摘要
随着现代社会的发展,由各种原因引起的臂丛神经损伤有增多的趋势。现代外科手术治疗正朝者精细化小损伤的方向发展。这就对臂丛的应用解剖学研究提出了更高更精细的要求。了解臂丛在组成上及各神经在节段分布上的可变性,对于臂丛神经损伤的临床调查与诊断,以及外科修复术中正确判别其解剖构成上的变异,以采取适宜的手术方式,无疑都是大有益处的。了解其相关交通支资料亦可减少颈腋部手术时的损伤。因此,臂丛解剖学变异及其相关交通支情况是实施颈部、上肢手术的外科医师必须要详细了解并掌握的基本知识之一。2003年Uysal等作胎儿臂丛变异观察时发现各种交通支的存在。2007年Pandey和Shukla也报道了成人束间交通支的存在,国内尚缺乏相关交通支报道。交感干与臂丛间灰、白交通支虽不属于变异范畴,但到目前为止未见详细描述其行走分布特征的文献。因此,本研究通过对50具成年尸体臂丛的观测,进一步积累臂丛变异资料并提供系统的臂丛交通支的应用解剖学资料;另通过对33具成年尸体交感干与臂丛间灰、白交通支的观测,提供交感干与臂丛间灰、白交通支的应用解剖学资料。
第一部分臂丛神经变异解剖学研究及其临床意义
目的观测臂丛神经变异情况并探讨其临床意义。
方法选用50具成年防腐尸体(男32具,女18具,计100侧臂丛),观测并拍摄臂丛神经变异情况。应用卡方检验对男女、左右侧变异臂丛出现率进行比较。
结果100侧臂丛中,正常型臂丛36侧,占(36±4.8)%;前置型臂丛46侧,占(46±4.98)%;后置型臂丛18侧,占(18±3.84)%。共发现干、股、束存在变异的臂丛16侧(3侧同时存在干及股束变异),占(16±3.67)%。其中,干变异臂丛6侧,股束变异臂丛13侧。其它形式的变异包括:C5穿前斜角肌浅出4侧,正中神经起点位于腋动脉后1侧。男女性、左右侧变异臂丛出现率均无显着性差异性(P＞0.10)。
结论了解臂丛神经变异资料,对颈腋部手术时避免臂丛损伤很有帮助。
第二部分臂丛神经交通支的观测及其临床意义
目的观测臂丛神经交通支的存在情况并探讨其临床意义。
方法选用50具成年防腐尸体(男32具,女18具,计100侧臂丛),尸体取平卧位,仔细解剖、鉴别臂丛的各个组成部分,观测交通支存在情况。记录交通支起止点及走向,测量各交通支长度、横径与前后径,并测量胸肩峰动脉干根部至内、外侧束部之间交通支跨过腋动脉点的距离。应用卡方检验对男女、左右侧交通支出现率进行比较。
结果共发现27侧存在交通支,发生率为(27±4.44)%。内、外侧束部之间的交通支占25侧,其中以外侧束至正中神经内侧根的交通支最多(16侧)。内、外侧束部之间的交通支均位于胸肩峰动脉干根部下(1.60±0.64)cm,长度为(1.67±0.62)cm,横径为(1.77±0.63)mm,前后径为(1.19±0.34)mm。男、女性束部之间交通支发生率无显着性差异性(P＞0.10)。左、右侧束部之间交通支发生率差异有统计学意义,右束部之间交通支发生率高于左侧(P＜0.05)。
结论臂丛交通支广泛存在,对其分型定位可为颈腋部手术时避免臂丛损伤提供临床解剖学资料。
第三部分交感干臂丛间灰、白交通支的解剖学特点及其临床意义
目的探讨交感干臂丛间交通支的走行分布特点及其临床意义。
方法选用33具成年防腐尸体(男性27具,女性6具,共计66侧),尸体取平卧位,由浅入深去除浅层颈部肌肉及软组织,显露双侧头长肌、颈长肌及交感干。观察交感干或神经节与臂丛交通支的走行及其与头长肌、颈长肌的关系。然后切除头长肌与颈长肌,去除C5、C6、C7颈椎横突孔前方骨板,进一步观察交感干或神经节与臂丛交通支的走行分布特点。
结果交感干与臂丛间有灰、白交通支相交通。白交通支多来自T1和T2,灰交通支可分为外后和内上二组。内上组交通支的分布特点:1.颈中神经节或节间支与臂丛交通支多对称分布,至第5、6颈神经的42条交通支在第5、6颈椎横突水平内行自头长肌、颈长肌间沟后行入神经。2.自星状神经节(或颈下神经节及胸1神经节)发出后行向内上方加入第7、8颈神经的交通支除1例外均对称分布。至C8神经的交通支与C8神经结合前51侧发出分支与C7神经相交通,其中45侧经第7颈椎横突孔。至C7神经的交通支(即椎神经)与C7神经结合前41侧发出分支与C6神经相交通,分支伴椎动脉经第6颈椎横突孔上行,29侧分支沿途发出许多细小纤维支至椎动脉及周围椎间、横突间关节。
结论1.交感干与臂丛间的交通支具有典型的分布特点,可为研究交感神经对臂丛神经功能支配及颈椎前路扩大减压术时减少损伤提供解剖学资料。2.至C7神经交通支(即椎神经)的分布特点可为临床上通过椎神经阻滞治疗顽固性颈痛提供解剖学依据。
With development of the society, the quantity of the brachial plexus palsy patients causing by various reasons has an increasing tendency. Modern surgical intervention is growing toward a subtile direction with little injury, which produce a higher and finer request for the anatomy of BP. Data of formation and variation of the BP is helpful for surgeons who need to diagnose the injury of BP, distinguish variation of BP and take correct modus operandi in surgical procedures. Data of communicating branches of the BP is also of interest to the surgeons who perform surgical procedures