臂丛神经移位进展

Textmasterformate durch Klicken bearbeiten,Zweite Ebene,Dritte Ebene,Vierte Ebene,Fnfte Ebene,Klicken Sie,um das Titelformat zu bearbeiten,Page,*,Textmasterformate durch Klicken bearbeiten,Zweite Ebene,Dritte Ebene,Vierte Ebene,Fnfte Ebene,Klicken Sie,um das Titelformat zu bearbeiten,臂丛损伤后神经移位术进展,复旦大学附属华山医院手外科,徐文东,上臂丛损伤,神经移位方案,副神经 肩胛上神经,膈神经,尺神经局部束 肌皮神经,同侧颈7 腋神经,肋间神经,胸前内测神经,胸背神经,三头肌长头支,腋神经前支,JK Terzis The Surgical Treatment of Brachial Plexus Injuries in Adults.Plast.Reconstr.Surg.119:73e,2007,华山医院的方法,：,1 副神经-肩胛上神经,膈神经-上干前股,颈丛运动支-上干后股,同侧颈7,2 副神经-肩胛上神经,尺神经局部束-二头肌支,正中神经局部束-肱肌肌支,三头肌支-腋神经,尺神经局部束-二头肌支,正中神经局部束-肱肌肌支,上臂丛损伤,神经移位方案,健侧C7-尺N-正中主干 或 健侧C7-腓肠N-下干或正中神经,肋间神经-下干,肌皮N肱肌肌支-正中N主干后1/3束顾玉东 2003,桡神经旋后肌支-前骨间神经E Hsiao 2021,肱肌肌支-正中神经局部束,下臂丛损伤,神经移位方案,华山医院的方法：,胸腔镜取全长膈神经-正中神经内侧头或前骨间神经,肱肌肌支-前骨间神经,同侧颈7-下干,肋间神经-正中神经,下臂丛损伤,神经移位方案,1,膈神经,-,上干前股,副神经,-,肩胛上神经,颈丛运动支,-,上干后股,肋间神经,-,桡神经、胸背神经,健侧,C7-,尺神经,-,正中神经,2,肋间神经或健侧,C7-,肌皮神经,副神经,-,肩胛上神经,肋间神经或健侧,C7-,尺神经,-,正中神经,肋间神经或健侧,C7-,桡神经,围绕有限的供体神经展开,全臂丛损伤,全臂丛损伤神经移位术恢复肢体功能的先后顺序,1,屈肘,2,肩外展,3,肩部稳定,4,手部感觉,5,屈腕屈指,6,伸腕伸指,1,屈肘,2,肩外展,3,肩部稳定,4,肩外旋,5,伸肘,6,伸腕伸指,Shin,Songcharoen,Millesi,Terzis,Chuang,1,屈肘,2,肩外展,3,肩部稳定,4,肩外旋,5,屈腕屈指,1,肩外展,2,肩外旋,3,屈肘,4,屈腕屈指,5,伸肘,6,手部感觉,1,屈肘,2,屈腕屈指,3,肩部稳定,4,肩外展,5,肩外旋,由近及远,JK Terzis.The Surgical Treatment of Brachial Plexus Injuries in Adults.Plast Reconstr Surg.119:73e,2007,DCC Chuang.Brachial plexus reconstruction based on the new definition of level of injury.Injury Int J Care Injured(2021)39S,S23-S29,AY Shin.Adult Traumiatic Brachial Plexus Injuries.J Am Acad Orthop Surg 2005;13:382-396.,P songcharoen.ManageMent of Brachial Plexus injury in adults.Sca J Surg 2021;97:317-323.,H Millesi.Surgical Treatment of Post-Traumatic Brachial Plexus Lesions.Eur Surg.2003;Vol35:No4.,神经移位术恢复肢体功能的先后顺序,1,伸腕屈指,2,屈腕伸指,3,肩肘关节,Doi,由远及近,远,近,K Doi.Technique of Intercostal Nerve Harvest and Transfer for Various Neurotization Procedures in Brachial Plexus Injuries.Techniques in Hand and Upper Extremity Surgery 11(3):184194,2007,全臂丛神经损伤,神经移位术恢复肢体功能的先后顺序：,主流观点：重建肩肘功能第一,最强有力的动力神经恢复肩肘功能。,华山医院的策略,：,副神经-肩胛上神经,膈神经-上干前股 颈丛-上干后股,肋间神经-三头肌肌支/伸腕伸指肌支、胸背神经,健侧颈7-尺神经-正中神经,With multiple root avulsions,the prevailing,attitude to date has been to reconstruct shoulder,and elbow flexion without attempting to restore,function of the hand.