1、臂叢損傷后神經(jīng)移位術(shù)進(jìn)展,復(fù)旦大學(xué)附屬華山醫(yī)院手外科,徐文東,上臂叢損傷,神經(jīng)移位方案,副神經(jīng) 肩胛上神經(jīng),膈神經(jīng) 尺神經(jīng)部分束 肌皮神經(jīng) 同側(cè)頸7 腋神經(jīng) 肋間神經(jīng) 胸前內(nèi)測(cè)神經(jīng) 胸背神經(jīng),三頭肌長(zhǎng)頭支 腋神經(jīng)前支,JK Terzis The Surgical Treatment of Brachial Plexus Injuries in Adults. Plast. Reconstr. Surg. 119: 73e, 2007,華山醫(yī)院的方法：,1 副神經(jīng)-肩胛上神經(jīng) 膈神經(jīng)-上干前股 頸叢運(yùn)動(dòng)支-上干后股 （同側(cè)頸7）,2 副神經(jīng)-肩胛上神經(jīng) 尺神經(jīng)部分束-二頭肌支 正中神經(jīng)部分束-肱

2、肌肌支 三頭肌支-腋神經(jīng),尺神經(jīng)部分束-二頭肌支 正中神經(jīng)部分束-肱肌肌支,上臂叢損傷,神經(jīng)移位方案,健側(cè)C7-尺N-正中主干 或 健側(cè)C7-腓腸N-下干或正中神經(jīng) 肋間神經(jīng)-下干 肌皮N肱肌肌支-正中N主干后1/3束（顧玉東 2003） 橈神經(jīng)旋后肌支-前骨間神經(jīng)（E Hsiao 2009）,肱肌肌支-正中神經(jīng)部分束,下臂叢損傷,神經(jīng)移位方案,華山醫(yī)院的方法：,胸腔鏡取全長(zhǎng)膈神經(jīng)-正中神經(jīng)內(nèi)側(cè)頭（或前骨間神經(jīng)） 肱肌肌支-前骨間神經(jīng) 同側(cè)頸7-下干 肋間神經(jīng)-正中神經(jīng),下臂叢損傷,神經(jīng)移位方案,1 膈神經(jīng)-上干前股, 副神經(jīng)-肩胛上神經(jīng), 頸叢運(yùn)動(dòng)支-上干后股, 肋間神經(jīng)-橈神經(jīng)、胸背神經(jīng)

3、健側(cè)C7-尺神經(jīng)-正中神經(jīng),2 肋間神經(jīng)或健側(cè)C7-肌皮神經(jīng), 副神經(jīng)-肩胛上神經(jīng), 肋間神經(jīng)或健側(cè)C7-尺神經(jīng)-正中神經(jīng), 肋間神經(jīng)或健側(cè)C7-橈神經(jīng),圍繞有限的供體神經(jīng)展開(kāi),全臂叢損傷,全臂叢損傷神經(jīng)移位術(shù)恢復(fù)肢體功能的先后順序,1 屈肘 2 肩外展 3肩部穩(wěn)定 4手部感覺(jué) 5屈腕屈指 6伸腕伸指,1 屈肘 2 肩外展 3肩部穩(wěn)定 4 肩外旋 5 伸肘 6伸腕伸指,Shin,Songcharoen,Millesi,Terzis,Chuang,1 屈肘 2 肩外展 3肩部穩(wěn)定 4 肩外旋 5屈腕屈指,1 肩外展 2 肩外旋 3 屈肘 4屈腕屈指 5 伸肘 6手部感覺(jué),1 屈肘 2屈腕屈指 3

4、肩部穩(wěn)定 4 肩外展 5肩外旋,由近及遠(yuǎn),JK Terzis.The Surgical Treatment of Brachial Plexus Injuries in Adults.Plast Reconstr Surg.119:73e,2007 DCC Chuang.Brachial plexus reconstruction based on the new definition of level of injury.Injury Int J Care Injured(2008)39S,S23-S29,AY Shin.Adult Traumiatic Brachial Plexus In

