關(guān)節(jié)鏡下松解尺神經(jīng)治療肘管綜合征療效

楊明 黃偉 王天兵 張殿英 付中國(guó) 熊建 陳建海 姜保國(guó)

·論著·

關(guān)節(jié)鏡下松解尺神經(jīng)治療肘管綜合征療效

楊明 黃偉 王天兵 張殿英 付中國(guó) 熊建 陳建海 姜保國(guó)

目的 探討關(guān)節(jié)鏡下松解尺神經(jīng)治療肘管綜合征的療效。 方法 通過回顧性分析2012年10月至2015年6月北京大學(xué)人民醫(yī)院創(chuàng)傷骨科收治的肘管綜合征患者35例，按照手術(shù)方式分為兩組,其中開放松解并前置組20例，關(guān)節(jié)鏡下原位松解組15例。分析兩組患者的并發(fā)癥、手術(shù)時(shí)間、住院時(shí)間、回到正常生活和工作的時(shí)間，采用Heithoff改良的Wilson和Krout評(píng)分系統(tǒng)評(píng)估患者療效。結(jié)果 經(jīng)過平均16個(gè)月的隨訪，兩組之間Wilson和Krout評(píng)估系統(tǒng)的優(yōu)良率比較差異無統(tǒng)計(jì)學(xué)意義。在并發(fā)癥、手術(shù)時(shí)間、住院時(shí)間、回到正常生活和工作的時(shí)間等方面關(guān)節(jié)鏡下原位松解組優(yōu)于開放松解并前置組。 結(jié)論 關(guān)節(jié)鏡輔助下松解尺神經(jīng)治療原發(fā)性肘管綜合征切口和創(chuàng)傷小，軟組織損傷小，并發(fā)癥少，患者能夠盡早恢復(fù)日常生活。

肘管綜合征；關(guān)節(jié)鏡；尺神經(jīng)

原發(fā)性肘管綜合征(cubitaltunnelsyndrome,CTS)在臨床上比較常見，發(fā)病率占上肢神經(jīng)卡壓的第二位[1]。由于其易累及手內(nèi)在肌，且尺神經(jīng)修復(fù)后功能恢復(fù)差，除發(fā)病早期嘗試保守治療外，其余患者均應(yīng)盡早進(jìn)行手術(shù)治療。尺神經(jīng)開放松解并前置曾是主流術(shù)式[1-2]，之后更多學(xué)者采用單純的開放原位減壓術(shù)[3-5]，近十余年又嘗試關(guān)節(jié)鏡下肘管松解術(shù)[6-10]，但哪種手術(shù)更有效仍有爭(zhēng)議。作者采用Cobb推薦的關(guān)節(jié)鏡下肘管松解術(shù)[11]治療原發(fā)性CTS患者，療效滿意，并以常規(guī)手術(shù)為對(duì)照進(jìn)行回顧性研究，現(xiàn)報(bào)道如下。

資 料 與 方 法

一、一般資料

2012年10月至2015年6月北京大學(xué)人民醫(yī)院創(chuàng)傷骨科收治的原發(fā)性CTS患者37例，排除復(fù)發(fā)患者、神經(jīng)瘤或神經(jīng)滑膜囊腫的患者，隨訪到完整資料者35例。按照手術(shù)方式分為兩組，其中對(duì)照組(開放松解并前置組)患者20例、試驗(yàn)組(關(guān)節(jié)鏡下原位松解組)患者15例。所有患者均在術(shù)前進(jìn)行了詳細(xì)的體格檢查，包括手部感覺減退、手內(nèi)在肌萎縮情況、肌力檢查、肘部Tinel′s征等。術(shù)前均行肌電圖檢查，確定診斷并記錄神經(jīng)傳導(dǎo)速度。術(shù)前按照McGowan分級(jí)[12]分為Ⅰ、Ⅱ和Ⅲ級(jí)。兩組患者的性別、年齡、優(yōu)勢(shì)側(cè)、發(fā)病時(shí)間及術(shù)前McGowan分級(jí)等資料見表1。

表1 兩組患者的一般資料

注：*表示采用Fisher確切概率法；-表示無數(shù)據(jù)

