Department of Surgery, Savonlinna Central Hospital, Savonlinna, Finland.
Department of Plastic Surgery, Helsinki University, Helsinki, Finland.
Clin Breast Cancer. 2017 Oct;17(6):471-485. doi: 10.1016/j.clbc.2017.04.011. Epub 2017 Apr 29.
We evaluated clinical against psychophysical (tactile and thermal quantitative sensory test [QST]), neurophysiologic (somatosensory evoked potential [SEP]), and epithelial nerve fiber density (ENFD) examinations in detection and follow-up of sensory alterations after breast reconstruction done with or without nerve anastomoses.
In a prospective 2-year follow-up design, 56 breast cancer patients underwent innervated and 20 patients noninnervated free rectus abdominis muscle-sparing flap (ms-TRAM) breast reconstruction. Healthy contralateral breasts (36 patients) and 20 healthy volunteer women served as control participants. The diagnostic values of clinical examination, QST, SEP, and ENFD tests were assessed at baseline, and 1 and 2 years postoperatively.
Sensation of mastectomized thoracic skin was impaired before reconstruction surgery, confirmed with QST (P < .001 for tactile, warm and cool detection; others not significant). All tests were further impaired at 1 year (P < .012-.0001), but mostly showed improvement during subsequent follow-up (P < .001-.0001), except for vibration and 2-point discrimination, ENFD, and SEP. QST improved diagnostic accuracy for large as well as small fiber function performing best in assessing sensory recovery at 2 years. Of clinical tests, sharp-blunt discrimination was modestly useful (sensitivity, 0.85; poor specificity, 0.17). Two-point and vibration discrimination tests had poor diagnostic values. SEP recording was modestly sensitive (0.50), but not specific (0.25). Because of sparse epithelial innervation already at baseline, ENFD performed poorly.
Most tests could identify sensory nerve damage postoperatively. Tactile and thermal QST were most reliable, and sensitive also in confirming sensory recovery. SEP recording was useful especially in differentiating surgical techniques, whereas ENFD and clinical examination performed poorly, with the exception of sharp-blunt discrimination.
我们评估了临床与心理物理学（触觉和热定量感觉测试[QST]）、神经生理学（体感诱发电位[SEP]）和上皮神经纤维密度（ENFD）检查在检测和随访乳房重建后感觉改变的作用，这些重建术有神经吻合或无神经吻合。
在一项前瞻性 2 年随访设计中，56 例乳腺癌患者接受了带神经吻合的游离腹直肌肌皮瓣（ms-TRAM）乳房重建，20 例患者接受了无神经吻合的游离腹直肌肌皮瓣乳房重建。36 例健康对侧乳房和 20 名健康志愿者女性作为对照组。在基线、术后 1 年和 2 年评估临床检查、QST、SEP 和 ENFD 测试的诊断价值。
胸廓皮肤的感觉在重建手术前就已经受损，QST 证实了这一点（触觉、温觉和冷觉检测的 P<0.001；其他无显著差异）。所有测试在术后 1 年均进一步受损（P<0.012-0.0001），但在随后的随访中大多显示出改善（P<0.001-0.0001），除了振动和两点辨别觉、ENFD 和 SEP。QST 改善了大纤维和小纤维功能的诊断准确性，在评估 2 年后的感觉恢复方面表现最佳。在临床检查中，锐钝觉辨别具有中等的实用性（敏感性为 0.85，特异性为 0.17）。两点和振动辨别测试的诊断价值较差。SEP 记录的敏感性中等（0.50），但特异性较差（0.25）。由于上皮神经支配稀疏，基线时 ENFD 表现不佳。
大多数测试可以识别术后的感觉神经损伤。触觉和热 QST 是最可靠的，也能敏感地确认感觉恢复。SEP 记录尤其有助于区分手术技术，而 ENFD 和临床检查的表现较差，除了锐钝觉辨别。
