同侧C7神经根（全根）移位治疗臂丛上干根性撕脱伤的基础研究
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摘要
第一部分同侧C7神经根移位治疗臂丛上干根性撕脱伤疗效的实验研究
目的臂丛上干根性撕脱伤常用丛外神经移位进行治疗。2002年顾玉东首创同侧C7全根移位手术治疗上干根性撕脱伤患者疗效显著。本实验通过动物模型比较同侧C7全根移位与其它三种常用治疗方案对臂丛上干根性撕脱伤的疗效，以确认同侧C7全根移位手术在臂丛损伤治疗中的应用价值。
方法120只SD大鼠随机等分为4组，均取颈部正中切口，沿弓状线切开胸大肌后，将胸小肌向侧方牵开，在前中斜角肌之间显露C5～7神经根，C56予以撕脱建立模型，分别以下述四组方案进行神经移位修复上干：(1)“同侧C7”组：同侧C7移位至上干+副神经至肩胛上神经；(2)“Oberlin”组：Oberlin手术(尺神经一束移位至肱二头肌支)+副神经至肩胛上神经+桡神经肱三头肌长头支至腋神经前支；(3)“膈神经”组：膈神经移位至上干前股+副神经至肩胛上神经+颈丛运动支至上干后股；(4)“放弃腋神经修复”组：膈神经移位至上干前股+副神经至肩胛上神经，不作腋神经修复。各组左侧为实验侧，右侧为对照侧。术后3、6和12周每组取10只大鼠作行为学检查和上干主要支配神经再生指标的检测，内容包括：(1)Ochiai临床评分：观测大鼠前肢活动情况并步态分析，按相应标准评分；(2)Barth足错步试验：观察大鼠患侧前肢是否跌入网格栏内，2分钟内记录其错步次数；(3)Terzis梳头试验：评价大鼠清理鼻面部水珠的动作完成程度予分级表示；(4)复合肌肉动作电位(Compound muscle action potential，CMAP)：用超强电流方波脉冲刺激肌皮神经与腋神经，记录CMAP的潜伏期及波幅；(5)肌肉功能与组织学：先使肱二头肌与三角肌处于最适初长度状态，用超强电流连续刺激上述两块肌肉入肌点处肌皮神经与腋神经，记录被检肌等长收缩时最大强直收缩张力变化，然后用分析天平测定肱二头肌与三角肌的湿重，最后对上述肌肉标本横向切取切片，行HE染色，采用图像分析系统测量肌细胞的截面积，将(4)和(5)对照侧的检测数据作1，求得实验侧上述各指标的恢复率；(6)再生有髓神经纤维计数：用甲苯胺蓝对肌皮神经与腋神经的缝合口组织进行染色，通过图像分析软件对缝合口近、远端有髓神经纤维进行计数，并计算再生有髓神经纤维的通过率(远端神经纤维数／近端神经纤维数)。采用Wilcoxon符号秩检验比较同侧颈7组与其余三组检测指标的差异，对检验水准α需进行调整，即α=0．05／3=0．017，以保证三次两两比较总的Ⅰ类错误水平为0．05。统计均采用双侧检验，P值＜0．017表示差异有统计学意义。
结果术后3周，“同侧C7”组上述三项行为学检测指标与三个对照组的统计学差异不显著(P均＞0．017)，该组腋神经CMAP潜伏期及波幅恢复率均显著优于三个对照组(Z值分别为3．184，3．593，3．672，3．104，3．266，3．674，P均＜0．017)，其各项腋神经及三角肌组织学与功能学指标均显著优于“膈神经”组(Z值分别为3．628，3．103，3．115，3．943，P均＜0．017)和“放弃腋神经修复”组(Z值分别为3．674，3．593，3．429，3．296，P均＜0．017)，但与“oberlin”组的差异不显著(Z值分别为2．343，0．613，1．143，1．375，P均＞0．017)。“同侧C7”组除肌皮神经再生有髓神经纤维通过率显著优于“膈神经”组外(Z值为3．533，P＜0．017)，该组其余肌皮神经及肱二头肌的电生理、组织学与功能学检测指标与三个对照组的差异不显著(P均＞0．017)。
至6周，“同侧C7”组Terzis梳头分级指标显著优于三个对照组(Z值分别为3．252，3．272，3．752，P均＜0．017)，该组Ochiai临床评分也已显著优于“放弃腋神经修复”组(Z值为2．443，P＜0．017)，但其余各行为学指标与三个对照组的差异并不显著(P均＞0．017)。“同侧C7”组腋神经电生理和组织学指标显著优于三个对照组(Z值分别为3．021，3．675，3．782，2．531，3．677，3．780，2．870，3．576，3．674，P均＜0．017)，该组三角肌组织学与功能学已显著优于“膈神经”组和“放弃腋神经修复”组(Z值分别为3．674，3．780，3．593，3．705，3．285，3．893，P均＜0．017)、但与“oberlin”组的差异不显著(Z值分别为2．286，1．306，1．846，P均＞0．017)。“同侧C7”组除肌皮神经再生有髓神经纤维通过率显著优于三个对照组(Z值分别为3．184，3．674，3．780，P均＜0．017)以及肌皮神经电生理指标显著优于“放弃腋神经修复”组(Z值分别为3．326，2．797，P均＜0．017)外，该组其余肌皮神经及肱二头肌的电生理、组织学与功能学检测指标与三个对照组的差异不显著(P均＞0．017)。
12周时，“同侧C7”组肱二头肌湿重恢复率与三个对照组之间的差异不显著(Z值分别为0．839，1．722，2．340，P均＞0．017)，“同侧C7”组腋神经CMAP潜伏期延迟率、肱二头肌肌细胞截面积恢复率及肱二头肌强直收缩张力恢复率与“Oberlin”组的差异不显著(Z值分别为1．752，1．810，1．547，P均＞0．017)，“同侧C7”组肌皮神经CMAP潜伏期延迟率与“Oberlin”和“膈神经”组的差异不显著(Z值分别为1．987，2．341，P均＞0．017)，“同侧C7”组肌皮神经CMAP波幅恢复率与“膈神经”和“放弃腋神经修复”组的差异不显著(Z值分别为2．135，2．188，P均＞0．017)；而“同侧C7”组其余各项行为学观察、几乎全部腋神经和三角肌的电生理、组织学与功能学检测以及部分肌皮神经和肱二头肌的电生理、组织学与功能学检测指标均已显著优于三个对照组(P均＜0．017)。
结论同侧C7神经根移位对治疗臂丛上干根性撕脱伤的实验性疗效显著，明显优于临床上常用的其他三种治疗方案。
第二部分同侧C7神经根移位治疗臂丛上干根性撕脱伤患肢功能代偿机制的实验研究
目的对于行同侧C7全根移位治疗臂丛上干根性撕脱伤的患者，长期随访发现并不造成患肢原有功能的明显损害。本实验通过大鼠模型研究臂丛上干根性撕脱伤再切取同侧C7后不造成肢体功能进一步损害的代偿机制，为同侧C7全根移位治疗臂丛神经上干根性撕脱伤的推广应用提供理论依据。
方法60只SD大鼠随机等分为“上干根性撕脱+同侧C7神经根切断”实验组及“单纯上干根性撕脱”对照组。两组大鼠均取颈部正中切口，沿弓状线切开胸大肌后，将胸小肌向侧方牵开，在前中斜角肌之间显露C5～7神经根，对照组C56予以撕脱建立模型，“C7切断”组上干撕脱后再将同侧C7神经根用1％普鲁卡因局封后，切除其3mm一段，断端缝扎，以阻止轴索再生。术后3、6和12周每组取10只大鼠对C7主要支配神经(胸背神经与桡神经)及C7代表肌(背阔肌、肱三头肌、桡侧腕短伸肌和指总伸肌)作以下检测：(1)神经电生理：超强电流单个方波脉冲刺激胸背神经与桡神经，同芯针电极插入以上四块被检肌记录CMAP的波幅和潜伏期；(2)肌肉功能与神经肌肉组织学：先使上述四块肌肉处于最适初长度状态，随即用超强电流连续方波刺激胸背神经与桡神经近入肌点段，记录被检肌等长收缩时最大强直收缩张力变化，再用甲苯胺蓝对胸背神经与桡神经主干进行染色，观察上述二根神经干内再生有髓神经纤维的分布变化特征，然后自止点处完整切取上述四块被检肌，去除表面结缔组织，即刻以分析天平称湿重，最后将上述肌肉标本拉直处于自然伸直状态，对上述肌肉标本的相同部位横向切取5μm切片，行HE染色，采用图像分析系统测量肌细胞的截面积；(3)肌肉组织突触分布和突触后膜面积：取上述四块C7代表肌神经入肌点组织行纵向冰冻切片，加α-银环蛇毒(α-bungarotoxin，α-BTX)进行突触后膜免疫荧光染色，于荧光显微镜下观察运动终板的分布特点，同上述步骤再应用图像分析系统计算突触后膜平均面积，各组左侧为实验侧，右侧为对照侧，将对照侧值作1，求得实验测上述各检测指标的恢复率；(4)神经肌肉超微结构：取上述四块肌肉神经入肌点组织，制成超薄切片，以醋酸铀-枸橼酸铅双染色，用透射电镜观察有髓神经纤维直径以及髓鞘厚度，骨骼肌运动终板的形态，即突触前膜与突触后膜的结构特点以及肌丝和肌小节的排列特征。采用Wilcoxon符号秩检验比较两组恢复率的差异。统计均采用双侧检验，P值＜0．05表示差异有统计学意义。
结果术后3周C7切断组较对照组相比，四块C7代表肌的湿重显著减轻，收缩张力明显降低且肌细胞截面积缩小，复合肌肉动作电位(CMAP)的潜伏期显著延长并波幅下降，运动终板突触后膜面积明显减小，上述指标的差异均有统计学意义(P＜0．05)。荧光显微镜观察显示C7切断组上述四块肌肉的运动终板分布稀疏，光镜及电镜下胸背神经及桡神经干内可见形态不规则的有髓纤维，有少量薄髓鞘的新生小轴突，间质内大量无髓纤维；四块代表肌神经肌接头处可见形态不成熟的再生运动终板，其突触前膜面积小但结构完整，突触后膜有皱褶但数量少且无深沟，突触间隙存在但较为狭窄。
伤后6周，C7切断组肱三头肌CMAP潜伏期及波幅的恢复率与对照组相比差异已不显著(Z值分别为1．143，1．633，P均＞0．05)，C7切断组桡侧腕短伸肌与指总伸肌肌细胞截面积、CMAP潜伏期及波幅和突触后膜面积的恢复率与对照组相比差异亦不显著(Z值分别为1．715，2．206，0．735，1．061，2．124，2．613，2．165，2．776，P均＞0．05)。C7切断组四块C7代表肌的运动终板数量已较3周时明显增多，光镜及电镜下胸背神经及桡神经干内有髓纤维形态渐趋规则，髓鞘较3周时增厚，并有新生小轴突增生，无髓纤维明显减少；四块代表肌的运动终板超微形态趋于成熟，其突触前膜面积逐渐增大，突触后膜皱褶增多加深但递质泡数量仍较少。
到12周，C7切断组各项检测指标的恢复率均已接近对照组(P均＞0．05)，该组C7代表肌的运动终板分布密集且数量较多，光镜及电镜下胸背神经及桡神经干内有髓纤维形态规则，髓鞘较6周时明显增厚，大量新生小轴突增生，并可见轴索芽生现象；四块被检肌的终板超微结构接近成熟，其突触前膜面积大并含线粒体、微管和丰富的突触小泡，突触后膜形成深的皱褶，突触间隙清晰，形态与对照组基本一致。
结论臂丛上干根性撕脱伤切取同侧C7神经根后，下干神经纤维能通过轴索的芽生和运动终板的再生对中干代表肌进行代偿性支配，故不会导致肢体功能的进一步损害。
Part 1 An experimental study on treatment outcome foripsilateral C7 nerve root transfer to repair the root avulsion of C5and C6 of the brachial plexus
Objective Multiple extraplexal nerve transfers were frequently carried out totreat root avulsion of C5 and C6 of the brachial plexus.Gu YD(2002) first used anintraplexal transfer,that is the ipsilateral C7 root transferred to the upper trunk,totreat that kind of lesion.The following study was to experimentally compare thetreatment outcome of the injured upper limb for the C5-C6 root avulsion of thebrachial plexus repaired by ipsilateral C7 nerve root transfer and other threecommonly used nerve transfers.
Methods 120 SD rats were randomly divided into four groups 30 each.All ofthem were fastened supine and anesthetized,then a midline cervical incision wasmade.After pectoralis major was incised along the arcuate line,pectoralis minor wasretracted laterally,and C5-T1 nerve roots were exposed between anterior and middlescalenus muscles.After C5 and C6 root was avulsed,each group underwent variouscombined nerve transfers,that is,(1)‘Ipsilateral C7’group:the ipsilateral C7 roottransferred to the upper trunk of brachial plexus and the spinal accessory nerve to thesuprascapular nerve.(2)‘Oberlin’group:partial fascicles of the ulnar nerve transferredto the biceps branch(Oberlin's procedure),the spinal accessory to the suprascapularand branches to the triceps long head to the axillary nerve.(3)‘phrenic nerve’group:the phrenic transferred to the musculocutaneous,cervical plexus motor branches tothe lower trunk(axillary nerve) of brachial plexus and the spinal accessory nerve to thesuprascapular nerve.(4)‘forsake repairing axillary nerve’group:the phrenictransferred to the musculocutaneous and the spinal accessory nerve to thesuprascapular nerve.Neurotization outcomes were evaluated at 3,6 and 12 weeks postoperatively by comparing changes of behavioral tests,neurophysiologicalinvestigations,muscular histology,and muscular functional examinations.Theparameters were listed as follows:(1) Ochiiai clinical scores:The clinical score wascalculated under two condition.First,the rats were held by the tail above a table,andthen they were placed on table to compare the printed walking patterns.(2) Barthfoot-fault test:the rat was placed on a horizontal grid floor.The foot-fault wasdetermined by an animal misplacing a forelimb and a paw falling through the gridbars.The number of forelimb faults occurring in 2 min was counted.(3) Terzisgrooming test:Squirting 1 to 3 ml of water over the rat's snout,which always elicitedbilateral grooming movements from the rats.We were able to instantaneously assessfunctioning of the experimental side and compare it with the normal side.(4)Compound muscle action potential(CMAP):Maximal current and single square-wavewere used to stimulate the musculocutaneous nerve and axillary nerve.The needleelectrodes were inserted 2 mm-depth for the biceps and deltoid muscles,thestimulating and recording electrodes were placed in the same position at bothforelimbs of rats,and the CAMP amplitude and latency were recorded.(5) Musclefunction,wet weight and cross-sectional area of muscle fiber.The distal portions ofbiceps and deltoid muscles were free,transected and attached to the force transducter.The musculocutaneous and axillary nerves were simulated respectively with asuper-high voltage and a high frequency series of square wave impulses.The curvesof maximum titanic contractile tension of isometric contraction were recorded on atwo-conduction physiological recorder.And then,the biceps and deltoid muscles wereharvested completely by removing connective tissues,then weighed by AnalyticBalance.Transverse sections of those muscle samples were stained by hematoxylinand eosin (HE),and image analysis system was used to measure the cross-sectionalarea of muscle fibers.(6) Regenerating myelinated axon counts.Musculocutaneousnerve and axillary nerve specimens were taken around the anastomotic site.Sectionsof each nerve were stained with toluidine blue and processed for computer-aidedimage analysis system of regenerative axon number.The left forelimbs of both grouprats were taken as the experimental sides,and the right forelimbs of them were takenas the control sides.Values of the control side were taken as 1,so that the recoveryrates of the left side could be obtained by the parameters of the left forelimb dividedby those of the fight forelimb.Wilcoxon signed-ranks test was used for the ratesbetween the‘ipsilateral C7’group and the other 3 control groups respectively. Bonferroni adjustment was used for multiple comparisons.All of the reported Pvalues were two-tailed,and values of p＜0.017 were considered significant.
Results 3 weeks after operation,no significant difference were found betweenthe‘ipsilateral C7’group and other three control groups in the three behavioralevaluations (P＞0.017).Neurophysiologic investigations of the axillary nerve showedthe‘ipsilateral C7’group was superior to the other three groups (Z-value were 3.184,3.593,3.672,3.104,3.266,3.674 respectively,P＜0.017) .Muscular histological andfunctional outcome of the axillary nerve and deltoid muscle showed the‘ipsilateralC7’group was superior to the‘phrenic nerve’(Z-value were 3.628,3.103,3.115,3.943respectively,P＜0.017) and‘forsake repairing axillary nerve’groups (Z-value were3.674,3.593,3.429,3.296 respectively,P＜0.017) ,while no significant differencewere found between the‘ipsilateral C7’and‘oberlin’groups (Z-value were 2.343,0.613,1.143,1.375 respectively,P＞0.017) .Except that the thruput of regeneratingmedullated musculocutaneous nerve fibers of‘ipsilateral C7’group was superior tothat of‘phrenic nerve’group (Z-value were 3.533,P＜0.017) ,neurophysiological,histological and functional outcome of the musculocutaneous nerve and bicepsshowed no significant difference were found between the‘ipsilateral C7’group andother three groups (P＞0.017 ) .
6 weeks after operation,Terzis grooming outcome showed the‘ipsilateralC7’group was superior to the other three groups (Z-value were 3.252,3.272,3.752respectively,P＜0.017) ,and Ochaii clinical score showed the‘ipsilateral C7’groupwas superior to the‘forsake repairing axillary nerve’group either.While,the restresults of the behavioral evaluations showed no significant difference were foundbetween the‘ipsilateral C7’group and other three groups (P＞0.017)Neurophysiologic and histological investigations of the axillary nerve showed the‘ipsilateral C7’group was superior to the other three groups (Z-value were 3.021,3.675,3.782,2.531,3.677,3.780,2.870,3.576,3.674respectively,P＜0.017) .Muscular histological and functional outcome of deltoid muscle showed the‘ipsilateral C7’group was superior to the‘phrenic nerve’and the‘forsake repairingaxillary nerve’groups (Z-value were 3.674,3.780,3.593,3.705,3.285,3.893respectively,P＜0.017) ,but showed no significant difference between the‘ipsilateralC7’group and the‘oberlin’group (Z-value were 2.286,1.306,1.846 respectively,P＞0.017) .Except that regenerating myelinated axon thruputs of musculocutaneousnerve of the‘ipsilateral C7’group were superior to those of three other control groups (Z-value were 3.184,3.674,3.780 respectively,P＜0.017) andneurophysiologicinvestigations of musculocutaneous nerve of the‘ipsilateral C7’group were superiorto those of the‘forsake repairing axillary nerve’group (Z-value were 3.326,2.797respectively,P＜0.017),rest outcomes of neurophysiologic,histological and functionalinvestigations showed no significant difference were found between the‘ipsilateralC7’group and other three groups (P＞0.017 ) .
