關節鏡下松解尺神經治療肘管綜合征療效

楊明 黃偉 王天兵 張殿英 付中國 熊建 陳建海 姜保國

·論著·

關節鏡下松解尺神經治療肘管綜合征療效

楊明 黃偉 王天兵 張殿英 付中國 熊建 陳建海 姜保國

目的 探討關節鏡下松解尺神經治療肘管綜合征的療效。 方法 通過回顧性分析2012年10月至2015年6月北京大學人民醫院創傷骨科收治的肘管綜合征患者35例，按照手術方式分為兩組,其中開放松解并前置組20例，關節鏡下原位松解組15例。分析兩組患者的并發癥、手術時間、住院時間、回到正常生活和工作的時間，采用Heithoff改良的Wilson和Krout評分系統評估患者療效。結果 經過平均16個月的隨訪，兩組之間Wilson和Krout評估系統的優良率比較差異無統計學意義。在并發癥、手術時間、住院時間、回到正常生活和工作的時間等方面關節鏡下原位松解組優于開放松解并前置組。 結論 關節鏡輔助下松解尺神經治療原發性肘管綜合征切口和創傷小，軟組織損傷小，并發癥少，患者能夠盡早恢復日常生活。

肘管綜合征；關節鏡；尺神經

原發性肘管綜合征(cubitaltunnelsyndrome,CTS)在臨床上比較常見，發病率占上肢神經卡壓的第二位[1]。由于其易累及手內在肌，且尺神經修復后功能恢復差，除發病早期嘗試保守治療外，其余患者均應盡早進行手術治療。尺神經開放松解并前置曾是主流術式[1-2]，之后更多學者采用單純的開放原位減壓術[3-5]，近十余年又嘗試關節鏡下肘管松解術[6-10]，但哪種手術更有效仍有爭議。作者采用Cobb推薦的關節鏡下肘管松解術[11]治療原發性CTS患者，療效滿意，并以常規手術為對照進行回顧性研究，現報道如下。

資 料 與 方 法

一、一般資料

2012年10月至2015年6月北京大學人民醫院創傷骨科收治的原發性CTS患者37例，排除復發患者、神經瘤或神經滑膜囊腫的患者，隨訪到完整資料者35例。按照手術方式分為兩組，其中對照組(開放松解并前置組)患者20例、試驗組(關節鏡下原位松解組)患者15例。所有患者均在術前進行了詳細的體格檢查，包括手部感覺減退、手內在肌萎縮情況、肌力檢查、肘部Tinel′s征等。術前均行肌電圖檢查，確定診斷并記錄神經傳導速度。術前按照McGowan分級[12]分為Ⅰ、Ⅱ和Ⅲ級。兩組患者的性別、年齡、優勢側、發病時間及術前McGowan分級等資料見表1。

表1 兩組患者的一般資料

注：*表示采用Fisher確切概率法；-表示無數據

二、手術方式

所有患者均采用臂叢麻醉，上臂上止血帶，止血帶壓力為250～300mmHg。

(一)對照組

行肘關節內側11～13cm長切口，切開皮膚及皮下組織，保護前臂內側皮神經(medialantebrachialcutaneousnerve，MACN)和貴要靜脈分支。首先在內上髁后方找到尺神經，然后向上顯露Struthers腱弓，內側肌間隔，向遠端顯露滑車上肘后肌和弓狀韌帶(肘管頂)，以及尺側腕屈肌(flexorcarpiulnaris，FCU)筋膜，徹底松解上述四個結構，并游離尺神經。然后在內上髁前方做出2cm×2cm大小的旋前圓肌和屈肌總腱筋膜瓣，將尺神經前置，將筋膜瓣固定至前側皮下組織，防止尺神經內移。止血后關閉切口。

(二)試驗組

本組病例采用Cobb推薦的關節鏡下肘管松解術，配套器械由北京航空航天大學工程制作培訓中心制造。操作步驟：肘關節屈曲90°，外翻位置于手術桌上，于內上髁和鷹嘴之間做縱切口，長約2～3cm，直視下松解滑車上肘后肌和弓狀韌帶，找到尺神經。然后在內上髁上下10cm范圍內，根據尺神經走行方向，將上臂和前臂深筋膜和皮下組織進行鈍性剝離，形成皮下隧道，分離時必須緊貼深筋膜，以便保護MACN和血管分支。然后沿著尺神經走行插入精細剪刀進行鈍性剝離，建立尺神經和其表面筋膜之間的工作空間，然后置入工作套筒，避免暴力猛推，此時套筒蓋位于FCU筋膜表面，套筒本身置于尺神經表面。首先于套筒蓋下方插入關節鏡，觀察筋膜表面有無殘留的皮神經分支和血管。然后抽出鈍芯，套筒內插入關節鏡，可旋轉套筒，確保鏡下能在套筒內全程觀察到深層的尺神經，鏡下插入叉刀，將套筒表面的FCU筋膜和肌束縱向切開。向遠端松解8～10cm，完畢后將套筒再插入至近端，同樣松解近端尺神經走行區域的筋膜，近端也松解8～10cm，也要注意保護皮神經和血管分支，并確保在套筒內全程看到尺神經以避免造成損傷。遠、近端均松解完畢后，反復屈肘，確定尺神經穩定性。如尺神經向前脫位至內上髁前內側，則延長切口進行前置。如尺神經穩定，則止血并關閉切口。加壓包扎，不放置引流管(圖1)。

