REMARKS on the OPERATIVE TREATMENT of CHRONIC FACIAL PALSY of PERIPHERAL ORIGIN
REMARKS on the OPERATIVE TREATMENT of CHRONIC FACIAL PALSY of PERIPHERAL ORIGIN
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周围源性慢性面瘫手术治疗浅议
DOI：
10.1136/bmj.1.2209.1009
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发表时间：
1903
影响因子：
--
通讯作者：
P. Stewart
中科院分区：
文献类型：
--
作者：
C. Ballance;H. Ballance;P. Stewart
脑外源性面神经麻痹的预后是非常多变的。虽然在大多数所谓的“风湿性”病例中，恢复的前景是好的，但在其他病例中，特别是那些由于创伤或化脓性中耳炎累及输卵管的病例中，可能无法恢复，患者注定终身毁容。下面的一系列病例是试图通过在另一个健康神经和瘫痪面部远端段之间进行吻合来处理未治愈的残留物。这种手术的基本原理在很大程度上是基于我们两人一年前发表的一项工作中得出的结论，根据这项工作，再生发生在分离神经的远段，即使与中枢神经分离。然而，这种再生不会达到完全成熟，除非远端节段连接到近端，以便允许神经中枢和外周之间的冲动传输。根据另一种观点，迄今为止更流行的一种观点，再生是通过从中央到远端的向下生长过程发生的。后者起着完全被动的作用，除非重新结合，否则一段时间后就会变成一条单纯的纤维索，沿着这条纤维索，神经纤维从中央段向外周向下生长，几乎不可能到达肌肉。另一方面，如果像我们已经证明的那样，再生发生在远段本身（不成熟，这是真的），那么只要有任何肌纤维存活下来，可以被再生和重新结合的神经支配，就不应该有太长的时间间隔来尝试重新结合。例如，在我们的一个案例中，瘫痪已经存在了将近三年，但随后又恢复了。而且，我们看不出有任何先验的理由不应超过这一限度，只要如前所述，肌肉纤维仍然存在，由恢复的神经支配。本系列病例的手术方法如下：-首先通过电流刺激确认麻痹侧面部的肌纤维仍然存活，然后通过手术在茎突乳突孔的出口处暴露面神经。尽可能高地切断神经干，并保留远端节段的微小部分用于显微镜检查。然后暴露脊副神经，在便于与分离的面神经结合的水平处切开其鞘，并通过细丝线缝合将面神经的远端段固定到鞘中。伤口愈合后，瘫痪一侧的肌肉连续几个月每天接受电流刺激，直到感应电兴奋性再次出现，这时感应电被取代。在每一个进行显微镜检查的情况下，新的神经纤维被证明在瘫痪的面部的远段。（比较图1和图2）8、9、10）。
THE prognosis in facial 'palsy of extracerebral origin is a very variable one. Whilst in the majority of so-called "rheumatic" cases the prospects of recovery are good, yet in other cases, and especially those due to traumatiam or to involvement of the Fallopian aqueduct by a suppurative otitis media, recovery may not occur and the patient is doomed to lifelong disfigurement. The following series of cases is an attempt to deal with the uncured residue by performing an anastomosis between another healthy nerve and the distal segment of the paralysed facial. The rationale of this procedure is based to a large extent upon the conclusions arrived at in a work published by two of us over a year ago,' according to which regeneration occurs in the distal segment of a divided nerve, even when separated from the central. Such regeneration, however, does not reach full maturity unless the distal segment is joined to the proximal, so as to permit of transmission of impulses between the nerve centres and the periphery. According to the other view, hitherto the more popular one, regeneration occurs by a process of downgrowth from the central into the distal segment. The latter playa an entirely passive part, and unless reunited becomes reduced after a time to a mere fibrous cord along which the downgrowth of nerve fibres from the central segment towards the periphery with any hope of reaching the muscles is practically impossible. If, on the other hand, as we have demonstrated, regeneration occurs (immature, it is true) in the distal segment itself, no interval of time ought to be too long for attempted reunion so long as any muscle fibres survive which can be innervated by the regenerated and reunited nerve. Thus, for example, in one of our cases the paralysis had existed for almost three years and yet recovery subsequently occurred. And we see no reason on a priori grounds why this limit should not be exceeded, providing always, as already stated, muscle fibres are still present to be innervated by the recovering nerve. The method of procedure in the present series of cases was as follows:-Having first assured ourselves by galvanic stimulation that muscle fibres still survived on the paralysed side of the face, the facial nerve was exposed by operation at its point of exit from the stylo-mastoid foramen. The nerve trunk was cut across as high up as possible, and a minute portion of the distal segment was reserved for microscopic examination. The spinal accessory nerve was then exposed, its sheath Incised at a level convenient for union with the divided facial, and into it the distal segment of the facial nerve was fixed by means of fine silk sutures. After healing of the wound, the muscles on the paralysed side were assiduously stimulated by daily galvanism for months, until faradic excitability reappeared, when faradism was substituted. In every case where microscopic examination was carried out, new nerve fibres were demonstrated in the distal segment of the paralysed facial. (Compare Figs. 8, 9, and io.)