerves as nerve grafts in hand reconstruction with rectus abdominis flaps. J Hand Surg [Am]
1994;19(2) :238-240．
36． Ristic B, Haralampiev K, Kitanoski B. Facial nerve lesions in gunshot injuries of the temporofacial region. Med Pregl 1994;47(3-4) :126-129
37． Haralampiev K, Ristic B, Kitanoski B, et al. Facial nerve injuries caused by firearms. Vojnosanit Pregl 1998;55(1) :15-18
38． Ghahremani S, Nejad AA. Restoring elbow flexion by pectoralis major transplantation in war-injured patients. Microsurgery 1996;17(2) :97-101
39． Stancic MF, Eskinja N, Bellinzona M, et al. The role of interfascicular nerve grafting after gunshot wounds. A report of 44 cases. Int Orthop 1996;20(2) : 87-91
40． Nulsen FE, Slade WW. Recovery following injury to the brachial plexus. In: Woodhal B, Beebe GW, eds. Peropheral Nerve Regeneration: A following study of 3656 World War n injuries. Washington, DC: Government Printing Office; 1956:389-408
41． 雷德林，周树夏，吕春堂等。面神经火器伤的实验研究.实用口腔医学 杂志,1991;7(4) :209-211
42． Sittel C, Stennert E. Prognostic value of electromyography in acute peripheral facial nerve palsy. Otol Neurotol. 2001 Jan;22(1) : 100-104．
2.Bajec J, Gang RK, Lari AR. Post Gulf war explosive injuries in liberated Kuwait. Injury. 1993 Sep;24(8):517-520.
3.Vrebalov-Cindro V, Reic P, Ognjenovic M, et al. Peripheral nerve war injuries. Military Medicine 1999;164(5):351-352
4.Cujic M. Rehabilitation of war injuries associated with peripheral nerve lesions. Med Pregl 1996;49(11-12):469-472
5.Henigsberg N, Lagerkvist B, Matek Z, et al. War victims in need of physical rehabilitation in Croatia. Scand J Soc Med 1997;25(3):202-206
6.Mallonee, S, Shariat, S, Stennies G, et al. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA 1996;276(5):382-387
7.Dubuisson A, Kline DG. Indications for periphral nerve and brachial plexus surgery. Neurosurg Clin 1992;10:935-951
8.Mahapatra AK. Bilateral optic nerve injury. Neurol India. 1999 Jun;47(2):92-93
9.Kline DG. Civilian gunshot wounds to the brachial plexus. J Neurosurg 1989;70(2):166-174
10.Miroslav MS, Lukas GR, Danica MG. Gunshot injuries to the brachial plexus. J Trauma 1997;43(4):645-649
11.Gousheh J. The treatment of war injuries of the brachial plexus. J Hand Surgery 1995;20A(3):568-576
12.Danic D, Prgomet D, Milicic D, et al. War injuries to the head and neck. Mil Med 1998 Feb;163(2):117-119
13.Flores AJ, Lavernia C J, Owens PW. Anatomy and physiology of peripheral nerve injury and repair. Am J Orthop 2000;29(3):167-173. Review.
