- 期刊
Local Anesthesia for Ulnar Nerve Anterior Subcutaneous Transposition: Experience in Treatment of 53 Limbs with Cubital Tunnel Syndrome
以局部麻醉施行尺骨神經皮下前方移位手術：治療53個肘隧道症候群的經驗
摘要
肘隧道症候群肇因於尺神經於手肘部位受到壓迫，為上肢中僅次於腕隧道症候群的次發性神經病變。病變初期病患主訴小指及無名指近小指側麻木，以及手指外展及內收無力。如不加以治療，可能會產生肌肉萎縮，形成爪狀手。肌電圖及神經傳導速度能幫助我們確立診斷。初期治療可使用藥物及手肘固定護具，若症狀沒改善或出現肌肉無力等情形，需考慮手術治療。手術方式主要分為單純神經減壓以及尺神經前方移位手術兩種，部分醫師選擇加以切除肱骨上髁。依照神經與屈後旋肌的相對位置，尺神經前方移位可分為皮下、肌肉內、以及肌肉下方移位。單純神經減壓手術優點在於傷口較小、復原快，不傷害神經周圍的血管，缺點則是可能會有減壓不足以致手術失敗、復發，神經在手肘彎曲時仍處於高壓力狀態，在手肘嚴重退化、尺神經脫位等病患不宜施行等缺點。尺神經前方移位優點為減壓較完全，可將神經從上臂至前臂處完全分離；缺點則是手術傷口大、以及可能破壞供應神經的血管等缺點。何種手術為最佳方式目前仍有爭議。 尺神經前方移位手術的麻醉方式，文獻上以腋下臂神經叢神經阻斷或全身麻醉為主。本論文提出五十三例肘隧道症候群的個案，自1999年一月到2005年六月間，於局部麻醉下，施行尺神經皮下前方移位手術的治療經驗。術前評估根據McGowan所提出的方法，依照手部肌肉力量及萎縮變形與否，區分為Ⅰ,ⅡA,ⅡB，ⅠⅡ四級，術後追蹤以Amadio的分類方式，將結果區分為excellent, good, fair和poor。其中excellent和good代表顯著改善。所有病患皆能忍受整個手術過程，90%對於局部麻醉的方式感到滿意，74%病患獲得顯著改善，預後與患者術前McGowan等級嚴重性及神經生理檢查結果相關。術中無使用上臂止血帶，術後無須置放引流管，亦無限制病患手肘活動。可於門診一日手術，多數病患於兩週內回復工作。對於年老或有嚴重內科疾病的病患，以門診局部麻醉，施行尺神經皮下前方移位手術，減少全身或區域麻醉的風險，有明顯的助益，可為治療肘隧道症候群優先的選擇。
關鍵字
無資料並列摘要
Objective: Anterior subcutaneous transposition of the ulnar nerve is one of the accepted treatments for cubital tunnel syndrome, but it is often performed under general or regional anesthesia. We have analyze our experience with less invasive local anesthesia for this procedure. Methods: We retrospectively reviewed the records of 51 patients (53 elbows) undergoing anterior subcutaneous transposition of the ulnar nerve under local anesthesia between January 1999 and June 2005. The elbows were assessed both clinically and electrophysiologically. A modification of the McGowan classification was used preoperatively, and Amadio's classification, consisting of four grades (excellent, good, fair and poor) based on a 9-point rating scale, was used postoperatively to assess the results. Excellent and good grades were considered significant improvement, while fair and poor were considered no significant improvement. Results: Preoperatively, of the 53 elbows, 13 were classified as grade I, 16 as grade IIA, 14 as grade IIB, and 10 as grade III. Significant improvement was achieved in 39 (74%), and 42 (79%) were at lest one grade better after surgery. The outcome was correlated with the pre-operative McGowan and electrophysiologic grading. All patients tolerated the procedure well, and 90% of them would again choose to have the operation performed under local anesthesia. Conclusions: Anterior subcutaneous transposition of the ulnar nerve can be performed reliably and effectively under local anesthesia. This has benefits in avoiding the potential complications of regional or general anaesthesia, especially in a group of elderly patients who are poor-risk, and it can be considered as an option for surgical management of ulnar nerve entrapment.