摘要
目的:回顾性分析6年85例肌力≥Ⅲ级,肌张力ⅡˉⅣ级的病期稳定期脑性瘫痪患者选择性脊神经后根切断术治疗的效果。方法:选择1999-04/2003-12重庆市中山医院收治的病情己经稳定的痉挛性脑性瘫痪患者85例为手术对象。男48例,女37例,平均年龄8.8岁。①瘫痪情况:双下肢瘫痪46例,双上肢瘫痪4例,偏瘫13例,三肢瘫12例,四肢瘫10例。②并发症情况:伴有流涎22例,斜视19例,语言障碍26例,明显智力低下12例;有癫痫病史5例,有内收肌切断史7例,合并扭转痉挛1例。③行走功能:术前不能独立行走54例(其中不能独自站、坐或/和双手扶助均不能行走3例,牵双手勉强可行走21例,牵一只手可行走29例),能独立行走但步态异常27例。④步态情况:不同程度尖足现象80例,交叉腿、剪刀步态62例,足内翻或外翻畸形42例,膝关节屈曲不能伸直18例。⑤肌力:指关节痉挛屈曲不能伸直及腕关节不能背伸(似爪形手)9例,肩关节肌肉痉挛(肩关节处于外展位不能内收)1例。术前检查患肢肌力Ⅲ级18例,Ⅳ级62例,Ⅴ级5例。⑥肌张力:肌张力Ⅱ级14例,Ⅲ级59例,Ⅳ级12例。⑦查体情况:髌阵挛阳性13例,踝阵挛阳性45例,巴彬斯基氏征阳性64例,霍夫曼氏征阳性19例。术前常规照片、准确定位,发现隐性脊柱裂8例,轻度脊柱侧弯5例,未发现脊柱滑脱及髋关节脱位。采用选择性腰骶神经后根切断术及选择性颈神经后根切断术进行治疗,随访2年并比较手术前后患者肌力、肌张力及肢体功能和步态的变化,并以此为临床有效和无效的评估标准。结果:85例患者均完成手术治疗,全部进入结果分析。①患肢肌力:83例与术前相当或好于术前,2例较术前略差。②肌张力改善:68例患肢肌张力降至正常,8例肌张力稍低于正常,9例肌张力仍然略高于正常,平均降低Ⅱ～Ⅲ级。③行走功能:腰骶神经后根切断术后44例已可独立行走,12例儿童开始上学,仍不能独立行走的10例中6例患者的行走能力得到不同程度的改善,仅4例行走功能改善不明显。27例术前能走的患儿,术后步幅增大,步速加快,步态更加平稳,行走能力得到明显改善。④步态改善:尖足现象及交叉腿、剪刀步态均得到不同程度改善。⑤查体情况:所有患者术后的髌阵挛,踝阵挛均消失,膝、踝反射基本正常或稍减弱,流涎、斜视、口词不清等症状也有所缓解,已有4例进行二期矫形手术。颈神经后根切断术后4例上肢痉挛症状缓解,3例术后手指、腕关节痉挛屈曲(爪形手)缓解,可以伸直手指,背伸腕关节,1例肩关节外展肌肉痉挛缓解,肩关节可以内收,活动范围增大。45例术后X射线随访未发现手术所致的脊柱前凸、侧弯、脊柱滑脱和髋关节脱位,⑥临床效果:2年随访,临床有效79例,临床无效4例,有效率约为95%。期内未发现病情短暂好转后又加重的病例。结论:实施个体化方案手术方案,掌握手术适应症,把握对患者实施手术的时机,准确选择神经后根切除比例,重点加强术后功能锻炼,手术过程中轻柔操作,尽量减少骨性结构的损伤,术后一般无严重并发症,绝大部分患者可取得满意的临床效果,不同程度的提高和改善下肢运动功能。
AIM: To retrospectively analyze the therapeutic effects of selective posterior rhizotomy on the treatment of 85 patients with cerebral palsy in the past six years, whose muscle strength has be recovered from ≥ grade Ⅲ to grade Ⅱ-Ⅳ in a stationary phase. METHODS: Eighty-five patients with cerebral palsy in a stationary phase admitted to the Zhongshan Hospital of Chongqing were selected between April 1999 and December 2003, including 48 males and 37 females at an average age of 8.8 years. ①Palsy: There were 46 cases of paralysis of the lower extremities, 4 of paralysis of the upper extremities, 13 of hemiplegia, 12 of triplegia, and 10 of tetraplegia. ②Complication: There were 22 cases of drooling, 19 of strabism, 26 of language disorder, 12 of obvious mental retardation, 5 cases of epilepsy, 7 of adductor disruption, and 1 of torsion spasm. ③Walking: Fifty-four patients could not walk without supporting before operation, among whom, 3 patients could not stand, sit and/or walk without supporting, 21 could walk limpingly with both hands pulled, and 29 could walk with one hand pulled. Twenty-seventy patients could walk independently with gait abnormality. ④Gait: There were 80 cases of sharp foot to different extents, 62 of crossing leg or scissors gait, 42 of foot inversion or eversion, and 18 of knee joint bent. ⑤Muscle strength: There were 9 cases of digital spastic flexion and claw band, and 1 of muscle spasm of shoulder. Preoperative examination showed that grade III strength was found in 18 cases, Ⅳ in 62 cases, and Ⅴ in 5 cases. ⑥ Muscular tension: There