二、手術(shù)方式

所有患者均采用臂叢麻醉，上臂上止血帶，止血帶壓力為250～300mmHg。

(一)對(duì)照組

行肘關(guān)節(jié)內(nèi)側(cè)11～13cm長(zhǎng)切口，切開皮膚及皮下組織，保護(hù)前臂內(nèi)側(cè)皮神經(jīng)(medialantebrachialcutaneousnerve，MACN)和貴要靜脈分支。首先在內(nèi)上髁后方找到尺神經(jīng)，然后向上顯露Struthers腱弓，內(nèi)側(cè)肌間隔，向遠(yuǎn)端顯露滑車上肘后肌和弓狀韌帶(肘管頂)，以及尺側(cè)腕屈肌(flexorcarpiulnaris，F(xiàn)CU)筋膜，徹底松解上述四個(gè)結(jié)構(gòu)，并游離尺神經(jīng)。然后在內(nèi)上髁前方做出2cm×2cm大小的旋前圓肌和屈肌總腱筋膜瓣，將尺神經(jīng)前置，將筋膜瓣固定至前側(cè)皮下組織，防止尺神經(jīng)內(nèi)移。止血后關(guān)閉切口。

(二)試驗(yàn)組

本組病例采用Cobb推薦的關(guān)節(jié)鏡下肘管松解術(shù)，配套器械由北京航空航天大學(xué)工程制作培訓(xùn)中心制造。操作步驟：肘關(guān)節(jié)屈曲90°，外翻位置于手術(shù)桌上，于內(nèi)上髁和鷹嘴之間做縱切口，長(zhǎng)約2～3cm，直視下松解滑車上肘后肌和弓狀韌帶，找到尺神經(jīng)。然后在內(nèi)上髁上下10cm范圍內(nèi)，根據(jù)尺神經(jīng)走行方向，將上臂和前臂深筋膜和皮下組織進(jìn)行鈍性剝離，形成皮下隧道，分離時(shí)必須緊貼深筋膜，以便保護(hù)MACN和血管分支。然后沿著尺神經(jīng)走行插入精細(xì)剪刀進(jìn)行鈍性剝離，建立尺神經(jīng)和其表面筋膜之間的工作空間，然后置入工作套筒，避免暴力猛推，此時(shí)套筒蓋位于FCU筋膜表面，套筒本身置于尺神經(jīng)表面。首先于套筒蓋下方插入關(guān)節(jié)鏡，觀察筋膜表面有無殘留的皮神經(jīng)分支和血管。然后抽出鈍芯，套筒內(nèi)插入關(guān)節(jié)鏡，可旋轉(zhuǎn)套筒，確保鏡下能在套筒內(nèi)全程觀察到深層的尺神經(jīng)，鏡下插入叉刀，將套筒表面的FCU筋膜和肌束縱向切開。向遠(yuǎn)端松解8～10cm，完畢后將套筒再插入至近端，同樣松解近端尺神經(jīng)走行區(qū)域的筋膜，近端也松解8～10cm，也要注意保護(hù)皮神經(jīng)和血管分支，并確保在套筒內(nèi)全程看到尺神經(jīng)以避免造成損傷。遠(yuǎn)、近端均松解完畢后，反復(fù)屈肘，確定尺神經(jīng)穩(wěn)定性。如尺神經(jīng)向前脫位至內(nèi)上髁前內(nèi)側(cè)，則延長(zhǎng)切口進(jìn)行前置。如尺神經(jīng)穩(wěn)定，則止血并關(guān)閉切口。加壓包扎，不放置引流管(圖1)。

注：圖F-J，L套管深層為尺神經(jīng)圖1 患者，男,21歲, 左側(cè)原發(fā)性肘管綜合征，行關(guān)節(jié)鏡下原位松解術(shù)。圖A體位及入路；圖B顯露滑車上肘后?。粓DC直視下松解肘管頂；圖D Cobb技術(shù)配套器械，套筒、叉刀及鈍芯；圖E向遠(yuǎn)端插入套筒；圖F套筒插入尺神經(jīng)表面；圖G套筒蓋插入尺側(cè)腕屈肌表面；圖H套筒內(nèi)全程看到尺神經(jīng)；圖I以叉刀松解；圖J證實(shí)遠(yuǎn)端松解徹底；圖K向近端插入套筒；圖L近端松解；圖M關(guān)閉切口，不放置引流管

