正中神经损伤延期修复的长期疗效研究

LONG-TERM RESULTS OF DELAYED REPAIR OF MEDIAN NERVE INJURY

目的 统计分析正中神经损伤延期修复的长期疗效。方法 选取2004年1月-2008年12月因正中神经损伤行延期修复且获4年以上随访的228例患者,回顾其损伤情况和手术方法。其中男176例（77.19%）,女52例（22.81%）;年龄2~71岁,中位年龄29岁。损伤以切割伤（159例,69.74%）为主,203例（89.04%）为开放性损伤。按神经损伤节段进行分区,Ⅰ区为上臂损伤（38例,16.67%）,Ⅱ区为肘部和前臂近端损伤（53例,23.25%）,Ⅰ、Ⅱ区为高位正中神经损伤（骨间前神经起点近端）;Ⅲ区为骨间前神经损伤（13例,5.70%）;Ⅳ区为前臂中远端至腕部损伤（低位正中神经损伤,124例,54.39%）。神经延期修复手术包括神经延迟缝合50例（21.93%）、神经松解149例（65.35%）和神经移植29例（12.72%）。结果 根据改良Birch和Raji正中神经修复评估系统,高位损伤修复效果达好23例（25.27%）、中56例（61.54%）、差12例（13.18%）,其中Ⅰ区损伤3种修复方法效果比较差异无统计学意义（χ2=2.241,P=0.326）,Ⅱ区损伤3种修复方法效果比较差异有统计学意义（χ2=6.228,P=0.044）;12例患者（13.18%）需行屈肌功能重建;而所有患者大鱼际肌均恢复差,但其中仅5例（5.49%）行大鱼际功能（拇对掌功能）重建。13例Ⅲ区损伤患者无论采用何种修复方式,效果均佳。124例低位正中神经损伤根据Birch和Raji评分系统标准,获优6例（4.84%）、良22例（17.74%）、中72例（58.06%）、差24例（19.35%）;3种修复方法效果比较差异有统计学意义（χ2=12.646,P=0.002）,延迟缝合效果略佳。结论 正中神经延期修复效果均差,高位损伤尤为明显,修复方式的影响因损伤部位不同而不同。对于一些延期修复患者可尝试采用神经转移方式,修复重要的神经束或束组或是解决方法。

Objective To review and analyze the long-term results of delayed repair of median nerve injury. Methods Between January 2004 and December 2008, 228 patients with median nerve injury undergoing delayed repair were followed up for more than 4 years, and the clinical data were retrospectively analyzed. There were 176 males （77.19%） and 52 females （22.81%）, aged 2-71 years （median, 29 years）. The main injury reason was cutting injury in 159 cases （69.74%）; 203 cases had open injury （89.04%）. According to the injury level, injury located at area I （upper arm） in 38 cases （16.67%）, at area II （elbow and proximal forearm） in 53 cases （23.25%）, at area III （anterior interosseous nerve） in 13 cases （5.70%）, and at area IV （distal forearm to wrist） in 124 cases （54.39%）. The delayed operations included delayed suture （50 cases, 21.93%）, nerve release （149 cases, 65.35%）, and nerve graft （29 cases, 12.72%）. Results For patients with injury at area I and area II, the results were good in 23 cases （25.27%）, fair in 56 cases （61.54%）, and poor in 12 cases （13.18%） according to modified Birch and Rail＇s median nerve grading system; there was significant difference in the results between 3 repair methods for injury at area II （~z=6.228, P=0.044）, but no significant difference was found for injury at area I （X2=2.241, P=0.326）. Twelve patients （13.18%） needed musculus flexor functional reconstruction. Recovery of thenar muscle was poor in all patients, but only 5 cases （5.49%） received reconstruction. Thirteen cases of nerve injury at area III had good results, regardless of the repair methods. For patients with injury at area IV, the results were excellent in 6 cases （4.84%）, good in 22 cases （17.74%）, fair in 72 cases （58.06%）, and poor in 24 cases （19.35%） according to Birch and Rail＇s grading system; there was significant difference in the results between 3 repair methods （X2=12.646, P=0.002）, and the result of delayed repair was better. Conclusion The results of delayed repair is poor for all median nerve injuries, especially for high level injury. The technique of repair methods vary with injury level. For some delayed median nerve injuries, early nerve transfer may be a better choice for indicative patients.