关节镜下松解尺神经治疗肘管综合征疗效

杨明 黄伟 王天兵 张殿英 付中国 熊建 陈建海 姜保国

·论著·

关节镜下松解尺神经治疗肘管综合征疗效

杨明 黄伟 王天兵 张殿英 付中国 熊建 陈建海 姜保国

目的 探讨关节镜下松解尺神经治疗肘管综合征的疗效。 方法 通过回顾性分析2012年10月至2015年6月北京大学人民医院创伤骨科收治的肘管综合征患者35例，按照手术方式分为两组,其中开放松解并前置组20例，关节镜下原位松解组15例。分析两组患者的并发症、手术时间、住院时间、回到正常生活和工作的时间，采用Heithoff改良的Wilson和Krout评分系统评估患者疗效。结果 经过平均16个月的随访，两组之间Wilson和Krout评估系统的优良率比较差异无统计学意义。在并发症、手术时间、住院时间、回到正常生活和工作的时间等方面关节镜下原位松解组优于开放松解并前置组。 结论 关节镜辅助下松解尺神经治疗原发性肘管综合征切口和创伤小，软组织损伤小，并发症少，患者能够尽早恢复日常生活。

肘管综合征；关节镜；尺神经

原发性肘管综合征(cubitaltunnelsyndrome,CTS)在临床上比较常见，发病率占上肢神经卡压的第二位[1]。由于其易累及手内在肌，且尺神经修复后功能恢复差，除发病早期尝试保守治疗外，其余患者均应尽早进行手术治疗。尺神经开放松解并前置曾是主流术式[1-2]，之后更多学者采用单纯的开放原位减压术[3-5]，近十余年又尝试关节镜下肘管松解术[6-10]，但哪种手术更有效仍有争议。作者采用Cobb推荐的关节镜下肘管松解术[11]治疗原发性CTS患者，疗效满意，并以常规手术为对照进行回顾性研究，现报道如下。

资 料 与 方 法

一、一般资料

2012年10月至2015年6月北京大学人民医院创伤骨科收治的原发性CTS患者37例，排除复发患者、神经瘤或神经滑膜囊肿的患者，随访到完整资料者35例。按照手术方式分为两组，其中对照组(开放松解并前置组)患者20例、试验组(关节镜下原位松解组)患者15例。所有患者均在术前进行了详细的体格检查，包括手部感觉减退、手内在肌萎缩情况、肌力检查、肘部Tinel′s征等。术前均行肌电图检查，确定诊断并记录神经传导速度。术前按照McGowan分级[12]分为Ⅰ、Ⅱ和Ⅲ级。两组患者的性别、年龄、优势侧、发病时间及术前McGowan分级等资料见表1。

表1 两组患者的一般资料

注：*表示采用Fisher确切概率法；-表示无数据

二、手术方式

所有患者均采用臂丛麻醉，上臂上止血带，止血带压力为250～300mmHg。

(一)对照组

行肘关节内侧11～13cm长切口，切开皮肤及皮下组织，保护前臂内侧皮神经(medialantebrachialcutaneousnerve，MACN)和贵要静脉分支。首先在内上髁后方找到尺神经，然后向上显露Struthers腱弓，内侧肌间隔，向远端显露滑车上肘后肌和弓状韧带(肘管顶)，以及尺侧腕屈肌(flexorcarpiulnaris，FCU)筋膜，彻底松解上述四个结构，并游离尺神经。然后在内上髁前方做出2cm×2cm大小的旋前圆肌和屈肌总腱筋膜瓣，将尺神经前置，将筋膜瓣固定至前侧皮下组织，防止尺神经内移。止血后关闭切口。

(二)试验组

本组病例采用Cobb推荐的关节镜下肘管松解术，配套器械由北京航空航天大学工程制作培训中心制造。操作步骤：肘关节屈曲90°，外翻位置于手术桌上，于内上髁和鹰嘴之间做纵切口，长约2～3cm，直视下松解滑车上肘后肌和弓状韧带，找到尺神经。然后在内上髁上下10cm范围内，根据尺神经走行方向，将上臂和前臂深筋膜和皮下组织进行钝性剥离，形成皮下隧道，分离时必须紧贴深筋膜，以便保护MACN和血管分支。然后沿着尺神经走行插入精细剪刀进行钝性剥离，建立尺神经和其表面筋膜之间的工作空间，然后置入工作套筒，避免暴力猛推，此时套筒盖位于FCU筋膜表面，套筒本身置于尺神经表面。首先于套筒盖下方插入关节镜，观察筋膜表面有无残留的皮神经分支和血管。然后抽出钝芯，套筒内插入关节镜，可旋转套筒，确保镜下能在套筒内全程观察到深层的尺神经，镜下插入叉刀，将套筒表面的FCU筋膜和肌束纵向切开。向远端松解8～10cm，完毕后将套筒再插入至近端，同样松解近端尺神经走行区域的筋膜，近端也松解8～10cm，也要注意保护皮神经和血管分支，并确保在套筒内全程看到尺神经以避免造成损伤。远、近端均松解完毕后，反复屈肘，确定尺神经稳定性。如尺神经向前脱位至内上髁前内侧，则延长切口进行前置。如尺神经稳定，则止血并关闭切口。加压包扎，不放置引流管(图1)。

