自体周围神经植入治疗脊髓陈旧性不完全性断裂伤(英文)

Autoperipheral nerve implantation for the treatment of obsolete incomplete paralysis

背景:临床上常可发现,脊髓损伤患者在排除了脊髓压迫与不稳定等因素外,许多影像学改变极为相似的患者其感觉运动功能的恢复程度差别却很大。研究表明为硬脊膜内的粘连、纤维索条的牵拉、脊髓本身的创伤后瘢痕化、软化、囊肿所致。目的:观察脊髓减压松解、神经组织植入治疗对陈旧性脊髓不完全性断裂伤的临床效果。设计:患者自身前后对照观察。对象:选择1994-06/2002-08解放军第二军医大学长海医院骨科外伤性陈旧性不完全瘫痪患者16例。损伤平面T7～95例,T10～127例,L1,24例。16例患者均曾于伤时行脊柱减压内固定,4例后路手术患者于本次手术前已取出内固定。6例患者曾针对外伤性不完全瘫痪进行过高压氧等治疗。有尿便功能障碍11例;神经根性疼痛4例。按Frankel分级:B级12例,C级4例。单位:解放军第二军医大学长海医院骨科。方法:采用显微外科技术切开患者硬脊膜,将蛛网膜、软脊膜、齿状韧带、神经根起始段与脊髓的粘连及周围的纤维条索彻底解除。将被瘢痕缩紧段的脊髓行3～6个切口纵行切开、深0.1～0.2mm、长度超过损伤节段;若发现脊髓内囊肿,则切开后吸出其中液体。然后,将自身腓肠神经用显微外科方法去除外膜、束膜,并剪开、使神经组织的质地、外观类似马尾组织,将其排列呈多条状、纵行植入已切开的脊髓处或原囊肿腔内,用9-0的无损伤线与软脊膜适当固定。最后用外科防粘连膜和骶棘肌瓣覆盖。主要观察指标:患者术后感觉和运动及尿便功能恢复情况。结果:16例患者平均随访2.5年,均进入结果分析。所有患者感觉和运动均增加1级以上,11例术前有尿便功能障碍者症状明显改善,其中6例按Frankel肌力分级,双下肢主要肌群肌力术后较术前增加2级以上,达4级,恢复行走能力,10例增加1级。结论:解除硬脊膜内粘连,瘢痕段脊髓切开,自体周围神经组织植入桥接,可以明显改善外伤性陈旧性不完全瘫痪患者的尿便功能并恢复其部分感觉运动功能。

BACKGROUND： It is often found in the clinic that apart from oppression and instability, there is much difference in sensibility and motion function recovery in patients who have similar imageologieal changes. Studies show that adhesion in the dura mater of spinal cord, traction of fibrous strip, traumatic scar, malacosis and cyst are the main causes. OBJECTIVE： To investigate the clinical effects of spinal decompression and nerve tissue implantation for obsolete incomplete paralysis. DESIGN： Self-control observation. SETTING： Department of Orthopaedics, Changhai Hospital of Second Military Medical University of Chinese PLA. PARTICIPANTS： We selected 28 patients with traumatic obsolete incomplete paralysis from the Department of Orthopaedics. Changhai Hospital of Second Military Medical University of Chinese PLA, from June 1994 to August 2002. Injured vertebral segments were T7-T9 （5 cases）, T10-T12 （12 cases）, and L1-2 （11 cases）. Sixteen patients had undergone decompression, fusion and internal fixation. Thirteen cases of them had undergone posterior decompression and pedicle screw internal fixation. The internal fixation devices had been removed in 7 patients before this procedure. Six cases of traumatic obsolete incomplete paralysis had been treated by hyperbaric oxygen. Aceording to the classification of Frankel, 16 cases were degree B and 12 cases were degree C. METHODS： The dura mater of spinal cord was opened, and the fibrous bands adhering to the spinal cord from arachnoid, pia mater spinalis, ligamenta dcnticulatum, initial part of nerve root were complete relieved. Then the spinal cord with scar fibers contracted was opened by 3-6 incisions. which were 0.1-0.2 mm deep and lnngcr than the scar part. Cyst found in the spinal cord in 6 cases was opened and the liquid in it was sucked. After that, we denuded spineurium and pcrineurium of the autogenous sural nerve graft, making the texture and appearance of the nerve look like cauda equine. The nerve was lined in several strips and longitudinally implanted into the incised spinal cord and cyst, and then it was sutured with pia mater spinalis with 9-0 scatheless wire. Finally the endorachis was sutured or covered by sacrospinal muscle. RESULTS： Sixteen cases were followed up for an average of 2.5 years, and all the patients entered the result analysis. The sensibility and motion function increased above one grade. Eleven patients who had suffered gatism had obvious progress. The strength of main muscle was increased by 2 grades and reached grade 4 in 16 cases, and walking capability was recovered. In 10 cases it was increased by 1 grade Only sensation had progress in 2 cases. CONCLUSION： Relieving adhesion in the endorhachis, incising the cicatricial spinal cord and bridging the autogenous peripheral nerve have good therapeutic results for gatism and recovering the muscle power of the extremities for the patients with traumatic obsolete incomplete paralysis.