Repair and regeneration of peripheral nerve injuries that ablate branch points

The peripheral nervous system has an extensive branching organization, and peripheral nerve injuries that ablate branch points present a complex challenge for clinical repair. Ablations of linear segments of the PNS have been extensively studied and routinely treated with autografts, acellular nerve allografts, conduits, wraps, and nerve transfers. In contrast, segmental-loss peripheral nerve injuries, in which one or more branch points are ablated so that there are three or more nerve endings, present additional complications that have not been rigorously studied or documented. This review discusses:(1) the branched anatomy of the peripheral nervous system,(2) case reports describing how peripheral nerve injuries with branched ablations have been surgically managed,(3) factors known to influence regeneration through branched nerve structures,(4) techniques and models of branched peripheral nerve injuries in animal models, and(5) conclusions regarding outcome measures and studies needed to improve understanding of regeneration through ablated branched structures of the peripheral nervous system.

Human obturator nerve: Gross anatomy

AIM: To study the anatomy(formation, course, relationships and branching pattern) of the obturator nerve in detail.METHODS: The study was based on 500 adult human formalin-embalmed cadavers, 342 males and 158 females. We studied the anatomical formation, course and relationships of the obturator nerve within the lesser pelvis before the obturator canal. Finally, the whole course of the obturator nerve was examined.RESULTS: We found numerous anatomical variations about the formation of the obturator nerve, its division into two main branches, its articular branches, its intrapelvic branches for the periosteum of the pubic bone, and also the number of its muscular divisions and its anatomical relationship to the obturator externus muscle and obturator artery. We found that fibers from the L3 and L4 spinal nerves are standard components of the obturator nerve. The main trunk of the obturator nerve divides into anterior and posterior branches, within the pelvis in 23.30%, within the obturator canal in 52.30% and extrapelvic in 24.35% of cases. The anterior branch of the obturator nerve supplies three muscular branches in 67.10%, two muscular branches in 28.94% and four muscular branches in 3.94% of the cases. The posterior branch of the obturator nerve supplies two muscular branches in 60.52%, three muscularbranches in 19.07%, one muscular branch in 14.47% and four muscular branches in 5.92% of cases.CONCLUSION: We present a gross anatomical study of the human obturator nerve based on a remarkably large number of cases as well as potential clinical applications of our findings.

骨盆骨折髂腹股沟入路避免神经血管损伤的临床解剖学

目的为髂腹股沟入路在骨盆骨折手术中避免神经血管损伤提供解剖学依据。方法在15具(男9具,女6具)30侧成尸标本上选择髂前上棘、耻骨结节和腹股沟韧带为标志观测股外侧皮神经(Lateral femoral cutaneous nerve,LFCN)、髂腹股沟神经(Ilioinguinal nerve,IN)、股神经耻骨肌支和闭孔动脉(Obturator artery,OA)的走形特点,所测数据统计学处理。结果①LFCN在髂前上棘内侧穿出腹股沟韧带占96.67%(29/30侧),距髂前上棘中心点(20.01±0.32)mm;被腹股沟韧带纵横纤维所包裹的占33.33%(10/30侧);在阔筋膜形成的筋膜鞘中走行占46.67%(14/30侧)。②IN穿出腹内斜肌部位距离髂前上棘中心点为(5.41±0.50)mm,穿出腹外斜肌腱膜部位距离耻骨结节中心点为(18.04±0.21)mm。结论在显露髂骨翼内侧面和骶髂关节时,应在LFCN走行的阔筋膜和腹股沟韧带部位进行显露和预防性松解,以免牵拉损伤;切开腹外斜肌腱膜时应从腹股沟韧带两端上方5 mm处开始,防止损伤深面的IN。在显露髂耻隆起时先寻找和结扎闭孔血管耻骨支,以免引起不可控制的出血。

