本文選題：跟內側神經 + 足跟痛��； 參考：《蘇州大學》2009年碩士論文

【摘要】： 足跟痛(plantar heel pain,PHP)是骨科中的一種常見癥狀,大多數文獻集中在踝管綜合征,足底腱膜炎或跟骨骨刺,一些作者提出跟內側、跟下神經受累也是重要原因,盡管跟內側、跟下神經的解剖研究已有少量報道,但其解剖描述還不全面,而且各種報道也不盡一致。本文通過進一步解剖學研究,更全面地描述跟內側、跟下神經的解剖特征,為神經源性足跟痛(neurogenic plantar heel pain,NPHP)的研究及診斷和治療提供應用解剖學指導 第一部分跟內側神經的應用解剖學及其與足跟痛的關系 目的探討跟內側神經的局部解剖特點及其與足跟痛的關系 方法32具(男19具,女13具)福爾馬林固定的成人尸體下肢標本(64側)被選用,自小腿內側中1/3處開始解剖暴露脛神經并向遠端追尋跟內側神經,觀察其起源、分支、走行和分布狀況,并以過內踝下和跟腱止點下緣的連線為參考線用游標卡尺(精確度0.02mm)測量起點和分支點到該參考線距離,對研究所得解剖學資料采用SPSS11.5統(tǒng)計軟件進行分析。 結果跟內側神經出現率100%,64側標本中,36側(56.25%)以單干的形式出現,且均起源于脛神經;20側(31.25%)以雙干的形式出現,8側(12.5%)為三干,其中,15側跟內側神經分別來自脛神經和足底內側神經,13側均來自脛神經。近半數(30側,46.88%)的跟內側神經起源點位于屈肌支持帶近側端并走行在屈肌支持帶內,淺出屈肌支持帶后,20側(31.25%)走行在(足母)展肌淺層筋膜形成的跟管內。跟內側神經多分為三終末支,中間支(主支)較恒定,其前支和后支獨立成干或和中間支共干。神經走行在跟墊脂肪組織與纖維組織圍成的小泡內,支配足底腱膜下方的淺層組織。 結論跟內側神經在進入和淺出屈肌支持帶處及跟管內均有可能被卡壓引發(fā)神經源性足跟痛;而且神經卡壓或病變可能與足底腱膜炎發(fā)生及其疼痛有關。 第二部分跟下神經的應用解剖學及其與足跟痛的關系 目的探討跟下神經的局部解剖特點及其與足跟痛的關系。 方法32具(男19具,女13具)福爾馬林固定的成人尸體下肢標本(64側)被選用,自于脛骨內后緣分開小腿三頭肌暴露脛后血管和神經,向遠端追蹤觀察跟下神經的起源、分支、走行和分布狀況,并以過內踝尖和跟腱止點下緣的連線為參考線用游標卡尺(精確度0.02mm)測量起點和到它的距離,對研究所得解剖學資料采用SPSS11.5統(tǒng)計軟件進行分析。 結果跟下神經出現率100%,其中20側(31.25%)起源于脛神經的分叉出處,12側(18.75%)跟下神經直接來自脛神經,其余32側(50%)均來自足底外側神經;跟下神經穿(足母)展肌和足底方肌內側頭之前分為后支和前支,后支支配跟骨結節(jié)內側突和跖長韌帶,到跟骨結節(jié)前緣的平均距離(6.02±0.68)mm,前支主要支配小趾展肌,平均距跟骨結節(jié)前緣(9.56±2.79)mm。 結論跟下神經前支與后支在(足母)展肌和足底方肌之間可同時或各自被卡壓,其表現癥狀也可不同;跟骨骨刺發(fā)生時,跖長韌帶神經支更容易被累及引發(fā)神經源性足跟痛,但不一定出現小趾展肌萎縮或外展受限等肌支癥狀。 第三部分跟內側神經與跟下神經的位置關系及其在足跟痛診治中的臨床意義 目的探討跟內側神經與跟下神經的位置關系及其在足跟痛診治中的臨床意義。 方法32具(男19具,女13具)福爾馬林固定的成人尸體下肢標本(64側)被解剖,向遠端暴露跟內側、跟下神經直到足底,觀測跟下神經起源點與跟內側神經起源點和脛神經分支點之間的位置關系;并以跟骨內側結節(jié)后緣(即跟腱止點下緣)為A點,內踝尖為B點,舟骨結節(jié)為C點,以AB、AC為參考線,盡可能將足置于中立位,觀測跟內側、跟下神經穿參考線的位置,結果用平均值±標準差((?)±s)和百分數(%)表示,并應用SPSS11.5統(tǒng)計軟件對測量數據進行處理。 結果跟下神經源點平均位于脛神經分支點下(14.70±5.80)mm和跟內側神經起源點下(34.19±10.35)mm;跟內側神經在跟內側分布廣泛,但中間支(主支)穿行位置相對恒定,平均穿AB、AC線的44.46%和39.68%處;而跟下神經為單干,其過AB、AC線的平均位置在49.26%和41.63%處。跟內側神經的中間支(主支)行程與跟下神經比較相似,跟內側神經走行于跟下神經的淺層或稍后方。經統(tǒng)計分析,AB、AC間距離男性略長于女性,但神經穿參考線的位置性別間無明顯差異。 結論跟下神經阻滯操作容易,且對其他神經影響較小,可被用于神經源性足跟痛的鑒別診斷;跟內側神經中間支(主支)和跟下神經行程較一致,熟悉其解剖特點對指導跟下神經外科減壓術避免或減少跟內側神經損傷有重要意義。
[Abstract]:Plantar heel pain (PHP) is a common symptom in the Department of orthopedics. Most of the literature focuses on the malleolus canal syndrome, the plantar aponeurotis or the calcaneus bone spur. Some authors suggest that the medial and subcalcaneal nerve involvement is also an important cause, although a few reports have been reported on the dissection of the medial and subfollowing nerves, but the anatomical description is not comprehensive, but In this paper, the anatomical features of the medial and subfollowing nerves are described more comprehensively through further anatomical studies, providing applied anatomical guidance for the research, diagnosis and treatment of neurogenic plantar heel pain (NPHP).
