摘要
目的:观察应用矫形手术,自体骨髓源神经干细胞移植并正中神经部分切断方法治疗重型脑性瘫痪上肢痉挛患儿,探讨其在降低肌张力的同时,提高肌力和手指功能的修复作用。方法:选择广东省第二人民医院2002-02确诊为重型脑性瘫痪后遗右上肢肘、腕关节严重痉挛和屈曲挛缩畸形的患者1例。男,12岁,病程12年。采用韦氏儿童智力量表评定患儿智商为55分(90～109分为平常;80～89分为低于平常;70～79分为边界;<69分为智力缺陷),应用巴氏指数(共10项,每项10分,评分越高,日常生活自理能力越强)评估患儿残疾自理能力45分,左上肢可支撑协助爬行。右上肢肌张力Ⅲ级,肘关节屈曲挛缩45°,腕关节屈曲挛缩105°,右腕骨质轻度畸形,右手不能持匙和分指。双下肢肌张力Ⅲ级,髋、膝、距小腿(踝)关节均有屈曲挛缩。对此患儿的治疗方案监护人知情同意。采用矫形手术:①上肢矫形手术:行屈腕屈指肌起点下移和尺侧屈腕肌腱背移;②术后2个月行右上肢正中神经部分切断和自体骨髓源神经干细胞移植。自患儿右髂后上棘取骨髓12mL,用梯度密度离心法获取骨髓基质细胞,接种于含维甲酸和碱性成纤维细胞生长因子的神经干细胞培养基中,连续培养11d后移植。取右腋窝纵切口,显露正中神经后切开神经外膜,将正中神经在神经外膜内切断一半,缝合外膜将培养好的干细胞注入外膜内,周围用凝胶海绵包埋,滴2mL神经节苷脂于凝胶海绵上,逐层缝合切口。治疗后采用改良Ashworth评定标准评定肌张力(0级:无肌张力增加;Ⅰ级:肌张力轻度增加;Ⅱ级:肌张力较明显增加;Ⅲ级:肌张力严重增高;Ⅳ级:强直)。结果:①上肢矫形手术2个月后复查右上肢,屈肘屈腕挛缩好转,但屈肘屈腕肌痉挛状态无改善,右手指随意伸屈功能无好转。②由于屈肘屈腕挛缩有复发趋向,因此决定行右上肢正中神经部分切断和自体骨髓源神经干细胞移植。③移植术后1周、2周、1个月时检查右上肢屈肘、屈腕、屈指肌张力低于正常,右手腕屈曲和手指屈曲肌力下降到Ⅱ级,正中神经支配区域感觉迟钝。但肘关节屈曲挛缩和腕关节屈曲挛缩均消失,右手也不能持匙,不能分指,手指不能夹纸。3个月后右上肢屈肘、屈腕、屈指肌张力,以及右手腕的屈曲和抓握肌力开始恢复。18个月后右手腕和手指屈曲肌力达到Ⅳ级,可持匙进食,可夹纸,肌张力和感觉基本正常,患儿可扶单拐行走,右上肢屈肌痉挛状态未见复发,2年后复查右手腕指屈伸功能仍在改善中。结论:本例脑性瘫痪患者所致肘、腕关节严重痉挛和屈曲挛缩,行正中神经部分切断和自体骨髓源神经干细胞移植后,不但降低了屈肌痉挛的状态,而且改善了正中神经部分切断后腕手指屈曲无力和感觉异常。说明此方法不仅有利于周围神经横断缺损感觉运动功能的修复,而且对肌痉挛状态具有较好的作用。
AIM： To investigate the effect of orthomorphia plus cutting segmental median nerve and autologous bone marrow-derived nerve stem cell transplantation in decreasing muscular tension, elevating muscle force and restoring finger function in the treatment of cerebral palsy in one child with severe spastic paralysis of upper extremity. METHODS： One serious cerebral palsy patient （male, 12 years old, a course of 12 years） with lingering severe spasm of deformed right elbow and wrist joint, and flexion contracture by final diagnosis in the Guangdong Second People＇s Hospital in February 2002 was selected for our investigation. His intelligence quotient （1Q） was 55 marks by Wechsler intelligence scale for children [Normal score： 90 to 109 marks; low score： 80 to 89 marks; border： 70 to 79 marks, mental deficiency（DM） less than 69 marks], and self-care ability of deformity 45 marks by Barthel index（a total of 10 items, each 10 marks, the higher the score was, the better the selfcare ability of daily life was）. He could support himself to crawl on the left upper extremity. Muscular tension of right upper extremity was grade Ⅲ, elbow joint was 45°flexion contracture, wrist joint 105°flexion contracture, bone matrix of right wrist joint was a little deformed, and the right hand could not hold spoon and separate fingers. Muscular tension of two lower extremities was grade Ⅲ, and joints of hip, knee, ankle all had flexion contracture. His guardian was told and consent about our treatment prescription. Orthomorphia：①Orthomorphia of upper extremity： infra-shifted initial muscular point of flexion wrist and finger, and dorsum-shifted ulnaris flexion wrist muscle. ②Two months later, segmental median nerve of right upper extremity was cut and autologous bone marrow-derived nerve stem cells were transplanted. Bone marrow 12 mL was drawn from his right posterior superior iliac