三、術(shù)后康復(fù)和隨訪

術(shù)后隨訪內(nèi)容包括手術(shù)并發(fā)癥，手術(shù)時(shí)間，回到正常生活和工作的時(shí)間，以及患者是否對(duì)本次手術(shù)表示滿意[10]。采用Heithoff改良的Wilson和Krout評(píng)分系統(tǒng)[13]評(píng)估患者恢復(fù)情況。最后一次隨訪復(fù)查肌電圖，并與術(shù)前比較，恢復(fù)情況分為恢復(fù)正常、部分改善、無變化三個(gè)等級(jí)[10]。

四、統(tǒng)計(jì)學(xué)分析

結(jié) 果

經(jīng)過平均16個(gè)月(8～32個(gè)月)的隨訪， 對(duì)照組的Wilson和Krout評(píng)分為：優(yōu)10例、良8例、可1例、差1例；試驗(yàn)組的Wilson和Krout評(píng)分為：優(yōu)7例、良6例、可1例、差1例。二組之間的優(yōu)良率差異無統(tǒng)計(jì)學(xué)意義(P=1.000)。在手術(shù)時(shí)間、住院時(shí)間、回到正常生活和工作時(shí)間方面，試驗(yàn)組均明顯短于對(duì)照組，且差異均有統(tǒng)計(jì)學(xué)意義。對(duì)照組有2例表示不滿意，試驗(yàn)組有1例表示不滿意，兩組之間的滿意度差異無統(tǒng)計(jì)學(xué)意義。并發(fā)癥方面， 對(duì)照組的MACN損傷為4例，而試驗(yàn)組為1例。另外，試驗(yàn)組還有1例患者出現(xiàn)皮下血腫。兩組均無復(fù)發(fā)患者。試驗(yàn)組不滿意的患者于術(shù)后1個(gè)月進(jìn)行了第二次手術(shù)，并采用了開放松解并前置技術(shù)。兩組患者治療結(jié)果詳見表2。

表2 兩組患者治療結(jié)果比較

注：MACN為前臂內(nèi)側(cè)皮神經(jīng)；*表示采用Fisher確切概率法；-表示無數(shù)據(jù)

討 論

原發(fā)性CTS的手術(shù)治療方法一直有爭(zhēng)議。松解Struthers腱弓，內(nèi)側(cè)肌間隔，滑車上肘后肌和弓狀韌帶(肘管頂)，以及FCU筋膜四個(gè)結(jié)構(gòu)的開放松解并前置一直是主流術(shù)式[1-2]。其優(yōu)點(diǎn)是確保神經(jīng)張力減少，缺點(diǎn)是需要廣泛的軟組織剝離，神經(jīng)伴行的尺側(cè)上副動(dòng)脈損傷致神經(jīng)缺血，高幾率的MACN損傷。多個(gè)隨機(jī)對(duì)照試驗(yàn)研究證實(shí)，開放原位減壓術(shù)的結(jié)果和前置類似，但并發(fā)癥相對(duì)較少[3-5], 因此開放原位減壓術(shù)開展越來越多。其優(yōu)點(diǎn)是松解充分，缺點(diǎn)是仍存在切口較大、MACN易損傷、傷口周圍疼痛和瘢痕形成等問題。

