Xu Ke, Yin Yaobin, Wang Shufeng, Li Feng, Li Wenjun
Department of Hand Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, P. R. China.
The 4th Medical College of Peking University, Beijing, 100035, P. R. China.
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2024 Aug 15;38(8):1010-1015. doi: 10.7507/1002-1892.202404012.
To observe the possibility of hyper selective neurectomy (HSN) of triceps branches combined with partial neurotomy of S nerve root for relieving spastic equinus foot.
Anatomical studies were performed on 12 adult cadaveric specimens. The S nerve root and its branches were exposed through the posterior approach. Located the site where S joined the sciatic nerve and measured the distance to the median line and the vertical distance to the posterior superior iliac spine plane, and the S nerve root here was confirmed to have given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. Between February 2023 and November 2023, 4 patients with spastic equinus foot were treated with HSN of muscle branches of soleus, gastrocnemius medial head and lateral head, and cut the branch where S joined the sciatic nerve. There were 3 males and 1 female, the age ranged from 5 to 46 years, with a median of 26 years. The causes included traumatic brain injury in 2 cases, cerebral hemorrhage in 1 case, and cerebral palsy in 1 case. The disease duration ranged from 15 to 84 months, with a median of 40 months. The triceps muscle tone measured by modified Ashworth scale (MAC) before operation was grade 3 in 2 cases and grade 4 in 2 cases. The muscle strength measured by Daniels-Worthingham manual muscle test (MMT) was grade 2 in 1 case, grade 3 in 1 case, and 2 cases could not be accurately measured due to grade 4 muscle tone. The Holden walking function grading was used to evaluate lower limb function and all 4 patients were grade 2. After operation, triceps muscle tone, muscle strength, and lower limb function were evaluated by the above grading.
The distance between the location where S joined the sciatic nerve and median line was (5.71±0.53) cm and the vertical distance between the location and posterior superior iliac spine plane was (6.66±0.86) cm. Before joining the sciatic nerve, the S nerve root had given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. All the 4 patients successfully completed the operation, and the follow-up time was 4-13 months, with a median of 7.5 months. At last follow-up, the muscle tone of the patients decreased by 2-3 grades when compared with that before operation, and the muscle strength did not decrease when compared with that before operation. Holden walking function grading improved by 1-2 grades, and there was no postoperative hypoesthesia in the lower limbs.
HSN of triceps branches combined with partial neurotomy of S nerve root can relieve spastic equinus foot without damaging other sacral plexus nerves.
观察比目鱼肌、腓肠肌内侧头和外侧头肌支的高选择性神经切除术（HSN）联合S神经根部分神经切断术缓解痉挛性马蹄足的可能性。
对12例成人尸体标本进行解剖学研究。经后路暴露S神经根及其分支。确定S神经根与坐骨神经汇合处的位置，测量其到中线的距离以及到髂后上棘平面的垂直距离，证实此处的S神经根发出了盆内脏神经、阴部神经和股后皮神经的分支。2023年2月至2023年11月，对4例痉挛性马蹄足患者行比目鱼肌、腓肠肌内侧头和外侧头肌支的HSN，并切断S神经根与坐骨神经汇合处的分支。其中男性3例，女性1例，年龄5～46岁，中位数为26岁。病因包括脑外伤2例，脑出血1例，脑瘫1例。病程15～84个月，中位数为40个月。术前改良Ashworth量表（MAC）测量三头肌肌张力，2例为3级，2例为4级。采用Daniels-Worthingham徒手肌力测试（MMT）测量肌力，1例为2级，1例为3级，2例因肌张力为4级无法准确测量。采用Holden步行功能分级评估下肢功能，4例患者均为2级。术后采用上述分级方法评估三头肌肌张力、肌力和下肢功能。
S神经根与坐骨神经汇合处到中线的距离为（5.71±0.53）cm，到髂后上棘平面的垂直距离为（6.66±0.86）cm。在与坐骨神经汇合之前，S神经根发出了盆内脏神经、阴部神经和股后皮神经的分支。4例患者均成功完成手术，随访时间4～13个月，中位数为7.5个月。末次随访时，患者的肌张力较术前降低2～3级，肌力较术前无下降。Holden步行功能分级提高1～2级，下肢无术后感觉减退。
比目鱼肌、腓肠肌内侧头和外侧头肌支的HSN联合S神经根部分神经切断术可缓解痉挛性马蹄足，且不损伤其他骶丛神经。
