跟内侧神经及跟下神经与足跟痛关系的应用解剖学研究

发布时间：2018-06-21 15:46

本文选题：跟内侧神经 + 足跟痛　；参考：《苏州大学》2009年硕士论文

【摘要】： 足跟痛(plantar heel pain,PHP)是骨科中的一种常见症状,大多数文献集中在踝管综合征,足底腱膜炎或跟骨骨刺,一些作者提出跟内侧、跟下神经受累也是重要原因,尽管跟内侧、跟下神经的解剖研究已有少量报道,但其解剖描述还不全面,而且各种报道也不尽一致。本文通过进一步解剖学研究,更全面地描述跟内侧、跟下神经的解剖特征,为神经源性足跟痛(neurogenic plantar heel pain,NPHP)的研究及诊断和治疗提供应用解剖学指导第一部分跟内侧神经的应用解剖学及其与足跟痛的关系目的探讨跟内侧神经的局部解剖特点及其与足跟痛的关系方法32具(男19具,女13具)福尔马林固定的成人尸体下肢标本(64侧)被选用,自小腿内侧中1/3处开始解剖暴露胫神经并向远端追寻跟内侧神经,观察其起源、分支、走行和分布状况,并以过内踝下和跟腱止点下缘的连线为参考线用游标卡尺(精确度0.02mm)测量起点和分支点到该参考线距离,对研究所得解剖学资料采用SPSS11.5统计软件进行分析。结果跟内侧神经出现率100%,64侧标本中,36侧(56.25%)以单干的形式出现,且均起源于胫神经;20侧(31.25%)以双干的形式出现,8侧(12.5%)为三干,其中,15侧跟内侧神经分别来自胫神经和足底内侧神经,13侧均来自胫神经。近半数(30侧,46.88%)的跟内侧神经起源点位于屈肌支持带近侧端并走行在屈肌支持带内,浅出屈肌支持带后,20侧(31.25%)走行在(足母)展肌浅层筋膜形成的跟管内。跟内侧神经多分为三终末支,中间支(主支)较恒定,其前支和后支独立成干或和中间支共干。神经走行在跟垫脂肪组织与纤维组织围成的小泡内,支配足底腱膜下方的浅层组织。结论跟内侧神经在进入和浅出屈肌支持带处及跟管内均有可能被卡压引发神经源性足跟痛;而且神经卡压或病变可能与足底腱膜炎发生及其疼痛有关。第二部分跟下神经的应用解剖学及其与足跟痛的关系目的探讨跟下神经的局部解剖特点及其与足跟痛的关系。方法32具(男19具,女13具)福尔马林固定的成人尸体下肢标本(64侧)被选用,自于胫骨内后缘分开小腿三头肌暴露胫后血管和神经,向远端追踪观察跟下神经的起源、分支、走行和分布状况,并以过内踝尖和跟腱止点下缘的连线为参考线用游标卡尺(精确度0.02mm)测量起点和到它的距离,对研究所得解剖学资料采用SPSS11.5统计软件进行分析。结果跟下神经出现率100%,其中20侧(31.25%)起源于胫神经的分叉出处,12侧(18.75%)跟下神经直接来自胫神经,其余32侧(50%)均来自足底外侧神经;跟下神经穿(足母)展肌和足底方肌内侧头之前分为后支和前支,后支支配跟骨结节内侧突和跖长韧带,到跟骨结节前缘的平均距离(6.02±0.68)mm,前支主要支配小趾展肌,平均距跟骨结节前缘(9.56±2.79)mm。结论跟下神经前支与后支在(足母)展肌和足底方肌之间可同时或各自被卡压,其表现症状也可不同;跟骨骨刺发生时,跖长韧带神经支更容易被累及引发神经源性足跟痛,但不一定出现小趾展肌萎缩或外展受限等肌支症状。第三部分跟内侧神经与跟下神经的位置关系及其在足跟痛诊治中的临床意义目的探讨跟内侧神经与跟下神经的位置关系及其在足跟痛诊治中的临床意义。方法32具(男19具,女13具)福尔马林固定的成人尸体下肢标本(64侧)被解剖,向远端暴露跟内侧、跟下神经直到足底,观测跟下神经起源点与跟内侧神经起源点和胫神经分支点之间的位置关系;并以跟骨内侧结节后缘(即跟腱止点下缘)为A点,内踝尖为B点,舟骨结节为C点,以AB、AC为参考线,尽可能将足置于中立位,观测跟内侧、跟下神经穿参考线的位置,结果用平均值±标准差((?)±s)和百分数(%)表示,并应用SPSS11.5统计软件对测量数据进行处理。结果跟下神经源点平均位于胫神经分支点下(14.70±5.80)mm和跟内侧神经起源点下(34.19±10.35)mm;跟内侧神经在跟内侧分布广泛,但中间支(主支)穿行位置相对恒定,平均穿AB、AC线的44.46%和39.68%处;而跟下神经为单干,其过AB、AC线的平均位置在49.26%和41.63%处。跟内侧神经的中间支(主支)行程与跟下神经比较相似,跟内侧神经走行于跟下神经的浅层或稍后方。经统计分析,AB、AC间距离男性略长于女性,但神经穿参考线的位置性别间无明显差异。结论跟下神经阻滞操作容易,且对其他神经影响较小,可被用于神经源性足跟痛的鉴别诊断;跟内侧神经中间支(主支)和跟下神经行程较一致,熟悉其解剖特点对指导跟下神经外科减压术避免或减少跟内侧神经损伤有重要意义。
[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.
【学位授予单位】：苏州大学
【学位级别】：硕士
【学位授予年份】：2009
【分类号】：R322;R681.8

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