were 14 cases of grade Ⅱ, 59 of grade Ⅲ, and 12 of grade Ⅳ. ⑦ Body examination: There were 13 cases of patella clonus, 45 of ankle clonus, 64 of Babinski sign, and 19 of Hoffmann sign. Preoperative routine photo and location showed that there were 8 cases of Cryptomerorachischisis and 5 of mild lateral curvature. However, there was no spinal slippage or dislocation of hip joint. Selective posterior rhizotomy (lumbosacral nerve and cervical nerve) was performed in the treatment. After two-year follow up, muscle strength, muscular tension, limb function and gait were measured and compared before and after operation, which were used as evaluation criteria of effectiveness or ineffectiveness. RESULTS: All the 85 patients underwent operation treatment, and were involved in the result analysis.①Muscle strength of affected extremity: Muscle strength was improved or unchanged in 83 cases, and was only decreased in 2 cases. ② Muscular tension: Muscular tension of affected extremity was recovered to the normal in 68 cases, lower than the normal in 8 cases and higher than the normal in 9 cases with averagely grade Ⅱ-Ⅲ. ③ Walking ability: After posterior rhizotomy on lumbosacral nerve, 44 children could walk independently, 12 children could go to school; only 4 cases of 10 patients who could not walk independently gained an unobvious improvement in walking ability. Improvement in walking ability was remarkable, accompanied with bigger step, faster speed and more stable gait. ④ Gait: Sharp foot, crossing leg and scissors gait were improved to different extents. ⑤ Body examination: Patella clonus and ankle clonus disappeared in all the patients after operation, knee and ankle jerk was recovered or relieved as well as drooling, strabism, lisp, etc. Second orthomorphia was conducted in 4 cases. After posterior rhizotomy on cervical nerve, spasm of upper limbs was relieved in 4 cases, finger or wrist spasm (claw band) was relieved in 3 cases, and abductor spasm was relieved in 1 case. Lordosis, lateral curvature, spinal slippage and dislocation of hip joint resulting from operation were found in 45 cases by using X-ray examination. ⑥ Clinical effect: After 2-year follow-up, effectiveness was in 79 cases, ineffectiveness in 4 cases, and the effective rate was 95%. None of Aggravated cases was found. CONCLUSION: Actualizing individualized operation, understanding operative symptoms, holding operative occasion, confirming ratio of resection, strengthening postoperative functional training, decreasing bone injury, and others are very important for the treatment of cerebral palsy, which can avoid the severe complication following operation. Most patients can have a satisfactory effect, and their motor function is improved and promoted to different extents.
出处
《中国临床康复》
CSCD
北大核心
2005年第23期201-203,共3页
Chinese Journal of Clinical Rehabilitation