注：圖F-J，L套管深層為尺神經圖1 患者，男,21歲, 左側原發性肘管綜合征，行關節鏡下原位松解術。圖A體位及入路；圖B顯露滑車上肘后?。粓DC直視下松解肘管頂；圖D Cobb技術配套器械，套筒、叉刀及鈍芯；圖E向遠端插入套筒；圖F套筒插入尺神經表面；圖G套筒蓋插入尺側腕屈肌表面；圖H套筒內全程看到尺神經；圖I以叉刀松解；圖J證實遠端松解徹底；圖K向近端插入套筒；圖L近端松解；圖M關閉切口，不放置引流管

三、術后康復和隨訪

術后隨訪內容包括手術并發癥，手術時間，回到正常生活和工作的時間，以及患者是否對本次手術表示滿意[10]。采用Heithoff改良的Wilson和Krout評分系統[13]評估患者恢復情況。最后一次隨訪復查肌電圖，并與術前比較，恢復情況分為恢復正常、部分改善、無變化三個等級[10]。

四、統計學分析

結 果

經過平均16個月(8～32個月)的隨訪， 對照組的Wilson和Krout評分為：優10例、良8例、可1例、差1例；試驗組的Wilson和Krout評分為：優7例、良6例、可1例、差1例。二組之間的優良率差異無統計學意義(P=1.000)。在手術時間、住院時間、回到正常生活和工作時間方面，試驗組均明顯短于對照組，且差異均有統計學意義。對照組有2例表示不滿意，試驗組有1例表示不滿意，兩組之間的滿意度差異無統計學意義。并發癥方面， 對照組的MACN損傷為4例，而試驗組為1例。另外，試驗組還有1例患者出現皮下血腫。兩組均無復發患者。試驗組不滿意的患者于術后1個月進行了第二次手術，并采用了開放松解并前置技術。兩組患者治療結果詳見表2。

表2 兩組患者治療結果比較

注：MACN為前臂內側皮神經；*表示采用Fisher確切概率法；-表示無數據

討 論

原發性CTS的手術治療方法一直有爭議。松解Struthers腱弓，內側肌間隔，滑車上肘后肌和弓狀韌帶(肘管頂)，以及FCU筋膜四個結構的開放松解并前置一直是主流術式[1-2]。其優點是確保神經張力減少，缺點是需要廣泛的軟組織剝離，神經伴行的尺側上副動脈損傷致神經缺血，高幾率的MACN損傷。多個隨機對照試驗研究證實，開放原位減壓術的結果和前置類似，但并發癥相對較少[3-5], 因此開放原位減壓術開展越來越多。其優點是松解充分，缺點是仍存在切口較大、MACN易損傷、傷口周圍疼痛和瘢痕形成等問題。

開放原位減壓術的有效性獲得證實后，為了減小手術創傷和并發癥，很多學者開始嘗試關節鏡下肘管松懈術，證實了其安全性和有效性[6-11]，并提示關節鏡下肘管松懈術較開放原位減壓術有更高的滿意度和更低的并發癥發生率[14]。除了有效性和與傳統手術類似外，還有創傷小、手術時間較短、松解廣泛、并發癥少等優勢[8，10-11]。關節鏡下肘管松懈術一般在十幾分鐘完成，可松解至肘上10cm和肘下10cm的范圍，患者能更快地恢復工作和生活。有多位學者如Tsai等[6]、Hoffmann等[7-8]、Mirza等[9]、Cobb[11]都研發了自己的技術，他們的特點類似，主要是配套器械有所區別。作者最先接觸到的是Cobb技術[11，15-16]，其配套器械制作比較簡單，松解過程中可明確保護尺神經。術中需注意兩點：第一，避免將套筒暴力推進至尺神經走行表面，可先通過鈍性分離建立工作套筒空間；第二，確保在套筒內觀察到尺神經的完整走行，一旦看不到神經，立刻停止松解，可通過旋轉工作套筒或重新插入，看到尺神經后再繼續松解。

