Uticaj rezultata hirurškog lečenja povreda žbičnog živca na stepen funkcionalnog oporavka gornjeg ekstremiteta i kvalitet života

Abstract

Žbični živac je glavni opružač gornjeg ekstremiteta i njegova povreda dovodi do viseće šake, čime je onemogućena funkcija hvata i fine motorike, što dovodi do značajne nesposobnosti u obavljanju svakodnevnih i radnih aktivnosti i velikih socioekonomskih problema. Oporavak motorne funkcije perifernih nerava nakon hirurškog lečenja zavisi od uzroka i mehanizama povređivanja, vrste i nivoa nervne lezije, vremena i vrste preduzete hirururške intervencije, kao i prisustva udruženih povreda. Motorni oporavak pojedinih mišića ne mora značiti da će doći do adekvatnog funkcionalnog oporavka bolesnika i regresije simptoma, tako da je veoma bitno uključivanje ispitivanja funkcionalnog oporavka i kvaliteta života. Cilj ove studije jeste ispitivanje stepena funkcionalnog oporavka, kvaliteta života i prognostičkih faktora kod bolesnika koji su operisani zbog povrede žbičnog živca. Posebno su ispitani slučajevi kod kojih nije došlo do adekvatnog funkcinalnog oporavka, radi evaluacije i poboljšanja dijagnostičkih i terapijskih procedura. Uključeni su ispitanici koji su operisani zbog povrede žbičnog živca u Klinici za neurohirurgiju, Kliničkog centra Srbije u periodu od 2001.g. do 2020.g., a čiji je ishod lečenja ispitivan nakon isteka 12 meseci od operacije. U studiju motornog oporavka je uključeno ukupno 140 ispitanika, dok su isključeni ispitanici koji su lečeni konzervativno, oni sa povredom površne (senzitivne) grane i oni koji su operisani arteficijelnim graftom i tetivnim transferom. U studiju ispitivanja funkcionalnog oporavka i kvaliteta života je uključeno 129 ispitanika, koji su prihvatili da učestvuju u anketi. Snaga mišića je ispitivana na osnovu „British Medical Research Council“ skale (MRC skala), dok je stepen motornog oporavka klasifikovan na osnovu modifikovane skale po Highet i Holmesu. Ispitivani su ekstenzija šake, ekstenzija prstiju uključujući i palac, kao i abdukcija palca. Funkcionalni oporavak i kvalitet života je ispitivan anketiranjem na osnovu DASH („The Disabilities of the Arm, Shoulder and Hand“) i PNSQoL upitnika („Peripheral Nerve Surgery Quality of Life“). Povrede žbičnog živca su se javljale kod mlađih ljudi i većina njih su bili muškarci, dok je najčešći mehanizam povređivanja živca bila kontuzija usled preloma kosti. Prekid kontinuiteta živca je bio značajno češći kod traume visokog intenziteta. Kod većine ispitanika je urađena neuroliza (68%) i transplantacija graftom (26%), dok su direktna sutura i nervni transfer bili značajno ređi. Korisni motorni oporavak dobijen kod 91.4% ispitanika i to u 96% slučajeva neurolize, 78% transplantacije graftom i kod 100% u slučaju direktne suture i nervnog transfera. Operacija u prvih 6 meseci od povrede, trauma niske energije, lezija nerva u kontinuitetu i transplantacija kraćim graftovima su bili povezani sa boljim motornim oporavkom, dok pol, starost, pušenje, udružene bolesti i stepen nervnog deficita nisu bili prognostički faktori. Prosečna vrednost DASH i PNSQoL skora je iznosila 18.2 i 66.2, što ukazuje na dobar funkcionalni oporavak i nizak stepen nesposobnosti operisanih bolesnika. Bolesnici sa prekidom kontinuiteta nerva su češće izjavljivali poteškoće u izvođenju pojedinih aktivnosti i imali manji stepen zadovoljstva ishodom operacije. Postojala je značajna negativna korelacija između vrednosti DASH skora i stepena motornog oporavka i značajna pozitivna korelacija u slučaju PNSQoL skora. Stepen funkcionalnog oporavka i kvaliteta života nakon hirurškog lečenja žbičnog živca je odličan, sa minimalnim stepenom nesposobnosti i visokim zadovoljstvom bolesnika. Kasno javljanje bolesnika, povrede silom visokog intenziteta, prekid kontinuiteta nerva i potreba za dugim graftovima imaju slabiji oporavak i zahtevaju strožiju evaluaciju, raniju hirurgiju i korišćenje nervnih i tetivnih transfera, kako bi se poboljšao ishod operativnog lečenja.