開放原位減壓術(shù)的有效性獲得證實(shí)后，為了減小手術(shù)創(chuàng)傷和并發(fā)癥，很多學(xué)者開始嘗試關(guān)節(jié)鏡下肘管松懈術(shù)，證實(shí)了其安全性和有效性[6-11]，并提示關(guān)節(jié)鏡下肘管松懈術(shù)較開放原位減壓術(shù)有更高的滿意度和更低的并發(fā)癥發(fā)生率[14]。除了有效性和與傳統(tǒng)手術(shù)類似外，還有創(chuàng)傷小、手術(shù)時(shí)間較短、松解廣泛、并發(fā)癥少等優(yōu)勢(shì)[8，10-11]。關(guān)節(jié)鏡下肘管松懈術(shù)一般在十幾分鐘完成，可松解至肘上10cm和肘下10cm的范圍，患者能更快地恢復(fù)工作和生活。有多位學(xué)者如Tsai等[6]、Hoffmann等[7-8]、Mirza等[9]、Cobb[11]都研發(fā)了自己的技術(shù)，他們的特點(diǎn)類似，主要是配套器械有所區(qū)別。作者最先接觸到的是Cobb技術(shù)[11，15-16]，其配套器械制作比較簡(jiǎn)單，松解過程中可明確保護(hù)尺神經(jīng)。術(shù)中需注意兩點(diǎn)：第一，避免將套筒暴力推進(jìn)至尺神經(jīng)走行表面，可先通過鈍性分離建立工作套筒空間；第二，確保在套筒內(nèi)觀察到尺神經(jīng)的完整走行，一旦看不到神經(jīng)，立刻停止松解，可通過旋轉(zhuǎn)工作套筒或重新插入，看到尺神經(jīng)后再繼續(xù)松解。

關(guān)節(jié)鏡下肘管松解術(shù)的禁忌證包括明顯肘外翻、嚴(yán)重屈曲攣縮、尺神經(jīng)脫位以及復(fù)發(fā)患者[6，8，10-11]，因?yàn)檫@些患者需要將尺神經(jīng)前置。對(duì)于外翻、屈曲攣縮和尺神經(jīng)脫位患者，如果不需要手術(shù)糾正外翻或松解攣縮，只是緩解尺神經(jīng)癥狀時(shí)，可以將鏡下松解和開放前置相結(jié)合，也可以大大縮小切口長(zhǎng)度，只需將切口延長(zhǎng)至5cm左右，而且手術(shù)時(shí)間無明顯增加。當(dāng)然，前置時(shí)必須切除部分內(nèi)側(cè)肌間隔，避免再次卡壓尺神經(jīng)。但鏡下松解和前置手術(shù)相結(jié)合的手術(shù)方式國(guó)內(nèi)外報(bào)道極少[17]，其意義和風(fēng)險(xiǎn)仍有爭(zhēng)議，作者只嘗試過幾例患者，經(jīng)驗(yàn)仍需進(jìn)一步總結(jié)。本研究的試驗(yàn)組病例都排除了上述禁忌證。

研究證實(shí)，關(guān)節(jié)鏡下肘管松解術(shù)可以取得和開放松解并前置相同的效果，在住院時(shí)間、手術(shù)時(shí)間、恢復(fù)時(shí)間等方面都較常規(guī)手術(shù)有優(yōu)勢(shì)。但關(guān)節(jié)鏡下肘管松解術(shù)的手術(shù)時(shí)間比國(guó)外學(xué)者報(bào)道時(shí)間增加1倍，且術(shù)后血腫和MACN損傷的幾率高于文獻(xiàn)的幾率[11，15-16]，主要是可能處在學(xué)習(xí)曲線中，病例和積累經(jīng)驗(yàn)相對(duì)較少。另外，有1例患者采用了關(guān)節(jié)鏡下肘管松解術(shù)，術(shù)后沒有任何緩解，隨后再次采用了開放松解并前置技術(shù)進(jìn)行治療。失敗的原因考慮患者病史短，進(jìn)展快，早期出現(xiàn)內(nèi)在肌肌力差，可能有神經(jīng)炎等因素致病。隨著技術(shù)完善和更嚴(yán)格的掌握適應(yīng)證，并發(fā)癥和再手術(shù)幾率應(yīng)該降低。

