背景:斜方肌运动功能丧失是手术中切断副神经(AN)后根治性颈清扫术的并发症之一。神经修复是恢复斜方肌功能的有效方法,包括神经溶解,直接缝合,和神经移植.肩胛骨上神经(SCN)和AN在位置上彼此相邻。AN和SCN在肩抬高和外展运动中的功能是协同的。外科医生可能会考虑使用SCN进行AN复活。
目的:获得肩胛骨上神经部分转移的解剖学和临床资料。
方法:从人体解剖学部门获得经福尔马林灌注的尸体的十面,组织学和胚胎学,北京大学医学部.SCN(n=10)和AN(n=10)在颈部后三角形被仔细解剖,解剖斜方肌,充分显示副神经。测量从臂丛神经起点(a点)到肩胛骨切迹(b点)的SCN长度和从起点(a点)到AN进入斜方肌边界的点(c点)的SCN距离。测量斜方肌中AN的长度和分支。一名55岁的女性患者在口腔颌面外科接受了部分SCN到AN转移的手术,北京大学口腔医院。患者患有复发性上牙龈癌。在右侧进行根治性颈清扫术,并且在神经和SCM肌肉的后边界之间的交叉点处移除右AN。SCN直径的三分之一被切断,并在SCN的切断束束的远端和AN的近端之间施加了神经外膜和神经外膜的联合缝线,没有张力。之前进行了主观和客观评估,三个月后,手术后9个月.对于主观评价,问卷包括颈部夹层损伤指数(NDII)和恒定肩关节量表。肌电图用于客观检查。采用SPSS19.0软件对数据进行t检验,确定SCN长度与直线距离的关系。<0.05的P值被认为是统计学上显著的。
结果:斜方肌AN的全长为16.89cm。分布在降序中的平均分支数,水平和上升部分分别为3.8、2.6和2.2。斜方肌前缘的AN直径为1.94mm。肩胛骨上神经从臂丛神经起点到肩胛骨切迹的长度长于肩胛骨上神经从起点到副神经进入斜方肌上边缘点的距离。斜方肌肌电图的幅度表明,术后9个月,右侧斜方肌的水平和上升部分的功能均优于左侧。结果表明,右侧冈上肌和冈下肌没有比左侧失去更多的功能。
结论:根据解剖学数据和临床应用,根治性颈清扫后,可以实现部分肩胛骨上神经到AN的转移,并可能改善受影响的斜方肌的神经支配。
BACKGROUND: Loss of motor function in the trapezius muscle is one complication of radical neck dissection after cutting the accessory nerve (AN) during surgery. Nerve repair is an effective method to restore trapezius muscle function, and includes neurolysis, direct suture, and nerve grafting. The suprascapular nerve (SCN) and AN are next to each other in position. The function of the AN and SCN in shoulder elevation and abduction movement is synergistic. SCN might be considered by surgeons for AN reanimation.
OBJECTIVE: To obtain anatomical and clinical data for partial suprascapular nerve-to-AN transfer.
METHODS: Ten sides of cadavers perfused with formalin were obtained from the Department of Human Anatomy, Histology and Embryology, Peking University Health Science Center. The SCN (n = 10) and AN (n = 10) were carefully dissected in the posterior triangle of the neck, and the trapezius muscle was dissected to fully display the accessory nerve. The length of the SCN from the origin of the brachial plexus (a point) to the scapular notch (b point) and the distance of the SCN from the origin point (a point) to the point (c point) where the AN entered the border of the trapezius muscle were measured. The length and branches of the AN in the trapezius muscle were measured. A female patient aged 55 years underwent surgery for partial SCN to AN transfer at Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology. The patient suffered from recurrent upper gingival cancer. Radical neck dissection was performed on the right side, and the right AN was removed at the intersection between the nerve and the posterior border of the SCM muscle. One-third of the diameter of the SCN was cut off, and combined epineurial and perineurial sutures were applied between the distal end of the cut-off fascicles of the SCN and the proximal end of the AN without tension. Both subjective and objective evaluations were performed before, three months after, and nine months after surgery. For the subjective evaluation, the questionnaire included the Neck Dissection Impairment Index (NDII) and the Constant Shoulder Scale. Electromyography was used for the objective examination. Data were analyzed using t tests with SPSS 19.0 software to determine the relationship between the length of the SCN and the linear distance. A P value of < 0.05 was considered as statistically significant.
RESULTS: The whole length of the AN in the trapezius muscle was 16.89 cm. The average numbers of branches distributed in the descending, horizontal and ascending portions were 3.8, 2.6 and 2.2, respectively. The diameter of the AN was 1.94 mm at the anterior border of the trapezius. The length of the suprascapular nerve from the origin of the brachial plexus to the scapular notch was longer than the distance of the suprascapular nerve from the origin point to the point where the accessory nerve entered the upper edge of the trapezius muscle. The amplitude of trapezius muscle electromyography indicated that both the horizontal and ascending portions of the trapezius muscle on the right side had better function than the left side nine months after surgery. The results showed that the right-sided supraspinatus and infraspinatus muscles did not lose more function than the left side.
CONCLUSIONS: Based on anatomical data and clinical application, partial suprascapular nerve-to-AN transfer could be achieved and may improve innervation of the affected trapezius muscle after radical neck dissection.