關節鏡下肘管松解術的禁忌證包括明顯肘外翻、嚴重屈曲攣縮、尺神經脫位以及復發患者[6，8，10-11]，因為這些患者需要將尺神經前置。對于外翻、屈曲攣縮和尺神經脫位患者，如果不需要手術糾正外翻或松解攣縮，只是緩解尺神經癥狀時，可以將鏡下松解和開放前置相結合，也可以大大縮小切口長度，只需將切口延長至5cm左右，而且手術時間無明顯增加。當然，前置時必須切除部分內側肌間隔，避免再次卡壓尺神經。但鏡下松解和前置手術相結合的手術方式國內外報道極少[17]，其意義和風險仍有爭議，作者只嘗試過幾例患者，經驗仍需進一步總結。本研究的試驗組病例都排除了上述禁忌證。

研究證實，關節鏡下肘管松解術可以取得和開放松解并前置相同的效果，在住院時間、手術時間、恢復時間等方面都較常規手術有優勢。但關節鏡下肘管松解術的手術時間比國外學者報道時間增加1倍，且術后血腫和MACN損傷的幾率高于文獻的幾率[11，15-16]，主要是可能處在學習曲線中，病例和積累經驗相對較少。另外，有1例患者采用了關節鏡下肘管松解術，術后沒有任何緩解，隨后再次采用了開放松解并前置技術進行治療。失敗的原因考慮患者病史短，進展快，早期出現內在肌肌力差，可能有神經炎等因素致病。隨著技術完善和更嚴格的掌握適應證，并發癥和再手術幾率應該降低。

當然，任何技術都有缺點，尤其是關節鏡下肘管松解術，對術者的技術要求高，因此國內開展仍較少[17]。另外，開展此手術之前，可能需要尸體上的模擬操作以便熟悉該技術。本研究也存在缺點，如病例數相對少、隨訪時間短、屬于回顧性研究、不同術者參與了手術和對術后療效的評估可能導致主觀偏見等。后期將進一步積累病例，總結經驗。

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(本文編輯：胡桂英)

楊明，黃偉，王天兵，等.關節鏡下松解尺神經治療肘管綜合征療效[J/CD]. 中華肩肘外科電子雜志,2016,4(4):230-235.

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Endoscopiccubitaltunnelreleaseintreatmentofidiopathiccubitaltunnelsyndrome

YangMing,HuangWei,WangTianbing,ZhangDianying,FuZhongguo,XiongJian,ChenJianhai,JiangBaoguo.

DepartmentofTraumatologyandOrthopaedics,PekingUniversityPeople′sHospital,Beijing100044,China

