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Title: [Applied anatomy study and preliminary clinical application of hyper selective neurectomy of triceps branches combined with partial neurotomy of S ₂ nerve root to relieve spastic equinus foot].
Author: Xu K, Yin Y, Wang S, Li F, Li W.
Journal: Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi; 2024 Aug 15; 38(8):1010-1015. PubMed ID: 39175325.
Abstract:
OBJECTIVE: To observe the possibility of hyper selective neurectomy (HSN) of triceps branches combined with partial neurotomy of S ₂ nerve root for relieving spastic equinus foot. METHODS: Anatomical studies were performed on 12 adult cadaveric specimens. The S ₂ nerve root and its branches were exposed through the posterior approach. Located the site where S ₂ joined the sciatic nerve and measured the distance to the median line and the vertical distance to the posterior superior iliac spine plane, and the S ₂ nerve root here was confirmed to have given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. Between February 2023 and November 2023, 4 patients with spastic equinus foot were treated with HSN of muscle branches of soleus, gastrocnemius medial head and lateral head, and cut the branch where S ₂ joined the sciatic nerve. There were 3 males and 1 female, the age ranged from 5 to 46 years, with a median of 26 years. The causes included traumatic brain injury in 2 cases, cerebral hemorrhage in 1 case, and cerebral palsy in 1 case. The disease duration ranged from 15 to 84 months, with a median of 40 months. The triceps muscle tone measured by modified Ashworth scale (MAC) before operation was grade 3 in 2 cases and grade 4 in 2 cases. The muscle strength measured by Daniels-Worthingham manual muscle test (MMT) was grade 2 in 1 case, grade 3 in 1 case, and 2 cases could not be accurately measured due to grade 4 muscle tone. The Holden walking function grading was used to evaluate lower limb function and all 4 patients were grade 2. After operation, triceps muscle tone, muscle strength, and lower limb function were evaluated by the above grading. RESULTS: The distance between the location where S ₂ joined the sciatic nerve and median line was (5.71±0.53) cm and the vertical distance between the location and posterior superior iliac spine plane was (6.66±0.86) cm. Before joining the sciatic nerve, the S ₂ nerve root had given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. All the 4 patients successfully completed the operation, and the follow-up time was 4-13 months, with a median of 7.5 months. At last follow-up, the muscle tone of the patients decreased by 2-3 grades when compared with that before operation, and the muscle strength did not decrease when compared with that before operation. Holden walking function grading improved by 1-2 grades, and there was no postoperative hypoesthesia in the lower limbs. CONCLUSION: HSN of triceps branches combined with partial neurotomy of S ₂ nerve root can relieve spastic equinus foot without damaging other sacral plexus nerves. 目的: 探讨小腿三头肌肌支超选择性神经切断术（hyper selective neurectomy，HSN）联合S ₂神经根部分切断缓解痉挛性马蹄足的可行性。. 方法: 采用12具成人尸体标本进行解剖学研究，从后路显露S ₂神经根及其分支，寻找S ₂神经根汇入坐骨神经的部位，测量其到中线的距离以及到髂后上棘平面的垂直距离，并确认此处的S ₂神经根是否已经发出盆内脏神经、阴部神经以及股后皮神经的分支。2023年2月—11月，对4例痉挛性马蹄足患者采用比目鱼肌及腓肠肌内、外侧头肌支HSN联合S ₂神经根汇入坐骨神经分支切断进行治疗。男3例，女1例；年龄5～46岁，中位年龄26岁。病因包括脑外伤2例，脑出血1例，脑瘫1例。病程15～84个月，中位时间40个月。术前小腿三头肌跖屈肌张力改良Ashworth分级（MAC）为3级2例、4级2例；Daniels-Worthingham徒手肌力分级（MMT）评定肌力为2级1例、3级1例，2例因肌张力4级而无法准确测量术前肌力；Holden步行功能分级评价下肢功能，4例患者均为2级。术后采用上述分级评价小腿三头肌跖屈肌张力、肌力及下肢功能。. 结果: S ₂神经根汇入坐骨神经位置至中线的距离为（5.71±0.53）cm，至髂后上棘平面的垂直距离为（6.66±0.86）cm。在汇入坐骨神经前S ₂神经根已发出盆内脏神经、阴部神经以及股后皮神经的分支。4例患者均顺利完成手术，随访时间4～13个月，中位时间7.5个月。末次随访时，患者肌张力较术前下降2～3级，肌力较术前无下降，Holden步行功能分级提升1～2级，均无下肢感觉减退。. 结论: 小腿三头肌肌支HSN联合S ₂神经根部分切断可缓解痉挛性马蹄足，且不损伤其余骶丛。.

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