孤立的上干型产伤性臂丛神经损伤中 C5 或 C6 神经根撕脱的外科重建。

Surgical Reconstruction of Isolated Upper Trunk Brachial Plexus Birth Injuries in the Presence of an Avulsed C5 or C6 Nerve Root.

机构信息

Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada.

Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada.

出版信息

J Bone Joint Surg Am. 2021 Jul 21;103(14):1268-1275. doi: 10.2106/JBJS.20.01379.

DOI:10.2106/JBJS.20.01379

PMID:33750752

Abstract

BACKGROUND

Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk.

METHODS

We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment.

RESULTS

Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement.

CONCLUSIONS

In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

摘要

背景

在臂丛神经产伤中，C5 或 C6 神经根撕脱合并中、下干完整较为少见。在这些情况下，只有 1 个近端神经根可用于丛内重建。本研究的目的是确定当单个神经根重建平衡于上干前、后元素时这些患者的结果。

方法

我们对 1993 年至 2014 年期间行初次神经重建的臂丛神经产伤患者前瞻性收集的数据进行了回顾性队列研究。纳入标准为具有完整中、下干的孤立上干损伤患者。研究组为 C5 或 C6 神经根撕脱，对照组为神经瘤连续性或上干断裂。使用主动运动评分（Active Movement Scale）和臂丛神经功能评定量表（Brachial Plexus Outcome Measure）评估结果。采用 Wilcoxon 符号秩检验评估治疗前后的变化。

结果

10 例臂丛神经产伤患者纳入神经根撕脱组。手术重建包括神经瘤切除和单个可用神经根的神经移植，将神经根平衡于所有远端靶标，同时或不进行副神经至肩胛上神经转移。在肩外展、肩前屈、外旋、肘屈和旋后方面，撕脱组和对照组均观察到治疗后显著改善。在平均 54.5±8.8 个月的随访中，撕脱组患者肘屈的主动运动评分（Active Movement Scale）达到 6.8±0.4，肩前屈和外展的评分为 6.5±0.9，外旋的恢复较小（3.3±2.8）。所有接受臂丛神经功能评定量表评估的患者均表现出功能运动。

结论

在上干 1 个神经根撕脱的情况下，用另 1 个上干神经根的神经移植对上干进行重建，可改善运动功能，提高主动运动评分（Active Movement Scale），根据臂丛神经功能评定量表（Brachial Plexus Outcome Measure）获得满意功能。这些数据支持了在上干病变时确保整个上干充分重建的策略。