前臂内侧皮神经桥接至尺神经深支的健侧颈7移位术的探索性研究

Contralateral C7 nerve transfer has gained the international recognition as the main surgery for the global brachial plexus avulsion. The previous clinical reports showed that for the patients who suffered global brachial plexus avulsion, the outcome of wrist and fingers flexion is great by contralateral C7 nerve transfer.In the recent years,contralateral C7 long term follow-up results showed the reinnervation of thenar muscle appeared.So we engender an idea that Contralateral C7 nerve transfer could make recovery of intrinsic muscles. The research is to make further improvement of contralateral C7 nerve transfer for providing intrinsic muscles an opportunity to be restored. The surgery design included three stages of contralateral C7 nerve transfer. The first stage: making retrograde separations of superficial and deep branches of the ulnar nerve until enough lengths, cutting off the deep branch of the ulnar nerve at the proximity and suturing the proximity on the median nerve or the ulnar flexor carpi for presetting, cutting off the most distal ends of superficial branch and dorsal branch of ulnar nerve and making coaptation with contralateral C7 nerve. The second stage: cutting off the proximity of the ulnar nerve in the arm and making coaptation with median nerve and antebrachial medial cutaneous nerve in the arm. The third stage: suturing the terminal branches of antebrachial medial cutaneous nerve to the proximity of deep branch of the ulnar nerve which was the presetting nerve in the first stage. Based on the design, the anatomical studies of antebrachial medial cutaneous nerve and deep branch of ulnar nerve would be performed. Then we would do animal experiments. If succeed, the new surgical approach would ignite the hope of intrinsic muscles recovery, without affecting the recovery process of the median nerve.

健侧颈7神经移位术目前已成为国际公认的治疗全臂丛根性撕脱伤的主要术式。以往临床报道表明，健侧颈7手术恢复屈腕、屈指疗效较好。近年来，健侧颈7移位术长期随访结果发现拇对掌功能也可恢复。因此我们提出设想：健侧颈7神经移位术能使手内在肌也得到恢复。研究目的是在原有健侧颈7经典手术的基础上进行进一步改良，使手内在肌再生。方案设计：I期手术：将尺神经深浅支沿主干逆行束支分离至足够长度，于最近端将尺神经深支切断后预置，将尺神经浅支及手背支于最远端切断后吻合至健侧颈7神经根。二期手术：将尺神经吻合至正中神经近端及前臂内侧皮神经近端。三期手术：将前臂内侧皮神经终末支吻合至尺神经深支，也就是前臂内侧皮神经起到桥接的作用。基于以上的方案设计，需要进行前臂内侧皮神经和尺神经的解剖学研究，在解剖学研究的基础上进行动物实验设计和研究。该手术方案的意义在于其既给予了手内在肌恢复的希望，又不影响正中神经的恢复。

健侧颈7神经移位术目前已成为治疗全臂丛根性撕脱伤的主要术式。近年来，健侧颈7移位术长期随访结果发现拇对掌功能也可恢复。因此我们提出设想：健侧颈7神经移位术能使手内在肌也得到恢复。方案设计：I期手术：将尺神经深浅支沿主干逆行束支分离至足够长度，于最近端将尺神经深支切断后预置，将尺神经浅支及手背支于最远端切断后吻合至健侧颈7神经根。二期手术：将尺神经吻合至正中神经近端及前臂内侧皮神经近端，同时将前臂内侧皮神经终末支吻合至尺神经深支，也就是前臂内侧皮神经起到桥接的作用。基于以上的方案设计，需要进行前臂内侧皮神经和尺神经的解剖学研究，在解剖学研究的基础上进行动物实验设计和临床研究。解剖学研究证实前臂内侧皮神经远端在肘部可与保留的尺神经深支进行吻合，其近端可吻合至尺神经近端。动物实验研究中，尽管使用改良的健侧C7方法恢复全臂丛损伤大鼠爪内肌的模型建立失败，但证实了利用腓肠神经移植直接桥接健侧C7及患侧尺神经，是一种可行的恢复全臂丛大鼠爪内肌的方法。临床研究发现，实验组中有1例患者小指展肌可测得肌力为M1，其余5例均未测得肌力恢复；对照组肌力均为0。两组患者骨间肌肌力肌力均为0。实验组和对照组分别有3例患者大鱼际肌测得肌力为M1。肌电图中，实验组早期有3例患者小指展肌可记录到新生MUP，1例患者第一至第四背侧骨间肌可分别于记录到CMAP，4例患者拇短展肌可记录到MUP。实验组6例患者神经B超检测肘部前臂内侧皮神经至尺神经深支吻合口神经束延续，其中4例患者前臂至腕尺管可明确判断为全程神经束延续走行，另外2例患者于前臂中段尺侧屈腕肌两头之间可见神经束走行中断。小鱼际肌HE染色肌纤维横截面积和MASSON三色染色胶原纤维比率上，实验组和对照组均有统计学差异。该研究从多方面证实了前臂内侧皮神经桥接至尺神经深支的健侧颈7移位术的可行性和有效性。