當(dāng)然，任何技術(shù)都有缺點(diǎn)，尤其是關(guān)節(jié)鏡下肘管松解術(shù)，對(duì)術(shù)者的技術(shù)要求高，因此國(guó)內(nèi)開展仍較少[17]。另外，開展此手術(shù)之前，可能需要尸體上的模擬操作以便熟悉該技術(shù)。本研究也存在缺點(diǎn)，如病例數(shù)相對(duì)少、隨訪時(shí)間短、屬于回顧性研究、不同術(shù)者參與了手術(shù)和對(duì)術(shù)后療效的評(píng)估可能導(dǎo)致主觀偏見等。后期將進(jìn)一步積累病例，總結(jié)經(jīng)驗(yàn)。

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(本文編輯：胡桂英)

楊明，黃偉，王天兵，等.關(guān)節(jié)鏡下松解尺神經(jīng)治療肘管綜合征療效[J/CD]. 中華肩肘外科電子雜志,2016,4(4):230-235.

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電子文獻(xiàn)載體和標(biāo)志代碼簡(jiǎn)表

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(本刊編輯部)

Endoscopiccubitaltunnelreleaseintreatmentofidiopathiccubitaltunnelsyndrome

YangMing,HuangWei,WangTianbing,ZhangDianying,FuZhongguo,XiongJian,ChenJianhai,JiangBaoguo.

DepartmentofTraumatologyandOrthopaedics,PekingUniversityPeople′sHospital,Beijing100044,China