14.Barisic N, Perovic D, Mitrovic Z, et al. Assessment of war and accidental nerve injuries in children. Pediatr Neurol 1999;21(1):450-455
15．李主一，徐永清，翁龙江等．四肢战伤修复与功能重建的研究．中国修复重建外科杂志 1997；11(4)：233-235
16．丁自海，蔡锦方．张力性神经伤的基础研究进展．前卫医药杂志 1997；14(2)：128-129
17．卢世璧，朱盛修，张伯勋等．自体神经束间游离移植治疗火器性周围神经损伤．中华外科杂志 1982；21(11)：646-649
18.Stanec S, Tonkovic I, Stanec Z, et al. Treatment of upper limb nerve war injuries associated with vascular trauma. Injury 1997;28(7):463-468
19．朱盛修，刘郑生，卢世壁等．枪弹震荡后坐骨神经内液压＼氧分压及超微结构观察．中华外科杂志 1986；24(2)：87-90
20．万芪，刘荫秋．高速投射物的压力波致伤效应．国外医学军事医学分册 1990；36(3)：100-103
21．许小珊，袁本利，沈菊英等．周围神经枪击震荡伤的病理观察．解放军医学杂志 1984；9(6)：414-416
22．陈革，赖西南．周围神经火器震荡伤的实验研究．解放军医学杂志 1992；17(1)：31-33
23.Samardzic MM, Rasulic LG, Vuckovic CD. Missile injuries of the sciatic nerve. Injury 1999;30(1):15-20
24.Micovic V, Stancic M, Eskina N, et al. Prognostic validity of different classifications in assessment of war inflicted nerve injury. Acta Med Croatica 1996;50(3):129-132
25.Seddon H. Surgical disorders of the peripheral nerves. 2nd ed. Edinburgh. London. New York: Churchill Livingstone, 1975;139-153
26．朱盛修．周围神经束膜减压术治疗灼性神经痛及其机理探讨．中华外科杂志 1984；10(2)：85-87
27．姚建祥，朱盛修，周中英等．火器性周围神经伤合并刺激性神经痛．北京医学 1988；10(2)：85-87．
28.Roganovic Z. Factors influencing the outcome of nerve repair. Vojnosanit Pregl 1998;55(2):119-131
29.Roganovic Z, Antic B, Petkovic S, et al. Post-gunshot wound lesions of the peripheral nerves which may be prevented with adequate primary surgical wound care. Vojnosanit Pregl 1996;53(1):11-17
30.Guelinckx PJ, Sinsel NK. The "Eve" procedure: the transfer of vascularized seventh rib, fascia, cartilage, and serratus muscle to reconstruct difficult defects. Plast Reconstr Surg. 1996;97(3):527-535.
31.Safak T, Akyurek M. Primary one-stage reconstruction of cheek defect after a shotgun blast to the face: use of the latissimus dorsi musculocutaneous free flap for soft-tissue repair and facial reanimation. Ann Plast Surg. 2001;47(4):438-441.
32．李建生，陈立龙，刘德诚．24例火器性周围神经损伤的手术治疗及疗效观察．解放军医学杂志 1983；8(1)：36-37
33.Motamedi MH, Behnia H. Experience with regional flaps in the comprehensive treatment of maxillofacial soft-tissue injuries in war victims. J Craniomaxillofac Surg. 1999;27(4):256-265.
34.Jorgenson DS, Antoine GA. Advances in the treatment of lower extremity wounds applied to military casualties. Ann Plast Surg. 1995;34(3):298-301; discussion 301-303.
35.Yim KK, Hui KC, Ramos D, et al. Use of intercostal nerves as nerve grafts in hand reconstruction with rectus abdominis flaps. J Hand Surg [Am]
1994;19(2) :238-240．
36． Ristic B, Haralampiev K, Kitanoski B. Facial nerve lesions in gunshot injuries of the temporofacial region. Med Pregl 1994;47(3-4) :126-129
37． Haralampiev K, Ristic B, Kitanoski B, et al. Facial nerve injuries caused by firearms. Vojnosanit Pregl 1998;55(1) :15-18
38． Ghahremani S, Nejad AA. Restoring elbow flexion by pectoralis major transplantation in war-injured patients. Microsurgery 1996;17(2) :97-101
39． Stancic MF, Eskinja N, Bellinzona M, et al. The role of interfascicular nerve grafting after gunshot wounds. A report of 44 cases. Int Orthop 1996;20(2) : 87-91
40． Nulsen FE, Slade WW. Recovery following injury to the brachial plexus. In: Woodhal B, Beebe GW, eds. Peropheral Nerve Regeneration: A following study of 3656 World War n injuries. Washington, DC: Government Printing Office; 1956:389-408
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