摘要
目的通过胫神经小腿三头肌运动神经分支选择性麻醉阻滞,确定造成脑卒中痉挛性垂足的责任肌。方法选择30例脑卒中患者,应用2%利多卡因进行腓肠肌和比目鱼肌运动分支神经麻醉阻滞,阻滞前后对肢体痉挛指标包括牵张反射评分(stretch reflex,SR)、痉挛严重程度分级Ashworth评分、踝关节活动角度(range of motion,ROM)包括休息位ROM(rest range of motion,rROM)、主动背屈ROM(active range of motion,AROM)和被动背屈ROM(passive range of motion,PROM)、足跖屈肌肌力以及下肢步行功能状态指标如10m舒适和快速步行速度、步频、3min步行距离、能量消耗指数(physicalconsume index,PCI)以及步长和足偏角进行观察。分别比较腓肠肌阻滞前后、比目鱼肌阻滞前后,以及腓肠肌阻滞后和比目鱼肌阻滞后上述指标的变化和差异。结果痉挛指标SR评分、Ashworth评分、AROM和PROM在腓肠肌运动分支阻滞后较阻滞前均下降,差异有统计学意义(P均<0.01);SR评分、Ashworth评分、rROM、AROM和PROM在比目鱼肌运动分支阻滞后较阻滞前均下降(P均<0.01);比目鱼肌运动分支阻滞后痉挛指标低于腓肠肌运动分支阻滞后(SR评分、AROM和PROM的P值均<0.01,Ashworth评分、rROM P值均<0.05)。对于足跖屈肌肌力,腓肠肌运动分支阻滞后较阻滞前肌力下降(P<0.01),比目鱼肌运动分支阻滞术后对肌力无影响,两种阻滞方法比较差异有统计学意义(P<0.01)。步行功能指标腓肠肌运动分支阻滞后较阻滞前无统计学差异,比目鱼肌运动分支阻滞后除3min步行距离较阻滞前无差异外,其余指标均有提高(10m快速步行速度、步频的P值均<0.01,10m舒适步行速度和PCI的P值均<0.05);除3min步行距离两种阻滞方法比较无差异外,其余指标比目鱼肌运动分支阻滞后均高于腓肠肌运动分支阻滞后(10m舒适步行速度P值<0.05,余P值均<0.01)。患侧步长和足偏角在两种阻滞方法术后较阻滞前差别均无统计学意义,两种方法比较也均无统计学差异。结论腓肠肌运动分支和比目鱼肌运动分支利多卡因阻滞均能降低痉挛性足下患者的痉挛程度,但是比目鱼肌运动分支阻滞较之腓肠肌运动神经阻滞改善患者步行功能更为显著。故认为比目鱼肌是造成小腿三头肌痉挛性足下垂畸形的主要责任肌。
Objective To evaluate the prominent role of the triceps surae muscle through selective anesthetic blocks of motor nerve branches to the triceps surae muscle on lower limb in patients with spastic equinus foot. Methods Thirty patients with stroke were assessed before and after selective anesthetic block of the superior soleus nerve or the gastrocnemius nerve, which performed by lidocaine injection. Clinical assessments such as SR（stretch reflex）, Ashworth scale, rROM（rest range of motion）, AROM（active range of motion）, PROM（passive range of motion）, strength of plantarflexion muscle, walking speed for 10m（at cosy speed and volant speed, separately）, cadence, walking distance for 3mins, PCI（physical consume index）, step length, toe out angle were performed 30mins before and after each motor block. The patients were devided into three groups, they were preoperative- postgastrocnemius, preoperative- postsoleus, postgastrocnemius - postsoleus separately. We compared differences in these indicators. Results Spasm index such as stretch reflex, Ashworth scale, AROM and PROM were all decreased in postgastrocnemius, there were statistically differences compared with preoperative, （P all 〈0.01）. Stretch reflex, Ashworth scale, rROM, AROM and PROM were all decreased in postsoleus, （P all 〈0.01）; there were significant differences between two blocks in each of them, they showed that on SR, AROM and PROM P all 〈0.01, on Ashworth, rROM P all 〈0.05; Plantar flexor muscle strength decreased in postgastrocnemius（P〈0.01） but not in postsoleus, comparison of two blocks P〈0.01; there were no significant differences on walking targets in postgastrocnemius but there were statistically differences in postsoleus except for walking distance for 3mins compared with preoperative, on walking speed for 10m at volant speed and cadence P all〈0.01, on walking speed for 10m at cosy speed and PCI P all〈0.05.Also there were significant difference between the two blocks except for walking distance for 3mins, they showed that on walking speed for 10m at cosy speed P〈0.05, other index P all〈0.01 .There were no significant difference for step length and toe out angle in the affected side compared with preoperative, also no statistically difference was observed between the two blocks in the affected side. Conclusion Both soleus nerve block and gastrocnemius nerve block could alleviate spasticity in patients with spastic equinus foot, but soleus nerve block appeared more appropriate than gastrocnemius nerve block to relieve spasticity clinically, which mainly manifested in people＇s walking ability. It constitutes an additional argument in favor of the predominant role of the soleus in spastic foot.
出处
《中国卒中杂志》
2010年第4期291-298,共8页
Chinese Journal of Stroke
关键词
胫神经
神经肌肉阻滞
卒中
步态障碍
神经性
Tibial nerve
Neuromuscular blockade
Stroke
Gait disorders, neurologic