At 12 weeks postoperatively,nearly all the behavioral,neurophysiological,histological and functional determination showed the‘ipsilateral C7’group wassuperior to the other three groups (P＜0.017) ,except that no significant differencewere found between the‘ipsilateral C7’and other three groups in recovery rate of wetbiceps muscle weight (Z-value were 0.839,1.722,2.340 respectively,P＞0.017),between the‘ipsilateral C7’group and the‘oberlin’group in recovery rate of latentperiods of CMAP with axillary nerve ,cross-sectional area of biceps muscle fibers andmaximum titanic contractile tension of biceps (Z-value were 1.752,1.810,1.547respectively,P＞0.017) ,between the‘ipsilateral C7’group and two control groupsincluding the‘oberlin’and‘phrenic nerve’groups in recovery rate of CMAP withmusculocutaneou nerve (Z-value were 1.987,2.341 respectively,P＞0.017) andbetween the‘ipsilateral C7’group and two control groups including the‘phrenicnerve’and‘forsake repairing axillary nerve’groups in recovery rate of amplitudes ofCMAP with musculocutaneous nerve (Z-value were 2.135,2.188 respectively,P＞0.017)
Conclusions Ipsilateral C7 transferred to the upper trunk of brachial plexuscombined with the spinal accessory nerve to the suprascapular nerve is found to besignificantly effective on treatment of the root avulsion of C5 and C6 of the brachialplexus,which has an better therapeutic effect than other three commonly used nervetransfers.
Part 2 An experimental study on mechanism of functionalcompensation for the injured extremity with brachial plexus uppertrunk avulsion after ipsilateral C7 transfer.
Objective It was well documented by the follow-up materials that ipsilateralC7 transection had not apparent impairment on the injured-extremity in patients withroot avulsion of C5-C6 of the brachial plexus.The following study was to investigatethe compensative mechanism of no further impairment of the upper limb afteripsilateral C7 transfer for treatment of root avulsion of C5 and C6 of the brachialplexus,which could provide theoretic evidence of generalization for the ipsilateral C7root transfer to treat avulsion of the brachial upper trunk.
Methods 60 SD rats were divided into 2 groups,one undergoing transection ofipsilateral C7 root after C5-C6 root avulsion as experimental group,and the othersimple C5-C6 root avulsion as control group.All the rats were fastened supine andanesthetized,then a midline cervical incision was made.After pectoralis major wasincised along the arcuate line,pectoralis minor was retracted laterally,and C5-C7nerve roots were exposed between anterior and middle scalenus muscles.After C5 andC6 nerve roots were avulsed,the ipsilateral C7 root was truncated by one-3mm-section(blocked by 1% procaine),and the neural stumps were sutured to preventthem to regenerate.Neurotization outcomes of the 2 groups were evaluated atpost-operative 3,6 and 12 weeks by comparing the electrophysiologic,histologic,functional and histomorphometric changes of C7-innervated nerves includingthoracodorsal nerve and radial nerve and C7-innervated muscles including latissimusdorsi,triceps brachii ,extensor carpi radialis brevis and extensor digiti communismuscles.The parameters were listed as follows:(1) CMAP:Maximal current andsingle square-wave were used to stimulate the thoracodorsal nerve and radial nerve.The needle electrodes were inserted 2 mm-depth for the four representive muscles,thestimulating and recording electrodes were placed in the same position at bothforelimbs of rats,and the CAMP amplitude and latency were recorded.(2) Musclefunction,regenerating myelinated axon counts,wet weight and cross-sectional area ofmuscle fiber.The distal portions of four representive muscles were free,transectedand attached to the force transducter.The thoracodorsal and radial nerves were simulated respectively with a super-high voltage and a high frequency series of squarewave impulses.The curves of maximum titanic contractile tension of isometriccontraction were recorded on a two-conduction physiological recorder.And then ,thoracodorsal and radial nerve specimens were taken around the anastomotic site.Sections of each nerve were stained with toluidine blue and processed forcomputer-aided image analysis system of regenerative axon number.At last,the fourrepresentive muscles were harvested completely by removing connective tissues,thenweighed by Analytic Balance.Transverse sections of those muscle samples werestained by hematoxylin and eosin (HE),and image analysis systemwas used tomeasure the cross-sectional area of muscle fibers.(3) Synapses distribution and postsynaptic membrane area of muscles.Nerve tissue of entry point to the muscle wereselected to make longitudinal frozen sections.α-bungarotoxin(α-BTX) were incubatedand measured by immunofluorescence staining.The motor end plates distributionfeatures were observed under fluorescent microscope and the overall areas of themwere calculated by imaging analysis system.The average area was obtained by overallareas divided by the number of the post synaptic membrane.(4) Ultramicrostructureof the nerves and muscles.Nerve tissue of entry point to the muscle was dehydratedby ethanol and propanone.After embedding and solidification,ultrathin sections weremade and double-dyed by uranyl acetate-lead citrate.The Morphology of skeletalmuscle motor end plates,i.e.the structure of the myofilament anterior synapticmembrane,the post synaptic membrane and the sarcomere,was observed undertransmission electron microscope.The left forelimbs of both group rats were taken asthe experimental sides,and the right forelimbs of them were taken as the control sides.Values of the control side were taken as 1,so that the recovery rates of the left sidecould be obtained by the parameters of the left forelimb divided by those of the rightforelimb.Those recovery rates between the C7-transection and control groups werecompared by Wilcoxon signed rank test.P-value＜0.05 were considered as significantlevel.
Results 3 weeks after operation,recovery rates of amplitude of CMAP andCMAP latency of those four representive muscles in the C7-transection group weresignificantly lower than those in the control group(p＜0.05).Recovery rates ofmuscular wet weight,muscular contractile tension and cross-sectional area of musclefibers of four representive muscles in the C7-transection group were also significantlylower than those in the control group(p＜0.05).In addition,the recovery rate of area of post synaptic membranes of those four muscles in the C7-transection group wassignificantly lower than that in the control group(p＜0.05).The abnormalultramicrostructure of the motor end plates of four representive muscles was found inthe C7-transection group,that is,immature morphology,smaller but integralmicrostructure in the anterior synaptic membrane area,less folds and absence of deepgrooves in the post synaptic membrane,narrower synaptic cleft,irregularly orderedmyocomma and myofilament.Motor end plates in part of latissimus dorsi and oftriceps were still in a primary stage of morphology in the C7-transection group.
At 6 weeks postoperatively,recovery rates of CMAP amplitude and latency fortriceps were not significantly different between the C7-transection and controlgroups(Z-value were 1.143,1.633 respectively,p＞0.05).For extensor carpi radialisbrevis and extensor digitorum communis,recovery rates of cross-sectional area ofmuscle fibers,of the amplitude and latency of CMAP and of the area of post synapticmembranes were not significantly different between the two groups (Z-value were1.715,2.206,0.735,1.061,2.124,2.613,2.165,2.776 respectively,p＞0.05),while,the rest of parameters of evaluation were still significantly different between the twogroups(p＜0.05).As far as the ultramicrostructure was concerned in the C7-transectiongroup,more motor end plates of four representive muscles were observed,and theirultramicrostructure also had a tendency to mature as compared with those at 3 weekspostoperatively.
12 weeks after operation,all parameters of the C7-transection group were notsignificantly different with those of the control group(p＞0.05).Motor end plates weredensely distributed and their ultramicrostructure in four representive muscles ofC7-transection group appeared to be mature as compared with those of the controlgroup,i.e.large area of anterior synaptic membrane containing chondriosomes,microtubules and abundant synaptic vesicle,deep folds in post synaptic membrane,clear synaptic cleft,well-ordered myocomma and myofilament without swelling ordisruption.
Conclusions After ipsilateral C7 transfer for treatment of root avulsion ofC5-C6 of the brachial plexus,the nerve fibers of lower trunk can compensativelyinnervate fibres of C7-representive muscles by means of neuraxon gemmation andmotor end plate regeneration,so there is no further impairment in the affectedextremity.
