胫神经肌支转位治疗高位腓总神经损伤的解剖学研究

Transferring motor branches from proximal tibial nerve for treatment of high fibular nerve injuries: an anatomical study

目的对近端胫神经的肌支情况进行解剖学测量,探讨胫神经肌支转位治疗腓总神经高位损伤或长段损伤的手术可行性。方法选取12具(23侧)中性甲醛固定的成人下肢标本,解剖并测量胫神经近端各肌支的长度、入肌点处的直径、分支点至腓骨小头平面的距离(位置)及至腓骨颈的距离;从分叉部向近端膜内分离腓总神经的腓深、腓浅两部分,测量腓总神经可分离的最大长度以及腓深神经的直径。将腓深神经于分离的最高点处切断并模拟移位,观察胫神经肌支与腓深神经无张力缝合的可行性。结果胫神经近端主要肌支有比目鱼肌支、腓肠肌外侧头支和腓肠肌内侧头支,其长度分别为(53.2±9.9)、(36.3±9.6)和(44.7±8.6)mm;从分叉部向近端膜内分离腓总神经的最大长度为(59.3±7.2)mm;分离后,所有标本的比目鱼肌支和腓肠肌外侧头支以及21侧(91.3%)标本的腓肠肌内侧头支均可直接与腓深神经无张力地吻合。结论膜内分离腓总神经后,胫神经肌支转位治疗腓总神经长段损伤或高位损伤在解剖学上可行。综合考虑各肌支的长度和直径,比目鱼肌支是移位的最佳供体神经。

Objective To observe the anatomy of proximal tibial nerve, so as to assess the feasibility of transferring motor branches from proximal tibial nerve for treatment of the high fibular nerve or long-segment injuries. Methods Totally 23 sides of lower limbs from 12 adult cadavers were included in the present study. The branching pattern, length, diameter of motor branches of the tibial nerve in the proximal leg, location of original point relative to fibular head level and the distance from original point to the fibular neck were examined. Intraneural dissection from the bifurcation of the common fibular nerve to the proximal （deep fibular nerve and superficial fibular nerve） was performed, and then the maximum dissected length and the diameter of deep fibular nerves were observed. The deep fibular nerve was severed at the top site and simulating transfer was performed; the feasibility of suturing the motor branches from proximal tibial nerve and the deep fibular nerve was assessed. Results There were three main motor branches at the proximal leg, including the branches to the lateral and medial head of the gastrocnemius and to the soleus muscle, with the length being （36.3±9.6） mm, （44.7±8.6） mm and （53.2±9.9） mm, respectively. The maximum length of intraneural dissection of the common fibular nerve was （59. 3 ±7. 2） mm. After dissection, the branches to the soleus muscle and the lateral head of the gastrocnemius were long enough for direct nerve suture with the deep fibular division in all cadavers without tension. The branches to the medial head of the gastrocnemius were long enough for nerve suture in 21 sides （91.3%）. Conclusion After intraneural dissection of the eommon fibular nerve, the motor branches from proximal tibial nerve can be transferred to restore the deep fibular nerve for treating high fibular nerve injuries. The branch to the soleus muscle is the best choice considering its length and diameter.