The first part is applied anatomy of medial and lateral nerve and its relationship with heel pain.
Objective to investigate the anatomical characteristics of medial collateral nerves and their relationship with heel pain.
Methods 32 adult cadavers (19 men and 13 women) were selected from the lower extremities of the adult cadavers (64 sides) fixed by Faure Marin. The tibial nerve was exposed and tracing the medial nerve to the distal part from the medial 1/3 of the calf. The origin, branch, walking and distribution of the nerve were observed, and the vernier caliper was used under the medial malleolus and the lower edge of the Achilles tendon. Accuracy 0.02mm) the distance from the starting point and the branch point to the reference line is measured, and the anatomical data obtained are analyzed by SPSS11.5 statistical software.
Results the occurrence rate of the medial nerve was 100%. Of the 64 sides, 36 sides (56.25%) appeared in the form of single stem and originated from the tibial nerve; the 20 side (31.25%) appeared in the form of double trunk and 8 (12.5%) was three dry, of which 15 sides of the medial nerve were from the tibial and medial plantar nerves and the 13 side were from the tibial nerve. Nearly half (30 side, 46.88%) in the heel. The origin of the lateral nerve is located in the proximal end of the flexor support band and walking in the flexor support belt, after the flexor support zone, 20 sides (31.25%) walk in the heel of the superficial fascia of the abductor muscle. The medial nerve is divided into three terminal branches, the middle branch (main Branch) is more constant, the anterior and posterior branches are dried independently or with the middle branch. In the vesicles surrounded by adipose tissue and fibrous tissue, the superficial tissue below the plantar aponeurosis is dominant.
Conclusion the nerve source heel pain may be caused by the entrapment of the medial nerve in the medial and superficial flexor support zones and in the canalar, and the nerve entrapment or lesion may be associated with the occurrence and pain of the plantar aponeurotis.