in the cervical and axillary regions. So, knowledge of the variation of BP and its related communicating branch has been become one of elementary knowledge for these surgeons. Uysal discovered miscellaneous communicating branches of the BPs in human fetuses in 2003. Pandey and Shukla also reported communicating branches between cords of human BPs in 2007. But literature about communicating branches of BPs has not been seen in our country. Though grey and white rami do not belong to variation of BP, few literature about distribution of the grey and white rami in detail has been published so far. Therefore, by investigating 50 fixed human cadavers and another 33 fixed specimens, the purpose of this study was to accumulate more data of the variations of BPs, and provide systemic applied data of the communicating branches of BPs and the grey and white rami between sympathetic trunks and BPs.
Part one Anatomical study of the variations of brachial plexuses and its clinical significance
Objective To investigate the variations of brachial plexus(BP) and its clinical significance.
Methods 50 fixed human cadavers(32 males, 18 females) were utilized in this study.The plexuses were dissected, the variations of BPs were determined and photographed.
Results There were no variations in 84 plexuses, and 16 plexuses were observed to have morphological variations. Prefixed plexuses were observed in 46 BPs, and postfixed plexuses were observed in 18 BPs. Six sides have variations in trunk in, and 13 sides in division or cord(three sides have variations in trunk and division or cord). Other type variations include: C5 nerve penetrated the scalenus anterior in 4 sides; both roots of the median nerve were joined behind the axillary artery to form a median nerve in 1 side. There were no significant statistical differences between the right and left sides or males and females(P> 0.05).
Conclusion The anatomical data of variation of BPs is helpful for surgeons who perform surgical procedures in the cervical and axillary regions.
Part two Anatomical study of communicating branches of the brachial plexus and its clinical significance
Objective To investigate the occurrence and clinical significance of brachial plexus (BP) .
Methods This study was performed with 50 fixed human cadavers(32 males, 18 females) . The plexuses were dissected, the presence of the communicating branches of BPs were determined, measured and photographed. Chi-square test was used to compare the differences between right and left sides or males and females.
