闭孔神经移位修复盆内脏神经治疗创伤性骶丛损伤致排尿障碍  

Transferring fascicles of obturator nerve restoring vesical branch of pelvic nerve to treat the micturition function of patients caused by sacral plexus injury

作　　者：李峰[1] 王树锋[1] 栗鹏程[1] 薛云皓[1] 王海东[2] Li Feng;Wang Shufeng;Li Pengcheng;Xue Yunhao;Wang Haidong(Department of Hand Surgery,Beijing Jishuitan Hospital,Beijing 100035,China;Department of Urology Surgery,Beijing Jishuitan Hospital,Beijing 100035,China)

机构地区：[1]北京积水潭医院手外科,100035 [2]北京积水潭医院泌尿外科,100035

出　　处：《中华骨科杂志》2019年第5期278-283,共6页Chinese Journal of Orthopaedics

摘　　要：目的探讨闭孔神经束支移位直接修复盆内脏神经膀胱支的可行性,以期恢复创伤致双侧下骶丛损伤患者的主动排尿功能。方法回顾性分析2018年5月至7月采用闭孔神经束支移位直接修复盆内脏神经膀胱支治疗5例创伤致双侧下骶丛神经根完全损伤患者资料,男4例,女1例;年龄23~30岁,平均26岁;高处坠落伤3例,车祸伤2例;伤后至手术时间7~14个月,平均10.2个月;术前患者临床表现为大小便失禁,尿动力学检查示膀胱逼尿肌无力、迟缓性膀胱。术中将盆内脏神经膀胱支近端切断,在同侧盆腔侧壁找到并分离出闭孔神经,在进入闭孔前切断其前支或后支,并向近端做干支分离,将其与盆内脏神经直接吻合。术中测量盆内脏神经与闭孔神经束支的直径和可游离长度,评价手术的可行性。术后测量供区大腿内侧的皮肤感觉及大腿内收肌肌力,评价手术的安全性。结果 5例患者中,3例行传统的腹旁正中入路盆内脏神经修复术,2例采用改良的腹直肌旁入路。手术过程顺利,5例均顺利找到盆内脏神经,无一例发生大血管、肠道及输尿管损伤等并发症。动力神经源的选择:2例选择闭孔神经的前支,1例选择后支,1例选择闭孔神经前支的2/3,另1例选择闭孔神经后支的2/3。闭孔神经束支可游离长度1.9~2.6 cm,平均2.28 cm;直径1.2~1.5 mm,平均1.36 mm。盆内脏神经可游离长度2.2~2.7 cm,平均2.46 cm;直径1.1~1.3 mm,平均1.2 mm。术后供侧大腿内收肌力均为4级,大腿内侧感觉无明显减退区。结论经腹膜内寻找盆内脏神经膀胱支较容易,同侧闭孔神经的前支或后支移位后可与盆内脏神经的膀胱支直接吻合,手术可行性好;闭孔神经束支移位后对供区无明显影响。Objective To explore the feasibility of transferring of the obturator nerve onto the vesical branch of pelvic nerve with direct anastomosis, in order to restore the automatic micturition function of patients with bilateral lower sacral plexus injury (S2-S4). Methods Data of five patients (4 males and 1 female) with bilateral lower sacral plexus injury who had surgery from May to July 2018 were retrospectively analyzed. The average age was 26 years old (range, 23-30 years old) and the average delay from injury to operation was 10.2 months (range, 7-14 months). Three patients suffered with fell off injury and two patients had car accident injury. All patients presented with continence and the urodynamics revealed flaccid neuropathic bladder with neurogenic adynamia of detrusor muscle. The vesical branch of pelvic nerve was dissected between the bladder and the ureter where it entered the bladder neck from backward to forward almost vertically. The obturator nerve was dissected along the pelvic sidewall, and the comparable bundle branch of obturator nerve was transferred onto the vesical branch of pelvic nerve with direct anastomosis. The diameter and freed length of pelvic nerve and the fascicles of the obturator nerve were measured intraoperatively, and the cutaneous sensation of medial thigh and the muscle strength of hip adduction were evaluated postoperatively. Results The surgery was performed through the traditional abdominal paramedian approach in 3 patients and through the pararectus approach in 2 patients. The vesical branch of pelvic nerve in all five patients could be revealed clearly and there was enough operative space for nerve transferring. The surgery was successful in all five patients without any complication. The donor nerves were anterior branch of obturator nerve in 2 patients, posterior branch of obturator nerve in 1 patient, 2/3 fascicles of anterior branch of obturator nerve in 1 patient and 2/3 fascicles of posterior branch of obturator nerve in 1 patient. The average length and diameter of

关 键 词：闭孔神经 内脏神经 腰骶丛 神经移位 

分 类 号：R688[医药卫生—骨科学]