股神经和闭孔神经肌支转位的解剖学测量和神经纤维定量

目的探索股神经肌支转位修复闭孔神经损伤与闭孔神经肌支修复股神经损伤的应用解剖。方法游标卡尺测量20具成人尸体股神经和闭孔神经肌支的长度;6具死亡3~10 h内尸体,其股神经和闭孔神经的肌支经Karnovsky-Roots法染色后,图像分析仪测量它们的横切面积和神经纤维数量。结果股神经肌支中股内侧肌长支最长,近端横断面积最大;闭孔神经肌支中股薄肌支最长,大收肌支近端横切面积最大。每条肌支内均以躯体运动纤维含量最高,股神经肌支中股内侧肌长支躯体运动纤维数量最多,而闭孔神经肌支中大收肌支最多,其次是股薄肌支。各肌支中γ-薄髓神经纤维的含量,股神经的肌支中以股内侧肌短支和股直肌支较高;而闭孔神经肌支中短收肌支含量最高。结论基于各肌支长度、近端横断面积和神经纤维数量的综合考虑,股神经和闭孔神经损伤修复中,股内侧肌长支和股薄肌支宜为供体神经;股内侧肌短支和股直肌支以及大收肌支宜为受体神经。

股前外侧(肌)皮瓣的解剖与修复足部严重缺损的应用

在21具股前外侧皮瓣的解剖学研究基础上,应用股前外侧(肌)皮瓣游离移植修复足部严重软组织缺损20例,获得良好疗效。股前外侧皮瓣具有皮瓣面积大,血管蒂长,径粗,解剖容易,皮瓣厚薄适中,有可供吻接的皮神经,皮动脉的位置可根据足部创面修复的需要,任意设计在皮瓣的中心或一端,亦可设计成肌皮瓣等优点。我们认为该皮瓣是修复足部严重软组织软损的最佳供区.

腓肠肌外侧头肌支神经转移术对大鼠腓深神经损伤的修复作用

目的探讨腓肠肌肌支神经转移术修复腓深神经损伤的可行性和有效性。方法 32只成年雌性Sprague-Dawley大鼠分成空白组、对照组、神经直接吻合组(腓深神经直接吻合)和神经转移组(腓肠肌外侧头肌支转移至腓深神经),每组各8只。术后12周,肉眼观察神经吻合口生长情况,测量胫神经各肌支长度(L1)、入肌点处直径(D1)、各肌支起点至腓骨颈平面的距离(S),腓总神经膜内可分离的最大长度(L2)、腓深神经的直径(D2),比较手术前后大鼠患肢腓神经功能指数(PFI)、复合肌肉动作电位(CMAP)波幅、神经传导速度(NCV)、胫前肌湿重、肌酸磷酸激酶(CK)酶活性。结果所有实验大鼠均L1<S,不能直接与腓骨颈处的腓深神经无张力吻合。神经膜内分离腓总神经后,比目鱼肌支和腓肠肌内、外侧头肌支均能与腓深神经无张力吻合。神经转移组PFI、CMAP波幅、NCV、胫前肌湿重、CK酶活性均优于对照组(P<0.05),与神经直接吻合组间无显著性差异(P>0.05)。结论腓肠肌外侧头肌支神经转移至腓深神经修复腓深神经在解剖上可行,但要实现无张力吻合需要将腓总神经向近端进行神经膜内无损伤分离。腓肠肌外侧头肌支神经转移术能有效恢复腓深神经功能。

大腿肌内侧群痉挛肌外神经阻滞靶点的定位

目的精确定位大腿肌内侧群痉挛肌外神经阻滞靶点的位置。方法设计经耻骨结节至股骨大转子外侧皮肤的连线为横向的H参考线,经耻骨结节至股骨内上髁水平的连线为纵向的L参考线。解剖暴露经甲醛固定的10具成人尸体的20侧闭孔神经及其肌支,涂抹硫酸钡于它们表面,烘干,X线摄片,PACS软件测量闭孔神经肌支肌外阻滞靶点在H线和L线上的百分位置。结果闭孔神经股薄肌支、长收肌支、短收肌支以及大收肌支在肌外的近侧运动点(P点)分别位于距耻骨结节外侧的大腿宽度(H线)的(21.48±1.80)%、(25.85±1.23)%、(28.07±1.65)%和(29.18±2.07)%处,位于距耻骨结节远侧的大腿长度(L线)的(8.83±1.01)%、(8.83±1.01)%、(7.57±0.63)%和(7.57±0.63)%处;远侧运动点(D点)分别位于距耻骨结节外侧大腿宽度(H线)的(16.9±1.33)%、(27.70±2.15)%、(31.18±2.18)%和(35.78±2.79)%处,位于距耻骨结节远侧大腿长度(L线)的(35.57±2.77)%、(26.9±1.96)%、(24.26±1.91)%和(28.04±2.17)%处。结论这些靶点的准确定位可提高大腿肌内侧群痉挛肌外神经靶点阻滞的安全性和有效性。