三种神经吻合方法修复双侧指固有神经缺损的比较研究

Comparison of three methods on bilateral proper digital nerve injuries for repairing severed fingers

目的：比较断指再植术中神经弓（移植神经弓和指神经弓）端侧吻合与传统端端吻合修复双侧指固有神经缺损的手术效果。方法回顾性分析2009年3月至2012年9月，治疗57例断指再植术中双侧指固有神经缺损患者资料，根据不同手术方式将患者分为移植神经弓端侧吻合组19例，取直径相近的前臂皮神经桥接于远端尺、桡侧神经间行神经端端吻合，形成远端神经弓，将近端尺、桡侧神经断端解剖游离，在无张力下与神经弓行端侧吻合；移植神经弓双端侧吻合组22例，将远、近端尺、桡侧指固有神经分别吻合，形成远、近神经弓，取前臂外侧皮神经，中点切为两段，分别与神经弓的尺、桡侧行端侧吻合；移植神经直接桥接端端吻合组16例。比较三组患者远节指腹感觉、两点辨别觉和指关节活动的恢复情况。结果术后57例患者伤口均甲级愈合，无一例出现伤口感染及皮肤软组织坏死。移植神经弓端侧吻合组18例获得随访，随访时间3~15个月，远节指腹感觉为S3~S4级，平均S3＋级；两点辨别觉为（5.1±0.8）mm。神经弓移植神经双端侧吻合组19例获得随访，随访时间4~15个月，远节指腹感觉为S2~S4级，平均S3级；两点辨别觉为（6.3±0.9）mm。移植神经直接桥接端端吻合组12例获得随访，随访时间3~14个月，远节指腹感觉为S2~S4级，平均S2级；两点辨别觉为（7.2±1.4）mm。三组患者指各关节活动均较术前改善，但组间无显著差异。结论神经弓端侧吻合的方法可以修复两侧指固有神经同时缺损，有效恢复指腹感觉，其中移植神经弓端侧吻合术操作较为易行。

Objective To compare the clinical efficacy of the nerve bow （digital nerve and cutaneous antebrachii later-als） with end-to-side neuroanastomosis and traditional end-to-end neuroanastomosis for repairing bilateral proper digital nerve inju-ries while replanting injured fingers. Methods A total of 57 patients with bilateral proper digital nerve injuries from March 2009 to September 2012 were retrospectively analyzed. The patients were divided into three groups according to different treatments：19 patients underwent nerve graft bow end-to-side neuroanastomosis. During operation, a cutaneous antebrachii laterals nerve was freed and obtained from the homolateral forearm, which were sutured with bilateral distal digital nerve end to end, then nerve bow was formed. The bilateral proximal ends of digital nerve were sutured end-to-side bow, respectively. 22 patients underwent digital nerve bow end-to-side neuroanastomosis. During operation, bilateral distal ends and proximal ends were sutured respectively;con-sequently, the distal and proximal nerve bows were formed. A cutaneous antebrachii laterals nerve was obtained from the homolat-eral forearm, then divided equally to 2 parts which were used to bridge the 2 nerve digital nerve bow end-to-side neuroanastomosis bows. 16 patients underwent nerve graft with end-to-end neuroanastomosis. The sensation of finger plup, two point discrimination and motion of joints were evaluated. Results All patients achieved primary healing of wound after operation, with 57 fingers re-covered uneventfully. In nerve graft bow end-to-side neuroanastomosis group, 18 patients were followed up for 3-15 months;the average result of sensation measurement was S3＋;the average result of two point discrimination was 5.1±0.8 mm. In digital nerve bow end-to-side neuroanastomosis group, 19 patients were followed up for 4-15 months;the average result of sensation measure-ment was S3; the average result of two point discrimination was 6.3 ± 0.9 mm. In nerve graft with end-to-end neuroanastomosis group, 12 patients were followed up for 3-14 months;the average result of sensation measurement was S2, the average result of two point discrimination was 7.2±1.4 mm. According to total active motion scales, there had no difference in results of motion of joints in the 3 groups. Conclusion The nerve bow end-to-side neuroanastomosis is valuable method for repairing bilateral proper digi-tal nerve injuries at the same time, which can restore sensation of fingers.