目的臂丛上干根性撕脱伤常用丛外神经移位进行治疗。2002年顾玉东首创同侧C7全根移位手术治疗上干根性撕脱伤患者疗效显著。本实验通过动物模型比较同侧C7全根移位与其它三种常用治疗方案对臂丛上干根性撕脱伤的疗效，以确认同侧C7全根移位手术在臂丛损伤治疗中的应用价值。
方法120只SD大鼠随机等分为4组，均取颈部正中切口，沿弓状线切开胸大肌后，将胸小肌向侧方牵开，在前中斜角肌之间显露C5～7神经根，C56予以撕脱建立模型，分别以下述四组方案进行神经移位修复上干：(1)“同侧C7”组：同侧C7移位至上干+副神经至肩胛上神经；(2)“Oberlin”组：Oberlin手术(尺神经一束移位至肱二头肌支)+副神经至肩胛上神经+桡神经肱三头肌长头支至腋神经前支；(3)“膈神经”组：膈神经移位至上干前股+副神经至肩胛上神经+颈丛运动支至上干后股；(4)“放弃腋神经修复”组：膈神经移位至上干前股+副神经至肩胛上神经，不作腋神经修复。各组左侧为实验侧，右侧为对照侧。术后3、6和12周每组取10只大鼠作行为学检查和上干主要支配神经再生指标的检测，内容包括：(1)Ochiai临床评分：观测大鼠前肢活动情况并步态分析，按相应标准评分；(2)Barth足错步试验：观察大鼠患侧前肢是否跌入网格栏内，2分钟内记录其错步次数；(3)Terzis梳头试验：评价大鼠清理鼻面部水珠的动作完成程度予分级表示；(4)复合肌肉动作电位(Compound muscle action potential，CMAP)：用超强电流方波脉冲刺激肌皮神经与腋神经，记录CMAP的潜伏期及波幅；(5)肌肉功能与组织学：先使肱二头肌与三角肌处于最适初长度状态，用超强电流连续刺激上述两块肌肉入肌点处肌皮神经与腋神经，记录被检肌等长收缩时最大强直收缩张力变化，然后用分析天平测定肱二头肌与三角肌的湿重，最后对上述肌肉标本横向切取切片，行HE染色，采用图像分析系统测量肌细胞的截面积，将(4)和(5)对照侧的检测数据作1，求得实验侧上述各指标的恢复率；(6)再生有髓神经纤维计数：用甲苯胺蓝对肌皮神经与腋神经的缝合口组织进行染色，通过图像分析软件对缝合口近、远端有髓神经纤维进行计数，并计算再生有髓神经纤维的通过率(远端神经纤维数／近端神经纤维数)。采用Wilcoxon符号秩检验比较同侧颈7组与其余三组检测指标的差异，对检验水准α需进行调整，即α=0．05／3=0．017，以保证三次两两比较总的Ⅰ类错误水平为0．05。统计均采用双侧检验，P值＜0．017表示差异有统计学意义。
结果术后3周，“同侧C7”组上述三项行为学检测指标与三个对照组的统计学差异不显著(P均＞0．017)，该组腋神经CMAP潜伏期及波幅恢复率均显著优于三个对照组(Z值分别为3．184，3．593，3．672，3．104，3．266，3．674，P均＜0．017)，其各项腋神经及三角肌组织学与功能学指标均显著优于“膈神经”组(Z值分别为3．628，3．103，3．115，3．943，P均＜0．017)和“放弃腋神经修复”组(Z值分别为3．674，3．593，3．429，3．296，P均＜0．017)，但与“oberlin”组的差异不显著(Z值分别为2．343，0．613，1．143，1．375，P均＞0．017)。“同侧C7”组除肌皮神经再生有髓神经纤维通过率显著优于“膈神经”组外(Z值为3．533，P＜0．017)，该组其余肌皮神经及肱二头肌的电生理、组织学与功能学检测指标与三个对照组的差异不显著(P均＞0．017)。
至6周，“同侧C7”组Terzis梳头分级指标显著优于三个对照组(Z值分别为3．252，3．272，3．752，P均＜0．017)，该组Ochiai临床评分也已显著优于“放弃腋神经修复”组(Z值为2．443，P＜0．017)，但其余各行为学指标与三个对照组的差异并不显著(P均＞0．017)。“同侧C7”组腋神经电生理和组织学指标显著优于三个对照组(Z值分别为3．021，3．675，3．782，2．531，3．677，3．780，2．870，3．576，3．674，P均＜0．017)，该组三角肌组织学与功能学已显著优于“膈神经”组和“放弃腋神经修复”组(Z值分别为3．674，3．780，3．593，3．705，3．285，3．893，P均＜0．017)、但与“oberlin”组的差异不显著(Z值分别为2．286，1．306，1．846，P均＞0．017)。“同侧C7”组除肌皮神经再生有髓神经纤维通过率显著优于三个对照组(Z值分别为3．184，3．674，3．780，P均＜0．017)以及肌皮神经电生理指标显著优于“放弃腋神经修复”组(Z值分别为3．326，2．797，P均＜0．017)外，该组其余肌皮神经及肱二头肌的电生理、组织学与功能学检测指标与三个对照组的差异不显著(P均＞0．017)。
12周时，“同侧C7”组肱二头肌湿重恢复率与三个对照组之间的差异不显著(Z值分别为0．839，1．722，2．340，P均＞0．017)，“同侧C7”组腋神经CMAP潜伏期延迟率、肱二头肌肌细胞截面积恢复率及肱二头肌强直收缩张力恢复率与“Oberlin”组的差异不显著(Z值分别为1．752，1．810，1．547，P均＞0．017)，“同侧C7”组肌皮神经CMAP潜伏期延迟率与“Oberlin”和“膈神经”组的差异不显著(Z值分别为1．987，2．341，P均＞0．017)，“同侧C7”组肌皮神经CMAP波幅恢复率与“膈神经”和“放弃腋神经修复”组的差异不显著(Z值分别为2．135，2．188，P均＞0．017)；而“同侧C7”组其余各项行为学观察、几乎全部腋神经和三角肌的电生理、组织学与功能学检测以及部分肌皮神经和肱二头肌的电生理、组织学与功能学检测指标均已显著优于三个对照组(P均＜0．017)。
结论同侧C7神经根移位对治疗臂丛上干根性撕脱伤的实验性疗效显著，明显优于临床上常用的其他三种治疗方案。
第二部分同侧C7神经根移位治疗臂丛上干根性撕脱伤患肢功能代偿机制的实验研究
目的对于行同侧C7全根移位治疗臂丛上干根性撕脱伤的患者，长期随访发现并不造成患肢原有功能的明显损害。本实验通过大鼠模型研究臂丛上干根性撕脱伤再切取同侧C7后不造成肢体功能进一步损害的代偿机制，为同侧C7全根移位治疗臂丛神经上干根性撕脱伤的推广应用提供理论依据。
方法60只SD大鼠随机等分为“上干根性撕脱+同侧C7神经根切断”实验组及“单纯上干根性撕脱”对照组。两组大鼠均取颈部正中切口，沿弓状线切开胸大肌后，将胸小肌向侧方牵开，在前中斜角肌之间显露C5～7神经根，对照组C56予以撕脱建立模型，“C7切断”组上干撕脱后再将同侧C7神经根用1％普鲁卡因局封后，切除其3mm一段，断端缝扎，以阻止轴索再生。术后3、6和12周每组取10只大鼠对C7主要支配神经(胸背神经与桡神经)及C7代表肌(背阔肌、肱三头肌、桡侧腕短伸肌和指总伸肌)作以下检测：(1)神经电生理：超强电流单个方波脉冲刺激胸背神经与桡神经，同芯针电极插入以上四块被检肌记录CMAP的波幅和潜伏期；(2)肌肉功能与神经肌肉组织学：先使上述四块肌肉处于最适初长度状态，随即用超强电流连续方波刺激胸背神经与桡神经近入肌点段，记录被检肌等长收缩时最大强直收缩张力变化，再用甲苯胺蓝对胸背神经与桡神经主干进行染色，观察上述二根神经干内再生有髓神经纤维的分布变化特征，然后自止点处完整切取上述四块被检肌，去除表面结缔组织，即刻以分析天平称湿重，最后将上述肌肉标本拉直处于自然伸直状态，对上述肌肉标本的相同部位横向切取5μm切片，行HE染色，采用图像分析系统测量肌细胞的截面积；(3)肌肉组织突触分布和突触后膜面积：取上述四块C7代表肌神经入肌点组织行纵向冰冻切片，加α-银环蛇毒(α-bungarotoxin，α-BTX)进行突触后膜免疫荧光染色，于荧光显微镜下观察运动终板的分布特点，同上述步骤再应用图像分析系统计算突触后膜平均面积，各组左侧为实验侧，右侧为对照侧，将对照侧值作1，求得实验测上述各检测指标的恢复率；(4)神经肌肉超微结构：取上述四块肌肉神经入肌点组织，制成超薄切片，以醋酸铀-枸橼酸铅双染色，用透射电镜观察有髓神经纤维直径以及髓鞘厚度，骨骼肌运动终板的形态，即突触前膜与突触后膜的结构特点以及肌丝和肌小节的排列特征。采用Wilcoxon符号秩检验比较两组恢复率的差异。统计均采用双侧检验，P值＜0．05表示差异有统计学意义。
结果术后3周C7切断组较对照组相比，四块C7代表肌的湿重显著减轻，收缩张力明显降低且肌细胞截面积缩小，复合肌肉动作电位(CMAP)的潜伏期显著延长并波幅下降，运动终板突触后膜面积明显减小，上述指标的差异均有统计学意义(P＜0．05)。荧光显微镜观察显示C7切断组上述四块肌肉的运动终板分布稀疏，光镜及电镜下胸背神经及桡神经干内可见形态不规则的有髓纤维，有少量薄髓鞘的新生小轴突，间质内大量无髓纤维；四块代表肌神经肌接头处可见形态不成熟的再生运动终板，其突触前膜面积小但结构完整，突触后膜有皱褶但数量少且无深沟，突触间隙存在但较为狭窄。
伤后6周，C7切断组肱三头肌CMAP潜伏期及波幅的恢复率与对照组相比差异已不显著(Z值分别为1．143，1．633，P均＞0．05)，C7切断组桡侧腕短伸肌与指总伸肌肌细胞截面积、CMAP潜伏期及波幅和突触后膜面积的恢复率与对照组相比差异亦不显著(Z值分别为1．715，2．206，0．735，1．061，2．124，2．613，2．165，2．776，P均＞0．05)。C7切断组四块C7代表肌的运动终板数量已较3周时明显增多，光镜及电镜下胸背神经及桡神经干内有髓纤维形态渐趋规则，髓鞘较3周时增厚，并有新生小轴突增生，无髓纤维明显减少；四块代表肌的运动终板超微形态趋于成熟，其突触前膜面积逐渐增大，突触后膜皱褶增多加深但递质泡数量仍较少。
到12周，C7切断组各项检测指标的恢复率均已接近对照组(P均＞0．05)，该组C7代表肌的运动终板分布密集且数量较多，光镜及电镜下胸背神经及桡神经干内有髓纤维形态规则，髓鞘较6周时明显增厚，大量新生小轴突增生，并可见轴索芽生现象；四块被检肌的终板超微结构接近成熟，其突触前膜面积大并含线粒体、微管和丰富的突触小泡，突触后膜形成深的皱褶，突触间隙清晰，形态与对照组基本一致。
结论臂丛上干根性撕脱伤切取同侧C7神经根后，下干神经纤维能通过轴索的芽生和运动终板的再生对中干代表肌进行代偿性支配，故不会导致肢体功能的进一步损害。
Part 1 An experimental study on treatment outcome foripsilateral C7 nerve root transfer to repair the root avulsion of C5and C6 of the brachial plexus
Objective Multiple extraplexal nerve transfers were frequently carried out totreat root avulsion of C5 and C6 of the brachial plexus.Gu YD(2002) first used anintraplexal transfer,that is the ipsilateral C7 root transferred to the upper trunk,totreat that kind of lesion.The following study was to experimentally compare thetreatment outcome of the injured upper limb for the C5-C6 root avulsion of thebrachial plexus repaired by ipsilateral C7 nerve root transfer and other threecommonly used nerve transfers.