JiangBaoguo，Email：jiangbaoguo@vip.sina.com

Background Idiopathic cubital tunnel syndrome is the second most common nerve entrapment in the upper extremity. Because of the poor prognosis, the treatment principle of the cubital tunnel syndrome is to release ulnar nerve as early as possible for the cases whose conservative treatment is failed. There are several kinds of surgical methods to treat cubital tunnel syndrome,such as open release and anterior transposition,open in situ decompression，and the newest endoscopic cubital tunnel release. There is no accepted standard for surgical treatment at present. We performed endoscopic cubital tunnel release for 15 cases and obtained satisfactory results. We performed this retrospective study to explore the new surgical methods and its effects. A group of 20 cases treated by conventional open release and anterior transposition were in the control group.Methods (1)General information: All the 35 cases of idiopathic cubital tunnel syndrome were treated by surgery and followed up from October 2012 to June 2015. According to the surgical method, all the case were divided into two groups. 20 cases accepted conventional open release and subcutaneous anterior transposition, and 15 cases accepted endoscopic cubital tunnel release. All the cases obtained detailed preoperative physical examination,such as sensory decrease of the hand, intrinsic muscle atrophy and strength decrease, and Tinel′s sign of the elbow. The accessory electrophysiology tests were performed. According to McGowan score, all the cases were divided into grade Ⅰ,Ⅱ and Ⅲ. The data such as gender, age, dominant side, durations of symptoms, and preoperative McGowan, can be seen in table 1.(2)Surgery methods:Open release and anterior transposition group: The patient was placed supine on the operating table, with the shoulder abducted and externally rotated and the arm was on the table. A tourniquet was placed high on the brachium. The procedure was performed under regional anesthesia with sedation. A longitudinal incision was performed on the medial side of the elbow. During the subcutaneous exposure, the medical antebrachial cutaneous nerve and vein branch must be identified. The ulnar nerve was then identified just posterior to medial epicondyle. Next we released the cubital tunnel retinaculum, anconeus epitrochlearis muscle and flexor carpi ulnaris (FCU) aponeurosis distally,and then released the deep brachial fascia, the intermuscular septum, and the arcade of Struthers proximally. After complete release, the ulnar nerve was transposed anterior to the medial epicondyle, and overhanged by sling which was made by partial aponeurosis of the flexor common muscle and pronator muscle. After complete hemostasis, the wound was closed.Endoscopic cubital tunnel release group: we applied the endoscopic cutital tunnel release (ECTR) technique which was recommend by Dr. Cobb. The instrument system was made in Beijing university of Aeronautics and Astronautics. The position, anesthesia and tourniquet were the same to those of the open release and anterior transposition group. A 2-3 cm longitudinal incision was made over the cubital tunnel, just posterior to the medial epicondyle. The ulnar nerve was then palpated just posterior to medial epicondyle. An anconeus epitrochlearis muscle and cubital tunnel retinaculum was incised directly over the cubital tunnel. After the the roof of the cubital tunnel is incised, the ulnar nerve was identified. The opening in the cubital tunnel should be sufficient enough to allow instrumentation placed without binding. Then we used blunt-tip scissors to dissect adipose tissue and superficial nerves off the deep fascia, and created a 10 cm subcutaneous cannal both proximally and distally. Then we created another cannal to dissect the soft tissue over the course of the ulnar nerve using blunt-tip scissors. Next the working instrument was placed into the two cannals. The spatula was placed into potential space between the deep fascia and the subcutaneous adipose. The cannula and trochar were immediately placed into the second cannal superficial to the ulnar nerve. Before the insertion of the instrument, it must be moistened by saline and should be advanced without resistance.Then the trochar was withdrawn, and the scope was placed into the cannula and turned to the inferior slots so the nerve could be identified. The ulnar nerve should be identified throughout the entire course of the cannula, and rotation of the cannula might be helpful in this procedure. Then the fascia was divided with bifurcate blade along the superior slot of the cannula. The fascia should be divided only if the nerve was clearly identified throughout the entire length of the intended release. Following the release of fascia, the completeness of release should be checked with endoscope. During the distal release, the muscle of the flexor pronator mass was seen through the superior slot of the cannula, but its release was not necessary because of the unnecessary bleeding. Then the tourniquet was deflated, and pressure was applied. The retractor was placed into the incision, and the endoscope was used to visualize the surgical field both proximally and distally, confirming that complete release and hemostasis had been obtained. At last, the passive flexion of the elbow must be performed to confirm there was no dislocation of the ulnar nerve. Once happened, the anterior transposition might be needed. The wound was tightly closed and a compressive dressing was applied.(3)Postoperative rehabilitation and follow-ups. The patients should mobilize the affected elbow as he or she could endure the pain. We evaluated the effect of surgery using the Wilson and Krout rating system modified by Heithoff. The difference between two groups were compared in complications, operating time, hospitalization time, time of returning to normal activity, the satisfactory degree,etc.The electrophysiology also performed and compared with pre-operation. (4) Statistical methods: SPSS 19.0 software was used. The measurement data were indicated as means ± standard deviations. Fisher′s test were performed in the comparison of the measurement data between two groups,the Independent-Samplettestwasusedforthecomparisonofmeacurementdatainthetwogroups;P<0.05wasconsideredstatisticallysignificant.ResultsAfterfollow-upsforanaverageof16months,theeffectoftwogroupswerethesameintheWilsonandKroutratingsystemmodifiedbyHeithoff.Theeffectofendoscopiccubitaltunnelreleasegroupwasbetterthanthatofopenreleaseandanteriortranspositiongroupincomplications,operatingtime,hospitalizationtimeandtimeofreturningtonormalactivity.Inthearthroscopiccubitaltunnelreleasegroup,therewasonecasewhoacceptedsecondopenreleaseandanteriortranspositionbecauseofthepoorresults.ConclusionsThecontraindicationsforarthroscopiccubitaltunnelreleaseweremassesorspace-occupyinglesions,elbowcontracturesrequiringrelease,cubitusvalgus,andulnarnervesubluxating.Endoscopiccubitaltunnelreleasewasareliabletechniquecharacterizedbyashortincision,minimumsofttissuedissection,lowercomplicationrateandearlypostoperativemobilization.However,therearesomechallengesinthetechnique,andcomplicationsmayoccursometimes.

Cubitaltunnelsyndrome;Endoscope;Ulnarnerve

10.3877/cma.j.issn.2095-5790.2016.04.007

衛(wèi)生公益性行業(yè)科研專項(xiàng)(201002014、201302007)；教育部創(chuàng)新團(tuán)隊(duì)(IRT1201)；北京市科委重大

100044北京大學(xué)人民醫(yī)院創(chuàng)傷骨科 北京大學(xué)交通醫(yī)學(xué)中心

姜保國(guó)，Email:jiangbaoguo@vip.sina.com

2015-02-05)

專項(xiàng)(Z101107052210001)；北京大學(xué)人民醫(yī)院研究與發(fā)展基金(RDB2014-01)