不同外膜缝合方法对神经移植再生影响的实验研究

发布时间：2018-04-11 01:37

本文选题：周围神经 + 移植　；参考：《西南医科大学》2017年硕士论文

【摘要】：目的:周围神经损伤在临床非常常见,目前并没有最有效的治疗方法。为了解决这类问题,我们针对显微缝合技术方面,设计了动物神经损伤模型进行自体神经移植,对比四个实验组神经损伤后的修复效果,并分析其原因,为得到理想的周围神经移植缝合方法提供实验依据。方法:将60只SD大鼠随机分组,等分为A、B、C、D四组,每组15只,右下肢为实验侧,左下肢为空白对照侧,每只大鼠均在右下肢做相应处理,左下肢不做处理,然后在组间进行比较。术前常规手术器械消毒,实验动物称重,对大鼠按体重行3%戊巴比妥钠0.2ml/100g腹腔注射麻醉,先给一半剂量,再逐渐加药至麻醉满意,术中密切观察大鼠生命体征,麻醉起效后,将大鼠俯卧位固定于动物实验台上,手术区(手术侧肢体臀肌上缘至踝部屈侧皮肤)剪毛后,2%的医用碘伏溶液消毒,常规铺巾,做右侧大腿后部正中切口,自右侧股骨后中1/3跨过乆窝至小腿后上方,于大腿后侧肌肉间隙钝性分离显露坐骨神经,注意勿损伤和神经伴行的血管及滋养血管。各组分别做以下处理:A组:避开坐骨神经的供养血管,选择坐骨神经切断位置在梨状肌出口下缘1cm处,第二次切断坐骨神经的位置为其远端距近端吻合口1cm处,将这段作为移植段坐骨神经,与周围组织完全游离,在双人双目显微镜下,分别于原位即移植段神经近端和远端保持一致的顺行放置行坐骨神经外膜缝合(将手术显微镜调到合适位置,保证视野清晰,首先将两断端对合,如无回缩,说明两断端可在无张力下对合。将断面上的神经束、系膜旁膜等逐一对合,接着备8-0无创缝合线开始缝合,在两断端的水平左右两侧,缝合外膜各一针,保留长线当作牵引,然后在两定点线之间,将外膜逐一间断行等距的缝合,前侧外膜缝合完毕后,助手提起对侧牵引线,将神经断端左右翻转180°,并将后侧的外膜用同样的方式等距缝合,缝合的过程中,如果出现神经束外露,可用显微镊轻轻将露出的神经束推入,然后继续缝合,打结使两侧断端神经刚好对合为最适松紧度,过紧或过松都不利于神经再生。)。b组:将移植段坐骨神经与周围组织及滋养血管完全游离,颠倒近端和远端,逆行放置,行坐骨神经外膜缝合。c组:根据该段坐骨神经滋养血管的具体情况,游离出一段软组织,其中包含有滋养血管,并保留不予以切除,同前面方法一样切除1cm坐骨神经作为移植段,于原位即移植段神经近端和远端保持一致的顺行放置行坐骨神经外膜缝合。d组:将带有滋养血管的移植段神经颠倒近端和远端,逆行放置,行坐骨神经外膜缝合。观察各组缝合后的神经张力情况,效果满意后,逐层缝合肌肉、皮下筋膜及皮肤,用无菌纱布包扎切口,放回笼中喂养。各组分别于4、8、12周后取材,通过一般观察及解剖观察、电生理检查、胫骨前肌湿重检测、再生轴突恢复率等观察神经移植效果。结果:1.一般观察:术后4周几乎所有大鼠均跛行步态、垂足,足背伸功能障碍,不同程度出现足底溃疡,大部分出现趾甲暗淡甚至脱落,胫骨前肌萎缩明显,术后8周、12周部分大鼠垂足有所改善,足背伸功能有所恢复,溃疡完全愈合,肌肉萎缩逐渐恢复,C组和D组的一般情况优于A组和B组;2.显微解剖观察:术后4周取材的坐骨神经HE染色切片后于光镜下观察显示有神经纤维变性、水肿,伴随着神经再生,髓鞘已经开始出现,C组和D组可以看见新的髓鞘形成较多,有少量的髓鞘变性、水肿、崩解,雪旺细胞增殖活跃,在移植神经的近侧吻合口,有部分再生的轴索通过;A组和B组可以看见新的髓鞘形成较少,有大量的髓鞘变形、水肿、崩解。术后8周、12周C、D组可见髓鞘密集,分布均匀,成熟度高,再生的神经纤维较多,排列较规则,周围的结缔组织增生少,再生的轴索通过远端吻合口进入坐骨神经的雪旺细胞索内,并向远端生长;A、B组可见髓鞘稀疏,排列紊乱,散在血管,再生的神经纤维较少,神经的排列不规则,周围的结缔组织增生明显增多。3.C组和D组在神经传导速度、胫骨前肌湿重以及再生轴突恢复率结果上要优于A组和B组,有统计学意义(P0.01),即带血供组优于不带血供组,C组与D组之间、A组与B组之间,即顺行放置与逆行放置之间比较无统计学意义(P)0.05)。结论:不同外膜缝合方法对神经移植再生的影响:1.带血供的自体神经移植优于不带血供的自体神经移植2.顺行放置外膜缝合与逆行放置外膜缝合对自体神经移植影响无明显差异。
[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.

【学位授予单位】：西南医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R688

【参考文献】