髂嵴区肋下神经外侧皮支定位研究及其带感觉的游离旋髂浅动脉穿支皮瓣的应用

Localization of the lateral cutaneous branch of subcostal nerve in iliac crest region and its application in the free sensory superficial circumflex iliac artery perforator flap

目的以肋下神经外侧皮支(LCSN)跨越髂嵴外侧唇区域的解剖定位探测,分析经皮神经电刺激仪、高频超声应用于该神经定位的可行性,讨论该神经作为游离感觉旋髂浅动脉穿支皮瓣的应用意义。方法2018年10月-2020年10月,行携带感觉神经的游离旋髂浅动脉穿支皮瓣或复合瓣修复四肢创面的患者及志愿者,分别采用经皮神经电刺激定位、超声定位对肋下神经外侧皮支进行定位,对患者术中测量定位。应用Passing-Bablok回归和Bland-Altman图对测量结果进行一致性评价。结果共收集肋下神经外侧皮支定位43例受试者:患者22例,志愿者21例。其中男39例,女4例,平均年龄39岁,平均BMI 24.08。经皮神经电刺激定位操作时间(6±1)min,探测距离为(80.7±5.9)mm。高频超声操作时间(23±4)min,距离(81.2±6.6)mm。22例手术患者测量距离为(80.9±8.2)(65~100)mm,神经直径(2.3±0.8)(1.0~4.0)mm,操作时间(5±1)min。手术与经皮神经电刺激、超声Passing-Bablok回归截距和斜率的95%CI分别包括0和1,Bland-Altman图上的点分布于两侧,且总体平均差、总体截距、斜率的95%CI均包括0,因此,可以认为经皮神经电刺激、超声应用于LCSN定位方法的一致性好。结论经皮神经电刺激、高频超声探测两种方式所探测到的肋下神经外侧皮支跨越髂嵴定位点与手术中测量结果接近,说明二者均可用于带感觉神经皮瓣感觉支的术前定位,便于优化皮瓣设计、缩短手术时间,减小手术的副损伤。

Objective To analyze the feasibility of applying transcutaneous electrical nerve stimulator and high-frequency ultrasound in superficial nerve positioning for detection anatomical location in the area of lateral lip of the iliac crest by lateral cutaneous branch of subcostal nerve(LCSN).The significance of using the nerve as a free sensory superficial circumflex iliac artery perforator flap was discussed.Methods The data of patients who underwent the repair of defects on limbs with free perforator flap or composite flap of superficial iliac circumflex artery carrying sensory nerve and the volunteers who agreed to have the location of the LCSN measured between October,2018 and October,2020 were collected.The LCSN were located by percutaneous electrical nerve stimulation and ultrasound,and the patients were measured and located during surgery.Using Passing-Bablok regression and Bland-Altman graph to evaluated the consistency between transcutaneous electrical nerve stimulation,ultrasound and the surgical positioning.Results A total of 43 subjects,including 22 patients and 21 volunteers,were selected for locating the LCSN.Thirty-nine males and 4 females,with an average age of 39 years old and an average BMI of 24.08.The operation time of percutaneous nerve electrical stimulation was(6±1)min,and the detection distance was(80.7±5.9)mm.The high-frequency ultrasound was(23±4)min,and the distance was(81.2±6.6)mm.The average operation time of surgical measured distance was(80.9±8.2)(65-100)mm,the diameter of nerve was(2.3±0.8)(1.0-4.0)mm,and the operation time was(5±1)min.A 95%CI of Passing-Bablok regression intercept and slope of operation,percutaneous electrical nerve stimulation and ultrasoundincluded 0 and 1,respectively.The points on Bland-Altman plot were distributed on both sides,and 95%CI of total mean difference,total intercept and slope included 0.Therefore,it was can be considered that the application of percutaneous electrical nerve stimulation and ultrasound in LCSN localization has good consistency.Conclusion The location point of the LCSN crossing the iliac crest which detected by transcutaneous electrical nerve stimulation and high-frequency ultrasound detection was close to the measurement taken during the operation.It was also showed that both of them can be used for preoperative locationing of the sensory branch of the sensory nerve flap,optimizing the design of the flap,shortening the operation time,and reducing the unnecessary injury in operation.