注：图F-J，L套管深层为尺神经图1 患者，男,21岁, 左侧原发性肘管综合征，行关节镜下原位松解术。图A体位及入路；图B显露滑车上肘后肌；图C直视下松解肘管顶；图D Cobb技术配套器械，套筒、叉刀及钝芯；图E向远端插入套筒；图F套筒插入尺神经表面；图G套筒盖插入尺侧腕屈肌表面；图H套筒内全程看到尺神经；图I以叉刀松解；图J证实远端松解彻底；图K向近端插入套筒；图L近端松解；图M关闭切口，不放置引流管

三、术后康复和随访

术后随访内容包括手术并发症，手术时间，回到正常生活和工作的时间，以及患者是否对本次手术表示满意[10]。采用Heithoff改良的Wilson和Krout评分系统[13]评估患者恢复情况。最后一次随访复查肌电图，并与术前比较，恢复情况分为恢复正常、部分改善、无变化三个等级[10]。

四、统计学分析

结 果

经过平均16个月(8～32个月)的随访， 对照组的Wilson和Krout评分为：优10例、良8例、可1例、差1例；试验组的Wilson和Krout评分为：优7例、良6例、可1例、差1例。二组之间的优良率差异无统计学意义(P=1.000)。在手术时间、住院时间、回到正常生活和工作时间方面，试验组均明显短于对照组，且差异均有统计学意义。对照组有2例表示不满意，试验组有1例表示不满意，两组之间的满意度差异无统计学意义。并发症方面， 对照组的MACN损伤为4例，而试验组为1例。另外，试验组还有1例患者出现皮下血肿。两组均无复发患者。试验组不满意的患者于术后1个月进行了第二次手术，并采用了开放松解并前置技术。两组患者治疗结果详见表2。

表2 两组患者治疗结果比较

注：MACN为前臂内侧皮神经；*表示采用Fisher确切概率法；-表示无数据

讨 论

原发性CTS的手术治疗方法一直有争议。松解Struthers腱弓，内侧肌间隔，滑车上肘后肌和弓状韧带(肘管顶)，以及FCU筋膜四个结构的开放松解并前置一直是主流术式[1-2]。其优点是确保神经张力减少，缺点是需要广泛的软组织剥离，神经伴行的尺侧上副动脉损伤致神经缺血，高几率的MACN损伤。多个随机对照试验研究证实，开放原位减压术的结果和前置类似，但并发症相对较少[3-5], 因此开放原位减压术开展越来越多。其优点是松解充分，缺点是仍存在切口较大、MACN易损伤、伤口周围疼痛和瘢痕形成等问题。

开放原位减压术的有效性获得证实后，为了减小手术创伤和并发症，很多学者开始尝试关节镜下肘管松懈术，证实了其安全性和有效性[6-11]，并提示关节镜下肘管松懈术较开放原位减压术有更高的满意度和更低的并发症发生率[14]。除了有效性和与传统手术类似外，还有创伤小、手术时间较短、松解广泛、并发症少等优势[8，10-11]。关节镜下肘管松懈术一般在十几分钟完成，可松解至肘上10cm和肘下10cm的范围，患者能更快地恢复工作和生活。有多位学者如Tsai等[6]、Hoffmann等[7-8]、Mirza等[9]、Cobb[11]都研发了自己的技术，他们的特点类似，主要是配套器械有所区别。作者最先接触到的是Cobb技术[11，15-16]，其配套器械制作比较简单，松解过程中可明确保护尺神经。术中需注意两点：第一，避免将套筒暴力推进至尺神经走行表面，可先通过钝性分离建立工作套筒空间；第二，确保在套筒内观察到尺神经的完整走行，一旦看不到神经，立刻停止松解，可通过旋转工作套筒或重新插入，看到尺神经后再继续松解。

关节镜下肘管松解术的禁忌证包括明显肘外翻、严重屈曲挛缩、尺神经脱位以及复发患者[6，8，10-11]，因为这些患者需要将尺神经前置。对于外翻、屈曲挛缩和尺神经脱位患者，如果不需要手术纠正外翻或松解挛缩，只是缓解尺神经症状时，可以将镜下松解和开放前置相结合，也可以大大缩小切口长度，只需将切口延长至5cm左右，而且手术时间无明显增加。当然，前置时必须切除部分内侧肌间隔，避免再次卡压尺神经。但镜下松解和前置手术相结合的手术方式国内外报道极少[17]，其意义和风险仍有争议，作者只尝试过几例患者，经验仍需进一步总结。本研究的试验组病例都排除了上述禁忌证。