Methods 120 SD rats were randomly divided into four groups 30 each.All ofthem were fastened supine and anesthetized,then a midline cervical incision wasmade.After pectoralis major was incised along the arcuate line,pectoralis minor wasretracted laterally,and C5-T1 nerve roots were exposed between anterior and middlescalenus muscles.After C5 and C6 root was avulsed,each group underwent variouscombined nerve transfers,that is,(1)‘Ipsilateral C7’group:the ipsilateral C7 roottransferred to the upper trunk of brachial plexus and the spinal accessory nerve to thesuprascapular nerve.(2)‘Oberlin’group:partial fascicles of the ulnar nerve transferredto the biceps branch(Oberlin's procedure),the spinal accessory to the suprascapularand branches to the triceps long head to the axillary nerve.(3)‘phrenic nerve’group:the phrenic transferred to the musculocutaneous,cervical plexus motor branches tothe lower trunk(axillary nerve) of brachial plexus and the spinal accessory nerve to thesuprascapular nerve.(4)‘forsake repairing axillary nerve’group:the phrenictransferred to the musculocutaneous and the spinal accessory nerve to thesuprascapular nerve.Neurotization outcomes were evaluated at 3,6 and 12 weeks postoperatively by comparing changes of behavioral tests,neurophysiologicalinvestigations,muscular histology,and muscular functional examinations.Theparameters were listed as follows:(1) Ochiiai clinical scores:The clinical score wascalculated under two condition.First,the rats were held by the tail above a table,andthen they were placed on table to compare the printed walking patterns.(2) Barthfoot-fault test:the rat was placed on a horizontal grid floor.The foot-fault wasdetermined by an animal misplacing a forelimb and a paw falling through the gridbars.The number of forelimb faults occurring in 2 min was counted.(3) Terzisgrooming test:Squirting 1 to 3 ml of water over the rat's snout,which always elicitedbilateral grooming movements from the rats.We were able to instantaneously assessfunctioning of the experimental side and compare it with the normal side.(4)Compound muscle action potential(CMAP):Maximal current and single square-wavewere used to stimulate the musculocutaneous nerve and axillary nerve.The needleelectrodes were inserted 2 mm-depth for the biceps and deltoid muscles,thestimulating and recording electrodes were placed in the same position at bothforelimbs of rats,and the CAMP amplitude and latency were recorded.(5) Musclefunction,wet weight and cross-sectional area of muscle fiber.The distal portions ofbiceps and deltoid muscles were free,transected and attached to the force transducter.The musculocutaneous and axillary nerves were simulated respectively with asuper-high voltage and a high frequency series of square wave impulses.The curvesof maximum titanic contractile tension of isometric contraction were recorded on atwo-conduction physiological recorder.And then,the biceps and deltoid muscles wereharvested completely by removing connective tissues,then weighed by AnalyticBalance.Transverse sections of those muscle samples were stained by hematoxylinand eosin (HE),and image analysis system was used to measure the cross-sectionalarea of muscle fibers.(6) Regenerating myelinated axon counts.Musculocutaneousnerve and axillary nerve specimens were taken around the anastomotic site.Sectionsof each nerve were stained with toluidine blue and processed for computer-aidedimage analysis system of regenerative axon number.The left forelimbs of both grouprats were taken as the experimental sides,and the right forelimbs of them were takenas the control sides.Values of the control side were taken as 1,so that the recoveryrates of the left side could be obtained by the parameters of the left forelimb dividedby those of the fight forelimb.Wilcoxon signed-ranks test was used for the ratesbetween the‘ipsilateral C7’group and the other 3 control groups respectively. Bonferroni adjustment was used for multiple comparisons.All of the reported Pvalues were two-tailed,and values of p＜0.017 were considered significant.
Results 3 weeks after operation,no significant difference were found betweenthe‘ipsilateral C7’group and other three control groups in the three behavioralevaluations (P＞0.017).Neurophysiologic investigations of the axillary nerve showedthe‘ipsilateral C7’group was superior to the other three groups (Z-value were 3.184,3.593,3.672,3.104,3.266,3.674 respectively,P＜0.017) .Muscular histological andfunctional outcome of the axillary nerve and deltoid muscle showed the‘ipsilateralC7’group was superior to the‘phrenic nerve’(Z-value were 3.628,3.103,3.115,3.943respectively,P＜0.017) and‘forsake repairing axillary nerve’groups (Z-value were3.674,3.593,3.429,3.296 respectively,P＜0.017) ,while no significant differencewere found between the‘ipsilateral C7’and‘oberlin’groups (Z-value were 2.343,0.613,1.143,1.375 respectively,P＞0.017) .Except that the thruput of regeneratingmedullated musculocutaneous nerve fibers of‘ipsilateral C7’group was superior tothat of‘phrenic nerve’group (Z-value were 3.533,P＜0.017) ,neurophysiological,histological and functional outcome of the musculocutaneous nerve and bicepsshowed no significant difference were found between the‘ipsilateral C7’group andother three groups (P＞0.017 ) .
6 weeks after operation,Terzis grooming outcome showed the‘ipsilateralC7’group was superior to the other three groups (Z-value were 3.252,3.272,3.752respectively,P＜0.017) ,and Ochaii clinical score showed the‘ipsilateral C7’groupwas superior to the‘forsake repairing axillary nerve’group either.While,the restresults of the behavioral evaluations showed no significant difference were foundbetween the‘ipsilateral C7’group and other three groups (P＞0.017)Neurophysiologic and histological investigations of the axillary nerve showed the‘ipsilateral C7’group was superior to the other three groups (Z-value were 3.021,3.675,3.782,2.531,3.677,3.780,2.870,3.576,3.674respectively,P＜0.017) .Muscular histological and functional outcome of deltoid muscle showed the‘ipsilateral C7’group was superior to the‘phrenic nerve’and the‘forsake repairingaxillary nerve’groups (Z-value were 3.674,3.780,3.593,3.705,3.285,3.893respectively,P＜0.017) ,but showed no significant difference between the‘ipsilateralC7’group and the‘oberlin’group (Z-value were 2.286,1.306,1.846 respectively,P＞0.017) .Except that regenerating myelinated axon thruputs of musculocutaneousnerve of the‘ipsilateral C7’group were superior to those of three other control groups (Z-value were 3.184,3.674,3.780 respectively,P＜0.017) andneurophysiologicinvestigations of musculocutaneous nerve of the‘ipsilateral C7’group were superiorto those of the‘forsake repairing axillary nerve’group (Z-value were 3.326,2.797respectively,P＜0.017),rest outcomes of neurophysiologic,histological and functionalinvestigations showed no significant difference were found between the‘ipsilateralC7’group and other three groups (P＞0.017 ) .
At 12 weeks postoperatively,nearly all the behavioral,neurophysiological,histological and functional determination showed the‘ipsilateral C7’group wassuperior to the other three groups (P＜0.017) ,except that no significant differencewere found between the‘ipsilateral C7’and other three groups in recovery rate of wetbiceps muscle weight (Z-value were 0.839,1.722,2.340 respectively,P＞0.017),between the‘ipsilateral C7’group and the‘oberlin’group in recovery rate of latentperiods of CMAP with axillary nerve ,cross-sectional area of biceps muscle fibers andmaximum titanic contractile tension of biceps (Z-value were 1.752,1.810,1.547respectively,P＞0.017) ,between the‘ipsilateral C7’group and two control groupsincluding the‘oberlin’and‘phrenic nerve’groups in recovery rate of CMAP withmusculocutaneou nerve (Z-value were 1.987,2.341 respectively,P＞0.017) andbetween the‘ipsilateral C7’group and two control groups including the‘phrenicnerve’and‘forsake repairing axillary nerve’groups in recovery rate of amplitudes ofCMAP with musculocutaneous nerve (Z-value were 2.135,2.188 respectively,P＞0.017)
Conclusions Ipsilateral C7 transferred to the upper trunk of brachial plexuscombined with the spinal accessory nerve to the suprascapular nerve is found to besignificantly effective on treatment of the root avulsion of C5 and C6 of the brachialplexus,which has an better therapeutic effect than other three commonly used nervetransfers.
Part 2 An experimental study on mechanism of functionalcompensation for the injured extremity with brachial plexus uppertrunk avulsion after ipsilateral C7 transfer.
Objective It was well documented by the follow-up materials that ipsilateralC7 transection had not apparent impairment on the injured-extremity in patients withroot avulsion of C5-C6 of the brachial plexus.The following study was to investigatethe compensative mechanism of no further impairment of the upper limb afteripsilateral C7 transfer for treatment of root avulsion of C5 and C6 of the brachialplexus,which could provide theoretic evidence of generalization for the ipsilateral C7root transfer to treat avulsion of the brachial upper trunk.
