| Objective: Utilizing body bony landmarks and spiral computed tomography technique,to identify the location of nerve entry points(N points)and the depth of the center of intramuscular nerve dense regions(CINDR)in the anterior brachial and thoracico-upper-limb muscles in order to provide morphological guidance for the treatment of spasticity by extramuscular neurolysisor and intramuscular chemodenervation.Methods: 1.Twenty-two Chinese adult cadavers with no history of neuromuscular diseases,no upper limb and thoracic joint deformity(man,16;women,6)were chosen for this study.Ten cadavers were used for gross observation,and the other 12 were used for target study.Cadavers were placed insupine anatomical position.2.The reference lines for nerve block in the anterior anterior brachial muscles were designed.A line joining the acromion and the most inferior point of the jugular notch was defined as a horizontal reference line(H1)for the N point of coracobrachialis muscle branch.Another line joining the lateral epicondyle and the medial epicondyle of humerus was defined as the horizontal reference line(H2)for the N point of the biceps brachii and brachialis muscle branches.A line joining the acromion to the lateral epicondyle of humerus was defined as the longitudinal reference line(L).3.The reference linesfor thoracico-upper-limb muscles were designed as the following: A line from the most inferior pointof the jugular notchto the junction of sternum and xiphoid process was defined as the longitudinal reference line(L).A line joining the acromion and the most inferior point of the jugular notch was defined as a horizontal reference line(H1)for the N point of pectoralis major and pectoralis minor muscles,and another line from the anterior axillary line to the posterior axillary line through the N point was defined as the horizontal reference line(H2)for the serratus anterior muscle.4.Sihler's staining showed intramuscular nerve dense regions(INDR)and CINDR.5.Following the dissection of nerve entry points(NEPs)and the identification of the contralateral muscle mass of CINDR,the NEPs were labeled with barium sulfate,scanned with spiral computed tomography,and three-dimensional reconstructed.The projection point of the NEP and CINDR on the body surface was designated as P;P by N or CINDR projecting on the opposite side of the body surface was designated as P';The intersection points between P and H,and that between P and L were designated as PH and PL,respectively;The location of PH and PL on the H and L,and the depth of NEP were determined by Syngo system.6.Statistical processing.Results: 1.General anatomical findings: usually only one N point was found for the 3muscles of the anterior arm.Two N points were found for the lateral pectoral nerve entering pectoralis major and they are close to each other.One N point is for the medial pectoral nerve and one for pectoralis minor.The end of long thoracic nerve entered the serratus anterior muscleat the fifth muscle teeth.Vasculature accompanied nerves at the entrance.2.Sihler's intramuscular nerve staining showed the following INDR distribution: The number of INDRs in coracobrachialis,biceps brachii,brachialis,pectoralis major,and pectoralis minor were 3,2,2,2 and 1,respectively.There were 1INDR in each muscle teeth on serratus anterior.3.The position and depth of the N points of the anterior brachial muscles: The PH of coracobrachialis branch,biceps brachii short head branch,biceps brachii long head branch,and brachialis muscle branch were located at(18.38 ± 1.78)% of H1,(56.85 ± 4.41)%,(52.81 ± 4.36)% and(57.52 ± 4.22)% of H2,respectively;PL were at(24.86 ± 4.52)%,(50.20 ± 4.89)%,(55.91 ± 3.89)% and(64.31±4.32)% of the L respectively.The depth of N points past P points were located at(23.16 ± 2.73)%,(24.68 ± 2.55)%,(26.32 ± 3.20)% and(38.19 ± 3.36)% of the PP' line respectively.4.The position and depth of the N points of the anterior thoracic muscles:The PH of pectoralis major lateral pectoralis nerve branch,pectoralis major muscle medial pectoralis nerve branch,and pectoralis minor muscle medial pectoralis nerve branchwere located at(47.83±1.75)%,(32.31±4.18)%(men)and(34.31±3.03)% of H1,respectively.The PH of serratus anterior long thoracic nerve branch were located at(63.77±3.33)% ofH2;PL were at(-9.84±1.62)%,(36.16±4.51)%(men),(2.44±1.16)% and(73.84±2.36)% of the L,respectively.The depth of N points past P points were located at(17.76±2.84)%,(17.53 ±3.14)%(men)and(25.51±2.31)% of the PP' line,respectively.The depth of N points of serratus anterior long thoracic nerve branch is at(1.63±0.24)cm.5.The position and depth of the CINDR of the anterior brachial muscle on body surface: The PH of coracobrachialis muscle CINDR 1,2and 3 were located at(24.22±1.49)%,(18.89±1.49)%and(8.15±1.14)% of H1,respectively,the PLwere at(21.37±2.48)%,(31.78±2.32)% and(30.07±1.12)% of the L,respectively.The depth of CINDR1,2 and 3 past P points were located at(22.81±1.59)%,(26.76±1.32)%,(27.99±2.04)% of the PP' line,respectively.The PH of biceps brachii CINDR1,2 were located at(49.68±2.03)% and(40.28±2.58)% of H2,respectively,PL were at(56.60 ± 3.35)% and(67.63 ± 3.29)% of the L,respectively.The depth of CINDR1 and 2 past P points were located at(14.79±1.35)% and(17.45±1.28)% of the PP' line,respectively.The PH of brachialis muscle CINDR1,2 were located at(48.34±3.25)% and(52.45±3.47)% of H2,PL were at(71.30±3.06)% and(81.62±4.70)% of the L,respectively.The depth of CINDR1 and 2 past P points were located at(34.03±1.10)% and(30.26±3.14)% of the PP' line,respectively.6.The position and depth of the CINDR of the thoracico-upper-limb muscles on the body surface: The PH of pectoralis major's CINDR1,2 were located at(41.95±2.72)% and(55.88±2.06)% of H1,respectively,PL were at(-3.87±0.92)% and(25.29±2.73)% of the L,respectively,The depth of CINDR1,2 past P points were located at(5.23±0.94)% and(6.75±0.98)% of the PP' line,respectively.The PH of pectoralis minor muscle CINDR was located at(32.58±3.77)% of H1,PL was at(-7.13±0.99)% of the L,the depth of CINDR past P points were located at(13.73 ± 2.27)% of the PP' line.The PH of the 7th CINDR of serratus anterior was located at(84.08±1.77)% of H2,PL were at(100±1.86)% of the L.The depth of CINDR averaged about(1.86±0.35)cm.Conclusion: 1.The body locations and puncture depth of nerve entry points are different from that of center of intramuscular nerve dense regions in the same muscle.2.The localization of the nerve entry points and center of intramuscular nerve dense regions can help to improve the efficacy and efficiency of the extramuscular neurolysis and intramuscular nerve block neurolysis for the treatment of spasticity inthe anterior brachial and thoracico-upper-limb muscles.3.It is advisable to block the nerve entry point of the lateral pectoral nerve when treating woman patients with pectoralis major muscle spasticity.4.Other than serratus anterior,which should preferably be treated with extramuscular neurolysis,any other muscles in this study can be arbitrarily treated for spasticity with either extramuscular neurolysis or intramuscular chemodenervation. |
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