Bagheri Shahrokh C, Meyer Roger A, Khan Husain Ali, Kuhmichel Amy, Steed Martin B
Department of Oral and Maxillofacial Surgery, Northside Hospital of Atlanta, Atlanta, GA, USA.
J Oral Maxillofac Surg. 2010 Apr;68(4):715-23. doi: 10.1016/j.joms.2009.09.111. Epub 2009 Dec 29.
Injury to the lingual nerve (LN) is a known complication associated with several oral and maxillofacial surgical procedures. We have reviewed the demographics, timing, and outcome of microsurgical repair of the LN.
A retrospective chart review was completed of all patients who had undergone microsurgical repair of the LN by one of us (R.A.M.) from March 1986 through December 2005. A physical examination, including standardized neurosensory testing, was completed of each patient preoperatively. All patients were followed up periodically after surgery for at least 1 year, with neurosensory testing repeated at each visit. Sensory recovery was determined from the patient's final neurosensory testing results and evaluated using the guidelines established by the Medical Research Council Scale. The following data were collected and analyzed: patient age, gender, nerve injury etiology, chief sensory complaint (numbness or pain, or both), interval from injury to surgical intervention, intraoperative findings, surgical procedure, and neurosensory status at the final evaluation. The patients were classified according to whether they achieved "useful sensory recovery" or better, according to the Medical Research Council Scale, or had unsatisfactory or no improvement in sensation. Logistic regression methods and associated odds ratios (OR) were used to quantify the association between the risk factors and improvement. Receiver operating characteristic curve analysis was used to find the age threshold and duration that maximally separated the patient outcomes.
A total of 222 patients (51 males and 171 females; average age 31.1 years, range 15 to 61) underwent LN repair and returned for at least 1 year of follow-up. The most common cause of LN injury was mandibular third molar removal (n = 191, 86%), followed by sagittal split mandibular ramus osteotomy (n = 14, 6.3%). Most patients complained preoperatively of numbness (n = 122, 55%) or numbness with pain (n = 94, 42.3%). The average interval from injury to surgery was 8.5 months (range 1.5 to 96). The most commonly performed operation was excision of a proximal stump neuroma with neurorrhaphy (n = 154, 69%), followed by external decompression with internal neurolysis (n = 29, 13%). Nineteen patients (8.6%) underwent an autogenous nerve graft procedure (greater auricular or sural nerve) for reconstruction of a nerve gap. A collagen cuff was placed around the repair site in 8 patients (3.6%; external decompression with internal neurolysis in 2 and neurorrhaphy in 6). Recovery from neurosensory dysfunction (defined by the Medical Research Council Scale as ranging from "useful sensory function" to a "complete return of sensation") was observed in 201 patients (90.5%; 146 patients with complete recovery and 55 patients with recovery to "useful sensory function"), and 21 patients (9.5%) had no or inadequate improvement. Using the logistic regression model, a shorter interval between nerve injury and repair resulted in greater odds of improvement (OR 0.942, P = .0064); with each month that passed, the odds of improvement decreased by 5.8%. The receiver operating characteristic analysis revealed that patients who waited more than 9 months for repair were at a significantly greater risk of nonimprovement. Statistical significance was observed between patient age and outcome (OR 0.945, P = .0067) representing a 5.5% decrease in the chance of recovery for every year of age in patients 45 years old and older. The odds of a return of acceptable neurosensory function were better when the patient's presenting symptom was pain and not numbness (OR 0.04, P < .001).
Microsurgical repair of LN injury has the best chance of successful restoration of acceptable neurosensory function if done within 9 months of the injury. The likelihood of recovery after nerve repair decreased progressively when the repair occurred more than 9 months after injury and with increasing patient age.
舌神经（LN）损伤是多种口腔颌面外科手术已知的并发症。我们回顾了舌神经显微外科修复的人口统计学资料、时间选择及结果。
对1986年3月至2005年12月期间由我们中的一人（R.A.M.）进行舌神经显微外科修复的所有患者进行回顾性病历分析。术前对每位患者进行体格检查，包括标准化神经感觉测试。所有患者术后定期随访至少1年，每次随访时重复进行神经感觉测试。根据患者最终的神经感觉测试结果确定感觉恢复情况，并按照医学研究委员会量表制定的指南进行评估。收集并分析以下数据：患者年龄、性别、神经损伤病因、主要感觉主诉（麻木或疼痛，或两者皆有）、从损伤到手术干预的间隔时间、术中发现、手术操作以及最终评估时的神经感觉状态。根据医学研究委员会量表，患者被分类为是否实现了“有用的感觉恢复”或更好，或者感觉不满意或无改善。采用逻辑回归方法及相关优势比（OR）来量化风险因素与改善之间的关联。使用受试者工作特征曲线分析来确定最大程度区分患者预后的年龄阈值和时间。
共有222例患者（51例男性和171例女性；平均年龄31.1岁，范围15至61岁）接受了舌神经修复并返回进行至少1年的随访。舌神经损伤最常见的原因是下颌第三磨牙拔除（n = 191，86%），其次是下颌升支矢状劈开截骨术（n = 14，6.3%）。大多数患者术前主诉麻木（n = 122，55%）或麻木伴疼痛（n = 94，42.3%）。从损伤到手术的平均间隔时间为8.5个月（范围1.5至96个月）。最常进行的手术是切除近端残端神经瘤并进行神经缝合（n = 154，69%），其次是外部减压加内部神经松解术（n = 29，13%）。19例患者（8.6%）接受了自体神经移植手术（耳大神经或腓肠神经）以修复神经缺损。8例患者（3.6%）在修复部位放置了胶原袖套（2例为外部减压加内部神经松解术，6例为神经缝合）。201例患者（90.5%）出现神经感觉功能障碍恢复（根据医学研究委员会量表定义为从“有用的感觉功能”到“感觉完全恢复”），其中146例患者完全恢复，55例患者恢复到“有用的感觉功能”，21例患者（9.5%）无改善或改善不足。使用逻辑回归模型，神经损伤与修复之间的间隔时间越短，改善的可能性越大（OR 0.942，P = .0064）；每过一个月，改善的可能性降低5.8%。受试者工作特征分析显示，等待超过9个月进行修复的患者无改善的风险显著更高。在患者年龄与预后之间观察到统计学显著性（OR 0.945，P = .0067），这表明45岁及以上患者每增加一岁，恢复的机会降低5.5%。当患者的主要症状为疼痛而非麻木时，恢复到可接受神经感觉功能的可能性更好（OR 0.04，P < .001）。
如果在损伤后9个月内进行舌神经损伤的显微外科修复，成功恢复可接受神经感觉功能的机会最大。当修复在损伤后超过9个月进行且患者年龄增加时，神经修复后恢复的可能性逐渐降低。