Methods 60 SD rats were divided into 2 groups,one undergoing transection ofipsilateral C7 root after C5-C6 root avulsion as experimental group,and the othersimple C5-C6 root avulsion as control group.All the rats were fastened supine andanesthetized,then a midline cervical incision was made.After pectoralis major wasincised along the arcuate line,pectoralis minor was retracted laterally,and C5-C7nerve roots were exposed between anterior and middle scalenus muscles.After C5 andC6 nerve roots were avulsed,the ipsilateral C7 root was truncated by one-3mm-section(blocked by 1% procaine),and the neural stumps were sutured to preventthem to regenerate.Neurotization outcomes of the 2 groups were evaluated atpost-operative 3,6 and 12 weeks by comparing the electrophysiologic,histologic,functional and histomorphometric changes of C7-innervated nerves includingthoracodorsal nerve and radial nerve and C7-innervated muscles including latissimusdorsi,triceps brachii ,extensor carpi radialis brevis and extensor digiti communismuscles.The parameters were listed as follows:(1) CMAP:Maximal current andsingle square-wave were used to stimulate the thoracodorsal nerve and radial nerve.The needle electrodes were inserted 2 mm-depth for the four representive muscles,thestimulating and recording electrodes were placed in the same position at bothforelimbs of rats,and the CAMP amplitude and latency were recorded.(2) Musclefunction,regenerating myelinated axon counts,wet weight and cross-sectional area ofmuscle fiber.The distal portions of four representive muscles were free,transectedand attached to the force transducter.The thoracodorsal and radial nerves were simulated respectively with a super-high voltage and a high frequency series of squarewave impulses.The curves of maximum titanic contractile tension of isometriccontraction were recorded on a two-conduction physiological recorder.And then ,thoracodorsal and radial nerve specimens were taken around the anastomotic site.Sections of each nerve were stained with toluidine blue and processed forcomputer-aided image analysis system of regenerative axon number.At last,the fourrepresentive muscles were harvested completely by removing connective tissues,thenweighed by Analytic Balance.Transverse sections of those muscle samples werestained by hematoxylin and eosin (HE),and image analysis systemwas used tomeasure the cross-sectional area of muscle fibers.(3) Synapses distribution and postsynaptic membrane area of muscles.Nerve tissue of entry point to the muscle wereselected to make longitudinal frozen sections.α-bungarotoxin(α-BTX) were incubatedand measured by immunofluorescence staining.The motor end plates distributionfeatures were observed under fluorescent microscope and the overall areas of themwere calculated by imaging analysis system.The average area was obtained by overallareas divided by the number of the post synaptic membrane.(4) Ultramicrostructureof the nerves and muscles.Nerve tissue of entry point to the muscle was dehydratedby ethanol and propanone.After embedding and solidification,ultrathin sections weremade and double-dyed by uranyl acetate-lead citrate.The Morphology of skeletalmuscle motor end plates,i.e.the structure of the myofilament anterior synapticmembrane,the post synaptic membrane and the sarcomere,was observed undertransmission electron microscope.The left forelimbs of both group rats were taken asthe experimental sides,and the right forelimbs of them were taken as the control sides.Values of the control side were taken as 1,so that the recovery rates of the left sidecould be obtained by the parameters of the left forelimb divided by those of the rightforelimb.Those recovery rates between the C7-transection and control groups werecompared by Wilcoxon signed rank test.P-value＜0.05 were considered as significantlevel.
Results 3 weeks after operation,recovery rates of amplitude of CMAP andCMAP latency of those four representive muscles in the C7-transection group weresignificantly lower than those in the control group(p＜0.05).Recovery rates ofmuscular wet weight,muscular contractile tension and cross-sectional area of musclefibers of four representive muscles in the C7-transection group were also significantlylower than those in the control group(p＜0.05).In addition,the recovery rate of area of post synaptic membranes of those four muscles in the C7-transection group wassignificantly lower than that in the control group(p＜0.05).The abnormalultramicrostructure of the motor end plates of four representive muscles was found inthe C7-transection group,that is,immature morphology,smaller but integralmicrostructure in the anterior synaptic membrane area,less folds and absence of deepgrooves in the post synaptic membrane,narrower synaptic cleft,irregularly orderedmyocomma and myofilament.Motor end plates in part of latissimus dorsi and oftriceps were still in a primary stage of morphology in the C7-transection group.
At 6 weeks postoperatively,recovery rates of CMAP amplitude and latency fortriceps were not significantly different between the C7-transection and controlgroups(Z-value were 1.143,1.633 respectively,p＞0.05).For extensor carpi radialisbrevis and extensor digitorum communis,recovery rates of cross-sectional area ofmuscle fibers,of the amplitude and latency of CMAP and of the area of post synapticmembranes were not significantly different between the two groups (Z-value were1.715,2.206,0.735,1.061,2.124,2.613,2.165,2.776 respectively,p＞0.05),while,the rest of parameters of evaluation were still significantly different between the twogroups(p＜0.05).As far as the ultramicrostructure was concerned in the C7-transectiongroup,more motor end plates of four representive muscles were observed,and theirultramicrostructure also had a tendency to mature as compared with those at 3 weekspostoperatively.
12 weeks after operation,all parameters of the C7-transection group were notsignificantly different with those of the control group(p＞0.05).Motor end plates weredensely distributed and their ultramicrostructure in four representive muscles ofC7-transection group appeared to be mature as compared with those of the controlgroup,i.e.large area of anterior synaptic membrane containing chondriosomes,microtubules and abundant synaptic vesicle,deep folds in post synaptic membrane,clear synaptic cleft,well-ordered myocomma and myofilament without swelling ordisruption.
Conclusions After ipsilateral C7 transfer for treatment of root avulsion ofC5-C6 of the brachial plexus,the nerve fibers of lower trunk can compensativelyinnervate fibres of C7-representive muscles by means of neuraxon gemmation andmotor end plate regeneration,so there is no further impairment in the affectedextremity.
引文
1．顾玉东．臂丛神经损伤与疾病的诊治．第2版，上海：上海医科大学出版社，2001：15-23．
2．Bertelli JA，Florianopolis，Gbizoni MF，et al．Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers： spinal accessory to suprascapular，ulnar fascicles to biceps branch，and triceps long or lateral head branch to axillary nerve[J]．J Hand Surg(Am)，2004；29：131-139．
3．Birch R，Bonney G, Wynn Parry CB．Surgical Disorders of the Peripheral Nerves[J]．Edinburgh： Churchill Livingstone，1998：157-207．
4．Gilbert A，Pivato G，Kheiralla T．Long-term results of primary repair of brachial plexus lesions in children[J]．Microsurgery，2006； 26： 334-342．
5．Kiat Witoonchart，Somsak Leechavengvongs，Chairoj Uerpairokjkit，et al．Nerve transfer to deltoid muscle using the nerve to the long head of the triceps，Part Ⅰ： an anatomic feasibility study[J]．J Hand Surg，2003；28A：628-632．
6．Gu YD，Cai PQ，Xu F，et al．Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus[J]．Microsurgery，2003； 23(2)：105-108．
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9．Bertelli JA，Mira JC，Gilbert A，et al．Anatomical basis of rat brachial plexus reconstruction[J]．Surg Radiol Anat，1992；14(1)：85-86．
10．Chen L，Gu YD．An experimental study of contralateral C7 root transfer with vascularized nerve grafting to treat brachial plexus root avulsion[J]．J Hand Surg[Br]，1994；19(B)：60-66．
