健侧颈7椎体前路移位直接修复下干联合股薄肌移植治疗臂丛根部撕脱伤

Treatment of total root avulsion of brachial plexus by contralaterai C7 nerve transfer for directly repairing CsT1 via prespinal route combined with functioning gracilis transplantation

目的探讨健侧颈，神经椎体前路移位直接修复下于联合功能性股薄肌移植重建术治疗全臂丛根部撕脱伤的手术设计及其临床疗效。方法12例全臂丛根性撕脱伤患者，于伤后1～3个月行臂丛神经根干部探查，一期健侧颈，经椎体前路移位直接修复患侧C8T1-下干，同时行膈神经移位修复肩胛上神经9例。于一期术后4～8个月分别行二期吻合血管的股薄肌移植（以副神经斜方肌支为缝接神经）重建屈肘、伸指伸拇功能。结果随访9～36个月。一期术后3个月12例患侧尺神经、正中神经Tinel征至上臂近段平面，术后6个月至肘关节与前臂近段平面，9个月至前臂远段与腕部。9例12个月Tinel征至手掌、手指部。7例术后9个月胸大肌胸肋部收缩，12个月肩内收可夹持物品；5例术后15．18个月手掌、手指与前臂内侧均有触痛觉恢复，尺侧腕屈肌和示、中、环、小指屈指肌收缩。3例术后24个月，拇指屈曲，1例鱼际肌出现收缩（M1）。二期股薄肌移植功能重建术后有7例于二期术后4～7个月移植肌肉收缩；9～12个月屈肘90°～120°（M3），伸指伸拇M3。结论健侧颈，神经经椎体前路移位直接修复C8T1-下干术，联合二期股薄肌移植重建屈肘、伸指伸拇功能治疗全臂丛根部撕脱伤的手术设计具有可操作性，初步观察神经再生进程顺利，能恢复手腕、手指的屈曲与感觉功能，重建屈肘、伸指功能。

Objective To explore the clinical design and therapeutic effect of total root avulsion of brachial plexus by contralateral C7 nerve transfer for directly repairing C8T1 via prespinal route combined with functioning gracilis transplantation. Methods Twelve cases of total roots avulsion of brachial plexus were operated at 1 month to 3 months after injury. The contralateral C7 nerve was successfully transferred to directly repair avulsed C8T1 roots or lower trunk via prespinal route. At 2rid operation stage after 4 to 8 months,the functioning gracills transplantation was preformed to reconstruct the elbow flexion and fingers extension. Results Follow-ups were carried out in all 1：2 cases who had been discharged for 9 to 36 months after the first operation. The positive Tinel signs of ulnar or median nerves were located in the proximal arm at 3 months after 1st operation, in the elbow or proximal forarm at 6 months, and in the wrist or distal forarm at 9 months. At 12 months the positive Tinel signs were found in the plam or fingers in 9 cases. The contraction of steruocostal part of pectoralis major was found at 9 months in 7 cases. There were the restoration of the taction-pain sensation in the palm, finger, and medial side of forearm and the contraction of flexor carpi ulnaris and flexor digitorum（M3） in 5 cases at 15 to 18 months after 1st operation. In 7 patients the flexion of elbow and extension of fingers and thumb restored at 9 to 12 months after the 2rid operation. Their elbow flexion was 90°-120° and M3 （Highet＇s method）, and their finger and thumb extension M3. Conclusion There is the possibility of the operative design and clinical application of total root avulsion of brachial plexus by contralateral C7 nerve transfer for directly repairing C8T1 via prespinal route combined with functioning gracilis transplantation. There are not only the restoration of sensation and flexion of wrist and fingers, but also the restoration of elbow flexion and fingers extension.