本文選題：周圍神經(jīng) + 移植�。� 參考：《西南醫(yī)科大學》2017年碩士論文

【摘要】：目的:周圍神經(jīng)損傷在臨床非常常見,目前并沒有最有效的治療方法。為了解決這類問題,我們針對顯微縫合技術方面,設計了動物神經(jīng)損傷模型進行自體神經(jīng)移植,對比四個實驗組神經(jīng)損傷后的修復效果,并分析其原因,為得到理想的周圍神經(jīng)移植縫合方法提供實驗依據(jù)。方法:將60只SD大鼠隨機分組,等分為A、B、C、D四組,每組15只,右下肢為實驗側,左下肢為空白對照側,每只大鼠均在右下肢做相應處理,左下肢不做處理,然后在組間進行比較。術前常規(guī)手術器械消毒,實驗動物稱重,對大鼠按體重行3%戊巴比妥鈉0.2ml/100g腹腔注射麻醉,先給一半劑量,再逐漸加藥至麻醉滿意,術中密切觀察大鼠生命體征,麻醉起效后,將大鼠俯臥位固定于動物實驗臺上,手術區(qū)(手術側肢體臀肌上緣至踝部屈側皮膚)剪毛后,2%的醫(yī)用碘伏溶液消毒,常規(guī)鋪巾,做右側大腿后部正中切口,自右側股骨后中1/3跨過乆窩至小腿后上方,于大腿后側肌肉間隙鈍性分離顯露坐骨神經(jīng),注意勿損傷和神經(jīng)伴行的血管及滋養(yǎng)血管。各組分別做以下處理:A組:避開坐骨神經(jīng)的供養(yǎng)血管,選擇坐骨神經(jīng)切斷位置在梨狀肌出口下緣1cm處,第二次切斷坐骨神經(jīng)的位置為其遠端距近端吻合口1cm處,將這段作為移植段坐骨神經(jīng),與周圍組織完全游離,在雙人雙目顯微鏡下,分別于原位即移植段神經(jīng)近端和遠端保持一致的順行放置行坐骨神經(jīng)外膜縫合(將手術顯微鏡調(diào)到合適位置,保證視野清晰,首先將兩斷端對合,如無回縮,說明兩斷端可在無張力下對合。將斷面上的神經(jīng)束、系膜旁膜等逐一對合,接著備8-0無創(chuàng)縫合線開始縫合,在兩斷端的水平左右兩側,縫合外膜各一針,保留長線當作牽引,然后在兩定點線之間,將外膜逐一間斷行等距的縫合,前側外膜縫合完畢后,助手提起對側牽引線,將神經(jīng)斷端左右翻轉(zhuǎn)180°,并將后側的外膜用同樣的方式等距縫合,縫合的過程中,如果出現(xiàn)神經(jīng)束外露,可用顯微鑷輕輕將露出的神經(jīng)束推入,然后繼續(xù)縫合,打結使兩側斷端神經(jīng)剛好對合為最適松緊度,過緊或過松都不利于神經(jīng)再生。)。b組:將移植段坐骨神經(jīng)與周圍組織及滋養(yǎng)血管完全游離,顛倒近端和遠端,逆行放置,行坐骨神經(jīng)外膜縫合。c組:根據(jù)該段坐骨神經(jīng)滋養(yǎng)血管的具體情況,游離出一段軟組織,其中包含有滋養(yǎng)血管,并保留不予以切除,同前面方法一樣切除1cm坐骨神經(jīng)作為移植段,于原位即移植段神經(jīng)近端和遠端保持一致的順行放置行坐骨神經(jīng)外膜縫合。d組:將帶有滋養(yǎng)血管的移植段神經(jīng)顛倒近端和遠端,逆行放置,行坐骨神經(jīng)外膜縫合。觀察各組縫合后的神經(jīng)張力情況,效果滿意后,逐層縫合肌肉、皮下筋膜及皮膚,用無菌紗布包扎切口,放回籠中喂養(yǎng)。各組分別于4、8、12周后取材,通過一般觀察及解剖觀察、電生理檢查、脛骨前肌濕重檢測、再生軸突恢復率等觀察神經(jīng)移植效果。結果:1.一般觀察:術后4周幾乎所有大鼠均跛行步態(tài)、垂足,足背伸功能障礙,不同程度出現(xiàn)足底潰瘍,大部分出現(xiàn)趾甲暗淡甚至脫落,脛骨前肌萎縮明顯,術后8周、12周部分大鼠垂足有所改善,足背伸功能有所恢復,潰瘍完全愈合,肌肉萎縮逐漸恢復,C組和D組的一般情況優(yōu)于A組和B組;2.顯微解剖觀察:術后4周取材的坐骨神經(jīng)HE染色切片后于光鏡下觀察顯示有神經(jīng)纖維變性、水腫,伴隨著神經(jīng)再生,髓鞘已經(jīng)開始出現(xiàn),C組和D組可以看見新的髓鞘形成較多,有少量的髓鞘變性、水腫、崩解,雪旺細胞增殖活躍,在移植神經(jīng)的近側吻合口,有部分再生的軸索通過;A組和B組可以看見新的髓鞘形成較少,有大量的髓鞘變形、水腫、崩解。術后8周、12周C、D組可見髓鞘密集,分布均勻,成熟度高,再生的神經(jīng)纖維較多,排列較規(guī)則,周圍的結締組織增生少,再生的軸索通過遠端吻合口進入坐骨神經(jīng)的雪旺細胞索內(nèi),并向遠端生長;A、B組可見髓鞘稀疏,排列紊亂,散在血管,再生的神經(jīng)纖維較少,神經(jīng)的排列不規(guī)則,周圍的結締組織增生明顯增多。3.C組和D組在神經(jīng)傳導速度、脛骨前肌濕重以及再生軸突恢復率結果上要優(yōu)于A組和B組,有統(tǒng)計學意義(P0.01),即帶血供組優(yōu)于不帶血供組,C組與D組之間、A組與B組之間,即順行放置與逆行放置之間比較無統(tǒng)計學意義(P)0.05)。結論:不同外膜縫合方法對神經(jīng)移植再生的影響:1.帶血供的自體神經(jīng)移植優(yōu)于不帶血供的自體神經(jīng)移植2.順行放置外膜縫合與逆行放置外膜縫合對自體神經(jīng)移植影響無明顯差異。
[Abstract]:Objective: peripheral nerve injury is very common in clinic, is not the most effective method of treatment. In order to solve this problem, we aimed at micro suture technology, designed animal nerve injury model of autologous nerve graft, repair effect comparison of four experimental groups after nerve injury, and to analyze the reasons, to provide the experimental basis for the methods peripheral nerve graft suture ideal. Methods: 60 SD rats were randomly divided into group A, B, C, D four groups, 15 rats in each group, the right lower limb as the experimental side, the left lower limb was the control side, each rat was treated in the right leg, left