JiangBaoguo，Email：jiangbaoguo@vip.sina.com

Background Idiopathic cubital tunnel syndrome is the second most common nerve entrapment in the upper extremity. Because of the poor prognosis, the treatment principle of the cubital tunnel syndrome is to release ulnar nerve as early as possible for the cases whose conservative treatment is failed. There are several kinds of surgical methods to treat cubital tunnel syndrome,such as open release and anterior transposition,open in situ decompression，and the newest endoscopic cubital tunnel release. There is no accepted standard for surgical treatment at present. We performed endoscopic cubital tunnel release for 15 cases and obtained satisfactory results. We performed this retrospective study to explore the new surgical methods and its effects. A group of 20 cases treated by conventional open release and anterior transposition were in the control group.Methods (1)General information: All the 35 cases of idiopathic cubital tunnel syndrome were treated by surgery and followed up from October 2012 to June 2015. According to the surgical method, all the case were divided into two groups. 20 cases accepted conventional open release and subcutaneous anterior transposition, and 15 cases accepted endoscopic cubital tunnel release. All the cases obtained detailed preoperative physical examination,such as sensory decrease of the hand, intrinsic muscle atrophy and strength decrease, and Tinel′s sign of the elbow. The accessory electrophysiology tests were performed. According to McGowan score, all the cases were divided into grade Ⅰ,Ⅱ and Ⅲ. The data such as gender, age, dominant side, durations of symptoms, and preoperative McGowan, can be seen in table 1.(2)Surgery methods:Open release and anterior transposition group: The patient was placed supine on the operating table, with the shoulder abducted and externally rotated and the arm was on the table. A tourniquet was placed high on the brachium. The procedure was performed under regional anesthesia with sedation. A longitudinal incision was performed on the medial side of the elbow. During the subcutaneous exposure, the medical antebrachial cutaneous nerve and vein branch must be identified. The ulnar nerve was then identified just posterior to medial epicondyle. Next we released the cubital tunnel retinaculum, anconeus epitrochlearis muscle and flexor carpi ulnaris (FCU) aponeurosis distally,and then released the deep brachial fascia, the intermuscular septum, and the arcade of Struthers proximally. After complete release, the ulnar nerve was transposed anterior to the medial epicondyle, and overhanged by sling which was made by partial aponeurosis of the flexor common muscle and pronator muscle. After complete hemostasis, the wound was closed.Endoscopic cubital tunnel release group: we applied the endoscopic cutital tunnel release (ECTR) technique which was recommend by Dr. Cobb. The instrument system was made in Beijing university of Aeronautics and Astronautics. The position, anesthesia and tourniquet were the same to those of the open release and anterior transposition group. A 2-3 cm longitudinal incision was made over the cubital tunnel, just posterior to the medial epicondyle. The ulnar nerve was then palpated just posterior to medial epicondyle. An anconeus epitrochlearis muscle and cubital tunnel retinaculum was incised directly over the cubital tunnel. After the the roof of the cubital tunnel is incised, the ulnar nerve was identified. The opening in the cubital tunnel should be sufficient enough to allow instrumentation placed without binding. Then we used blunt-tip scissors to dissect adipose tissue and superficial nerves off the deep fascia, and created a 10 cm subcutaneous cannal both proximally and distally. Then we created another cannal to dissect the soft tissue over the course of the ulnar nerve using blunt-tip scissors. Next the working instrument was placed into the two cannals. The spatula was placed into potential space between the deep fascia and the subcutaneous adipose. The cannula and trochar were immediately placed into the second cannal superficial to the ulnar nerve. Before the insertion of the instrument, it must be moistened by saline and should be advanced without resistance.Then the trochar was withdrawn, and the scope was placed into the cannula and turned to the inferior slots so the nerve could be identified. The ulnar nerve should be identified throughout the entire course of the cannula, and rotation of the cannula might be helpful in this procedure. Then the fascia was divided with bifurcate blade along the superior slot of the cannula. The fascia should be divided only if the nerve was clearly identified throughout the entire length of the intended release. Following the release of fascia, the completeness of release should be checked with endoscope. During the distal release, the muscle of the flexor pronator mass was seen through the superior slot of the cannula, but its release was not necessary because of the unnecessary bleeding. Then the tourniquet was deflated, and pressure was applied. The retractor was placed into the incision, and the endoscope was used to visualize the surgical field both proximally and distally, confirming that complete release and hemostasis had been obtained. At last, the passive flexion of the elbow must be performed to confirm there was no dislocation of the ulnar nerve. Once happened, the anterior transposition might be needed. The wound was tightly closed and a compressive dressing was applied.(3)Postoperative rehabilitation and follow-ups. The patients should mobilize the affected elbow as he or she could endure the pain. We evaluated the effect of surgery using the Wilson and Krout rating system modified by Heithoff. The difference between two groups were compared in complications, operating time, hospitalization time, time of returning to normal activity, the satisfactory degree,etc.The electrophysiology also performed and compared with pre-operation. (4) Statistical methods: SPSS 19.0 software was used. The measurement data were indicated as means ± standard deviations. Fisher′s test were performed in the comparison of the measurement data between two groups,the Independent-Samplettestwasusedforthecomparisonofmeacurementdatainthetwogroups;P<0.05wasconsideredstatisticallysignificant.ResultsAfterfollow-upsforanaverageof16months,theeffectoftwogroupswerethesameintheWilsonandKroutratingsystemmodifiedbyHeithoff.Theeffectofendoscopiccubitaltunnelreleasegroupwasbetterthanthatofopenreleaseandanteriortranspositiongroupincomplications,operatingtime,hospitalizationtimeandtimeofreturningtonormalactivity.Inthearthroscopiccubitaltunnelreleasegroup,therewasonecasewhoacceptedsecondopenreleaseandanteriortranspositionbecauseofthepoorresults.ConclusionsThecontraindicationsforarthroscopiccubitaltunnelreleaseweremassesorspace-occupyinglesions,elbowcontracturesrequiringrelease,cubitusvalgus,andulnarnervesubluxating.Endoscopiccubitaltunnelreleasewasareliabletechniquecharacterizedbyashortincision,minimumsofttissuedissection,lowercomplicationrateandearlypostoperativemobilization.However,therearesomechallengesinthetechnique,andcomplicationsmayoccursometimes.

Cubitaltunnelsyndrome;Endoscope;Ulnarnerve

10.3877/cma.j.issn.2095-5790.2016.04.007

衛生公益性行業科研專項(201002014、201302007)；教育部創新團隊(IRT1201)；北京市科委重大

100044北京大學人民醫院創傷骨科 北京大學交通醫學中心

姜保國，Email:jiangbaoguo@vip.sina.com

2015-02-05)

專項(Z101107052210001)；北京大學人民醫院研究與發展基金(RDB2014-01)