【作者】 马韬；

【导师】 田德虎；

【作者基本信息】 河北医科大学 ， 外科学， 2017， 硕士

【摘要】 目的:对腕管综合征患者腕管切开正中神经松解减压术后予以神经肌肉电刺激治疗,通过疗程的变化和随访临床数据的分析,评价腕管综合症术后神经肌肉电刺激辅助治疗的有效性和必要性,探索腕管综合征腕管切开正中神经松解减压术后合理的辅助治疗方式,为腕管综合征术后有效的辅助治疗提供指导方案。腕管综合征是临床上最常见的上肢周围神经卡压性疾病,病因复杂,临床诊断较为明确。腕管综合征的治疗方式已基本达成共识,轻度腕管综合征患者行保守治疗,中、重度腕管综合征患者及保守治疗无效的患者及时行手术治疗。手术方式多样,但原则均为纵行切开腕横韧带,适当松解正中神经,通过对正中神经卡压严重部分的适当松解,均能取得较满意的疗效。部分病程长或因术后疼痛等原因未能及时行功能训练的患者术后功能恢复不理想,患肢感觉及功能恢复有待改善。手术后积极的功能训练及适当的辅助治疗有助于患者患肢功能及感觉的恢复。本文通过分析腕管综合征术后神经肌肉电刺激治疗的疗效,为腕管综合征术后辅助治疗提供更好的选择。方法:根据课题需要制定病例入选标准:1.通过对主诉、病史、体格检查、肌电图检查等综合分析(图1-6)确诊为腕管综合征的患者;2.按照顾玉东提出的腕管综合征分型[1-3],属中、重度腕管综合征需行手术治疗的患者;3.无中枢系统疾病或其他周围神经卡压性疾病;4.无代谢性疾病、未处于妊娠期及哺乳期、患侧无腕关节炎症、腕部骨折史、手术史患者;5.无影响治疗的其他全身性疾病。选择河北医科大学第三医院2015年1月至2016年6月所收治CTS患者中符合入组标准的85例。采用随机数字表法将85例患者随机分为3组,其中非电刺激治疗组:空白对照组(NS组)27例;电刺激治疗1组:单纯电刺激治疗组(S1组)29例;电刺激治疗2组:医用几丁糖+电刺激治疗组(S2组)29例。3组患者均行腕管切开正中神经松解术,其中S2组于术中创面止血后正中神经周围均匀涂抹医用几丁糖凝胶,另两组(NS组和S1组)仅创面充分止血,不应用医用几丁糖凝胶。S1组和S2组患者均于术后第5天开始予以神经肌肉电刺激治疗:两组均予以电刺激治疗每日20min,连续14d。应用神经肌肉电刺激仪在拇短展肌表面施加脉冲电刺激,刺激强度依据患者所能承受的强度予以调整,20ma为大多数患者所能承受的平均强度,刺激频率0.6hz,脉冲宽度10ms。3组患者术后均常规给予营养神经及改善循环治疗2周。于术前及术后第1、3、6个月测定并记录患肢握力,采用上肢功能障碍评定量表(dash)评价患者术后功能及生活质量,术后第1、3、6个月复查患肢肌电图。将所得数据采用spss21.0统计学软件进行统计学分析。计量资料用(?x±s)表示,组间比较应用方差分析和t检验;计数资料应用卡方检验;显著性水准α=0.05。结果:1一般结果3组患者85例中共72例获得随访至术后6个月,其中ns组23例,s1组24例,s2组25例。另13例因未能按时返院复查等原因脱组。患者均于术后12-14天拆除伤口缝线,伤口Ⅰ期愈合,未出现一例伤口感染、伤口不愈合等并发症。至术后6个月,未出现一例屈肌腱弓弦畸形、柱状痛或患肢严重的功能障碍。所有获得随访患者的临床症状均有不同程度改善,腕部正中神经tinel征(-),phalen试验(-),肌电图检查恢复或接近正常水平。2术后综合疗效评价根据顾玉东提出的腕管综合征功能评定标准[1-3],ns组优18例,良2例,可3例,差0例,优良率86.9%。s1组优20例,良2例,可2例,差0例,优良率91.7%。s2组优22例,良1例,可2例,差0例,优良率92.0%。3组患者术后疗效优良率比较无统计学差异(p>0.05)。3患者肌电图复查结果评定术后3组患者术后1个月、3个月、6个月组间运动电位、mcv及scv比较无统计学差异(p>0.05)。4患肢握力测量结果评定术前3组患者握力测量结果比较无统计学差异(p>0.05)。术后第1个月3组患者握力测量结果比较无统计学差异(p>0.05)。术后第3个月3组患者握力测量结果比较有统计学差异(p<0.05),两组间比较,ns组与s1组,ns组与s2组有统计学差异(p<0.05),S1与S2组间比较无统计学差异(P>0.05)。术后第6个月患者握力测量结果比较有统计学差异(P<0.05),两组间比较,NS组与S1组,NS组与S2组有统计学差异(P<0.05),S1与S2组间比较无统计学差异(P>0.05)。5患者DASH评分评定术前3组患者DASH评分比较无统计学差异(P>0.05)。术后第1个月3组患者DASH评分比较无统计学差异(P>0.05)。术后第3个月3组患者DASH评分比较无统计学差异(P>0.05)。术后第6个月3组患者DASH评分比较有统计学差异(P<0.05)。两组间比较,NS组与S1组,NS组与S2组,S1与S2组间比较均有统计学差异(P<0.05)。结论:在腕管切开正中神经松解术后,辅以神经肌肉电刺激治疗(每日20min,连续14d),能加速患者神经功能修复,缓解肌肉萎缩,促进患者患肢功能更快更好的恢复。神经肌肉电刺激治疗操作简单易行,花费少,痛苦小,疗程短,且疗效确切,适宜作为周围神经卡压术后首选辅助治疗方法,于临床推广应用。更多还原

【Abstract】 Purpose:In this research,neuromuscular electrical stimulation was administered to carpal tunnel syndrome(CTS)patients after the commonly used procedure of carpal incision and median nerve decompression to assess the efficacy and the necessity of postoperative neuromuscular electrical stimulation,to explore an effective postoperative adjunctive therapeutic strategy and to provide guidance to the postoperative management of carpal tunnel syndrome through observing the changes in the course of treatment and analyzing the clinical follow-up data.Carpal tunnel syndrome is one of most common peripheral nerve compression disease in the upper-extremity,which is easy to be diagnosed but has very complicated causes.It is widely agreed upon that conservative treatment is recommended for patients with milder cases while surgery is used in patients with moderate or severe