مقايسة ميزان بازگشت حس بعد از ترميم عصب اولنار و مديان در مچ دست

Comparison of Sensory Recovery Following the Repair of Ulnar and Median Nerves at the Wrist Level

ﺯﻣﻴﻨﻪ ﻭ ﻫﺪﻑ: ﺩﺭ ﺍﻏﻠﺐ ﻣﻄﺎﻟﻌﺎﺕ ﺍﻧﺪﺍﻡ ﻓﻮﻗﺎﻧﻲ، ﭘﻴﺶ ﺁﮔﻬﻲ ﺗﺮﻣﻴﻢ ﻋﺼﺐ ﺭﺍﺩﻳﺎﻝ ﺑﻬﺘﺮ ﺍﺯ ﻋﺼﺐ ﻣﺪﻳﺎﻥ ﻭ ﺍﻳﻦ ﻋﺼﺐ ﺑﻬﺘﺮ ﺍﺯ ﻋﺼﺐ ﺍﻭﻟﻨﺎﺭ ﺍﺳﺖ. ﺍﻳﻦ ﻣﻄﺎﻟﻌﺎﺕ ﺑﻴﺸﺘﺮ ﺑﻪ ﺟﺰﺀ ﺣﺮﮐﺘﻲ ﺍﻋﺼﺎﺏ ﭘﺮﺩﺍﺧﺘﻪ ﺍﻧﺪ. ﻣﻄﺎﻟﻌﻪ ﻣﺴﺘﻘﻠﻲ ﺩﺭ ﻣﻮﺭﺩ ﺗﻔﺎﻭﺕ ﺑﺎﺯﮔﺸﺖ ﺣﺲ ﺑﻌﺪ ﺍﺯ ﻗﻄﻊ ﺍﻳﻦ ﺍﻋﺼﺎﺏ ﺍﻧﺠﺎﻡ ﻧﺸﺪﻩ ﺍﺳﺖ. ﺑﺮﺍﻱ ﺑﺮﺭﺳﻲ ﺍﻳﻦ ﻣﻮﺿﻮﻉ ﮐﻪ ﺩﺭ ﺷﺮﺍﻳﻂ ﻣﺸﺎﺑﻪ ﺑﺎﺯﮔﺸﺖ ﺣﺲ ﺩﺭ ﮐﺪﺍﻡ ﻳﮏ ﺍﺯ ﺍﻋﺼﺎﺏ ﻣﺪﻳﺎﻥ ﻭ ﺍﻭﻟﻨﺎﺭ ﺑﻬﺘﺮ ﺍﺳﺖ، ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻃﺮﺍﺣﻲ ﻭ ﺍﺟﺮﺍ ﺷﺪﻩ ﺍﺳﺖ ﻣﻮﺍﺩ ﻭ ﺭﻭﺵ ﻫﺎ: 65 ﺑﻴﻤﺎﺭ ﻣﺮﺍﺟﻌﻪ ﮐﻨﻨﺪﻩ ﺑﻪ ﻣﺮﮐﺰ ﺁﻣﻮﺯﺷﻲ ﻭ ﺩﺭﻣﺎﻧﻲ ﺣﻀﺮﺕ ﻓﺎﻃﻤﻪ ﺱ( ﮐﻪ ﺑﻪ ﻋﻠﺖ ﻗﻄﻊ ﻋﺼﺐ ﻣﺪﻳﺎﻥ، ﺍﻭﻟﻨﺎﺭ ﻳﺎ ﻫﺮ ﺩﻭ، ﺩﺭ ﻧﺎﺣﻴﺔ ﻣﭻ ﺩﺳﺖ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺷﺪﻩ ﺑﻮﺩﻧﺪ ﻭ ﺣﺪﺍﻗﻞ 9 ﻣﺎﻩ ﺍﺯ ﺯﻣﺎﻥ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺁﻧﻬﺎ ﻣﻲ ﮔﺬﺷﺖ، ﻣﻮﺭﺩ ﻣﻄﺎﻟﻌﻪ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻨﺪ. ﺗﺴﺖ ﻫﺎﻱ ﺍﻓﺘﺮﺍﻕ ﺩﻭ ﻧﻘـﻄﻪ ﺛﺎﺑﺖ ﻭ ﻣﺘﺤﺮﮎ ﻭ ﺗﺴﺖ ﻣﻮﻧﻮﻓﻴﻼﻣﺎﻥ ﺑﻪ ﺭﻭﺵ ﺍﺳﺘﺎﻧﺪﺍﺭﺩ ﺍﻧﺠﺎﻡ ﺷﺪ. ﻳﺎﻓﺘﻪ ﻫﺎ: ﻣﻴﺎﻧﮕﻴـﻦ ﺳﻨﻲ ﺑﻴﻤﺎﺭﺍﻥ 10 ± 27/2 ﺑﻮﺩ. 58 ﻧﻔﺮ ﺍﺯ ﺑﻴﻤﺎﺭﺍﻥ ﻣﺮﺩ ﺑﻮﺩﻧﺪ. ﺑﻴﺸﺘﺮﻳﻦ ﻋﺼﺒﻲ ﻛﻪ ﺩﭼﺎﺭ ﺁﺳﻴﺐ ﺩﻳﺪﮔﻲ ﺷﺪﻩ ﺑﻮﺩ، ﻋﺼـﺐ ﺍﻭﻟﻨﺎﺭ ﺍﺳﺖ ﻛﻪ ﺩﺭ 46/2 ﺑﻴﻤﺎﺭﺍﻥ ﺭﺥ ﺩﺍﺩﻩ ﺑﻮﺩ. ﻋﺼﺐ ﻣﺪﻳﺎﻥ ﺩﺭ 36/9 ﺑﻴﻤﺎﺭﺍﻥ ﺁﺳﻴﺐ ﺩﻳﺪﻩ ﺑﻮﺩ. ﺁﺳﻴﺐ ﺗﻮﺃﻡ ﻋﺼﺐ ﺍﻭﻟﻨـﺎﺭ ﻭ ﻣﺪﻳﺎﻥ ﺩﺭ 16/9 ﺑﻴﻤـﺎﺭﺍﻥ ﻭﺟﻮﺩ ﺩﺍﺷﺖ. ﻣﻴﺎﻧﮕﻴﻦ ﺯﻣﺎﻥ ﺑﺮﺭﺳﻲ ﺑﻴﻤﺎﺭﺍﻥ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ ﺟﺮﺍﺣﻲ 12 ± 24/5 ﻣﺎﻩ ﺑﻮﺩ. ﺩﺭ ﻣﺒﺘﻼﻳﺎﻥ ﺑﻪ ﺁﺳﻴﺐ ﻋﺼـﺐ ﻣﺪﻳﺎﻥ ﺍﻧﮕﺸﺖ ﻣﻴﺎﻧﻲ ﻭ ﺩﺭ ﻣﺒﺘﻼﻳﺎﻥ ﺑﻪ ﺁﺳﻴﺐ ﻋﺼﺐ ﺍﻧﮕﺸﺖ ﮐﻮﭼﮏ ﺑﻴﺸﺘﺮﻳﻦ ﺍﺧﺘﻼﻝ ﺣﺴﻲ ﺭﺍ ﺩﺍﺷﺘﻨﺪ. ﻧﺘﺎﻳﺞ ﺗﺴﺖ ﻣﻨـﻮﻓﻴﻼﻣﺎﻥ، ﺍﻓﺘـﺮﺍﻕ ﺩﻭ ﻧﻘـﻄﻪ ﺍﺳﺘﺎﺗﻴﮏ ﻭ ﺩﻳﻨﺎﻣﻴﮏ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ ﺑﺎ ﺁﺳﻴﺐ ﻋﺼﺐ ﻣﺪﻳﺎﻥ ﺑﻪ ﻧﺴﺒﺖ ﺁﺳﻴﺐ ﻋﺼﺐ ﺍﻭﻟﻨﺎﺭ ﺑﻬﺘﺮ ﻭ ﺗﻔﺎﻭﺕ ﻣﻌﻨﻲ ﺩﺍﺭ ﺑﻮﺩ. ﻧﺘﻴﺠﻪ ﮔﻴـﺮﻱ: ﻫﺮﭼﻨﺪ ﺩﺭ ﺍﻏﻠﺐ ﻣﻨـﺎﺑﻊ ﺍﻧﮕﺸﺖ ﺍﺷﺎﺭﻩ ﺑﻪ ﻋﻨﻮﺍﻥ ﻣﻨﻄـﻘﻪ ﺑﺮﺭﺳﻲ ﺍﺧﺘﻼﻝ ﺣﺲ ﺩﺭ ﻗﻄـﻊ ﻋﺼـﺐ ﻣﺪﻳﺎﻥ ﺫﮐﺮ ﺷﺪﻩ ﺍﺳﺖ، ﺍﻣﺎ ﺩﺭ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺑﻴﺸﺘﺮﻳﻦ ﻣﻴﺰﺍﻥ ﺍﺧﺘﻼﻝ ﺣﺲ ﺩﺭ ﻫﺮ ﺳﻪ ﺗﺴﺖ ﺍﻧﺠـﺎﻡ ﺷﺪﻩ ﺍﻧﮕﺸﺖ ﻣﻴﺎﻧﻲ ﺑﻴﻤﺎﺭﺍﻥ ﺑﻮﺩﻩ ﺍﺳﺖ، ﺑﻪ ﻫﻤﻴﻦ ﺩﻟﻴﻞ ﺑﻬﺘﺮ ﺍﺳﺖ، ﻫﻨﮕﺎﻡ ﻣﻌﺎﻳﻨﻪ ﻳﺎ ﺍﻧﺠـﺎﻡ ﺗﺴﺖ ﻫﺎﻱ ﺗﺸﺨﻴﺼﻲ ﺩﺭ ﺑﻴﻤـﺎﺭﺍﻥ ﺑﺎ ﻗﻄـﻊ ﻋﺼﺐ ﻣﺪﻳﺎﻥ ﺑﻪ ﺍﻧﮕﺸﺖ ﻣﻴﺎﻧﻲ ﺑﻪ ﻋﻨﻮﺍﻥ ﻣﻨﻄﻘﻪ ﺩﺍﺭﺍﻱ ﺑﻴﺸﺘﺮﻳﻦ ﺍﺧﺘﻼﻝ ﺣﺲ ﺗﻮﺟﻪ ﺷﻮﺩ. ﻫﻤﭽﻨﻴﻦ ﺩﺭ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺛﺎﺑﺖ ﺷﺪﻩ ﺍﺳﺖ ﺩﺭ ﺷﺮﺍﻳﻂ ﻣﺸﺎﺑﻪ ﺍﺯ ﻧﻈﺮ ﺳﻦ، ﻧﻮﻉ ﺻﺪﻣﻪ، ﻓﺎﺻﻠﻪ ﺯﻣﺎﻧﻲ ﺑﻴﻦ ﺻﺪﻣﻪ ﺗﺎ ﺗﺮﻣﻴﻢ ﻭ ﻧﻮﻉ ﺗﺮﻣﻴـﻢ، ﻧﺘﺎﻳﺞ ﺣﺴﻲ ﺩﺭ ﻋﺼﺐ ﻣﺪﻳﺎﻥ ﺑﻬﺘﺮ ﺍﺯ ﺍﻭﻟﻨﺎﺭ ﺍﺳﺖ. ﺗﻮﭘﻮﮔﺮﺍﻓﻲ ﮐﻤﺘﺮ ﭘﻴﭽﻴﺪﻩ ﻋﺼﺐ ﻣﺪﻳﺎﻥ، ﺁﻧﺎﺗﻮﻣﻲ ﺳﺎﺩﻩ ﺗﺮ ﺍﻳﻦ ﻋﺼﺐ، ﮐﻮﭼﮑﺘـﺮ ﺑﻮﺩﻥ ﻗﺴﻤﺖ ﺣﺮﮐﺘﻲ ﺁﻥ ﺩﺭ ﻣﭻ ﻭ ﺭﺍﺣﺖ ﺗﺮ ﺩﺭ ﻣﻌـﺮﺽ ﺩﻳﺪ ﻗـﺮﺍﺭ ﮔﺮﻓﺘﻦ ﻋﺼﺐ ﺩﺭ ﻃﻲ ﺟﺮﺍﺣﻲ ﻣﻲ ﺗﻮﺍﻧﻨﺪ ﺍﺯ ﻋﻠﻞ ﺍﻳﻦ ﻧﺘﺎﻳﺞ ﺑﻬﺘـﺮ

Introduction & Objective: Traumatic nerve damage is quiet a frequent event in the upper extremity. Microscopic reconstructive nerve repair is usually used to restore the continuity of the injured nerve. Restoration of the sensory ability of the nerve is of great importance in normalization of the hand function. Since we could not find an individual study comparing the sensory out come between median and ulnar repair, we designed this study to better understand the results of sensational out comes between these two nerves. Materials & Methods: During 3 Months period, 65 patients who had median, ulnar or both nerves injuries at the wrist level, and who had been operated upon in Hazrat Fatemeh Hospital were assessed with regard sensibility improvement