带血管肋间神经移位重建截瘫膀胱功能的初步临床应用

Preliminary Clinical Studying of Using Intercostal Nerve with Vascular Shift to Reconstruct Spinal Cord Injury with Bladder Dysfunction

目的:探讨带血管肋间神经移位、腓肠神经移植桥接吻合骶神经根重建脊髓损伤后膀胱功能障碍的可行性及初步临床疗效。方法:胸腰段脊髓损伤后膀胱功能障碍7例患者,选择截瘫平面以上最近位2条正常的肋间神经,完整游离后移位到腰后,显露骶2、3神经根起始部,选择性切断每条神经根的大部分神经束;取同侧等长度的带血管腓肠神经;行2股电缆式移植桥接吻合移位的肋间神经近端与骶2、3神经根远端,每股缝合2～3针,吻合肋间血管与腓肠神经血管、腓肠神经血管与臀下动脉。分析本组病例的临床资料及随访资料。结果:手术时间为120～180分钟,平均150分钟;术中出血量为350～550ml,平均400ml;住院时间10～14天,平均12天;随访8～12个月,平均9个月,1例术后12个月有排尿、排便反射及主动排尿功能的恢复,但仍存在轻度的尿失禁,会阴部S1～2级的感觉恢复,右提睾反射恢复,2例术后10个月有排尿便意改善,1例术后9个月出现会阴部S1～2级的感觉恢复,1例术后6个月无明显改善。结论:应用截瘫平面以上正常的带血管肋间神经移位、带血管腓肠神经移植吻合骶神经根重建脊髓损伤后膀胱功能障碍的可控性排尿功能是可行的和有效的,重建的排尿功能最接近生理性,可能是目前重建弛缓性膀胱功能的理想方法之一。

Objective：To explore the feasibility and preliminary clinical curative effects of using intercostal nerve with vascular shift and sural nerve transplantation bridging to suture sacral nerve root reconstruction after spinal cord injury with bladder dysfunction. Methods： 7 bladder dysfunction patients with spinal cord injury in thoracic and lumbar segment, choosed 2 normal intercostal nerves above the nearest paraplegia level, shifted to the waist after complete freed; exposed the second and third sacral nerve roots in initial parts, selectived to cut each nerve root with most nerve bundle. Choosed the length of the same side sural nerve with vascular, sutured thenear-end of the intercostal nerve and the far end of the second and third sacral nerve roots by 2 strands cable type transplantation bridging and sutured. Every strand sutured 2 to 3 needles. Suture the costal vessel and the calf nerve vessel, sural nerve vessel and hip artery. Analyse the clinical datas and follow-up materials in all the cases. Results： Operative time was 150 minutes （range from 120 to 180 minutes）.The blood lost was 400ml （range from 350 to 550ml）.Hospitalization was 12 days （range from 10 to 14 days）. Follow-up time was of 9 months （range from 8 to 12 months）. One case had urination after 12 months, recovered the defecation reflex, perineum S1-2 level feeling and the right cremaster reflex active of urinary function. However, there were still mild urinary incontinence. 2 cases intended to improve the voiding after 10 months ,one case perineal S1-2 level feeling recovered after 9 months , one case without significant improvements after 6 months. Conclusions： Used normal blood vessels with the intercostal nerve shift above paraplegia level, transplanted and sutured sural nerve with vessels to reconstruct bladder dysfunction after spinal cord injury was feasible and effective. Reconstruction of micturition function is most close to physiological one. This might be the ideal method to the flaccid bladder function reconstruction.