胫神经缩窄术在治疗脑瘫下肢痉挛肢体中的应用

Neurotomy of the tibial nerve for treatment of spastic lower limbs in cerebral palsy

目的探讨胫神经缩窄术在治疗脑瘫下肢痉挛肢体及矫正内翻马蹄足中的应用及手术效果。方法 2006年9月～2008年12月对27例脑瘫患儿53肢下肢痉挛肢体行胫神经缩窄术,单侧1例,双侧26例。术前详细检查、明确病因,对下肢挛缩肌肉及神经支配进行详细分析。术中以神经电刺激对运动神经肌肉支配进行定位。手术显微镜下行胫神经缩窄术。结果共行胫神经缩窄术27例(53肢)。所有患者随访6个月～1年3个月,平均10.3个月。术后手术肢体功能全部改善。踝关节增加15～50度背屈,改善率96%。内翻足19例,16例足改善,改善率84.2%。27例患儿术后足底位置正常(足底完全着地)11例(40.8%),基本正常(与地面夹角小于10度或足底外侧3分之2以上着地)13例(48.1%),尚不正常3例(11.1%)。随访期间下肢肢体随意运动功能改善22例(81%),其中显著改善7例(26%)。术后下肢肢体无感觉障碍。3例(11%)肌力不同程度下降,康复训练后肌力均有恢复和增强。结论胫神经缩窄术可有效矫正治疗脑瘫下肢痉挛性瘫痪及内翻马蹄足,改善脑瘫下肢运动障碍。

Objective To explore indication and approaches of neurotomy of tibial nerve for the treatment of the talipes equinovarus and spastic paralysis in cerebral palsy.Methods A total of 27 cerebral palsy children with 53 spastic lower limbs were diagnosed with clear etiology,spastic muscles with supplied nerves were analyzed in detail,neurotomy of the tibial nerve was performed under microscope,during operation,motor nerve was located with electronic stimuli and monitored with induced electromyocardiogram.The surgical results were analyzed.Results 53 neurotomies of tibial nerve were done in 27 cases of cerebral palsy children with 53 spastic limbs.All patients were followed up from 6 to 15 months（means 10.3 months）,and evaluated with dorsum flex of ankle joint,touching ground of feet,talipes equinovarus,random movement improving evaluation and satisfactory grade of the parents.A total of 26 of 27（96%） neurotomy of the tibial nerve were improved with dorsum flex of ankle at 15～50 degree,and 16 of 19（84%） talipes aquinovarus improved clinically.Of 27 feet with surgery,11 feet（40.8%） were in normal position and could touch ground completely,13 feet（48.1%） had 10 degree with ground or could contact ground with external one third of the feet,3 feet（11.1%） were abnormal.All patients were followed up from 6 to 15 months（means 10.3 months）.During follow-up,the random movement improving rate of spastic lower limbs is 81%（22/27）,7 patients（26%）improved dramatically.Conclusion Neurotomy of tibial nerve is an effective method to treat talipes equinovarus,and can improve the motor activity of spastic lower limbs in cerebral palsy children.