联合式周围神经选择性部分切断术治疗儿童脑性瘫痪下肢痉挛  

Combined selective peripheral neurotomy for treatment of spasticity in lower limbs of cerebral palsy patients

作　　者：杨培中[1] 刘向东[1] 刘永博[1] 刘学来[1] 宋振宇 李纪森 张黎[2] Yang Peizhong;Liu Xiangdong;Liu Yongbo;Liu Xuelai;Song Zhenyu;Li Jisen;Zhang Li(Department of Neurosurgery,Linyi Traditional Chinese Medicine Hospital,Linyi 276002, China;Department of Neurosurgery ,China-Japan Friendship Hospital,Beijing 100029,China)

机构地区：[1]临沂市中医医院神经外科,山东276002 [2]中日友好医院神经外科,北京100029

出　　处：《中华神经外科杂志》2019年第1期47-50,共4页Chinese Journal of Neurosurgery

摘　　要：目的探讨联合式周围神经选择性部分切断术(SPN)治疗儿童脑性瘫痪下肢痉挛状态的有效性和安全性。方法回顾性纳入2007年3月至2017年3月于临沂市中医医院神经外科采用双侧闭孔神经前支、胫神经、坐骨神经联合式SPN治疗,且临床及随访资料完整的脑性瘫痪下肢痉挛状态患儿,共109例(218侧肢体)。术后采用改良Ashworth分级(mAS)评估下肢痉挛的缓解程度,采用粗大运动功能分级(GMFCS)评估下肢运动功能的改善程度,并观察手术相关并发症的发生率。结果全部患儿随访时间为12~132个月,平均(73.6±16.7)个月。218侧中,209侧(95.9%)肢体术后痉挛状态即刻有不同程度的缓解,末次随访缓解率为90.8%(198侧);术前髋内收肌、踝跖屈肌的mAS分别为(2.66±0.49)分、(3.36±0.52)分,末次随访时分别为(1.52±0.46)分、(1.57±0.56)分,差异均有统计学意义(均P<0.01)。末次随访下肢运动功能改善率为87.2%(95/109);术前与术后末次随访的GMFCS分级差异有统计学意义(P<0.05)。218侧肢体中,术后住院期间发生下肢感觉障碍51侧(23.4%),发生下肢肌力下降39侧(17.9%),以上症状在随访期间均有不同程度好转。结论对于因各种原因不能行腰骶段选择性脊神经后根部分切断术(SPR)或行SPR后下肢仍存在较重痉挛的脑性瘫痪患儿,采用双侧闭孔神经前支、胫神经、坐骨神经联合式SPN可有效、安全地缓解痉挛状态,改善下肢运动功能。Objective To study the surgical outcome and safety of combined selective peripheral neurotomy (SPN) for treatment of spasticity in lower limbs of cerebral palsy patients. Methods A total of 109 cerebral palsy patients with lower limb spasticity (218 limbs) were treated with combined SPN on bilateral obturator nerve, tibial nerves and sciatic nerves from March 2007 to March 2017 at Department of Neurosurgery, Linyi Traditional Chinese Medicine Hospital. The modified Asworth scale (mAS) was used for the evaluation of the patients’ spasticity and their movement ability was assessed by the gross motor function classification system (GMFCS). Results The mean follow-up period was 73.6±16.7 months (range: 12-132 months). The spasticity was alleviated in 209 (95.9%) lower limbs immediately post surgery, and the rate of alleviation was 90.8% (198 limbs) at the last follow-up. The mAS scores of adductor muscle of hip and ankle metatarsal flexor muscle were 2.66±0.49 and 3.36±0.52 respectively prior to surgery and 1.52±0.46 and 1.57±0.56 respectively at last follow-up. Those differences were statistically significant (P<0.01). At the last follow-up, 95 of 109 (87.2%) had improvement on motor function. There was significant improvement on motor function indicated by elevated GMFCS scales (P<0.05). The sensory disorder of limb was found in 51 (23.4%) lower limbs, decreased muscle strength occurred in 39 (17.9%) lower limbs during hospitalization, and both complications were improved during the follow-up period. Conclusions Combined SPN on bilateral obturator nerve, tibial nerves and sciatic nerves was an effective and safe method for the treatment of lower limb spasticity and improvement of lower limb movement in cerebral palsy patients who cannot undergo selective posterior rhizotomy (SPR) due to various reasons or those whose spasticity cannot be completely relieved after SPR.

关 键 词：肌痉挛状态 脑性瘫痪 神经外科手术 周围神经 儿童 

分 类 号：R726.5[医药卫生—儿科]