正中神经掌皮支尺侧支损伤--腕管综合征术后柱状痛的重要病因

Injury of ulnar branch of pahnar cutaneous branch of median nerve： an important cause of pillar pain after surgical treatment for carpal tunnel syndrome

目的通过解剖研究及临床研究，找出腕管综合征术后柱状痛的可能原因。方法首先通过对6具尸体12侧肢体腕管综合征手术区域的解剖研究，找出此区域的神经细小分支的分布规律，并据此改进常规开放手术的切口设计及进入路线。应用于临床，分析术后柱状痛的发生情况，与同期常规手术柱状痛的发生情况进行统计学比较，分析两者之间是否存在统计学差异，以找出柱状痛发生的可能原因。结果腕管综合征手术区域的神经支配来源于正中神经掌皮支，正中神经掌皮支于0点远侧平均8．1mm处穿出掌腱膜，主要分支类型为三种，单支型16．7％、双支型33．3％、三支型50％。单支型与双支型主干行走于大鱼际纹桡侧，有不规则细小分支走向尺侧，三支型其尺侧支在距0点平均11．2mm从主干发出走向尺侧，平均在距0点14．6mm处跨过大鱼际纹。据此设计手术方式：切口位于大鱼际纹尺侧0．5cm，长约3．0cm，切口近端不超过距0点2．0cm，切开皮肤后只切开腕横韧带，保护好切口近端至0点处的掌腱膜，以免损伤正中神经掌皮支的尺侧支。对102例患者的手术方式进行改进，以同期常规手术110例作为对照。术后1个月改进组柱状痛发生率为12．7％，对照组34．5％；术后3个月改进组发生率14．7％，对照组41．0％，两组差异有统计学意义（P〈0．05）；术后6个月两组无明显差异；术后1年所有患者柱状痛消失。结论正中神经掌皮支尺侧支损伤可能是腕管综合征术后柱状痛的一个重要原因。

Objective To find out the possible causes of pillar pain after surgical treatment for carpal tunnel syndrome through anatomical and clinical study. Methods Through the anatomical study of the surgical area of carpal tunnel syndrome in 6 cadavers （12 sides）, the distribution rule of the nerve branches in this area was found. According to this rule, the incision design and entry route were improved and applied to the clinic, and the occurrence of pillar pain was analyzed. A statistical comparison was made between the occurrence of pillar pain in routine surgical and modified surgical in order to find out the possible causes of the occurrence of pillar pain. Results The nerve innervation in the surgical area of carpal tunnel syndrome was derived from the palmar cutaneous branch of the median nerve. The palmar cutaneous branch of the median nerve emerged off the palmar fascia 8.1 mm at the distal side to the zero point. There were 3 types of main branch including 16.7% in single branch, 33.3% in double branches and 50% in three branches. The nerve trtmk of the single and double branches walked in the radial side of the thenar crease with several irregular fine branches to the ulnar side. The ulnar branch of the three branches went from the main trunk to the ulnar side at the site to zero point averaging 11.2 mm and crossed the thenar crease at the site to zero point averaging 14.6 ram. According to this, the operative method was designed： the incision was located at 0.5 cm of the ulnar side of the thenar crease. The incision was about 3.0 cm long, and the proximal end of the incision was at least 2.0 cm to zero point. After incision, only the transverse carpal ligament was cut to protect the palmar aponeurosis at the proximal end of the incision to zero point and avoid the injury of the ulnar branch of palmar cutaneous branch. 102 patients were performed with the improved surgery while 110 cases were treated by routine surgery. The incidence of pillar pain in the improved group was 12.7%, and that in the control group was 34.5% one month after the operation. The incidence of pillar pain in the improved group was 14.7%, and that in the control group was 41.0% 3 months after the operation. The two groups had significant differences （P〈0.05）. There was no significant differences between the two groups 6 months after the operation, and the pillar pain disappeared in all the patients one year after the operation. Conclusion The injury of the ulnar branch of the palmar cutaneous branch of median nerve may be an important cause of pillar pain after surgical treatment for carpal tunnel syndrome.