胫神经近端肌支转位修复腓深神经的可行性研究

A FEASIBILITY STUDY ON TRANSPOSITION OF PROXIMAL MOTOR BRANCHES FROM TIBIAL NERVE TO RECONSTRUCT DEEP FIBULAR NERVE

目的探讨胫神经近端肌支转位修复腓深神经的可行性,为手术治疗高位腓总神经损伤提供解剖学依据。方法取8具新鲜冷冻尸体双下肢标本以及由3例高位截肢术患者自愿捐赠的新鲜下肢标本(左侧2具、右侧1具),解剖腘窝部各神经,测量胫神经3条运动分支(比目鱼肌支和腓肠肌内、外侧头肌支)长度、直径及其发出点至腓总神经分支点的距离,腓深神经无损伤分离束长度及直径,评价各条运动支与腓深神经束行无张力吻合的可行性。切取以上神经分支行HE及乙酰胆碱酯酶染色观察,计数神经纤维。结果大体解剖观察示,腓肠肌内、外侧头肌支及比目鱼肌支发出点至腓总神经分支点之间的距离分别为:(71.44±2.76)、(75.66±3.20)、(67.50±3.22)mm;以上各分支以及腓深神经无损伤分离束长度分别为(31.09±2.01)、(38.44±2.38)、(59.18±2.72)、(66.44±2.85)mm,直径分别为(1.72±0.08)、(1.88±0.08)、(2.10±0.10)、(2.14±0.12)mm。组织学观察示腓肠肌内、外侧头肌支、比目鱼肌支、腓深神经无损伤分离束运动神经纤维数分别为(2 032±58)、(2 186±24)、(3 102±85)、(3 512±112)根。比目鱼肌支直径以及运动神经纤维数与腓深神经无损伤分离束相似(P>0.05),腓肠肌内、外侧头肌支以上指标均显著低于腓深神经无损伤分离束(P<0.05)。结论胫神经腘窝部3条运动神经分支均可直接转位吻合腓深神经无损伤分离束修复高位腓总神经束损伤,其中比目鱼肌支为首选供体神经。

Objective To explore the feasibility of transposition of the proximal motor branches from tibial nerve（TN） as direct donors to suture the deep peroneal nerve（DPN） so as to provide a basis for surgical treatment of high fibular nerve injury. Methods Nineteen lower limb specimens were selected from 3 donors who experienced high-level amputation（2 left limbs and 1 right limb） and 8 fresh frozen cadavers（8 left limbs and 8 right limbs）. The length and diameter of the three motor branches from TN（soleus,medial gastrocnemius,and lateral gastrocnemius） and the distance from the initial points to the branch point of the common peroneal nerve（CPN）,as well as the length and diameter of the noninvasive separated bundles of DPN,then the feasibility of tensionless suturing between the donor nerves and the DPN bundle was evaluated. At last,part of the nerve tissue was cut out for HE and Acetylcholine esterase staining observation and the nerve fiber count. Results Gross anatomic observation indicated the average distance from the initial points of the three donor nerves to the branch point of the CPN was（71.44±2.76）（medial gastrocnemius）,（75.66±3.20）（lateral gastrocnemius）,and（67.50±3.22） mm（soleus）,respectively. The three donor nerves and the DPN bundles had a mean length of（31.09±2.01）,（38.44±2.38）,（59.18±2.72）,and（66.44±2.85） mm and a mean diameter of（1.72±0.08）,（1.88±0.08）,（2.10±0.10）,and（2.14±0.12） mm,respectively. The histological observation showed the above-mentioned four nerve bundles respectively had motor fiber number of 2032±58,2186±24,3102±85,and 3512±112. Soleus nerve had similar diameter and number of motor fibers to DPN bundles（P〉0.05）,but the diameter and number of motor fibers of the medial and lateral gastrocnemius were significantly less than those of DPN bundles（P〈0.05）. Conclusion All of the three motor branches from TN at popliteal fossa can be used as direct donors to suture the DPN for treating high CPN injuries. The nerve to the soleus muscle should be the first choice.