创伤性全臂丛撕脱伤上肢整体功能重建的临床研究

The clinical research of restoring the global upper limber function in traumatic total brachial plexusavulsion injuries

目的观察采用多组神经移位术结合后期手功能重建恢复全臂丛神经撕脱伤患者主动拾物功能的疗效。方法33例全臂丛神经撕脱伤患者，一期手术均采用多组神经移位术，即副神经移位修复肩胛上神经恢复肩外展，健侧C7神经经椎体前通路移位与患侧下干直接吻合蕈建屈指、屈腕功能，同时将下干发出的前臂内侧皮神经移位修复肌皮神经恢复屈肘功能，膈神经与下十后股直接吻合同时重建伸肘、伸指功能。术后选择肌力获得有效恢复（肩外展恢复到30°或以上，仲肘、仲指肌力达到3级或以上，屈肘、屈腕、屈指肌力达到4级或以上）的患者进行二期手功能蓖建恢复患手的主动抓握功能。主要包括腕关节固定术、拇外展功能最建及掌板紧缩术等。结果一期忡经移位术后平均41±7．7（36－73）个月。10例患者的肌力恢复达到二期手功能重建的条件，其中8例已进行二期手功能重建。6例患者恢复了部分主动拾物功能．1例冈爪形指纠正失败，另l例因腕融合术后仲指肌腱粘连致仲指功能丧失。结论新设计的多组神经移位术町同时恢复全臂丛撕脱伤患者的肩外展、屈肘、屈腕、屈指及伸肘、伸指的有效肌力，在此基础上通过后期手功能重建，可成功重建患侧上肢的部分主动拾物功能。

Objective To observe the outcomes of the modified multiple nerve transfer s combinedwith the late hand function reconstruction to restore the active pick-up function of the paralyzed upper extremity in patients with total brachial plexus avulsion injuries （TBPAI）. Methods 33 patients suffered with TBPAI firstly underwent multiple nerve transfers, whic.h including aceessory nerve transfers to neurotize the suprascapular nerve to recover the shoulder abduction, contralateral C7 （CC7） nerve transfers via the modified pre-spinal route with direct coaptation to restore lower trunk function and the musculnc, utaneous nerve was also neurotized by the transferred CC7 nerve via a cutaneous nerve graft in restore the function of elbow flexion, as well as the phrenic nerve transfers to neurotize the posterior division of lower trunk to restore the function of elbow and finger extension. The patients with muscle recovery were selected to perform the hand function reeonstruction at the second stage for restoring the active pick-up function. The patients were chosen as followcriterias： the degree of shoulder abduction attained 30°or more, the motor power of elbow, wrist, and finger flexion attained grade M4 or more, elbow and finger extension attained M3 or more. The methods of hand function reconstruction included wrist fusion and flexor carpal ulnaris upponensplasty, in addition to palmar capsulodesis of the metacarpophalangeal joint. Results The mean follow up was 41±7.7 （range, 36- 73 months） ＇after the first procedure of multiple nerve transfers, the muscle strength of elbow and finger and wrist flexion attained M 4 as well as the elbow and finger extension achieved M3 or more in 10 patients, all of 10 patients achieved 40°-80°shoulder abduction. 8 out of 10 patients had performed the second surgical procedure for hand functional reconstruction. 6 of them had successfully recovered the active pick-up function. Conclusions The newly designed procedure of multiple nerve transfers could effectively restore the function of shoulder abduction, elbow, wrist, and finger flexion, as well as elbows and finger extension in patients with TBPAI, combined with the hand functional reconstruction, active pick-up function couht be successfully reconstructed.