经椎体前路移位健侧颈_7神经根修复臂丛上中干根性撕脱伤

Contralateral C_7 transfer via prcspinal route to repair upper and middle trunk avulsions of the brachial plexus

目的探讨健侧颈,神经根经椎体前路移位,修复臂丛上、中干根性撕脱伤的最短通路及其安全性,并分析其应用指征和临床疗效。方法将颈部双侧前斜角肌切断,经椎体前、食管后间隙构制健侧颈,神经根移位通路,将颈,神经根自锁骨后股束交界处切断,近端游离至椎间孔,通过皮神经桥接或直接缝合修复患侧颈_(5、6)神经根或上干前后股。2005年12月—2007年5月,对8例臂丛上、中干根性撕脱伤伴下干部分损伤,或合并副、膈神经损伤的患者进行修复。结果术后1周内,8例患者在咳嗽、进食时健侧手指有轻度麻木感,2～3周后症状逐步消失;体感诱发电位(SSEP)在术后3个月时均能引出,7个月时能引出支配肌复合肌肉动作电位(CMAP);术后12个月肩、肘功能部分恢复。结论切断双侧前斜角肌不仅可以缩短移植神经的长度,且健侧颈,神经根翻转通路更通畅、安全。直接修复或短段皮神经移植极大地缩短了神经再生的距离,利于患肢肩、肘功能的恢复。术后早期禁食可以减轻食道的组织创伤反应,利于颈,神经根缝合口的愈合。

Objective To investigate safety and feasibility of contralateral C7 transfer via prespinal route and evaluate the surgical indications and clinical outcomes. Methods Eight male patients who sustained brachial plexus upper and middle trunk avulsions along with partial lower trunk injury or spinal accessory or phrenic nerve injury were treated from Dec 2005 to May 2007. The bilateral scalenus anterior muscles were transected before a prespinal and retropharyngeal tunnel was made. We transected C7 at division-cord junction level retroclavicularly to obtain more length and then C7 nerve root was dissected proximally close to the intervertebral foramen. The contralateral C7 nerve root was used to repair the residual C5 and C6 nerve roots or the anterior and posterior divisions of the upper trunk of the injured side via this route, using direct neurorrhaphy or nerve grafting. Results All patients complained of tingling in the contralateral fingers when coughing or eating within the first week following the surgery, which gradually subsided in 2 - 3 weeks. At 3 month follow-up, ipsilateral SSEP could be recorded. At 7 month follow-up, CMAP could be recorded in biceps, deltoids and infraspinatus muscles. At 12 month follow-up, movement of the shoulder and elbow was observed. Conclusion Transection of bilateral scalenus muscles could reduce the length of nerve graft and create a smoother and safer prespinal and retropharyngeal route for C7 nerve transfer. Direct neurorrhaphy or short bridging by 3 to 4 em nerve graft greatly shortens the distance needed for nerve regeneration and should facilitate recovery of function of the shoulder and elbow. Postoperative fasting for 4 days could reduce tension at the nerve coaptation site and facilitate healing of the nerves and avoid complications.