Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, NY; Weill Medical College of Cornell University, New York, NY.
Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, NY; Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY; Weill Medical College of Cornell University, New York, NY.
J Hand Surg Am. 2021 Jan;46(1):43-53. doi: 10.1016/j.jhsa.2020.07.015. Epub 2020 Aug 28.
Wide variability in the recovery of patients affected by neuralgic amyotrophy (NA) is recognized, with up to 30% experiencing residual motor deficits. Using magnetic resonance imaging and ultrasound (US), we identified hourglass constrictions (HGCs) in all affected nerves of patients with chronic motor paralysis from NA. We hypothesized that chronic NA patients undergoing microsurgical epineurolysis and perineurolysis of constrictions would experience greater recovery compared with patients managed nonsurgically.
We treated 24 patients with chronic motor palsy from NA and HGCs identified on magnetic resonance imaging and US either with microsurgical epineurolysis and perineurolysis of HGCs (11 of 24) or nonsurgically (13 of 24). Muscle strength (both groups) and electrodiagnostic testing (EDX) (operative group) was performed before and after surgery. Preoperative EDX confirmed muscle denervation in the distribution of affected nerve(s). All patients met criteria for microneurolysis: 12 months without improvement since onset or failure of clinical and EDX improvement after 6 months documented by 3 successive examinations, each at least 6 weeks apart.
Mean time from onset to surgery was 12.5 ± 4.0 months. Average time to most recent post-onset follow-up occurred at 27.3 months (range, 18-42 months; 15 nerves). Average time to latest follow-up among nonsurgical patients was 33.6 months (range, 18-108 months; 16 nerves). Constrictions involved individual fascicular groups (FCs) of the median nerve and the suprascapular, axillary and radial nerves proper (HGCs). Nine of 11 operative patients experienced clinical recovery compared with 3 of 13 nonsurgical patients. EMG revealed significant motor unit recovery from axonal regeneration in the operative group.
Microsurgical epineurolysis and perineurolysis of FCs and HGCs was associated with significantly improved clinical and nerve regeneration at an average follow-up of 14.8 months compared with nonsurgical management. We recommend microneurolysis of HGCs and FCs as a treatment option for patients with chronic NA who have failed to improve with nonsurgical treatment.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
神经痛性肌萎缩（NA）患者的恢复存在很大差异，多达 30%的患者存在运动功能残留缺陷。我们使用磁共振成像（MRI）和超声（US）发现，患有慢性运动性瘫痪的 NA 患者的所有受累神经均存在沙漏样狭窄（HGC）。我们假设，接受 HGC 显微神经松解术和神经外膜松解术的慢性 NA 患者的恢复情况将优于非手术治疗的患者。
我们治疗了 24 例慢性运动性瘫痪的 NA 患者，这些患者的 HGC 可在 MRI 和 US 上显示，其中 11 例（24 例中的 11 例）接受了 HGC 的显微神经外膜松解术和神经束膜松解术，13 例（24 例中的 13 例）接受了非手术治疗。手术前后对所有患者进行肌肉力量（两组）和电诊断测试（EDX）（手术组）。术前 EDX 证实受累神经分布存在肌肉失神经支配。所有患者均符合微创神经松解术的标准：自发病以来 12 个月无改善，或 6 个月后临床和 EDX 改善但未能持续 3 次检查（每次检查至少间隔 6 周）。
发病至手术的平均时间为 12.5±4.0 个月。末次发病后最近一次随访的平均时间为 27.3 个月（范围为 18-42 个月；15 根神经）。非手术患者的平均末次随访时间为 33.6 个月（范围为 18-108 个月；16 根神经）。狭窄累及正中神经、肩胛上神经、腋神经和桡神经的单个束组（FC）（HGC）。11 例手术患者中有 9 例出现临床恢复，而 13 例非手术患者中有 3 例出现临床恢复。电生理学显示手术组的运动单位有明显的轴突再生恢复。
与非手术治疗相比，显微神经外膜松解术和神经束膜松解术治疗 FC 和 HGC 的平均随访时间为 14.8 个月，与非手术治疗相比，可显著改善临床和神经再生。我们建议对慢性 NA 患者，在非手术治疗失败后，将 HGC 和 FC 的微创神经松解术作为一种治疗选择。
研究类型/证据水平：治疗性 IV 级。
