胸交感神经支配手掌皮肤汗腺的神经通路及手汗症术式研究

发布时间：2018-05-01 22:52

本文选题：手汗症 + 胸腔镜手术　；参考：《福建医科大学》2013年博士论文

【摘要】：目的：进一步研究胸交感神经支配手掌皮肤汗腺的神经通路，探讨胸交感神经切断术治疗的解剖依据。分析胸交感神经切断术术后长期随访结果，，探讨手汗个体化治疗术式选择。方法：（1）15只大鼠前肢足垫皮肤辣根过氧化物酶逆行示踪交感节后神经元定位。（2）胸腔镜下50例100侧手汗症患者、60例60侧正常对照上胸段交感神经链结构镜下结构观察及对照，I型20段，II型18段，III型14段Kuntz神经纤维核固红－固绿髓鞘染色研究其有髓与无髓神经纤维比例。I型9段，II型8段， III型5段kuntz神经纤维透射电镜超微结构观察。（3）996例胸腔镜胸交感神经切断术术后3年以上手汗症患者长期随访调查，到访的809例中分为：R2组：R2-4交感神经干切断162例；R3组：R3交感神经干及R3旁路神经切断374例、R3-4组：R3-4交感神经干及R3-4旁路纤维切断138例，R4组：R4交感神经干及R4旁路纤维切断135例，比较各组术中手温监测特点，术后手汗及伴发的头、腋窝、脚部多汗治疗效果。结果：(1)15例大鼠支配前肢足垫皮肤的交感节后神经元主要位于颈中神经节（23.5%）、颈胸神经节（72.9%）、T3神经节（2.8%）。(2)每侧胸腔T2-T4肋骨表面出现至少一种类型kuntz神经的概率：手汗症为81%（81/100），正常对照为35%（21/60），两者对比差别具统计学意义。核固红－固绿髓鞘染色显示kuntz神经纤维中有髓神经比例：I型78.2%，II型93.7%，III型92.6%。透视电镜超微结构观察显示I型kuntz神经以有髓神经纤维为主，II型及III型kuntz神经以无髓神经纤维为主。（3）996例胸腔镜胸交感神经切断术术后3年以上手汗症患者到访809例，手汗100%有效，长期随访有1.48%复发，头汗、腋汗、脚汗有效率分别为63.2%、68.7%、32.9%。中、重度代偿性多汗是引起术后病人不满意甚至后悔的主要原因， R2、R3、R3-4、R4组中-重度代偿性多汗分别为19.7%，9.8%，13.1%，4.2%，四组之间及各组之间两两比较差异有统计学意义（P0.05）。R2组病人术后满意度最低。结论：（1）手部皮肤的交感节后神经元主要位于颈胸和颈中神经节，胸交感神经手术治疗手汗症切除神经节没有必要。（2）治疗手汗症不需要完全阻断手的交感神经支配，低位切断有利于降低术后代偿性多汗的发生率，但R4切断应该慎重，应该根据术前病人对手干燥的要求，结合术中手温变化和解剖特点综合考虑。
[Abstract]:Objective: to study the nerve pathway of thoracic sympathetic nerve innervating the sweat gland of palmar skin and to explore the anatomical basis of thoracic sympathetic neurotomy. To analyze the results of long-term follow-up of thoracic sympathetic neurotomy and discuss the choice of individualized treatment for hand sweat. Methods horseradish peroxidase retrograde tracing of postganglionic neuronal localization in the skin of forelimb foot pad of 15 rats was performed in 15 rats. Under thoracoscope, 50 cases (100 sides of hand hyperhidrosis) and 60 cases (60 sides of normal control) with sympathetic nerve chain structure of upper thoracic segment were observed under thoracoscope. Study on the ultrastructure of medullary and unmyelinated nerve fibers in type I, type 9, type II, and III type 5 kuntz nerve fibers, ultrastructure of transmission electron microscopy in 14 segments of Kuntz nerve fiber nuclei of type I, II, II, and III, and of 14 segments of Kuntz nerve fiber, type I, type I and type I, type I, type I and type I To observe the long-term follow-up of 996 patients with palmar hyperhidrosis after thoracoscopic thoracic sympathetic neurotomy for more than 3 years. The 809 cases were divided into two groups: 1 / R2 group: R2-4 sympathetic trunk transection 162 cases: R3 group: R3 sympathetic trunk and R3 bypass nerve transection 374 cases R3-4 group: R3-4 sympathetic trunk and R3-4 bypass fiber transection 138 cases: R4 group R: 4 sympathetic trunk and R4 bypass fiber transection 135 cases. The monitoring characteristics of hand temperature during operation and the therapeutic effect of hand sweating and accompanied head, axillary and foot hyperhidrosis were compared in each group. Results in 15 rats, the sympathetic postganglionic neurons innervating the skin of forelimb and foot pad were mainly located in the middle cervical ganglion, 72.9% T 3 ganglion and 2.8% T 3 ganglion.) the probability of at least one type of kuntz nerve on the surface of each side of the thoracic T2-T4 rib was as follows: palmar hyperhidrosis was the same as that of palmar hyperhidrosis. 81 / 100 and 35 / 21 / 60 in normal control, the difference was statistically significant. The myelin staining of nucleus fixed red and solid green showed that the proportion of myelinated nerve in kuntz nerve fibers was 78.2% in type I and 93.7% in type II, and 92.6% in type III. The ultrastructural observation of electron microscopy showed that the type I kuntz nerves were mainly myelinated nerve fibers and the III type kuntz nerves were mainly unmyelinated nerve fibers. 996 patients with palmar hyperhidrosis more than 3 years after thoracoscopic thoracic sympathetic neurotomy visited 809 cases. The effective rate of hand sweat was 100%, and the recurrence rate was 1.48%. The effective rates of head sweat, axillary sweat and foot sweat were 63.2% and 68.7% respectively. Moderate and severe compensatory hyperhidrosis was the main cause of dissatisfaction and even regret. The moderate to severe compensatory hyperhidrosis in R2R3R3R3-4 group was 19.7and 9.80.13.1and 4.2.The difference between the four groups and between the four groups was the lowest (P0.05.R2 group). Conclusion the sympathetic postganglionic neurons in the skin of the hand are mainly located in the cervical thoracic and middle cervical ganglion. There is no need for thoracic sympathetic nerve operation in the treatment of palmar hyperhidrosis with excision of ganglion. 2) the sympathetic nerve innervation of the hand should not be completely blocked in the treatment of hand hyperhidrosis. Lower transection is helpful to reduce the incidence of compensatory hyperhidrosis after operation, but R4 transection should be considered carefully, according to the requirement of dry hands before operation, combined with the changes of hand temperature and anatomical characteristics during operation.
【学位授予单位】：福建医科大学
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R655

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