were compared with each other. The criterias for inclusion were negative history of medical illness and adequate follow-up (at last 9 months) after surgery. The sensory evaluation was performed by monofilament test, static and moving two point discrimination, and the results were compared. Results: Of the 65 patients included in this study, the mean age was 27.2 years. The cause of trauma was predominantly laceration with glass. Ulnar nerve was the most commonly injured nerve (46.2%) and sole median nerve injury was observed in 36.9% of patients. In 16.9% of the patients both ulnar and median nerve were damaged. The mean time for patient evaluation was 24.5 months after surgery. Middle finger was the mostly impaired one in the test after median nerve injuries and the little finger was the mostly impaired one in the tests after ulnar injuries. The results show that the sensory return is better and higher in median nerve repairs in comparison to ulnar nerve repairs at the wrist level. Conclusions: In upper limb nerve injuries, radial nerve has the best prognosis and the ulnar nerve has the worst one. In our study, however it is shown that in the same condition of age, cause of trauma, time elapsed before surgery and surgical method, sensory return in median nerve is better that ulnar nerve at wrist level. This can be due to less complexity of the median nerve in terms of anatomy and topography, smaller motor component and easier exposure during surgery. Also, the best area for evaluation of sensory impairment and return after median nerve injury is the volar side of middle finger.