Bertelli Jayme A, Patel Neehar, Soldado Francisco, Duarte Elisa Cristiana Winkelmann
1Department of Neurosurgery, Center of Biological and Health Sciences, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil.
2Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil.
J Neurosurg. 2021 Mar 19;135(5):1524-1533. doi: 10.3171/2020.9.JNS202742. Print 2021 Nov 1.
The purpose of this study was to describe the anatomy of donor and recipient median nerve motor branches for nerve transfer surgery within the cubital fossa.
Bilateral upper limbs of 10 fresh cadavers were dissected after dyed latex was injected into the axillary artery.
In the cubital fossa, the first branch was always the proximal branch of the pronator teres (PPT), whereas the last one was the anterior interosseous nerve (AIN) and the distal motor branch of the flexor digitorum superficialis (DFDS) on a consistent basis. The PT muscle was also innervated by a distal branch (DPT), which emerged from the anterior side of the median nerve and provided innervation to its deep head. The palmaris longus (PL) motor branch was always the second branch after the PPT, emerging as a single branch together with the flexor carpi radialis (FCR) or the proximal branch of the flexor digitorum superficialis. The FCR motor branch was prone to variations. It originated proximally with the PL branch (35%) or distally with the AIN (35%), and less frequently from the DPT. In 40% of dissections, the FDS was innervated by a single branch (i.e., the DFDS) originating close to the AIN. In 60% of cases, a proximal branch originated together with the PL or FCR. The AIN emerged from the posterior side of the median nerve and had a diameter of 2.3 mm, twice that of other branches. When dissections were performed between the PT and FCR muscles at the FDS arcade, we observed the AIN lying lateral and the DFDS medial to the median nerve. After crossing the FDS arcade, the AIN divided into: 1) a lateral branch to the flexor pollicis longus (FPL), which bifurcated to reach the anterior and posterior surfaces of the FPL; 2) a medial branch, which bifurcated to reach the flexor digitorum profundus (FDP); and 3) a long middle branch to the pronator quadratus. The average numbers of myelinated fibers within each median nerve branch were as follows (values expressed as the mean ± SD): PPT 646 ± 249; DPT 599 ± 150; PL 259 ± 105; FCR 541 ± 199; proximal FDS 435 ± 158; DFDS 376 ± 150; FPL 480 ± 309; first branch to the FDP 397 ± 12; and second branch to the FDP 369 ± 33.
The median nerve's branching pattern in the cubital fossa is predictable. The most important variation involves the FCR motor branch. These anatomical findings aid during nerve transfer surgery to restore function when paralysis results from injury to the radial or median nerves, brachial plexus, or spinal cord.
本研究旨在描述用于肘窝内神经移植手术的供体和受体正中神经运动支的解剖结构。
向10具新鲜尸体的双侧上肢腋窝动脉注入染色乳胶后进行解剖。
在肘窝内，第一分支始终是旋前圆肌（PPT）的近端分支，而最后一支始终是骨间前神经（AIN）和指浅屈肌（DFDS）的远端运动支。旋前圆肌（PT）还由一个远端分支（DPT）支配，该分支从中正中神经前侧发出，支配其深头。掌长肌（PL）运动支始终是PPT之后的第二分支，与桡侧腕屈肌（FCR）或指浅屈肌近端分支一起作为单支发出。FCR运动支易于变异。它近端与PL支一起发出（35%），或远端与AIN一起发出（35%），较少见从DPT发出。在40%的解剖中，指浅屈肌由靠近AIN发出的单支（即DFDS）支配。在60%的病例中，近端分支与PL或FCR一起发出。AIN从中正中神经后侧发出，直径为2.3mm，是其他分支的两倍。在指浅屈肌弓处的PT和FCR肌之间进行解剖时，我们观察到AIN位于正中神经外侧，DFDS位于正中神经内侧。穿过指浅屈肌弓后，AIN分为：1）至拇长屈肌（FPL）的外侧支，该支再分为两支分别到达FPL的前表面和后表面；2）内侧支，该支再分为两支分别到达指深屈肌（FDP）；3）至旋前方肌的长中间支。每条正中神经分支内有髓纤维的平均数如下（数值表示为平均值±标准差）：PPT 646±249；DPT 599±150；PL 259±105；FCR 541±199；指浅屈肌近端435±158；DFDS 376±150；FPL 480±309；至FDP的第一支397±12；至FDP的第二支369±33。
正中神经在肘窝内的分支模式是可预测的。最重要的变异涉及FCR运动支。这些解剖学发现有助于在因桡神经、正中神经、臂丛或脊髓损伤导致麻痹时进行神经移植手术以恢复功能。