Results The communicating branches were identified in 27 sides of the upper extremity, 25 sides of which linked the lateral cord with the medial cord of BP. The most common branches communicated the lateral cord with the medial root of median nerve (16 sides). All the communicating branches between lateral cords and medial cords obliquely crossed anterior to the axillary artery and passed below the thoracoacromial artery trunk. The distance of communicating branch with the origin of TAT was (1.60±0.64) cm. The length, transverse diameter and anteroposterior diameter of communicating branch were (1.67±0.62) cm, (1.77±0.63) mm and 0.91±0.34) mm, respectively. There was no significant difference between males and females (P> 0.05), the occurrence of right sides communicating branches of BPs is higher than left sides.
Conclusion: There existed extensive communicating branches in BPs, the anatomical data will be helpful for surgeons who perform surgical procedures in the cervical and axillary regions.
Part three Anatomical study and its clinical significance of the rami communicans between cervical sympathetic trunk and brachial plexus
Objective To explore anatomic features and clinical significance of the rami communicans between cervical sympathetic trunk(CST) and brachial plexus(BP).
Methods This study utilized 33 fixed human cadavers: 27 males and 6 females without morphological abnormalities. In the supine position, musculi colli and soft tissue were removed to reveal cervical sympathetic trunk, longus scapitis and longus colli. Then the longus scapitis and longus colli were removed, the transverse foramina of C5,C6 and C7 were opened to observe the anatomic characteristics of communicating branches between CSTs and BPs.
Results The rami communicans between CST and BP include white and gray rami communicans. White rami communicans are derived from C8 and/or T1 spinal nerves. Gray rami communicans could be divided two groups: medial group and lateral group . The distribution of the rami communicans of the medial group: 1.Most of the rami communicans between middle cervical ganglion(or interganglionic segments rami) and BP are symmetrical. 42 rami distributed to C5 or C6 spinal nerves run medially first at the level of the transverse process of C5 or C6 spinal nerves, turn backward through the groove between longus scapitis muscle and longus colli muscle, and then joined C5 or C6 spinal nerves. 2.Except 1 case, all the medial rami communicans between the cervicothoracic ganglion (CTG) and C7、C8 spinal nerves are symmetrical. Before joining C8 spinal nerve, in 51 sides rami from the CTG to C8 spinal nerve give off a branch ascending through the C7 transverse foramina and communicating with C7 spinal nerve. Before joining C7 spinal nerve, in 41 sides rami from the CTG to C7 spinal nerve send out a branch ascending posteromedia to the vertebral artery(VA) to the C6 spinal nerve, and fine branches can be seen in 29 sides between the branch and VA or the fibrous capsule of adjacent zygapophyseal and intervertebral joints.
Conclusion 1 .The distribution of the rami communicans between CST and BP has typical features. These anatomic data may be useful in studying the inference of sympathetic nerve to upper limb and could avoid injuries of the rami communicans in extensive decompression during anterior cervical approach. 2. The distribution of the branch to the fibrous capsule of adjacent zygapophyseal and intervertebral joints could provide anatomic evidence to clinicians in treating medically intractable neck pain by allowing neural blockade of the vertebral nerve(the rami from CTG to C6,C7 spinal nerves).
引文
1.朱长庚.神经解剖学[M].北京:人民卫生出版社,2002,792-794.
2.马鸿绍.国人臂丛的检查与统计[J].解剖学报,1959,4(1-2):84-90.
3.雷琦.国人臂丛神经及其有关血管的观察[J].解剖学报,1963,6(4):372-381.
4.徐林,陈中伟,鲍国正.臂丛神经的显微外科解剖学研究及其临床意义[J].中国临床解剖学杂志,1988,6(3):184-187.
5.Uysal Ⅱ.Seker M.Karabulut AK.et al.Brachial plexus variations in human fetuses[J].Neurosurgery,2003,53(3):676-684.
6.Pandey SK,Shukla VK.Anatomical Variations of the Cords of Brachial Plexus and the Median Nerve[J].Clin Anat,2007,20(2):150-156.
1.中国解剖学会体质调查委员会(黄瀛主编).中国人解剖学数值[M].北京:人民卫生出版社,2002,406-407.