Radial nerve is the main extensor of the upper extremity and its injury leads to wrist fall, characterized by dysfunction of grasp and fine motor movement, which further leads to disability in every day and work activities, as well as to socioeconomic problems. Recovery of motor function following peripheral nerve surgery may depend on the cause and mechanism of injury, type and location of nerve lesion, the timing of the treatment, type of surgical procedure, as well as presence of associated injuries. Motor recovery of some muscles do not guarantee the adequate functional recovery of the patient´s symptoms regression, therefore, it is very important to include an assessment of the functional recovery and quality of life. The aim of this study was to examine functional recovery, quality of life, and prognostic factors in patients surgically treated due to radial nerve injury. The patients without adequate functional recovery were further analyzed, in order to evaluate and improve diagnostic and therapeutic procedures. The study included patients surgically treated due to radial nerve injury at the Clinic for Neurosurgery, University Clinical Center of Serbia, in the period from 2001-2020, with minimal follow up of 12 months. 140 patients were included for motor recovery examination, while few were excluded (conservative treatment; isolated superficial sensory radial nerve (SSRN) lesion; treatment with artificial nerve graft or tendon transfer). 129 patients, who accepted to fill the questionnaires, were included for functional recovery and quality of life assessment. Muscle strength was evaluated by using the „British Medical Research Council“ scale (MRC scale), while the level of motor recovery was classified using a modified scale of Highet and Holmes. Extension of the wrist, extension of the fingers and thumb, and thumb abduction were evaluated. Functional recovery and quality of life were evaluated by filling the questionnaires: DASH („The Disabilities of the Arm, Shoulder and Hand“) and PNSQoL („Peripheral Nerve Surgery Quality of Life“). Radial nerve injuries occurred more commonly in younger individuals, and the majority of them were male, while the most common mechanism of nerve injury was fracture-related contusion. Disruption of nerve continuity was significantly more common in high-energy traumas. The majority of the patients were treated by neurolysis (68%) and sural nerve grafting (26%), while only a few were treated by direct suture or nerve transfer. Useful functional recovery was achieved in 91.4% of the analyzed patients, as well as in 96% of the cases with neurolysis, 78% of the cases with sural nerve grafting, and all cases with direct suture. Surgical treatment in the first 6 months since the injury, low-energy trauma, lesions with preserved continuity and lower graft length were associated with better motor recovery, while gender, age, smoking habits, presence of associated diseases, and level of nerve failure were not significant prognostic factors. Mean DASH and PNSQoL scores were 18.2 and 66.2, respectively, which indicates good functional recovery and a low rate of postoperative disability. The patients with the nerve disrupted in continuity more commonly reported difficulties in performing some activities and were less satisfied with the result of surgery. There was a significant negative correlation between the DASH score and quality of motor recovery, as well as a significant positive correlation with the PNSQoL score. The level of the functional recovery, as well as the quality of life following surgical treatment of radial nerve injuries were excellent, with a minimal rate of disability and a high level of patient’s satisfaction. Late referral of the patients, injuries due to high-energy trauma, disruption in nerve continuity and need for long grafts were associated with the poorer recovery and require stricter evaluation, earlier surgery and use of the nerve and tendon transfers, in order to improve final outcome.