Varitimidis S E, Sotereanos D G
Department of Orthopaedics, University of Pittsburgh Medical Center, Pennsylvania, USA.
Hand Clin. 2000 Feb;16(1):141-9.
The level of injury of a peripheral nerve is a critical factor that has a great impact on the result of the repair. At the level of the wrist, the median and ulnar nerves have pure motor and sensory fascicular groups. Proximal to the wrist, the motor fascicular groups combine with sensory fascicles and become mixed nerves. Mapping the fascicular orientation with electrical stimulation is indicated for injuries located from the wrist to the distal third of the forearm. Successful application of this technique depends on the level of injury, anesthetic technique, and careful patient selection. Children and patients with other serious coexisting injuries are not candidates for this technique. The depth of anesthesia must provide adequate analgesia while allowing the patient to communicate and cooperate with the surgeon during the procedure. There are few reports in the literature about repair of partially injured nerves in the upper extremities and the comparison of functional outcomes with or without the use of nerve grafts is not easy. Even under ideal operative conditions and with ideal indications, the outcomes are not always satisfactory. Hurst et al reported very good results using end-to-end repair of fascicular groups in their series. Using the rating system of the British Medical Research Council, they reported motor values of 4.0 (normal 5.0), and sensory values of 3.8 (normal 4.0). Kato et al reported very good results in their series of 51 cases with group fascicular end-to-end suture using orientation with electrical stimulation. In this series, there were five patients with partial nerve laceration and end-to-end coaptation of the fascicular groups provided very satisfactory outcome. End-to-end repair of the fascicular groups seems to provide better results than repair of the nerve using nerve grafts. It is desired, however, that the nerve gap be less than 2 cm for the application of end-to-end repair of the nerve.
周围神经的损伤程度是对修复结果有重大影响的关键因素。在腕部水平，正中神经和尺神经有纯运动和感觉束组。在腕部近端，运动束组与感觉束合并成为混合神经。对于从腕部到前臂远侧三分之一处的损伤，用电刺激来描绘束的走向是适用的。这项技术的成功应用取决于损伤程度、麻醉技术以及仔细的患者选择。儿童和有其他严重并存损伤的患者不适合这项技术。麻醉深度必须提供足够的镇痛效果，同时要让患者在手术过程中能够与外科医生交流并配合。关于上肢部分损伤神经的修复以及使用或不使用神经移植物的功能结果比较，文献中报道较少。即使在理想的手术条件和理想的适应证下，结果也并非总是令人满意。赫斯特等人在他们的系列研究中报告了使用束组端端修复取得的非常好的结果。根据英国医学研究委员会的评分系统，他们报告运动评分为4.0（正常为5.0），感觉评分为3.8（正常为4.0）。加藤等人在他们的51例使用电刺激定位进行束组端端缝合的系列研究中报告了非常好的结果。在这个系列中，有5例部分神经撕裂伤患者，束组端端对接取得了非常满意的结果。束组端端修复似乎比使用神经移植物修复神经能提供更好的结果。然而，对于神经端端修复的应用，期望神经缺损小于2厘米。
