全长膈神经移位恢复伸腕指功能的解剖学研究和临床应用

Anatomical and clinical study of full length phrenic nerve transfer for restoration of wrist and finger extension

目的在应用显微解剖学方法对上臂段桡神经深支部位进行研究的基础上，探讨将全长隔神经移位到上臂段桡神经深支部分以恢复伸腕、指功能的手术疗效。方法对16具32侧尸体标本应用显微解剖学的方法，研究桡神经深、浅支在上臂段的特点及背阔肌的肌腱止点处桡神经深支在主干中的部位；在临床上开展2例经胸将全长膈神经移位到背阔肌止点处桡神经深支部分的手术，并评价其疗效。结果通过显微解剖学研究发现上臂段桡神经前臂支内均可看见2个大的神经束组，在背阔肌的肌腱止点处桡神经深支主要位于前臂支的内侧神经束组中。1例术后1年10个月随访，肩外展80°，屈肘90°，伸肘0°，伸腕、指到位，屈腕10°，屈指尚不能；伸腕肌力达到M4，伸指肌力达到M3。另1例术后2年随访，肩外展40°，屈肘30°，伸肘0°，伸腕到位，伸指轻限，屈腕、指尚不能；伸腕肌力M3，伸指肌力达到M3-。结论将全长膈神经移位到背阔肌的肌腱止点处桡神经前臂支的内侧神经束组可能是恢复全臂丛根性撕脱伤患者伸腕、指功能的有效方法。

Objective To find out the topographic location of radial nerve deep branch in the main trunk of radial nerve at the upper arm level, and to investigate the results of transferring full length phrenic nerve to the deep branch of the radial nerve for restoration of wrist and finger extension. Methods Thirty- two sides of 16 cadavers were dissected. Microsurgical retrograde dissection of the radial nerve was carried out to delineate the fascicular features of the deep and superficial branches of the radial nerve at the upper arm. The topographic location of the deep branch in the main trunk of radial nerve at the level of latissimus dorsi insertion was also observed. Clinically full length phrenic nerve was transferred to the deep branch of the radial nerve at the level of latissimus dorsi insertion in 2 cases. Postoperatively the results of the transfer were evaluated. Results There were two large fascicular groups in the antebrachial portion of the radial nerve in the arm. The deep branch of the radial nerve was mostly in the medial portion at the level of latissimus dorsi insertion. One of the 2 cases was followed for 1 year and 10 months. The patient had 80° of shoulder abduction, 90° of elbow flexion, 0° of elbow extension, 10° of wrist flexion, full wrist and finger extension but no fmger flexion. Muscle power of wrist extensor and finger extensor was M4 and M3 respectively. The other patient had 40° of shoulder abduction, 30° of elbow flexion, 0° of elbow extension, full wrist extension, slightly impaired finger extension but no wrist and finger flexion at 2-year follow-up. Muscle power of wrist extensor and finger extensor was M3 and M3- respectively. Conclusion Targeted transfer of full length phrenie nerve to the medial fascicles of the antebrachial portion of the radial nerve at the level of latissimus dorsi insertion could be an effective procedure to recover wrist and finger extension in total brachial plexus injury patients.