副神经移位膈神经重建高位颈髓损伤患者呼吸功能的解剖学研究

Anatomic research on the phrenic nerve reconstruction by the spinal accessory nerve

中文关键词:  脊髓损伤  副神经  膈神经  解剖学  修复重建

英文关键词:Spinal cord injury  Phrenic nerve  Accessory nerve  Anatomy  Reconstruction

中文摘要:

  【摘要】 目的：探讨副神经移位膈神经重建高位颈髓损伤患者呼吸功能的解剖学可行性。方法：选取经福尔马林固定的成人尸体30具，解剖分离颈部双侧膈神经及副神经共60侧，测量副神经主干终点（设定为副神经进入斜方肌处）及膈神经起始点的宽度及厚度、副神经出胸锁乳突肌外侧缘点至膈神经主干起始点及终点的距离、胸锁乳突肌外侧缘与斜方肌内侧缘之间的副神经长度，寻找副神经沿胸锁乳突肌外侧缘斜出的位置、副神经起始点与甲状软骨的位置关系及副神经入斜方肌内侧缘的位置与锁骨中线的关系。选取5具尸体（10侧）的副神经主干终点及膈神经起始点标本，进行切片、免疫组织化学染色，计数运动神经纤维含量。结果：副神经进入胸锁乳突肌后，5侧穿过胸锁乳突肌下行，55侧在胸锁乳突肌的深面继续向下外穿行，其在胸锁乳突肌后缘，距胸锁乳突肌锁骨止点85.2±5.9mm处浅出；在肩胛提肌表面，副神经越过颈后三角行至斜方肌前缘于锁骨中线内侧13.2±1.9mm处进入斜方肌，于斜方肌深面分为2~5支支配斜方肌。副神经主干终点的宽度为1.61±0.39mm，厚度为0.61±0.23mm，胸锁乳突肌外侧缘与斜方肌内侧缘之间的副神经长度为59.2±12.2mm。16侧膈神经起始点位于甲状软骨的中点水平，32侧位于甲状软骨上缘水平，6侧位于甲状软骨下缘水平，6侧位于甲状软骨上1/3水平。膈神经起始点处的宽度为1.43±0.27mm，厚度为0.60±0.26mm，副神经胸锁乳突肌外侧缘点至膈神经起始点的距离为26.9±6.0mm，至膈神经终点的距离为76.7±8.2mm。胸锁乳突肌外侧缘与斜方肌内侧缘间的副神经长度大于副神经胸锁乳突肌外侧缘至膈神经起始点的距离（P=0.000）。膈神经起始点的运动神经纤维含量为836±311条，副神经主干终点的运动神经纤维含量为1290±371条，两者比较差异有统计学意义（P=0.019）。结论：胸锁乳突肌外侧缘与斜方肌内侧缘之间的副神经长度明显大于副神经胸锁乳突肌外侧缘点至膈神经起始点的距离，从解剖学的角度证明了在不损伤胸锁乳突肌的情况下副神经可与膈神经起始点无张力直接吻合。

英文摘要:

  【Abstract】 Objectives: To provide anatomic evidence on the reconstruction of respiratory function by transpositioning of accessory nerve into phrenic nerve in the patients with cervical spinal cord injury. Methods: 30 cadavers(60 accessory and 60 phrenic nerves) were dissected in the study. The width and thickness of the end of accessory nerve(AN) and the beginning of phrenic nerve(PN) were measured. The distance from the point of the AN leaving the sternocleidomastoid to the origin and the end of the PN, the length of AN between the lateral border of sternocleidomastoid and the medial edge of trapezius were also measured. The point of the AN leaving from the lateral border of sternocleidomastoid, the positional relationship between the origin of the AN and the thyroid cartilage, the positional relationship between the clavicular line and the point of AN entering the medial edge of trapezius were evaluated. Then the end of the AN and the origin of the PN from 5 cadavers(10 sides) were made as specimens and the number of motor nerve fibers was calculated by using the technique of immunohistochemistry. Results: After AN gave out branches into the sternocleidomastoid, 5 sides descended through sternocleidomastoid, 55 sides continued to descend along the deep surface of sternocleidomastoid, then emerged from the posterior border of sternocleidomastoid, where were 85.2±5.9mm away from the clavicular terminal of sternocleidomastoid. AN crossed posterior triangle to the anterior border of trapezius and entered into trapezius at about 13.2±1.9mm medial to midclavicular line. The width and the thickness of the end of AN was 1.61±0.39mm and 0.61±0.23mm respectively. The length of the accessory nerve between the lateral border of sternocleidomastoid and the medial edge of trapezius was 59.2±12.2mm. The level of the origin of the PN could be at the level of the thyroid cartilage(16 sides), above the thyroid cartilage(32 sides) or below the thyroid cartilage(6 sides). The width and thickness of the origin of the PN was 1.43±0.27mm and 0.60±0.26mm respectively. The length between the point of the AN leaving from the lateral border of sternocleidomastoid and the origin and the end of PN was 26.9±6.0mm and 76.7±8.2mm respectively. The distance of the AN between the lateral border of sternocleidomastoid and the medial edge of trapezius was longer than the length between the point of the AN leaving from the lateral border of sternocleidomastoid and the origin of PN(P=0.000). The number of the motor nerve fibers at the origin of PN, the end of the trunk AN was 836±311 and 1290±371. The difference was statistically significant(P=0.019). Conclusions: The length of AN between the lateral border of sternocleidomastoid and the medial edge of trapezius is significantly longer than the length between the point of the AN leaving from the lateral border of sternocleidomastoid and the origin of PN. Anatomically， it is proved that the AN and the origin of PN can be sutured directly and freely without the injury to the sternocleidomastoid.