The second part is applied anatomy of inferior nerve and its relationship with heel pain.
Objective to investigate the anatomical characteristics of the inferior heel nerve and its relationship with heel pain.
Methods the lower limb specimens (64 sides) of 32 adult cadavers (19 men, 13 women) were selected. The posterior tibial vessels and nerves were exposed from the posterior edge of the tibia, and the origin, branch, walking and distribution of the subcalc nerve were traced to the distal end of the tibia, and the connection between the medial malleolus tip and the lower edge of the Achilles tendon was used as the reference line. Vernier caliper (accuracy 0.02mm) were used to measure the distance between the starting point and the distance. The anatomical data obtained from the study were analyzed by SPSS11.5 statistical software.
Results the occurrence rate of the subfollowing nerve was 100%, of which 20 (31.25%) originated from the bifurcation of the tibial nerve, and the 12 (18.75%) subfollowing nerve came directly from the tibial nerve, and the other 32 sides (50%) all came from the lateral nerve of the plantar. The inferior and anterior branches of the inferior nerve were divided into the posterior and anterior branches, and the posterior branch innervated the medial process of the calcaneus tubercle and the metatarsal length. The average distance from ligaments to the anterior edge of the calcaneal tubercle was (6.02 + 0.68) mm, and the anterior branch dominated the abductor minor toe, with an average distance from the anterior edge of the calcaneal tubercle (9.56 + 2.79) mm..
Conclusion the anterior branch and posterior branch of the inferior nerve between the abductor muscle and the plantar muscle can be pressed simultaneously or separately, and the symptoms can be different. The nerve branches of the long ligaments of the metatarsal ligament are more likely to be involved in the neurogenic heel pain when the calcaneal spur occurs, but it is not necessarily symptomatic of the atrophy of the small toe abductor muscle or abduction limitation.
The third part is about the location of the medial and inferior nerves and its clinical significance in the diagnosis and treatment of heel pain.
Objective to investigate the location of the medial collateral nerve and the inferior heel nerve and its clinical significance in the diagnosis and treatment of heel pain.
Methods the lower extremities (64 sides) of 32 Faure Marin fixed adult cadavers (64 men) were dissected and exposed to the medial and inferior nerve to the foot to the distal end. The relationship between the origin of the subcalar nerve and the origin of the medial nerve and the branch point of the tibial nerve was observed, and the posterior margin of the medial calcaneal nodule (the inferior edge of the Achilles tendon) was A point. The apex of the medial malleolus was B point, the scaphoid tubercle was C point, AB and AC as the reference line, and the foot was placed in the neutral position as far as possible. The position of the medial and inferior nerve was observed with the reference line. The results were expressed with the mean standard deviation ((?) + s) and percentage (%), and the measurement data were processed with the SPSS11.5 software.
Results the mean location of the subfollowing nerve source was (14.70 + 5.80) mm and the origin of the medial nerve (34.19 + 10.35) mm, and the medial nerve was widely distributed on the medial part of the heel, but the middle branch (main branch) was located relatively constant, with an average of AB, 44.46% and 39.68% of the AC line, while the subfollowing nerve was a single trunk, and the average position of AB, AC line The middle branch of the medial nerve (main branch) was similar to that of the inferior heel nerve at 49.26% and 41.63%. The medial nerve followed the superficial or slightly rear of the inferior heel nerve. By statistical analysis, the distance between AB and AC was slightly longer than that of the female, but there was no significant difference between the gender and the position of the nerve.
Conclusion the subfollowing nerve block is easy to operate and has less influence on other nerves. It can be used in the differential diagnosis of neurogenic heel pain. The middle branch of the medial nerve (main branch) is more consistent with the subfollowing nerve. It is of great significance to guide the decompression of the lower Department of Neurosurgery to avoid or reduce the injury of the medial nerve.
【學位授予單位】：蘇州大學
【學位級別】：碩士
【學位授予年份】：2009
【分類號】：R322;R681.8

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