研究证实，关节镜下肘管松解术可以取得和开放松解并前置相同的效果，在住院时间、手术时间、恢复时间等方面都较常规手术有优势。但关节镜下肘管松解术的手术时间比国外学者报道时间增加1倍，且术后血肿和MACN损伤的几率高于文献的几率[11，15-16]，主要是可能处在学习曲线中，病例和积累经验相对较少。另外，有1例患者采用了关节镜下肘管松解术，术后没有任何缓解，随后再次采用了开放松解并前置技术进行治疗。失败的原因考虑患者病史短，进展快，早期出现内在肌肌力差，可能有神经炎等因素致病。随着技术完善和更严格的掌握适应证，并发症和再手术几率应该降低。

当然，任何技术都有缺点，尤其是关节镜下肘管松解术，对术者的技术要求高，因此国内开展仍较少[17]。另外，开展此手术之前，可能需要尸体上的模拟操作以便熟悉该技术。本研究也存在缺点，如病例数相对少、随访时间短、属于回顾性研究、不同术者参与了手术和对术后疗效的评估可能导致主观偏见等。后期将进一步积累病例，总结经验。

[1]OstermanAL,DavisCA.Subcutaneoustranspositionoftheulnarnervefortreatmentofcubitaltunnelsyndrome[J].HandClin,1996,12(2):421-433.

[2]HamidrezaA,SaeidA,MohammadrezaD,etal.Anteriorsubcutaneoustranspositionofulnarnervewithfascialflapandcompleteexcisionofmedialintermuscularseptumincubitaltunnelsyndrome:aprospectivepatientcohort[J].ClinNeurolNeurosurg, 2011, 113(8): 631-634.

[3]GervasioO,GambardellaG,ZacconeC,etal.Simpledecompressionversusanteriorsubmusculartranspositionoftheulnarnerveinseverecubitaltunnelsyndrome:aprospectiverandomizedstudy[J].Neurosurgery, 2005, 56(1): 108-117.

[4]BiggsM,CurtisJA.Randomized,prospectivestudycomparingulnarneurolysisinsituwithsubmusculartransposition[J].Neurosurgery, 2006, 58(2): 296-303.

[5]BartelsRH,VerhagenWI,vanderWiltGJ,etal.Prospectiverandomizedcontrolledstudycomparingsimpledecompressionversusanteriorsubcutaneoustranspositionforidiopathicneuropathyoftheulnarnerveattheelbow:part1[J].Neurosurgery, 2005, 56(3): 522-530.

[6]TsaiTM,ChenIC,MajdME,etal.Cubitaltunnelreleasewithendoscopicassistance:resultsofanewtechnique[J].JHandSurgAm, 1999, 24(1): 21-29.

[7]HoffmannR,SiemionowM.Theendoscopicmanagementofcubitaltunnelsyndrome[J].JHandSurg, 2006,31(1):23-29.

[8]HoffmannR,LubahnJ.Endoscopiccubitaltunnelreleaseusingthehoffmanntechnique[J].JHandSurgAm, 2013, 38 (6): 1234-1239.

[9]MirzaA,ReinhartMK,BoveJ,etal.Scope-assistedreleaseofthecubitaltunnel[J].JHandSurgAm, 2011, 36 (1): 147-151.

[10]AhcanU,ZormanP.Endoscopicdecompressionoftheulnarnerveattheelbow[J].JHandSurgAm, 2007, 32 (8): 1171-1176.

[11]CobbTK.Endoscopiccubitaltunnelrelease[J].JHandSurgAm, 2010, 35 (10): 1690-1697.

[12]McGowanAJ.Theresultsoftranspositionoftheulnarnervefortraumaticulnarneuritis[J].JBoneJointSurg,1950,32 (3):293-301.

[13]HeithoffSJ,MillenderLH,NalebuffEA,etal.Medialepicondylectomyfortreatmentofulnarnervecompressionattheelbow[J].JHandSurg,1990,15(1):22-29.

[14]WattsAC,BainGI.Patient-ratedoutcomesofulnarnervedecompression:acomparisonofendoscopicandopeninsitudecompression[J].JHandSurg,2009,34(8):1492-1498.

[15]CobbTK,SterbankPT,LemkeJH.Endoscopiccubitaltunnelrecurrencerates[J].Hand(NY), 2010, 5(2): 179-183.

[16]CobbTK,WaldenAL,MerrellPT,etal.Settingexpectationsfollowingendoscopiccubitaltunnelrelease[J].Hand(NY), 2014, 9(3): 356-363.

[17]JiangS,XuW,ShenY,etal.Endoscopy-assistedcubitaltunnelreleaseundercarbondioxideinsufflationandanteriortransposition[J].AnnPlastSurg, 2012, 68(1): 62-66.

(本文编辑：胡桂英)

杨明，黄伟，王天兵，等.关节镜下松解尺神经治疗肘管综合征疗效[J/CD]. 中华肩肘外科电子杂志,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

卫生公益性行业科研专项(201002014、201302007)；教育部创新团队(IRT1201)；北京市科委重大

100044北京大学人民医院创伤骨科 北京大学交通医学中心

姜保国，Email:jiangbaoguo@vip.sina.com

2015-02-05)

专项(Z101107052210001)；北京大学人民医院研究与发展基金(RDB2014-01)