lower limb do the processing, and compared in groups. Preoperative routine sterilization of surgical instruments, experimental animal weighing, to rats for 3% 0.2ml/100g intraperitoneal injection of pentobarbital sodium anesthesia, give half dose, and then gradually adding to anesthesia satisfaction, intraoperative close observation In the life signs after the onset of anesthesia, the rats were fixed in the prone position in the animal experimental stage, surgery (surgical limb of gluteal muscle from the upper edge of ankle flexor side of the skin) after shearing, medical disinfection of 2% povidone iodine solution, conventional napkin, do the right thigh posterior median incision from right femoral bone, after 1/3 in the cross people wo to leg on the thigh muscles above the gap blunt separation revealed the sciatic nerve, pay attention not to damage the nerve and blood vessels and vessels with the line. They were the following: group A: support to avoid the sciatic nerve vascular, sciatic nerve cut off position in the piriformis exit margin of 1cm. The second position of the transection of sciatic nerve in the distal from the proximal anastomosis at 1cm, this time as a graft segment of the sciatic nerve, completely free from the surrounding tissues in double binocular microscope, respectively in situ that nerve grafts proximal and distal consistent Placed in sciatic nerve epineurial suture (surgical microscope will be transferred to the appropriate position, ensure clear vision, the first segment of the show, such as retraction, the two ends can not under tension. The section on the nerve bundle, mesangial membrane adjacent to one by one to 8-0, then by atraumatic suture line ends in suture, left and right sides of the level, the outer membrane suture needle, long-term retention as traction, and then in the two point line between the outer one by one intermittently isometric anterior suture, epineurial suture after assistant against side traction line, the nerve turned around 180 degrees, and will be back the envelope in the same way in the process of isometric suture, suture, nerve bundle if exposed, available microforceps gently exposed nerve bundle into, and then continue to suture, tying the nerve on both sides of it is the most suitable tightness, too tight or loose Not conducive to nerve regeneration.).B group: the allograft of sciatic nerve completely free with the surrounding tissue and vessels, reversed proximal and distal sciatic nerve, retrograde placement, epineurial suture group.C: according to the specific circumstances of the segment of the sciatic nerve nutrient vessels, free soft tissue section, which includes feeding vessels don't be removed and retained as the previous method, 1cm resection of sciatic nerve were used as grafts in situ, in which nerve grafts proximal and distal consistent antegrade placement for sciatic nerve epineurial suture group.D: nerve