2.朱长庚.神经解剖学[M].北京:人民卫生出版社,2002:792-794.
3.马鸿绍.国人臂丛的检查与统计[J].解剖学报,1959,4(1-2):84-90.
4.雷琦.国人臂丛神经及其有关血管的观察[J].解剖学报,1963,6(4):372-381.
5.张咸中,黎晓华,张振伟.胎儿臂丛神经解剖学研究及其临床意义[J].中华显微外科杂志,1993,16(2):132-135.
6.Uysal Ⅱ,Seker M,Karabulut AK,et al.Brachial plexus variations in human fetuses[J].Neurosurgery,2003,53(3):676-684.
7.曲永松,吕美玲,姜殿军.臂丛C5前支穿过前斜角肌变异1例[J].中国临床解剖学杂志,2002,20(4):320-321.
8.Cooke J,Cooke D,Parsons C.The anatomy and pathology of the brachial plexus as demonstrated by computed tomography[J].Clin Radiol,1988,39(6):595-601.
9.Kawai H,Kawabata H,Masada K,et al.Nerve repairs for traumatic brachial plexus palsy with root avulsion[J].Clin Orthop Relat Res,1988,237:75-86.
10.Ransford AO,Hughes SP.Complete brachial plexus lesions:a ten-year follow-up of twenty cases[J].J Bone Joint Surg Br,1977,59-B(4):417-420.
11.Lin PY,Luo CY,Kan CD,et al.Brachial plexus injury following coronary artery bypass surgery:a case report[J].Kaohsiung J Med Sci,2000,16(12):638-642.
12.徐林,陈中伟,鲍国正.臂丛神经的纤维外科解剖学研究及其临床意义[J].中国临床解剖学杂志,1988,6(3):184-187.
13.Harry WG,Bennett JD,Guha SC.Scalene muscles and the brachial plexus:anatomical variations and their clinical significance[J].Clin Anat,1997,10(4):250-252.
1.Saeed M,Rufai AA.Median and musculocutaneous nerves:variant formation and distribution[J].Clin Anat,2003,16(5):453-457.
2.Choi D,Rodriguez-Niedenfuhr M,Vazquez T,et al.Patterns of connections between the musculocutaneous and median nerves in the axilla and arm[J].Clin Anat,2002,15(1):11-17.
3.Venieratos D,Anagnostopoulou S.Classification of communications between the musculocutaneous and median nerves[J].Clin Anat,1998,11(5):327-331
4.Louskas M,Louis ZR Jr,Stewart L.The surgical anatomy of ulnar and median nerve communications in the palmar surface of the hand[J].J Neurosurg,2007,106(5):887-893.
5.曾纳新,沈为栋,陈琳等.正中神经与肌皮神经的交通支及其临床意义[J].中华实验外科杂志,2006,23(12):1513-1514.
6.Uysal Ⅱ,Seker M,Karabulut AK,et al.Brachial plexus variations in human fetuses [J].Neurosurgery,2003,53(3):676-684.
7.Pandey SK,Shukla VK.Anatomical Variations of the Cords of Brachial Plexus and the Median Nerve[J].Clin Anat,2007,20(2):150-156.
8.顾玉东.臂丛神经损伤与疾病的诊治[M].第二版.上海:复旦大学出版社,上海医科大学出版社,2001,94-96
9.Sargon MF,Uslu SS,Celik HH,et al.A variation of the median nerve at the level of brachial plexus[J].Bull Assoc Anat(Nancy),1995,79(246):25-26.
10.高学彬,张学俊.国人臂丛及其主要分支的观察[J].青岛大学医学院学报,1982,18(2):176-185.
11.汪立鑫,许健,张文志.正中神经的形成及其与动脉的关系[J].解剖学杂志,1965,3:37～39.
12.Uzun A,Bilgic S.Some variations in the formation of the brachial plexus in infants [J].Turkis J Med Sci,1999,29:573-577.
1.Pather N,Partab P,Singh B,et al.Cervico-thoracic ganglion:its clinical implications[J].Clin Anat,2006,19(4):323-326.