-Terzis.,JK Terzis The Surgical Treatment of Brachial Plexus Injuries in Adults.Plast.Reconstr.Surg.119:73e,2007,全臂丛损伤后神经移位术的新观点：,1,尝试恢复复杂的协调运动：,A,有动力的背阔肌移位 动态,B,肱骨旋转截骨矫形 静态,肩胛骨稳定,肩外展功能,肩外旋功能不能外旋的屈肘效果有限,H.Millesi1.Coordinated function oriented movements after multiple,root avulsion Acta Neurochir Suppl(2007)100:117-119.,全臂丛损伤后神经移位术的新观点：,2,伸肘功能的修复,维持肘关节的稳定性,用至少两根肋间神经移位至三头肌支,Narakas,A.,and Hentz,V.Neurotization in brachial plexus injuries:Indications and results.,Clin.Orthop.,237:75,1988.,JK Terzis The Surgical Treatment of Brachial Plexus Injuries in Adults.Plast.Reconstr.Surg.119:73e,2007,伸肘比屈肘功能更难恢复,尝试对原有观点的突破,臂丛修复后几乎所有的相关报道显示肩外展、外旋以及伸肘伸腕伸指功能恢复较差,Narakas and Hentz等人认为这一现象和胚胎学相关，抓握的功能对于生存比较重要,神经移位术开展的趋势,近靶器官移位,Close Target Neurotization,Close-target neurotisation(CTN),：,a direct,coaptation,at a more distal site,closer to the,targets,muscle,or skin,without the need for nerve graft,faster recovery of motor and sensory outcomes.,-Chuang,DCC Chuang.Brachial plexus reconstruction based on the new,definition of level of injury.Injury,Int.J.Care Injured(2021)39S,S23S29,神经移位术开展的趋势,要求：高选择性符合神经移位的原那么,1,纯运动支,-,纯运动支效果更佳,Normally the aim is to restore motor function,but in any case sometimes also sensibility can be restored,as we see below.So it is important to utilize a pure motor nerve.-C.Novelli,A.Gilbert,2,尽量靠近靶肌肉,-,缩短再生距离,C.Novelli,A.Gilbert.Neurotizations in Brachial Plexus Injuries:New Approaches.Page 67-77.,Samii A,Carvalho GA,Samii M.Brachial plexus injury:factors affecting functional outcome in spinal accessory nerve transfer for the restoration of elbow flexion.J Neurosurg 2003;98:30712,.,The length and,duration of axonal regrowth is therefore shortened,and we,know that this is a major factor in influencing outcomes,.-Samii A,神经移位术开展的趋势:,例如：,尺神经局部束-二头肌支Oberlin 1994,肌皮N肱肌肌支-正中N主干后1/3束顾玉东 2003,桡神经旋后肌支-前骨间神经E Hsiao 2021,三头肌肌支-腋神经前支(Leechavengvongs S 2003),全长膈神经-正中神经内侧头徐文东 2021,前骨间神经,Close Target Neurotization,神经移位术开展：,手术方法的改进：,胸腔镜取全长膈神经,椎体前路健侧颈,7,-,缩短再生距离,不是只注重单一的运动功能恢复,力争恢复有功能意义的复杂运动,健侧颈,7-,正中神经,选择性健侧颈,7-,正中、桡神经,端侧吻合技术的应用,神经移位后大脑功能重组成为了一项新的挑战,神经移位术开展：,神经移位观念的进步：,The real goal for evaluation of brachial plexus surgery should be the ability to perform coordinated,complex movements.In such cases,cerebral plasticity,plays a,decisive role,.,-,Millesi 2007,H Millesi Coordinated function oriented movements after multiple root avulsion Acta Neurochir Suppl(2007)100:117119,神经移位术开展：观念,恢复复杂运动功能,肩肘部的组合运动,肩外旋,伸肘,手部功能健侧C7是最常用的动力,健侧颈7移位正中神经,91.6%患者获得保护性感觉,运动20%-50%,选择性健侧颈7移位恢复屈腕屈指或伸腕伸指 协同问题？,JK Terzis.Selective Contralateral C7 Transfer in,Posttraumatic Brachial Plexus Injuries:,A Report of 56 Cases.Plast Reconstr Surg123:927,2021.,JK Terzis.Vascularized Ulnar Nerve Graft:151,Reconstructions for Posttraum