5、juries.J Am Acad Orthop Surg 2005;13:382-396. P songcharoen.ManageMent of Brachial Plexus injury in adults.Sca J Surg 2008;97:317-323. H Millesi.Surgical Treatment of Post-Traumatic Brachial Plexus Lesions.Eur Surg.2003;Vol35:No4.,神經(jīng)移位術(shù)恢復(fù)肢體功能的先后順序,1伸腕屈指 2屈腕伸指 3肩肘關(guān)節(jié),Doi,由遠(yuǎn)及近,遠(yuǎn),近,K Doi.Technique of In

6、tercostal Nerve Harvest and Transfer for Various Neurotization Procedures in Brachial Plexus Injuries. Techniques in Hand and Upper Extremity Surgery 11(3):184194, 2007,全臂叢神經(jīng)損傷,神經(jīng)移位術(shù)恢復(fù)肢體功能的先后順序：,主流觀點(diǎn)：重建肩肘功能第一 最強(qiáng)有力的動(dòng)力神經(jīng)恢復(fù)肩肘功能。,華山醫(yī)院的策略：,副神經(jīng)-肩胛上神經(jīng) 膈神經(jīng)-上干前股 （頸叢-上干后股） 肋間神經(jīng)-三頭肌肌支/伸腕伸指肌支、胸背神經(jīng) 健側(cè)頸7-尺神經(jīng)-正中神經(jīng)

7、,With multiple root avulsions, the prevailing attitude to date has been to reconstruct shoulder and elbow flexion without attempting to restore function of the hand.-Terzis.,JK Terzis The Surgical Treatment of Brachial Plexus Injuries in Adults. Plast. Reconstr. Surg. 119: 73e, 2007,全臂叢損傷后神經(jīng)移位術(shù)的新觀點(diǎn)：

8、,1 嘗試恢復(fù)復(fù)雜的協(xié)調(diào)運(yùn)動(dòng)：,A 有動(dòng)力的背闊肌移位 動(dòng)態(tài) B 肱骨旋轉(zhuǎn)截骨矯形 靜態(tài),肩胛骨穩(wěn)定,肩外展功能,肩外旋功能（不能外旋的屈肘效果有限）,H. Millesi1.Coordinated function oriented movements after multiple root avulsion Acta Neurochir Suppl (2007) 100:117-119.,全臂叢損傷后神經(jīng)移位術(shù)的新觀點(diǎn)：,2 伸肘功能的修復(fù)維持肘關(guān)節(jié)的穩(wěn)定性,用至少兩根肋間神經(jīng)移位至三頭肌支,Narakas, A., and Hentz, V. Neurotization in brach

9、ial plexus injuries: Indications and results. Clin. Orthop. 237: 75, 1988. JK Terzis The Surgical Treatment of Brachial Plexus Injuries in Adults. Plast. Reconstr. Surg. 119: 73e, 2007,伸肘比屈肘功能更難恢復(fù),嘗試對(duì)原有觀點(diǎn)的突破,臂叢修復(fù)后幾乎所有的相關(guān)報(bào)道顯示肩外展、外旋以及伸肘伸腕伸指功能恢復(fù)較差 Narakas and Hentz等人認(rèn)為這一現(xiàn)象和胚胎學(xué)相關(guān)，抓握的功能對(duì)于生存比較重要,神經(jīng)移位術(shù)發(fā)展的趨

10、勢(shì),近靶器官移位Close Target Neurotization,Close-target neurotisation (CTN)： a direct coaptation at a more distal site, closer to the targets,muscle or skin, without the need for nerve graft faster recovery of motor and sensory outcomes. . -Chuang,DCC Chuang. Brachial plexus reconstruction based on the new

11、definition of level of injury. Injury, Int. J. Care Injured (2008) 39S, S23S29,神經(jīng)移位術(shù)發(fā)展的趨勢(shì),要求：高選擇性（符合神經(jīng)移位的原則）,1 純運(yùn)動(dòng)支-純運(yùn)動(dòng)支效果更佳,Normally the aim is to restore motor function, but in any case sometimes also sensibility can be restored, as we see below. So it is important to utilize a pure motor nerve.-C

12、. Novelli, A. Gilbert,2 盡量靠近靶肌肉-縮短再生距離,C. Novelli, A. Gilbert. Neurotizations in Brachial Plexus Injuries:New Approaches. Page 67-77. Samii A, Carvalho GA, Samii M. Brachial plexus injury: factors affecting functional outcome in spinal accessory nerve transfer for the restoration of elbow flexion. J

