近日，澳大利亚墨尔本奥斯丁健康中心Natasha van Zyl研究团队进行了一项前瞻性病例分析，通过扩展传统的肌腱为基础的神经移植技术来恢复四肢瘫痪患者的上肢功能。 2019年8月17日出版的《柳叶刀》发表了这项成果。

这项研究招募了早期颈脊髓损伤的患者（受伤<18个月，运动水平C5及以下），均被认为适合神经移植。所有参与者均在一条或两条上肢进行了单次或多次神经移植，有时与肌腱移植相结合，以恢复肘部伸展、抓握、捏夹和张手的功能。参与者分别在术后12个月和24个月接受评估。主要观察指标为上肢动作研究量表（ARAT）、抓放测验（GRT）和脊髓损伤独立性测量（SCIM）评分。

2014年4月14日至2018年11月22日，研究组招募了16名外伤性脊髓损伤患者（27条上肢），共进行了59次神经移植。在10名参与者（12条上肢）中，神经移植与肌腱移植联合进行。随访24个月后有3例患者（5条上肢）失访。在第24个月时，参与者的ARAT中位总评分为34.0，显著高于基线的16.5；GRT中位总评分为125.2，显著高于基线的35.0；SCIM中位总评分、室内移动评分、使用厕所评分和自我护理评分均显著高于基线。

治疗24个月后，参与者的医学研究委员会肱三头肌力量等级中位数为3，指伸肌力量等级中位数为4；5例接受远端神经移植患者的平均握力为3.2 kg，9例接受近端神经移植患者为2.8 kg，8例肌腱移植患者为3.9 kg。手术发生6例不良反应，但均未造成持续性损伤。

早期神经移植手术是对四肢瘫痪患者上肢恢复术的一种安全有效的补充。神经移植可显著改善患肢功能，并可结合肌腱移植成功令患者获益。

研究人员表示，颈脊髓损伤后上肢功能丧失严重影响了患者的独立性，包括社交、工作和社会活动。神经移植手术为四肢瘫痪患者恢复上肢功能提供了一个令人振奋的新选择。

附：英文原文

Title: Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series

Author: Natasha van Zyl, Bridget Hill, Catherine Cooper, Jodie Hahn, Prof Mary P Galea

Issue&Volume: Volume 394 Number 10198, 17 August 2019

Summary:

Background

Loss of upper extremity function after cervical spinal cord injury greatly affects independence, including social, vocational, and community engagement. Nerve transfer surgery offers an exciting new option for the reanimation of upper limb function in tetraplegia. The aim of this study was to evaluate the outcomes of nerve transfer surgery used for the reanimation of upper limb function in tetraplegia.

Methods

In this prospective case series, we consecutively recruited people of any age with early (<18 months post-injury) cervical spinal cord injury of motor level C5 and below, who had been referred to a single centre for upper extremity reanimation and were deemed suitable for nerve transfer. All participants underwent single or multiple nerve transfers in one or both upper limbs, sometimes combined with tendon transfers, for restoration of elbow extension, grasp, pinch, and hand opening. Participants were assessed at 12 months and 24 months post-surgery. Primary outcome measures were the action research arm test (ARAT), grasp release test (GRT), and spinal cord independence measure (SCIM).

Findings

Between April 14, 2014, and Nov 22, 2018, we recruited 16 participants (27 limbs) with traumatic spinal cord injury, among whom 59 nerve transfers were done. In ten participants (12 limbs), nerve transfers were combined with tendon transfers. 24-month follow-up data were unavailable for three patients (five limbs). At 24 months, significant improvements from baseline in median ARAT total score (34·0 [IQR 24·0–38·3] at 24 months vs 16·5 [12·0–22·0] at baseline, p<0·0001) and GRT total score (125·2 [65·1–154·4] vs 35·0 [21·0–52·3], p<0·0001) were observed. Mean total SCIM score and mobility in the room and toilet SCIM score improved by more than the minimal detectable change and the minimal clinically important difference, and the mean self-care SCIM score improved by more than the minimal detectable change between baseline and 24 months. Median Medical Research Council strength grades were 3 (IQR 2–3) for triceps and 4 (IQR 4–4) for digital extensor muscles after 24 months. Mean grasp strength at 24 months was 3·2 kg (SD 1·5) in participants who underwent distal nerve transfers (n=5), 2·8 kg (3·2) in those who had proximal nerve transfers (n=9), and 3·9 kg (2·4) in those who had tendon transfers (n=8). There were six adverse events related to the surgery, none of which had any ongoing functional consequences.

Interpretation

Early nerve transfer surgery is a safe and effective addition to surgical techniques for upper limb reanimation in tetraplegia. Nerve transfers can lead to significant functional improvement and can be successfully combined with tendon transfers to maximise functional benefits.

DOI: https://doi.org/10.1016/S0140-6736(19)31143-2

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31143-2/fulltext#