经纵隔内切取长段膈神经与下干后股直接吻合重建全臂丛撕脱伤的伸指功能

Clinical study of direct coaptation of phrenic nerve harvested in mediastinum with posterior division of lower trunk to recover finger extension with brachial plexus root avulsion

目的为全臂丛神经撕脱伤的伸指功能重建寻找一种新的有效的神经移位方法。方法经纵隔直视下切取一段膈神经,以增加其长度。锁骨上、下臂丛神经探查联合切口,截断锁骨,找到下干后股,向近端干支分离后切断,将膈神经与下干后股直接吻合。本组12例臂丛神经撕脱伤,男10例,女2例;年龄6～39岁,平均28岁。伤后到手术时间2～11个月,平均6个月,其中全臂丛神经撕脱伤11例,中、下干撕脱伴上干不全损伤1例。术前需胸透及电生理检查均证实患侧膈神经功能良好。结果经纵隔内直视下切取膈神经可使其长度增加3～7cm,平均4cm。12例均实施了膈神经与下干后股的直接吻合,其中3例术后随访1年以上,有2例指总伸肌肌力恢复到2级,另1例吸气时指总伸肌内有新生电位出现。结论经纵隔内切取膈神经可使其长度明显延长,可与下干后股进行直接吻合重建伸指功能,初步临床应用证实是可行的。

Objective To find out a new effective method of nerve transfer to reconstruct the func- tion of finger extension in patient suffered brachial plexus root avulsion. Methods The length of phrenic nerve was enlongated by harvested in the mediastinum. The entire brachial plexus of in- juried side was exposed through the combined incision superior and inferior to the clavicle and the clavicle was osteotomied. The posterior division of lower trunk was identified and severed as proximal as possible,direct anastomosis of phrenic nerve with posterior division of lower trunk was performed. From Jun.2005 to Mar.2007, 12 patients including 10 males and 2 females with brachial plexus nerve root avulsion were performed with this procedure,11 cases with total nerve roots avul- sion and 1 cases with middle and lower trunk avulsion,the average age was 28 years with a range of 6 to 39 years. The interval from injury to operation ranged from 2 to 11 months with a mean of 6 months.The normal function of the phrenic nerve on the injuried side should be proved preoperatively by chest radiographic and electromyography examination.Results The length of phrenic nerve harvested from the mediastinum was elongated 3-7cm, with an average of 4cm. All the cases were successfully performed by the direct coaptation of phrenic nerve with posterior division of lower trunk. 3 cases were followed up more than 12 months after operation, the muscle strength of extensor digitorum was M2 in 2 cases and newborn potential appeaed in the muscle of extensor digitorum in another case.Conclusion The direct coaptation of the phrenic nerve harvested in the mediastinum with the posterior division of lower trunk to recover the extension of finger in patient with brachial plexus injury was feasibile.