2.Kiray A,Arman C,Naderi S,et al.Surgical anatomy of the cervical sympathetic trunk[J].Clin Anat,2005,18(3):179-185.
3.何精选,王艳炜,程雄飞等.椎动脉、颈交感干和颈长肌的解剖关系及其在颈椎手术中的意义[J].局解手术学杂志,2006,15(6):363-364.
4.杨玉辉,高忠礼,刘景臣等.颈椎前路扩大减压术的应用解剖[J].吉林大学学报(医学版),2005,31(1):76-78.
5.张朝佑.人体解剖学[M].下册.第二版.北京:人民卫生出版社,1998.1633-1639.
6.朱长庚.神经解剖学[M].北京:人民卫生出版社,2002.929-933.
7.黄轶刚.产瘫Horner征发生机制的基础研究[D].2005.14-22.
8.Vredeveld JW,Blaauw G,Slooff BA,et al.The findings in paediatric obstetric brachial palsy differ from those in older patients:a suggested explanation[J].Dev Med Child Neuro,2000,42(3):158-161.
9.Colon AJ,Vredeveld JW,Blaauw G,et al.Extensive somatosensory innervation in infants with obstetric brachial palsy[J].Clin Anat,2003,16(1):25-29.
10.顾玉东.臂丛神经损伤与疾病的诊治[M].第二版.上海:复旦大学出版社,上海医科大学出版社,2001,21-22.
11.Dibona GF.Differentiation of vasoactive renal sympathetic nerve fibres[J].Acta Physiol Scand,2000,168(1):195-200.
12.Rechthand E,Hervonen A,Sato S.Distribution of adrenergic innervation of blood vessels in peripheral nerve[J].Brain Res,1986,374(1):185-189.
13.王金武,陈德松,王劫.颈部交感神经干及交感神经节受刺激因素的解剖学观察及其临床意义[J].解剖与临床,2000,5(2):68-70.
14.沙轲,陈德松,陈琳等.臂丛神经的交感神经支配及其临床意义[J].中华手外科杂志,2003,19(1):52-54.
15.曾炳芳,张长青.2004创伤骨科新进展[M].第一版.北京:人民卫生出版社.2003,220-221.
16.Tubbs RS,Loukas M,Remy AC,et al.The vertebral nerve revisited[J].Clin Anat,2007,20(6):644-647.
1.Cooke J,Cooke D,Parsons C.The anatomy and pathology of the brachial plexus as demonstrated by computed tomography[J].Clin Radiol,1988,39(6):595-601.
2.Kawai H,Kawabata H,Masada K,et al.Nerve repairs for traumatic brachial plexus palsy with root avulsion[J].Clin Orthop Relat Res,1988,237:75-86.
3.Ransford AO,Hughes SP.Complete brachial plexus lesions:a ten-year follow-up of twenty cases[J].J Bone Joint Surg Br,1977,59-B(4):417-420.
4.Lin PY,Luo CY,Kan CD,et al.Brachial plexus injury following coronary artery bypass surgery:a case report[J].Kaohsiung J Med Sci,2000,16(12):638-642.
5.Walsh JF.The anatomy of the brachial plexus[J].Am J Med Sci,1877,74:389-399.
6.Kerr AT.The brachial plexus of nerves in man,the variations in its formation and branches[J].Am J Anat,1918,23:285-395.
7.朱长庚.神经解剖学[M].第一版.北京:人民卫生出版社.2002,792-794.
8.顾玉东.臂丛神经的临床解剖及其意义[J].临床解剖学杂志,1987,5(4):228-230.
9.Uzun A,Bilgic S.Some variations in the formation of the brachial plexus in infants[J].Turkis J Med Sci,1999,29:573-577.
10.马鸿绍.国人臂丛的检查与统计[J].解剖学报,1959,4(1-2):84-90.
11.雷琦.国人臂丛神经及其有关血管的观察[J].解剖学报,1963,6(4):372-381.