spine. Marrow stromal cells were gotten by gradient density centrifugation, then seeded into nerve stem cell culture medium consisting of retinoic acid（RA） and basic fibroblast growth factor（bFGF） to culture for 11 consecutive days for transplantation. Right axilla was cut longitudinally to expose median nerve followed by incising the epineurium; Half of segment was cut in its epineurium, then the epineurium was sutured and injected with the cultured autologous bone marrow-derived nerve stem cells. Gelatin sponge was used to embed circumambience of epineurium, 2 mL ganglioside was dropped on the gelatin sponge and then the incisions were sutured layer by layer. Muscular tension was postoperatively evaluated by modified Ashworth criteria （grade 0： no addition of muscular tension; grade Ⅰ： slight increase; grade Ⅱ： obvious increase; grade Ⅲ： serious increase; grade Ⅳ： rigidity）. RESULTS：①At 2 months after orthomorphia of upper extremity, the flexion contracture of elbow and wrist of right upper extremity was improved, but his muscular spasticity had no improvement, and function of random flexion or extension was also unimproved. ②It was decided to cut the segmental median nerve of right upper extremity and transplant autologousbone marrow-derived nerve stem cells because of the recurrence trend of elbow and wrist flexion contracture. ③At 1, 2 weeks, 1 month after transplantation, muscular tension of right flexion elbow, wrist and finger was under normal, muscle force of right wrist and finger flexion dropped into grade Ⅱ, and the region innervated by median nerve was dysesthesia. But the flexion contracture of elbow and wrist disappeared. He could not hold spoon, separate fingers and clamp paper in the right hand. Three months later, his muscular tension of elbow, wrist and finger flexion of right upper extremity, right wrist flexion and grasping muscle force began to recover. Eighteen months later, muscle force of right wrist and finger reached grade Ⅳ; He could eat by holding spoon, clamped paper, and his sense and muscular tension were almost normal, He could walk with single crutch, spasticity of right upper extremity was not found recurrent. Two years later, the flexion-extension function of right hand and wrist was still being improved. CONCLUSION： Segmental transection of median nerve plus transplantation of autologous bone marrow-derived nerve stem cells can not only relieve flexion muscular spasticity, but also prevent asthenia of flexion muscle and paresthesia of wrist and finger due to segmental transection of median nerve in the patient with cerebral palsy-caused severe spasm and flexion contracture of elbow and wrist joint, which indicates that the treatment prescription is not only helpful to recover sensorimotor after the peripheral nerve is transected, but also favorable to improve muscular spasticitv.
出处
《中国临床康复》
CSCD
北大核心
2005年第30期63-65,i0001,共4页
Chinese Journal of Clinical Rehabilitation
基金
广东省团队项目[粤科基办
(2000)25]
广东省组织工程项目[粤财企(2001)367
(2003)207
(2004)08]基金资助~~
