Functional reconstruction following brachial plexus root avulsion

OBJECTIVE： To sum up the treatment of brachial plexus root avulsion and the progress in functional reconstruction and rehabilitation following brachial plexus root avulsion. DATA SOURCES： A search of Medline was performed to select functional reconstruction and rehabilitation following brachial plexus injury-related English articles published between January 1990 and July 2006, with key words of ＂brachial plexus injury, reconstruction and rehabilitation＂. Meanwhile, a computer-based search of CBM was carried out to select the similar Chinese articles published between January 1998 and July 2006, with key words of ＂brachial plexus injury, reconstruction and rehabilitation＂. STUDY SELECTION： The materials were checked primarily, and the literatures of functional reconstruction and rehabilitation of brachial plexus injury were selected and the full texts were retrieved. Inclusive criteria： ①Functional reconstruction following brachial plexus injury. ②Rehabilitation method of brachial plexus injury. Exclusive criteria： Reviews, repetitive study, and Meta analytical papers. DATA EXTRACTION： Forty-six literatures about functional reconstruction following brachial plexus injury were collected, and 36 of them met the inclusive criteria. DATA SYNTHESIS： Brachial plexus injury causes the complete or incomplete palsy of muscle of upper extremity. The treatment of brachial plexus is to displace not very important nerves to the distal end of very important nerve, called nerve transfer, which is an important method to treat brachial plexus injury. Postoperative rehabilitations consist of sensory training and motor functional training. It is very important to keep the initiativeness of exercise. Besides recovering peripheral nerve continuity by operation, combined treatment and accelerating neural regeneration, active motors of cerebral cortex is also the important factor to reconstruct peripheral nerve function. CONCLUSION： Consciously and actively strengthening functional exercise after operation is helpful to form cerebral plasticity and produce voluntary movements, can re-educate re-dominated muscle, obviously improves postoperative therapeutic effect and promote functional reconstruction.

臂丛根性撕脱伤的功能数字表示法

本文对臂丛根性撕脱伤（节前损伤），进行了手术前后的功能数字测定，作出了符合临床实际的系列化功能数字（包括百分数），此法对治疗效果的评定和伤残病人的鉴定都是一种定量测评的方法，比单纯文字叙述要规范、客观、明了。

神经移位术恢复臂丛根性撕脱伤后屈肘功能的中期疗效观察

目的 观察不同神经移位于肌皮神经对臂丛根性撕脱伤后的肘关节功能重建的疗效.方法 2006年6月～2010年6月对12例臂丛根性撕脱伤（其中,8例为臂丛上干根性撕脱伤,4例为全臂丛损伤）的患者行不同神经移位于肌皮神经重建臂丛损伤后的屈肘功能,术后进行32～78个月的中期随访,并评价其中期疗效.结果 12例患者患侧肘关节的屈曲功能均得到不同程度的恢复,其中膈神经移位术后最早出现肱二头肌主动收缩及肘关节主动屈曲.最终复查肘关节功能肌力4级以上、活动度60°以上的完整恢复及功能状态评价的优良率均为75％.结论 运用膈神经移位于肌皮神经是重建臂丛根性撕脱伤后肘关节功能较为优良的神经移位术.

Comparison between direct repair and humana cellular nerve allografting during contralateral C7 transfer to the upper trunk for restoration of shoulder abduction and elbow flexion

Direct coaptation of contralateral C7 to the upper trunk could avoid the interposition of nerve grafts. We have successfully shortened the gap and graft lengths, and even achieved direct coaptation. However, direct repair can only be performed in some selected cases, and partial procedures still require autografts, which are the gold standard for repairing neurologic defects. As symptoms often occur after autografting, human acellular nerve allografts have been used to avoid concomitant symptoms. This study investigated the quality of shoulder abduction and elbow flexion following direct repair and acellular allografting to evaluate issues requiring attention for brachial plexus injury repair. Fifty-one brachial plexus injury patients in the surgical database were eligible for this retrospective study. Patients were divided into two groups according to different surgical methods. Direct repair was performed in 27 patients, while acellular nerve allografts were used to bridge the gap between the contralateral C7 nerve root and upper trunk in 24 patients. The length of the harvested contralateral C7 nerve root was measured intraoperatively. Deltoid and biceps muscle strength, and degrees of shoulder abduction and elbow flexion were examined according to the British Medical Research Council scoring system;meaningful recovery was defined as M3–M5. Lengths of anterior and posterior divisions of the contralateral C7 in the direct repair group were 7.64 ± 0.69 mm and 7.55 ± 0.69 mm, respectively, and in the acellular nerve allografts group were 6.46 ± 0.58 mm and 6.43 ± 0.59 mm, respectively. After a minimum of 4-year follow-up, meaningful recoveries of deltoid and biceps muscles in the direct repair group were 88.89% and 85.19%, respectively, while they were 70.83% and 66.67% in the acellular nerve allografts group. Time to C5/C6 reinnervation was shorter in the direct repair group compared with the acellular nerve allografts group. Direct repair facilitated the restoration of shoulder abduction and elbow flexion. Thus, if direct coaptation is not possible, use of acellular nerve allografts is a suitable option. This study was approved by the Medical Ethical Committee of the First Affiliated Hospital of Sun Yat-sen University, China (Application ID:[2017] 290) on November 14, 2017.

臂丛神经根性撕脱伤的治疗

神经移位术是治疗臂丛根性撕脱伤的主要方法。臂丛丛外移位神经包括肋间神经(Tsuyama1969)、副神经(Kotani1970)、颈丛运动支(Brunelli1977)、膈神经(顾玉东1970)、健侧颈7神经根(顾玉东1986)等。其中,健侧颈7根移位神经纤维数量最多,安全有效,已被国内外广泛应用。近年来,胸腔镜下超长切取膈神经,有效缩短了神经再生时间。对颈5、6根性撕脱伤,改良的Oberlin术式———臂丛丛内部分尺神经或正中神经移位修复肌皮神经肱二头肌支,手术简单,屈肘功能疗效肯定;同侧颈7根移位术有效且能恢复多组肌肉功能。对颈8胸1根性撕脱伤,肌皮神经肱肌肌支移位修复正中神经屈指肌束或骨间前神经以恢复屈指功能。对全臂丛根性撕脱伤,改良的Doi术式———双股薄肌移位联合神经移位较好恢复了手握持功能;肢体短缩,健侧颈7移位直接修复正中、尺神经,能恢复屈拇屈指功能,但手内肌功能仍无恢复。如何重建手内肌仍需作进一步探索。