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2 Bertelli JA，Florianopolis，Gbizoni MF，et al．Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers： spinal accessory to suprascapular，ulnar fascicles to biceps branch，and triceps long or lateral head branch to axillary nerve[J]．J Hand Surg，2004； 29A：131-139．
3 Birch R，Bonney G，Wynn Parry CB．Surgical Disorders of the Peripheral Nerves[J]．Edinburgh： Churchill Livingstone，1998： 157-207．
4 Gu YD，Cai PQ，Xu F，et al．Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus[J]．Microsurgery，2003； 23(2)：105-108．
5 Bertelli JA，Mira JC，Gilbert A，et al．Anatomical basis of rat brachial plexus reconstruction[J]．Surg Radiol Anat，1992； 14(l)：85-86．
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8 陈亮，顾玉东．健侧颈7神经根移位治疗臂丛根性撕脱伤的实验研究[J]．中华外科杂志，1992； 30(9]： 525-527．
9 顾玉东，沈丽英，沈尊理，等．臂丛神经根支配功能的电生理研究[J]．中华外科杂志1996； 34(1)：40-43．
10 Jesus Gil B．Inciong，William C．Marrocco，Julia K．Terzis．Efficacy of intervention strategies in a brachial plexus global avulsion model in the rat[J]．Plastic and Reconstructive Surgery，2000； 105(6)： 2059-2071．
11 Oberlin，C，Beal D，Leechavengvongs S，Salon A，et，al．Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus： anatomical study and report of four cases[J]．J Hand Surg，1994；19A：232-237．
12 Kiat Witoonchart，Somsak Leechavengvongs，Chairoj Uerpairokjkit，et al．Nerve transfer to deltoid muscle using the nerve to the long head of the triceps，Part Ⅰ： an anatomic feasibility study[J]．J Hand Surg，2003；28A：628-632．
13 Hidenobu Ochiai，Tomoaki Ikeda，Kenichi Mishima，et al．Development of a novel experimental rat model for neonatal preganglionic upper brachial plexus injury[J]．J．Neurosci．Methods，2002； 119：51-57．
14 Bona E，Johansson BB，Hagberg H．Sensoriomotor function and neuropathology 5-6 weeks after hypoxia-ischemia in 7-day-old rats[J]．Pediatr Res，1997；42：678-683．
15 Bertelli，J．A．，and Mira，J．C．Behavioral evaluating methods in the objective clinical assessment of motor function after experimental brachial plexus reconstruction in the rat[J]．J．Neurosci．Methods，1993；46：203．
16 Gilbert A，Pivato G，Kheiralla T．Long-term results of primary repair of brachial plexus lesions in children．Microsurgery，2006； 26： 334-342．
17 Gu YD，Wu MM，Zhen YL，et al．Nerve transfer for brachial plexus motor neurotization[J]．Microsurgery，1989；10：287_289．
18 顾立强，裴国献主编．周围神经损伤基础与临床．北京，人民军医出版社，2001；76-82．
19 陈亮，顾玉东，李大村等．维持肢体正常运动感觉功能所需最少神经根数的实验研究[J]．中华手外科杂志，1998；14：234．
20 胡韶楠，顾玉东，徐建光．臂丛神经损伤后不同部位失神经骨骼肌萎缩后细胞凋亡的研究[J]．中华手外科杂志，2000； 16(4)： 194-197．
21 汤晓芙主编．临床肌电图学．第一版．人民卫生出版社，1995：84．
1 Gu YD，Cai PQ，Xu F，et al．Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus[J]．Microsurgery，2003； 23(2)：105-108．
2 薛锋，蔡佩琴，顾玉东，等．同侧C7神经根移位后对其支配肌影响的初步观察[J]．中华手外科杂志，2001； 17(3)：133-135．
3 蔡佩琴，顾玉东，薛锋等．同侧颈7神经根移位术的临床应用[J]．中华手外科杂志，2002；18(2)：73-74．
4 Bertelli JA，Mira JC，Gilbert A，et al．Anatomical basis of rat brachial plexus reconstruction[J]．Surg Radiol Anat，1992；14(1)：85-86．
5 Chen L，Gu YD．An experimental study of contralateral C7 root transfer with vascularized nerve grafting to treat brachial plexus root avulsion[J]．J Hand Surg[Br]，1994；19(B)：60-66．
6 Gu YD，Shen L Y．Electrophysiological changes after severance of the C7 nerve root[J]．J Hand Surg[Br]，1994；19(1)69-71．
7 Gilbert A，Pivato G，Kheiralla T．Long-term results of primary repair of brachial plexus lesions in children[J]．Microsurgery，2006； 26： 334-342．
8 Kiat Witoonchart，Somsak Leechavengvongs，Chairoj Uerpairokjkit，et al．Nerve transfer to deltoid muscle using the nerve to the long head of the triceps，Part Ⅰ： an anatomic feasibility study[J]．J Hand Surg，2003；28A：628-632．
9 虞聪，徐建光，等．同侧颈7移位修复臂丛上干不全损伤的疗效与背阔肌功能的关系[J]．中华手外科杂志，2002； 18： 75-76．
10 陆伟，徐建光，肖建德，等．大鼠臂丛上中干损伤后肱三头肌背阔肌功能状态变化的实验研究[J]．中国矫形外科杂志，2004； 12(18)：1410-1412．
11 Madsen K，Franch J，Clansen T，et al．Effects of intensified endurance training on the concentration of Na，K-ATP and Ca-ATPase in human skeletal muscle[J]．Acta Physiol Scand，1994；150：253．
12 Jakers EV，Vassiloulos D．Skeletal muscle CK-B activity in neurogenic muscular atrophies[J]．J Neurol，1989；236：284．
13 Tyc F，Vrbova G．．Increased activity improves recovery of partially denervated fast rat muscle[J]．Bran Res Dev Brain Res，1998；109(2)：149-55．
14 Shimizu K．Effect of endurance running training on the structural and metabolic properties of partially denervated soleus muscle in rats[J]．Nippon Seikeigeka Gakkai Zasshi，1993；67(10)：944-52．
15 顾玉东．臂丛神经损伤与疾病的诊治．第2版，上海：上海医科大学出版社，2001：15-23．
16 顾立强，裴国献主编．周围神经损伤基础与临床．北京，人民军医出版社，2001：76-82．
17 Simonati A，Cavanagh JB．Changes in terminal sprout formation in rat sternocostalis muscle during chronic intoxication with 2，5 hexanedione[J]．Muscle Nerve，1984：7(5)：355-61．
1 Gu YD．Zhang GM．Chen DS．Yan JG，et al．Seventh cervical nerve root transfer from the contralateral nealmv sloe for treatment or oracmal plexus root avulsion[J]．J Hand Surg[Br]．1992：17(B)：518-521．
2 Chuang DCC，Wei FC．Cross-chest C/ nerve graffing followed by fred muscle transplantatlon for th etreatmentor to talavulsed bracnlal plexus mlurles[J]．Plastic Reconstr Surg．1993：92：717-25．
3 Songcharoen P，Wongtrakul S，Spinner RJ．Hemi-contralateral C7 transfer to median nerve in the treatment of root avulsion brachial plexus injury[J]．J Hand Surg，2001；26(A)：1058-64．
4 顾玉东．臂丛神经损伤与疾病的诊治[第2版]．上海医科大学出版社，2001：14-30．
5 Bertelli JA，Ghizoni MF．Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers： spinal accessory to suprascapular，ulnar fascicles to biceps branch，and triceps long or lateral head branch to axillary nerve[J]．J Hand Surg[Am]．，2004 Jan； 29(1)：131-9．
6 Birch R，Bonney G，Wynn Parry CB．Surgical Disorders of the Peripheral Nerves[J]．Edinburgh： Churchill Livingstone，1998： 157-207．
7 Gu YD，Cai PQ，Xu F，et al．Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus[J]．Microsurgery，2003；23(2)：105-108．
8 徐建光，胡韶楠，顾玉东．颈7神经根与桥接尺神经缝合断面的解剖学研究[J]．中国临床解剖学杂志，2000；18：14-15．
9 Gilbert A，Pivato G，Kheiralla T．Long-term results of primary repair of brachial plexus lesions in children[J]．Microsurgery，2006； 26： 334-342．
10 Slingluff CL，Terzis J K．The quantitative microanatomy of the brachial plexus in man： reconstructive relevance[J]．Microreconst ruction of Nerve Injuries，1987；285-324．
11 Gu YD．Functional motor innervation of brachial plexus roots．An intraoperative electrophysiological study[J]．Chin Med J(Engl)，1996；109：749-751．
12 Gu YD，Chen DS，Zhang GM，et al ．Long-term functional results of contralateral C7 transfer[J]．J Reconstr Microsurg，1998；14：57-59
13 Bertelli JA，Mira JC，Gilbert A，et al．Anatomical basis of rat brachial plexus reconstruction[J]．Surg Radiol Anat，1992；14(1)：85-86．
14 Chen L，Gu YD．An experimental study of contralateral C7 root transfer with vascularized nerve grafting to treat brachial plexus root avulsion[J]．J Hand Surg[Br]，1994；19(B)：60-66．
15 陆伟，肖建德，徐建光，何睛雯等．大鼠颈7神经根及其束支运动纤维含量与分布特点的研究[J]．中国修复重建外科杂志，2005；19(11)：857-859
16 Gu YD，Wu MM，Zhen YL，et al．Phrenic nerve transfer for brachial plexus motor neurotization[J]．Microsurgery，1989；10(4)：287-289．
17 Gu YD，Shen LY．Electrophysiological changes after severance of the C7 nerve root[J]．J Hand Surg，1994；19B：69-71．
18 Gu YD．Functional motor innervation of brachial plexus roots： an intraoperative electrophysiological study．[J]．J Hand Surg，1997； 22B： 258-260．
19 Chen L，Gu YD．Lowest number of brachial plexus nerve roots required for maintaining normal limb function-an experimental study[J]．Hand Surg，2001；6：37-45．
20 顾玉东，张高孟，陈德松等．健侧颈7神经根移位术治疗臂丛根性撕脱伤[J]．中华医学杂志，1989；69(10)569-565．
21 Terzis JK．Neurotization procedure for devasting paralysis of the brachial plexus[J]．6th Congress of the International Federation of Societies for Surgery of the Hand(IFSSH)，Abstract book，Helsinki，1995：86．
22 Waikakul S，Orapin S，Vanadurongwan V．Clinical results of contralateral C7 root neurotization to the median nerve in brachial plexus injuries with total root avulsions[J]．J Hand Surg，1999； 24B： 556-560．
23 El-Gammal TA，El-Sayed A，Kotb MM．Surgical treatment of brachial plexus traction injuries in children，excluding obstetric palsy[J]．Microsurgery，2003；23：14-17．
