Nogueira Monica Paschoal, Paley Dror, Bhave Anil, Herbert Andrew, Nocente Catherine, Herzenberg John E
International Center for Limb Lengthening, Rubin, Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Maryland 21215-5271, USA.
J Bone Joint Surg Am. 2003 Aug;85(8):1502-10. doi: 10.2106/00004623-200308000-00011.
Nerve injury is one of the most serious complications associated with limb-lengthening. We examined the risk, assessment, and treatment of nerve lesions associated with limb-lengthening.
We retrospectively studied the records on 814 limb-lengthening procedures. Nerve lesions were defined by clinical signs and symptoms of motor function impairment, sensory alterations, referred pain in the distribution of an affected nerve, and/or positive results of quantitative sensory testing with use of a pressure specified sensory device.
Seventy-six (9.3%) of the limbs had a nerve lesion. Eighty-four percent of the nerve lesions occurred during gradual distraction, and 16% occurred immediately following surgery. The pressure specified sensory device showed 100% sensitivity and 86% specificity in the detection of nerve injuries. The patients in whom the lesion was diagnosed with this method, or with this method as well as with nerve conduction studies, had significantly faster recovery than did those diagnosed on the basis of clinical symptoms or nerve conduction studies alone (p = 0.02). Patients undergoing double-level tibial lengthening and those with skeletal dysplasia were at higher risk for nerve lesions (77% and 48%, respectively). Nerve decompression was performed in fifty-three cases (70%). The time between the diagnosis and the surgical decompression was strongly associated with the time to recovery (p = 0.0005). Complete clinical recovery was achieved in seventy-four of the seventy-six cases.
Early detection based on signs and symptoms or testing with a pressure specified sensory device improves the prognosis for nerve injury that occurs during limb-lengthening. Of the methods that we used to identify neurologic compromise, testing with the pressure specified sensory device was the most sensitive. Aggressive early treatment (slowing the rate of lengthening and/or performing decompression) allows continued lengthening without incurring permanent nerve injury. When indicated, decompression of the affected nerve should be performed as soon as possible, thereby improving the chances of and shortening the time to complete recovery.
神经损伤是肢体延长最严重的并发症之一。我们研究了与肢体延长相关的神经损伤的风险、评估及治疗。
我们回顾性研究了814例肢体延长手术的记录。神经损伤通过运动功能障碍的临床体征和症状、感觉改变、受累神经分布区的牵涉痛和/或使用特定压力感觉装置进行的定量感觉测试的阳性结果来定义。
76条（9.3%）肢体出现神经损伤。84%的神经损伤发生在逐渐牵张过程中，16%发生在手术后即刻。特定压力感觉装置在检测神经损伤方面显示出100%的敏感性和86%的特异性。通过该方法或该方法与神经传导研究共同诊断出损伤的患者，其恢复速度明显快于仅根据临床症状或神经传导研究诊断出损伤的患者（p = 0.02）。接受双平面胫骨延长术的患者和患有骨骼发育异常的患者发生神经损伤的风险更高（分别为77%和48%）。53例（70%）患者进行了神经减压。诊断与手术减压之间的时间与恢复时间密切相关（p = 0.0005）。76例患者中有74例实现了完全临床恢复。
基于体征和症状或使用特定压力感觉装置进行检测的早期诊断可改善肢体延长过程中发生的神经损伤的预后。在我们用于识别神经功能损害的方法中，使用特定压力感觉装置进行检测最为敏感。积极的早期治疗（减缓延长速度和/或进行减压）可使延长继续进行而不导致永久性神经损伤。如有指征，应尽快对受累神经进行减压，从而增加完全恢复的机会并缩短恢复时间。