13、 Neurosurg 2003;98:30712.,The length and duration of axonal regrowth is therefore shortened, and we know that this is a major factor in influencing outcomes. -Samii A,神經(jīng)移位術(shù)發(fā)展的趨勢(shì):,例如： 尺神經(jīng)部分束-二頭肌支（Oberlin 1994） 肌皮N肱肌肌支-正中N主干后1/3束（顧玉東 2003） 橈神經(jīng)旋后肌支-前骨間神經(jīng)（E Hsiao 2009） 三頭肌肌支-腋神經(jīng)前支(Leechavengvongs S 2003

14、) 全長(zhǎng)膈神經(jīng)-正中神經(jīng)內(nèi)側(cè)頭（徐文東 2008） 前骨間神經(jīng),Close Target Neurotization,神經(jīng)移位術(shù)發(fā)展：,手術(shù)方法的改進(jìn)：,胸腔鏡取全長(zhǎng)膈神經(jīng),椎體前路健側(cè)頸7,-,縮短再生距離,不是只注重單一的運(yùn)動(dòng)功能恢復(fù) 力爭(zhēng)恢復(fù)有功能意義的復(fù)雜運(yùn)動(dòng) 健側(cè)頸7-正中神經(jīng) 選擇性健側(cè)頸7-正中、橈神經(jīng) 端側(cè)吻合技術(shù)的應(yīng)用 神經(jīng)移位后大腦功能重組成為了一項(xiàng)新的挑戰(zhàn),神經(jīng)移位術(shù)發(fā)展：,神經(jīng)移位觀念的進(jìn)步：,The real goal for evaluation of brachial plexus surgery should be the ability to perform

15、coordinated, complex movements. In such cases cerebral plasticity plays a decisive role. -Millesi 2007,H Millesi Coordinated function oriented movements after multiple root avulsion Acta Neurochir Suppl (2007) 100: 117119,神經(jīng)移位術(shù)發(fā)展：觀念,恢復(fù)復(fù)雜運(yùn)動(dòng)功能,肩肘部的組合運(yùn)動(dòng) 肩外旋 伸肘 手部功能（健側(cè)C7是最常用的動(dòng)力） 健側(cè)頸7移位正中神經(jīng) 91.6%患者獲得保護(hù)性感

16、覺(jué) 運(yùn)動(dòng)（20%-50%） 選擇性健側(cè)頸7移位恢復(fù)屈腕屈指或伸腕伸指 協(xié)同問(wèn)題？,JK Terzis.Selective Contralateral C7 Transfer in Posttraumatic Brachial Plexus Injuries: A Report of 56 Cases.Plast Reconstr Surg123:927,2009. JK Terzis.Vascularized Ulnar Nerve Graft: 151 Reconstructions for Posttraumatic Brachial Plexus Palsy.Plast Reconstr

17、 Surg123:1276,2009.,肢體復(fù)雜功能與大腦功能重組,手部功能精細(xì)而且復(fù)雜。 手部控制區(qū)在運(yùn)動(dòng)皮層中占據(jù)了相當(dāng)大的區(qū)域。,健側(cè)頸7移位恢復(fù)患肢的功能對(duì)大腦是一種挑戰(zhàn) C7本身功能解剖的復(fù)雜性 參與5大神經(jīng)，多個(gè)功能（內(nèi)收、伸肘、伸指） 伸指總肌（C7：1.4mV，C8：0.8mV，C5,C6,T1：0.2-0.5mV） Gu YD:J Hand Surg(Br)1997 對(duì)側(cè)移位后腦功能重組的難度增加,臨床研究,Group(Normal Control) at active state (adducting right shoulder),Group (Patients Group) at active state (adducting right shoulder),健側(cè)C7移位正中神經(jīng) （PET檢測(cè)）,很明顯，大腦發(fā)生了跨越兩半球長(zhǎng)程的功能重組,如何提高復(fù)雜功能的恢復(fù)是神經(jīng)移位領(lǐng)域發(fā)展的趨勢(shì) 大腦功能重組的研究是重要