中国修复重建外科杂志

中国修复重建外科杂志

肌腱转移术重建颈脊髓损伤患者手功能

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目的探讨肌腱转移术重建颈脊髓损伤患者手抓握和侧捏功能的效果。方法2013 年 7 月—2016 年 1 月采用肌腱转移术重建 21 例颈脊髓损伤(运动损伤平面 C6 )患者(41 只瘫痪手)手抓握和拇、示指侧捏功能。男 18 例,女 3 例;年龄 17~65 岁,平均 42.3 岁。其中完全性颈脊髓损伤患者 19 例,根据美国脊髓损伤学会(ASIA)分级标准评价为 A 级;颈脊髓损伤后中央管综合征、双侧完全性瘫痪手、下肢肌力正常 1 例,ASIA 分级为 D 级;脊髓型颈椎病 1 例,ASIA 分级为 D 级。患者受伤至入院时间 12~22 个月,平均 16.8 个月。入院后根据四肢瘫的国际手外科分级(ICSHT),O3 级 6 例,O4 级 10 例,OCu5 级 3 例,O5 级 2 例。手术分两期,期间间隔 6~11 个月。一期手术均采用桡侧腕长伸肌由桡侧经皮下隧道转移至掌侧,与拇长屈肌及指深屈肌编织缝合重建手的抓握功能;二期手术采用尺侧腕伸肌桡侧半(ICSHT O3 级者)或旋前圆肌(ICSHT O3 级以上者)与拇长伸肌、拇长展肌编织缝合,重建拇指与示指的侧捏功能。分别于术前及术后各时间点测量患手握力、拇指与示指侧捏力以及拇示指指尖最大距离;二期术后 6 个月采用改良 Lamb and Chan 手功能评分量表评价手功能。结果术后 1 例患者出现肘部皮肤水疱,1 例患者出现腕关节僵硬,均经相应处理后治愈。21 例均获随访,随访时间 15~32 个月,平均 19.6 个月。未发生伤口感染、肌腱粘连、肌腱断裂等并发症。一期术后 4 周、3 个月、6 个月、1 年患手握力均较术前显著改善(P<0.05),术后各时间点间比较差异无统计学意义(P>0.05)。二期术后 4 周、3 个月、6 个月、1 年 ICSHT O3 级组及 O3 级以上组患手拇指与示指侧捏力以及拇示指指尖最大距离均较术前显著改善(P<0.05),术后各时间点间比较差异无统计学意义(P>0.05);二期术后各时间点 ICSHT O3 级组及 O3 级以上组组间比较上述指标,差异均无统计学意义(P>0.05)。二期术后 6 个月采用改良 Lamb and Chan 手功能评分量表评价,获好 19 例,一般 1 例,差 1 例。结论肌腱转移术能够明显改善完全性颈脊髓损伤患者的手功能,改善患者生活质量。

ObjectiveTo explore the effectiveness of functional reconstruction of hand grasp and pinch by tendon transfers in patients with cervical spinal cord injury.MethodsBetween July 2013 and January 2016, tendon transfer surgery were performed in 21 patients (41 hands) with cervical spinal injury that motion level was located at C6 to reconstruct hand grasp and pinch function. There were 18 males and 3 females with a mean age of 42.3 years (range, 17-65 years). Nineteen patients were with complete spinal cord injury [American Spinal Injury Association (ASIA) grading A], 1 patient was with central cord syndrome whose bilateral hands were completely paralyzed and lower limbs were normal (ASIA grading D), and 1 patient was with cervical spondylotic myelopathy (AISA grading D). The time from injury to hospitalization was 12-22 months (mean, 16.8 months). According to the International classification of surgery of the hand in tetraplegia (ICSHT), there were 6 cases of grade O3, 10 of grade O4, 3 of grade OCu5, and 2 of grade O5. The surgery was divided into two stages with an interval of 6-11 months. At the first stage, grip function was reconstructed in all patients by transfering the extensor carpi radialis longus from radialis side to palmar side through subcutaneous tunnel, and braided and sutured with the flexor pollicis longus and flexor digitorum profundus. At the second stage, the lateral pinch function of the thumb and index finger was reconstructed by braiding and suturing the radial half of the extensor carpi ulnaris (the patients graded as ICSHT O3) or pronator tere (the patients graded above ICSHT O3) with extensor pollicis longus and abductor pollicis longus. The grasp force, the thumb and index finger lateral pinch force, and the maximum fingertips distance between the thumb and index finger were measured at preoperation and at different time points after operation. The modified Lamb and Chan questionnaire, based upon the activities of daily living, was used to evaluate the hand function of all patients at 6 months after sencond stage surgery.ResultsThere was 1 patient with elbow skin lesion, 1 patient with wrist stiffness; both of them recovered after corresponding treatment. All the 21 patients were followed up 15-32 months (mean, 19.6 months) without wound infection, tendon adhesion, tendon rupture, and other complications. The grasp forces of all patients were significantly improved at 4 weeks, 3 months, 6 months, and 1 year after the first stage surgery when compared with preoperative value (P<0.05); and no significant difference was found between different time points after operation (P>0.05). The thumb and index finger lateral pinch force and the maximum fingertips distance between the thumb and index finger of all patients were also significantly improved at 4 weeks, 3 months, 6 months, and 1 year after the second stage surgery when compared with preoperative values (P<0.05); and no significant difference was found between different time points after operation (P>0.05). And there was no significant difference of above indexes between the patients graded as ICSHT O3 and above ICSHT O3 (P>0.05). The functional outcome was good in 19 cases, fair in 1 case, and poor in 1 case according to modified Lamb and Chan questionnaire at 6 months after second stage surgery.ConclusionTendon transfer can significantly improve the hand function and the quality of life of the patients with complete cervical spinal cord injury.

关键词: 肌腱转移; 颈脊髓损伤; 重建; 手功能

Key words: Tendon transfer; cervical spinal cord injury; reconstruction; hand function

引用本文: 李军, 杜良杰, 刘宏炜, 高峰, 刘璐, 郭韵, 王冲, 杨明亮, 李建军, 张友乐. 肌腱转移术重建颈脊髓损伤患者手功能. 中国修复重建外科杂志, 2018, 32(5): 542-547. doi: 10.7507/1002-1892.201711078 复制

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