grafts reversed with vessels proximal and distal, retrograde placement, sciatic nerve epineurial suture. The observation group after nerve tension suture, satisfactory after sutured muscle, subcutaneous fascia and skin incision with sterile gauze, the cage in feeding. Rats in each group were harvested after 4,8,12 weeks, the general Observation and anatomical observation, electrophysiological examination, anterior tibial muscle wet weight measurement, axon recovery rate of nerve transplantation. Results: 1. general observation: after 4 weeks, almost all rats were limping gait, pedal, foot dorsiflexion dysfunction, varying degrees of thenar ulcer, toenail most dim or even fall off the tibialis anterior muscle atrophy, after 8 weeks, 12 weeks some rats pedal improved, foot function recovery, ulcer healing, muscle atrophy gradually restored, C group and D group generally better than that of A group and B group; 2.: microscopic anatomical observation of sciatic nerve at 4 weeks after operation HE the stained sections under light microscope observation showed that after nerve fiber degeneration, edema, accompanied by nerve regeneration, myelin has begun to appear, C group and D group can see new myelination more, there is a small amount of myelin degeneration, edema, disintegration, Schwann cell proliferation, Anastomosis in the proximal part of the nerve transplantation, axonal regeneration through; A group and B group can see new myelin formation is less, there are a large number of myelin deformation, edema, disintegration. After 8 weeks, 12 weeks C, D group showed myelin dense, uniform distribution, high maturity, nerve fiber more regeneration, regularly with the surrounding connective tissue hyperplasia, Schwann cell axon regeneration through the axon distal anastomosis into the sciatic nerve, and to the distal growth; A, B group showed myelin sparse, scattered in disorder, blood vessels, nerve fibers less nerve regeneration, irregular arrangement around the connective tissue hyperplasia was significantly increased in.3.C group and D group in nerve conduction velocity, anterior tibial muscle wet weight and the recovery rate of axonal regeneration is better than A group and B group, there was statistical significance (P0.01), which is for the blood group than without blood supply group, C group and D group, A group with the B group, the CIS The line is placed between and retrograde placement was not statistically significant (P) 0.05). Conclusion: different methods of epineurial nerve graft regeneration: effect of autologous nerve autograft is better than 1. with blood supply without the blood supply of the graft in 2. placed epineurial suture and retrograde placement of epineurial suture had no obvious difference on autogenous nerve transplantation.

【學位授予單位】：西南醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R688

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