cases and patients responding not well to conservative therapy.The surgical methods are various but all make longitudinal incision in the transverse ligament and release median nerve,which usually produces satisfying clinical benefit.However,the postoperative condition needs to be improved for patients who fail to have rehabilitation due to the prolonged courses of disease or postoperative pains,because an aggressive rehabilitation and adjuvant therapy in the postoperative period proved helpful to functional and sensory recovery.This research aims to provide a better postoperative adjuvant therapy option by examining the efficacy of postoperative neuromuscular electrical stimulation in carpal tunnel syndrome.Methods: The inclusion criterions are:(1)diagnosed with CTS by history inquiry,physical exams,electrophysiological examination or imaging test(Fig.1-6),(2)identified as moderate or severe cases(based on the staging system ofcarpal tunnel syndrome proposed by Gu Yudong)for which surgical treatment is indicated(3)without pregnancy,metabolic disorder or a history of arthritis,fracture,or surgery in the affected wrist(4)without systemic diseases that may potentially influence the treatment.In consistence with this criterion,85 patients who were admitted to The Third Hospital of Hebei Medical University from January 2015 to June 2016 were recruited.Among them,27 cases in non-electric stimulation group: blank control group(NS group);29cases in neuromuscular electrical stimulation group 1: simple electrical stimulation group(S1 group);29 cases in neuromuscular electrical stimulation group 2: medical chitosan+electrical stimulation treatment group(S2 group).The patients of three groups were divided into the median nerve lysis,the S2 group were evenly coated with medical chitosan in the carpal tunnel after hemostasis,the other two groups(NS group and S1 group)only done the wound hemostasis,not to use medical chitosan gel.The patients of S1 and S2 groups received neuromuscular electrical stimulation at the 5th day after operation: both groups were treated with electrical stimulation of 20 min daily for 14 days.The neuromuscular electrical stimulation of stimulator was used to stimulate the surface of the abductor pollicis brevis.the intensity of stimulation was adjusted according to the intensity of the patient,and 20 mA was the average strength that the most patients could endured,.The stimulus was 0.6Hz and the pulsewidth was 10 ms.A routine treatment to nourish nerves and improve circulation was given to all of the patients in the three groups.The patient’s grip strength in the affected side was evaluated before the procedure and at 1st,3rd,6th month after the procedure.The patients quality of postoperative life was assessed using a DASH scale.SPSS 21.0 was used to analyze the data collected in this research and the data were presented using(? x±s).Variance analysis and t-test were used for group comparison.Chi-squared test was used for measurement data.