12.中国解剖学会体质调查委员会(黄瀛主编).中国人解剖学数值[M].北京:人民卫生出版社.2002,406-407.
13.张咸中,黎晓华,张振伟.胎儿臂丛神经解剖学研究及其临床意义[J].中华显微外科杂志,1993,16(2):132-135
14.Uysal Ⅱ,Seker M,Karabulut AK,et al.Brachial plexus variations in human fetuses[J].Neurosurgery,2003,53(3):676-684.
15.中国医科大学.人体解剖学[M].第一版.北京:人民卫生出版社.1978,403.
16.Higo S,Koizumi M,Kawai K,et al.Anomaly with no right ventral root at the seventh cervical segment in humans:gross anatomical and neuroanatomical study[J].Anat Sci Int.2007,82(3):133-138.
17.闫厚军,田光磊.臂丛中干变异2例分析[J].中国误诊学杂,2006,6(18):3490.
18.Abdullah S,Bowden RE.The blood supply of the brachial plexus[J].Proc R Soc Med,1960,53:203-205.
19.彭田红,唐茂林,徐达传等.椎管外臂丛的血供分布特点及其临床意义[J].中华骨科杂志,2006,26(7):472-475.
20.Midha R.Nerve transfers for severe brachial plexus injuries:a review[J].Neurosurg Focus,2004,16(5):E5.
21.顾玉东.21世纪臂丛损伤诊治的研究方向与任务[J].中华手外科杂志,2000,16:7-9.
22.Fernandz E,Pallini R,Marchese E,et al.Neurosurgery of the peripheral nervous system:entrapment syndromes of the brachial plexus[J].Surg Neurol,2000,53(1):82-85.
23.Mackinnon SE,Novak CB.Thoracic outlet syndrome[J].Cuur Probl Surg,2002,39:1070-1145.
24.Rusnak-Smith S,Moffat M,Rosen E.Anatomical variations of the scalene triangle:dissection of 10 cadavers[J].J Orthop Sports Phys Ther,2001,31(2):70-80.
25.方有生,陈德松,顾玉东.前、中斜角肌起点与臂丛上干的关系及其临床意义[J].中国临床解剖学杂志,1999,17(3):225-226.
26.方有生,陈德松.小斜角肌的应用解剖[J].中华手外科杂志,1997,13(2):113-115.
27.邵正仁,崔经建,徐达传.中斜角肌内缘腱性束带的形态及其临床意义[J].中国临床解剖学杂志,1999,17(3):227-228.
28.Bonnel F.Microscopic anatomy of the adult human brachial plexus:an anatomical and histological basis for microsurgery[J].Microsurgery,1984,5(3):107-118.
29.彭田红,丁红梅,陈胜华.臂丛根部的显微解剖学研究及其临床意义[J],中国临床解剖学杂志,2007,25(3):231-235
30.黄轶刚,陈亮,顾玉东.产瘫与成人臂丛损伤发生机制差异的解剖学研究[J].中华手外科杂志,2005,21(2):75-78.
31.Frey M.Avulsion injuries to the brachial plexus and the value of motor reinnervation by ipsilateral nerve transfer[J].J Hand Surg[Br],2000,25(4):323-324.
32.Jabaley ME,Wallace WH,Heckler FR.Internal topography of major nerves of the forearm and hand:a current view[J].J Hand Surg[Am],1980,5(1):1-18.
33.Narakas A.Neurotization or nerve transfer for brachial plexus lesions[J].Ann Chir Main,1982,1(2):101-118.
34.Schalow G,Aho A,Lang G.Nerve fibre counts for an intercostal nerve to cauda equina nerve root anastomosis[J].Zentralbl Chir,1987,112(7):457-461.
35.Schalow G,Aho A,Lang G.Microanatomy and number of nerve fibres of the lower intrcostal nerve with respect to a nerve anastomosis donor nerve analysis[J].Electromygr Clin Neurophysiol,1992,32(4-5):171-185.
36.马建军,张高孟,徐建光.治疗臂丛损伤移位神经的组织化学研究[J],中华手外科杂志,1997,13(4):235-237.