Krishnan Kartik G, Pinzer Thomas, Reber Friedemann, Schackert Gabriele
Department of Neurological Surgery, Carl Gustav Carus University Hospital, Technical University of Dresden, Fetscherstrasse 74, D-01307 Dresden, Germany.
Neurosurgery. 2004 Feb;54(2):401-8; discussion 408-9. doi: 10.1227/01.neu.0000103423.08860.a9.
The indications for and timing of brachial plexus exploration in closed injuries are controversial. The time-consuming surgery proves its worth in some cases, whereas spontaneous regeneration might have been possible in others. The differentiation is difficult, because no investigational method reveals the exact morphological correlates of the nerve lesions. Minimally invasive, direct observation of the structures is a possible solution. Here we describe our surgical technique and the anatomic features of the normal brachial plexus appreciated with the endoscope.
Twenty-one brachial plexus in 11 fresh cadavers were investigated. Endoscopic exploration was performed at the supraclavicular and infraclavicular levels. The method involves insertion of an optic shaft-integrated retractor through a stab wound; retraction of landmark muscles produces a working space, into which other instruments are introduced for dissection. After completion of endoscopic surgery, open dissection was performed to verify the endoscopically identified structures and to assess iatrogenic injuries.
The omohyoid muscle is a reliable landmark in the supraclavicular region, beneath which the suprascapular nerve can be observed. Following the suprascapular nerve proximally leads to the plexus trunks. Infraclavicular exploration first reveals the axillary artery. The plexus and its nerves are traced around this artery. The anatomic features were constant in all cases, with variations in fat accumulation depending on the corporeal constitution. We detected iatrogenic injuries to the medial circumflex humeral vessels in two cases. No nerve injuries were observed.
The endoscopic technique combined with intraoperative nerve stimulation studies might provide important information on the type of morphological damage in closed brachial plexus injuries and thus might become an important tool for determination of the surgical treatment strategy. Clinical work is under way.
闭合性损伤时臂丛神经探查的适应证和时机存在争议。这种耗时的手术在某些情况下证明了其价值，而在其他情况下可能原本可以实现自发再生。由于没有任何研究方法能够揭示神经损伤的确切形态学关联，因此这种区分很困难。微创、直接观察结构可能是一种解决方案。在此，我们描述我们的手术技术以及通过内镜观察到的正常臂丛神经的解剖特征。
对11具新鲜尸体的21条臂丛神经进行了研究。在锁骨上和锁骨下水平进行内镜探查。该方法包括通过一个小切口插入一个集成光轴的牵开器；牵开标志性肌肉以形成一个工作空间，再将其他器械引入该空间进行解剖。在内镜手术完成后，进行开放解剖以验证内镜识别的结构并评估医源性损伤。
肩胛舌骨肌是锁骨上区域的一个可靠标志，在其下方可以观察到肩胛上神经。沿着肩胛上神经向近端追踪可到达神经丛干。锁骨下探查首先显露腋动脉。围绕该动脉追踪神经丛及其神经。所有病例的解剖特征均恒定，脂肪堆积情况因身体体质而异。我们在两例中检测到医源性旋肱后血管损伤。未观察到神经损伤。
内镜技术结合术中神经刺激研究可能为闭合性臂丛神经损伤的形态学损伤类型提供重要信息，从而可能成为确定手术治疗策略的重要工具。临床工作正在进行中。