α=0.05Result:1 General ResultThree groups with altogether 72 patients were followed for six monthsafter the surgery: including 23 patients in NS group,24 in S1 group and 25 in S2 group.Stitches were removed 12-14 days after the surgery in all patients whose incisions were all healed by primary intention without infection or hematoma.6th month after surgery,all patients’ symptoms improved at varying degrees without bowstring deformity of flexor tendons,severe pillar pain or hand dysfunction.The tinel sgin of median nerve and phalen test were all negative and all electrodiagnostic testing result were back to normal or nearly normal.2 Therapeutic benefit in the postoperative period.According to Yudong Gu’s CTS type,group NS has 18 patients leveled as good,2 patients moderate,3 patients acceptable and 0 patient disappointing,the rate of good and moderate is 86.9%;group S1 has 20 patients leveled as good,2 patients moderate,2 patients acceptable and 0 patient disappointing,the rate of good and moderate cases is 91.7%;group S2 has 22 patients leveled as good,1 patients moderate,2 patients acceptable and 0 patient disappointing,the rate of good and moderate cases is 92.0%.There was no statistical difference(P>0.05)in the number of cases leveled as good or moderate among the three groups.3 Evaluation of EMG resultsThere was no significant difference between the 3 groups in the motor potential,MCV and SCV after the operation in the 1st months,3rd months and6 th months(P>0.05)4 Grip strength in the affected wristBefore surgery,there was no statistical difference(P>0.05)in the grip strength among 3 groups.1month after surgery,there was no statistical difference(P>0.05)in the grip strength of patients among 3 groups.3 months after surgery,it was found that between NS and S1,NS and S2,there was statistical difference(P<0.05)in the grip strength of patients.But there was still no statistical difference between group S1 and S2.6 month after surgery,a statistical difference(P<0.05)was foundbetween NS and S1,NS and S2.But it was not found between group S1 and S2(P>0.05).5 DASH results among patientsBefore surgery,there was no statistical difference(P>0.05)in DASH among 3 groups1 month after surgery,there was no statistical difference(P>0.05)in DASH among 3 groups3 months after surgery,there was no statistical difference(P>0.05)in DASH among 3 groups6 month after surgery,there were statistical difference(P<0.05)in DASH among 3 groups.But a statistical difference was found in DASH between NS and S1,NS and S2,S1 and S2.Conclusions:Neuromuscular electrical stimulation was administered to carpal tunnel syndrome(CTS)patients after carpal incision and median nerve decompression(20min/day,14days).It was more effective in speeding up repairs of nerve function,alleviating muscle atrophy,enhancing functional recovery in the affect wrist and improving postoperative condition.Neuromuscular electrical stimulation can be easily administered with lower cost,less pains,shortened course of treatment and improved clinical benefit.It is advisable that neuromuscular electrical stimulation be generalized as a first-line adjunctive therapy in the postoperative period in peripheral nerve compression patients.更多还原