24 Mcguiness CN，Kay SPJ．The prespinal route in contralateral C7 nerve root transfer for brachial plexus avulsion injuries[J]．J Hand Surg．，2002；27(B)：159-160
25 王树锋，胡琪，潘勇卫．健侧颈7神经移位与下干直接缝合的可行性研究[J]．实用手外科杂2006； Vol 19： 67-69．
26 陈亮，顾玉东．第一届中欧臂丛神经损伤研讨会纪要[J]．中华创伤骨科杂志，2008；5：480-482．
27 孙贵新，顾玉东，史其林等．健侧颈7神经根移位同时修复两条神经的初步临床疗效[J]．中华手外科杂志，2004；20(4)：224-225．
28 Chen L，Gu YD，Hu SN，et al．Contralateral C7 transfer for the treatment of brachial plexus root avulsions in children-a report of 12 cases[J]．J Hand Surg，2007；32A：96-103．
29 顾玉东．臂丛神经损伤研究的方向[J]，中华手外科杂志，2008；24(3)：129．
30 徐建光，胡韶楠，王欢等．颈7神经根的组化研究及临床意义[J]．中国临床解剖学杂志，1996； 14(4)： 243 - 245．
31 徐建光，胡韶楠，王欢等．同侧颈7神经根选择性束组移位术的临床应用[J]．中华手外科杂志，1999； 15(3)： 151-153．
32 徐建光，顾玉东等．选择性颈7神经根移位与隔神经移位术疗效比较的实验研究[J]．中华显微外科杂志，2000； 23(2)： 118-121．
33 Chuang DCC．Restoration of shoulder abduction by nerve transfer in a vulsed brachial plexus injury： Evaluation of 99 patients with various nerve transfers[J]．Plastic and Reconstr Surg，1996(1)：122-128．
34 顾玉东．臂丛神经根性撕脱伤的治疗[J]．中华创伤骨科杂志，2004；6(1)：3-6
35 蔡佩琴，顾玉东，薛锋等．同侧颈7神经根移位术的临床应用[J]．中华手外科杂志，2002；18(2)：73-74．
36 薛锋，蔡佩琴，顾玉东．健侧颈7神经根移位后对其支配肌影响的初步观察[J]．中华手外科杂志，2001；17(3)： 133-135．
37 YU Cong，XU Jianguang，LAO Jie Relationship between treatment outcome and function of latissimus dorsi muscle at patients with incomplete injury of upper trunk of brachial plexus repaired by transfer of ipsilateral C7 root[J]．Chinese Journal of Hand Surgery，2002； 18(2)：75-76．
38 劳克诚，姜学恩，宋修竹，周少麟．同侧C7神经根移位治疗臂丛上干根性撕脱伤[J]．中华手外科杂志，2003； 19(2)：75-76．
39 高飞，石宁跃．，王明君，等．颈7神经根移位术治疗颈段哑铃型神经鞘瘤[J]．中华神经外科杂志，2003； Vo119： 9．
40 孙坚，李军，蒋继党．颈7神经根后股与副神经移位吻合重建斜方肌功能[J]．中国修复重建外科杂志，2005； 19(11)，890-893．
2．Bertelli JA，Florianopolis，Gbizoni MF，et al．Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers： spinal accessory to suprascapular，ulnar fascicles to biceps branch，and triceps long or lateral head branch to axillary nerve[J]．J Hand Surg(Am)，2004；29：131-139．
3．Birch R，Bonney G, Wynn Parry CB．Surgical Disorders of the Peripheral Nerves[J]．Edinburgh： Churchill Livingstone，1998：157-207．
4．Gilbert A，Pivato G，Kheiralla T．Long-term results of primary repair of brachial plexus lesions in children[J]．Microsurgery，2006； 26： 334-342．
5．Kiat Witoonchart，Somsak Leechavengvongs，Chairoj Uerpairokjkit，et al．Nerve transfer to deltoid muscle using the nerve to the long head of the triceps，Part Ⅰ： an anatomic feasibility study[J]．J Hand Surg，2003；28A：628-632．
6．Gu YD，Cai PQ，Xu F，et al．Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus[J]．Microsurgery，2003； 23(2)：105-108．
7．薛锋，蔡佩琴，顾玉东，等．同侧C7神经根移位后对其支配肌影响的初步观察[J]．中华手外科杂志，2001；17(3)：133-135．
8．Yu C，Xu JG，Lao J．Relationship between treatment outcome and function of latissimus dorsi muscle at patients with incomplete injury of upper trunk of brachial plexus repaired by transfer of ipsilateral C7 root[J]．Chinese Journal of Hand Surgery，2002；18(2)：75-76．
9．Bertelli JA，Mira JC，Gilbert A，et al．Anatomical basis of rat brachial plexus reconstruction[J]．Surg Radiol Anat，1992；14(1)：85-86．
10．Chen L，Gu YD．An experimental study of contralateral C7 root transfer with vascularized nerve grafting to treat brachial plexus root avulsion[J]．J Hand Surg[Br]，1994；19(B)：60-66．
11．Inciong JGB，Marrocco WC，Terzis JK．Efficacy of intervention strategies in a brachial plexus global avulsion model in the rat[J]．Plastic and Reconstructive surgery，2000；105(6)：2059-71．
12．Hidenobu Ochiai，Tomoaki Ikeda，Kenichi Mishima，et al．Development of a novel experimental rat model for neonatal preganglionic upper brachial plexus injury[J]．J．Neurosci．Methods，2002；119：51-57．
1 顾玉东．臂丛神经损伤与疾病的诊治．第2版，上海：上海医科大学出版社，2001：55-65．
2 Bertelli JA，Florianopolis，Gbizoni MF，et al．Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers： spinal accessory to suprascapular，ulnar fascicles to biceps branch，and triceps long or lateral head branch to axillary nerve[J]．J Hand Surg，2004； 29A：131-139．
3 Birch R，Bonney G，Wynn Parry CB．Surgical Disorders of the Peripheral Nerves[J]．Edinburgh： Churchill Livingstone，1998： 157-207．
4 Gu YD，Cai PQ，Xu F，et al．Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus[J]．Microsurgery，2003； 23(2)：105-108．
5 Bertelli JA，Mira JC，Gilbert A，et al．Anatomical basis of rat brachial plexus reconstruction[J]．Surg Radiol Anat，1992； 14(l)：85-86．
6 Chen L，Gu YD．An experimental study of contralateral C7 root transfer with vascularized nerve grafting to treat brachial plexus root avulsion[J]．J Hand Surg[Br]，1994； 19(B)：60-66．
7 董震，成效敏，顾玉东等．膈神经移位接上干前股的解剖与临床研究[J]．中华手外科杂志，2000； 16(2)，102-104．
8 陈亮，顾玉东．健侧颈7神经根移位治疗臂丛根性撕脱伤的实验研究[J]．中华外科杂志，1992； 30(9]： 525-527．
9 顾玉东，沈丽英，沈尊理，等．臂丛神经根支配功能的电生理研究[J]．中华外科杂志1996； 34(1)：40-43．
10 Jesus Gil B．Inciong，William C．Marrocco，Julia K．Terzis．Efficacy of intervention strategies in a brachial plexus global avulsion model in the rat[J]．Plastic and Reconstructive Surgery，2000； 105(6)： 2059-2071．
11 Oberlin，C，Beal D，Leechavengvongs S，Salon A，et，al．Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus： anatomical study and report of four cases[J]．J Hand Surg，1994；19A：232-237．
12 Kiat Witoonchart，Somsak Leechavengvongs，Chairoj Uerpairokjkit，et al．Nerve transfer to deltoid muscle using the nerve to the long head of the triceps，Part Ⅰ： an anatomic feasibility study[J]．J Hand Surg，2003；28A：628-632．
13 Hidenobu Ochiai，Tomoaki Ikeda，Kenichi Mishima，et al．Development of a novel experimental rat model for neonatal preganglionic upper brachial plexus injury[J]．J．Neurosci．Methods，2002； 119：51-57．
14 Bona E，Johansson BB，Hagberg H．Sensoriomotor function and neuropathology 5-6 weeks after hypoxia-ischemia in 7-day-old rats[J]．Pediatr Res，1997；42：678-683．
15 Bertelli，J．A．，and Mira，J．C．Behavioral evaluating methods in the objective clinical assessment of motor function after experimental brachial plexus reconstruction in the rat[J]．J．Neurosci．Methods，1993；46：203．
16 Gilbert A，Pivato G，Kheiralla T．Long-term results of primary repair of brachial plexus lesions in children．Microsurgery，2006； 26： 334-342．
17 Gu YD，Wu MM，Zhen YL，et al．Nerve transfer for brachial plexus motor neurotization[J]．Microsurgery，1989；10：287_289．
18 顾立强，裴国献主编．周围神经损伤基础与临床．北京，人民军医出版社，2001；76-82．
19 陈亮，顾玉东，李大村等．维持肢体正常运动感觉功能所需最少神经根数的实验研究[J]．中华手外科杂志，1998；14：234．
20 胡韶楠，顾玉东，徐建光．臂丛神经损伤后不同部位失神经骨骼肌萎缩后细胞凋亡的研究[J]．中华手外科杂志，2000； 16(4)： 194-197．
21 汤晓芙主编．临床肌电图学．第一版．人民卫生出版社，1995：84．
1 Gu YD，Cai PQ，Xu F，et al．Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus[J]．Microsurgery，2003； 23(2)：105-108．
2 薛锋，蔡佩琴，顾玉东，等．同侧C7神经根移位后对其支配肌影响的初步观察[J]．中华手外科杂志，2001； 17(3)：133-135．
3 蔡佩琴，顾玉东，薛锋等．同侧颈7神经根移位术的临床应用[J]．中华手外科杂志，2002；18(2)：73-74．
4 Bertelli JA，Mira JC，Gilbert A，et al．Anatomical basis of rat brachial plexus reconstruction[J]．Surg Radiol Anat，1992；14(1)：85-86．
5 Chen L，Gu YD．An experimental study of contralateral C7 root transfer with vascularized nerve grafting to treat brachial plexus root avulsion[J]．J Hand Surg[Br]，1994；19(B)：60-66．
6 Gu YD，Shen L Y．Electrophysiological changes after severance of the C7 nerve root[J]．J Hand Surg[Br]，1994；19(1)69-71．
7 Gilbert A，Pivato G，Kheiralla T．Long-term results of primary repair of brachial plexus lesions in children[J]．Microsurgery，2006； 26： 334-342．
8 Kiat Witoonchart，Somsak Leechavengvongs，Chairoj Uerpairokjkit，et al．Nerve transfer to deltoid muscle using the nerve to the long head of the triceps，Part Ⅰ： an anatomic feasibility study[J]．J Hand Surg，2003；28A：628-632．
9 虞聪，徐建光，等．同侧颈7移位修复臂丛上干不全损伤的疗效与背阔肌功能的关系[J]．中华手外科杂志，2002； 18： 75-76．
10 陆伟，徐建光，肖建德，等．大鼠臂丛上中干损伤后肱三头肌背阔肌功能状态变化的实验研究[J]．中国矫形外科杂志，2004； 12(18)：1410-1412．
11 Madsen K，Franch J，Clansen T，et al．Effects of intensified endurance training on the concentration of Na，K-ATP and Ca-ATPase in human skeletal muscle[J]．Acta Physiol Scand，1994；150：253．
12 Jakers EV，Vassiloulos D．Skeletal muscle CK-B activity in neurogenic muscular atrophies[J]．J Neurol，1989；236：284．
13 Tyc F，Vrbova G．．Increased activity improves recovery of partially denervated fast rat muscle[J]．Bran Res Dev Brain Res，1998；109(2)：149-55．
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