周围神经选择性部分切断术治疗脑性瘫痪肢体痉挛  

Selective peripheral neurotomy for limb spasticity in cerebral palsy

作　　者：王世杰[1] 陈业涛[1] 苗素华[1] 王云朋[1] 张玉琪[1] Wang Shijie;Chen Yetao;Miao Suhua;Wang Yunpeng;Zhang Yuqi(Department of Neurosurgery,Yuquan Hospital,Tsinghua University,Belling 100049,China)

机构地区：[1]清华大学玉泉医院神经外科,北京100049

出　　处：《中华神经外科杂志》2019年第1期25-29,共5页Chinese Journal of Neurosurgery

摘　　要：目的探讨周围神经选择性部分切断术(SPN)治疗脑性瘫痪(简称脑瘫)肢体痉挛的病例选择、手术方法、疗效及并发症。方法回顾性分析2016年1月至2017年6月清华大学玉泉医院神经外科收治的119例痉挛型脑瘫患者的临床资料。所有患者均行SPN,其中上肢40侧,下肢156侧,共计360支周围神经。手术前、后肌张力的变化采用改良Ashworth分级标准、表面肌电图(sEMG)进行评价,上、下肢运动功能的变化分别采用手臂动作测试量表(ARAT)、粗大运动功能量表(GMFM)进行评估。结果术后神经支配肌肉的即刻痉挛缓解率为95.6%(344/360)。改良Ashworth分级评定结果表明,术后肌张力0级占60.0%(216/360),1级占25.6%(92/360),2级占8.9%(32/360),3级占1.1%(4/360),无效占4.4%(16/360)。术后即刻出现神经支配区域感觉障碍的比率为10.3%(37/360),末次随访肌力较术前下降1个级别以上的比率为1.9%(7/360)。感觉障碍均在3个月内缓解。所有患者均获随访,随访时间为6~24个月,平均(17.2±4.9)个月。末次随访肢体运动功能改善率为67.3%(132/196),其中上肢改善率为47.5%(19/40),下肢改善率为72.4%(113/156)。32支(8.9%)神经所支配肌肉的痉挛有不同程度的复发,其中肌张力恢复至术前水平13支(3.6%)。结论SPN对脑性瘫痪肢体痉挛状态具有明显的缓解作用。正确掌握手术适应证和手术方法是提高疗效、降低并发症的关键。Objective To investigate the candidate selection, surgical methods, efficacy and complications of selective peripheral neurotomy (SPN) for the treatment of limb spasticity in cerebral palsy. Methods A total of 119 patients with spastic cerebral palsy admitted to Department of Neurosurgery, Yuquan Hospital, Tsinghua University from January 2016 to June 2017 were enrolled into study. All those patients underwent SPN, which involved 40 upper limbs and 156 lower limbs with 360 nerves operated on. The changes of muscle tension following operation were evaluated by modified Ashworth scale and surface electromyography (sEMG). The changes of upper and lower limb motor function were evaluated by action research arm test (ARAT) and gross motor function measure (GMFM) scales. Results The immediate postoperative successful rate with limb spasticity relief was 95.6% (344/360). Moreover, the patients with Ashworth scales of 0, 1, 2, 3 accounted for 60.0% (216/360), 25.6% (92/360), 8.9% (32/360), 1.1% (4/360) respectively. Inefficient treatment accounted for 4.4% (16/360). The rate of sensory disturbance immediately post operation in the innervated region was 10.3% (37/360) and the rate of postoperative muscle strength decline over at least 1 grade was 1.9% (7/360). Sensory disturbance was all relieved within 3 months. All those patients were followed up for 6-24 (17.2±4.9) months. The improvement rate of limb motor function during follow-up was 67.3% (132/196), of which the upper limb improvement rate was 47.5% (19/40) and the lower limb improvement rate was 72.4% (113/156). Recurrence with varying degrees was reported in 32 (8.9%) cases, of which 13 (3.6%) returned to preoperative levels. Conclusions The SPN has a significant alleviating effect on the limb spasticity of cerebral palsy. Proper surgical indications and operative methods are keys to improvement of treatment efficacy and reduction of clinical complications.

关 键 词：脑性瘫痪 肌痉挛状态 神经外科手术 治疗结果 周围神经选择性部分切断术 

分 类 号：R651.3[医药卫生—外科学]