滑膜增生型腕管綜合征的手術(shù)治療

李建強(qiáng) 姜保國 陳建海 付中國 王天兵

滑膜增生型腕管綜合征的手術(shù)治療

李建強(qiáng) 姜保國 陳建海 付中國 王天兵

目的探討滑膜增生型腕管綜合征（carpal tunnel syndrome，CTS）的臨床表現(xiàn)、手術(shù)治療方法及療效。方法對2004年10月至2010年10月收治的63例（75側(cè)）經(jīng)保守治療3個月無效的滑膜增生型CTS患者行腕橫韌帶切開減壓、腕管內(nèi)滑膜清除、正中神經(jīng)松解治療，術(shù)后將切除滑膜進(jìn)行病理學(xué)檢查。以Kelly標(biāo)準(zhǔn)評價手術(shù)效果。結(jié)果術(shù)后46例（50側(cè)）患者獲得隨訪，隨訪時間為3～12個月，平均4．6個月；病理學(xué)檢查顯示：正中神經(jīng)周圍纖維結(jié)締組織水腫變性，滑膜組織增生，淋巴細(xì)胞、漿細(xì)胞浸潤；術(shù)后3個月行神經(jīng)電生理檢查50側(cè)，正中神經(jīng)運(yùn)動傳導(dǎo)速度、感覺傳導(dǎo)速度、運(yùn)動遠(yuǎn)端潛伏期、感覺遠(yuǎn)端潛伏期與術(shù)前比較差異有統(tǒng)計學(xué)意義（t＝－6．095、－2．935、15．895、16．011，P均＜0．05）；按照Kelly標(biāo)準(zhǔn)：優(yōu)32側(cè)，良14側(cè)，一般4側(cè)，差0側(cè)。結(jié)論夜間因滑膜充血腫脹劇烈導(dǎo)致麻木疼痛加劇，以及神經(jīng)電生理檢查顯示正中神經(jīng)運(yùn)動、感覺傳導(dǎo)速度降低程度較輕，是滑膜增生型CTS的典型臨床表現(xiàn)；切斷腕橫韌帶的同時行腕管內(nèi)滑膜切除是治療滑膜增生型CTS的有效方法。

腕管綜合征；神經(jīng)電生理檢查；腕管切開減壓；正中神經(jīng)松解術(shù)

腕管綜合征（carpal tunnel syndrome，CTS）是周圍神經(jīng)卡壓性疾病中最常見的一種，是正中神經(jīng)在腕管內(nèi)受到壓迫所產(chǎn)生的一組臨床綜合征［1］，腕橫韌帶堅韌、近側(cè)緣增厚是壓迫正中神經(jīng)的主要因素。正常情況下，腕管內(nèi)存在大量的肌腱滑膜，對肌腱起到營養(yǎng)和潤滑作用。但是，由于肌腱滑膜過度增生，甚至出現(xiàn)充血、水腫等炎癥反應(yīng)會導(dǎo)致或加重對正中神經(jīng)的壓迫，并對神經(jīng)產(chǎn)生炎性刺激。CTS的主要臨床表現(xiàn)是橈側(cè)三個半手指麻木和疼痛，疼痛向手部和前臂放射，拇指對掌功能受限，大魚際肌萎縮，握力和捏力減弱［2］。而滑膜增生型CTS由于滑膜在夜間充血加重，回流停滯，會出現(xiàn)明顯的夜間疼痛、麻木，甚至在夜間的固定時間麻醒，這是滑膜增生型CTS的典型癥狀。很多患者在麻醒后通過活動手指、手腕促進(jìn)了腕管內(nèi)滑膜的回流，降低腕管內(nèi)壓力以緩解疼痛。所以在臨床上會出現(xiàn)靜息狀態(tài)下臨床表現(xiàn)與活動后電生理檢查結(jié)果不能夠完全符合的現(xiàn)象。自2004年10月至2010年10月北京大學(xué)人民醫(yī)院創(chuàng)傷骨科共收治滑膜增生型CTS患者63例（75側(cè)），采用腕管切開、腕橫韌帶切斷、滑膜切除、正中神經(jīng)松解的方法進(jìn)行治療，取得了良好的治療效果，報道如下。

材料和方法

一、一般資料

本組患者63例（75側(cè)），其中男性16例，女性47例；年齡40～82歲，平均年齡62歲；右側(cè)36例，左側(cè)15例，雙側(cè)12例；病程最長8年，最短3個月。出現(xiàn)癥狀至就診的時間為3周至2年。發(fā)病原因：49例為長期慢性損傷所致，14例由代謝免疫性疾病所致（多為雙側(cè)），例如類風(fēng)濕性關(guān)節(jié)炎、痛風(fēng)、干燥綜合征等。所有患者無明確腕部外傷、骨折、脫位病史，無腕部腫物。患者癥狀主要為腕部疼痛、麻木和握、捏無力，夜間常常痛醒，有時可向肘部和肩部放射，不停甩手后癥狀可改善。查體：腕部Tinel征陽性，橈側(cè)3個半手指掌側(cè)感覺異常、大魚際肌不同程度的萎縮。術(shù)前行神經(jīng)電生理檢測，包括正中神經(jīng)運(yùn)動傳導(dǎo)速度、感覺傳導(dǎo)速度、運(yùn)動遠(yuǎn)端潛伏期和感覺遠(yuǎn)端潛伏期。本組患者術(shù)前均接受過非甾體抗炎藥，局部理療和腕管內(nèi)注射等保守治療，保守治療后臨床癥狀均有不同程度的緩解，但多數(shù)因癥狀復(fù)發(fā)或反復(fù)發(fā)作，嚴(yán)重影響患者的生活質(zhì)量來我院要求手術(shù)治療。63例（75側(cè)）患者均行腕橫韌帶切開減壓、腕管內(nèi)滑膜切除、正中神經(jīng)松解治療。

二、手術(shù)方法

患者均采用臂叢神經(jīng)阻滯麻醉，麻醉成功后患者取平臥位，患肢外展，上氣囊止血帶，壓力300mmHg，常規(guī)消毒鋪無菌巾，魚際紋中點(diǎn)至腕橫紋做長約3cm弧形切口，切開皮膚、皮下組織及掌腱膜層。首先在腕橫紋水平切開腕橫韌帶，并直視下向近端切開腕橫韌帶，切開腕橫韌帶時嚴(yán)格防止損傷深層的正中神經(jīng)，直至全部切斷腕橫韌帶，在魚際紋中點(diǎn)及其以遠(yuǎn)注意損傷正中神經(jīng)返支。術(shù)中見腕橫韌帶明顯增厚，正中神經(jīng)在腕橫韌帶下方受壓，神經(jīng)變扁，外膜增厚，受壓部色澤暗淡，可見神經(jīng)營養(yǎng)血管中斷現(xiàn)象，周圍有疤痕，腕管內(nèi)屈指深、淺肌腱被大量滑膜組織包裹。在切斷腕橫韌帶之后，分離正中神經(jīng)，根據(jù)神經(jīng)受到卡壓及增生情況決定是否行神經(jīng)外膜松解。如果行神經(jīng)外膜松解，用顯微手術(shù)剪松解神經(jīng)增生的組織，縱行切開病變上下端的神經(jīng)外膜，直至顯露正常柔軟的神經(jīng)，從而完成徹底松解。嚴(yán)格保護(hù)正中神經(jīng)，分離腕管內(nèi)的屈指深、淺肌腱，仔細(xì)切除增生、病變的滑膜組織。松止血帶，嚴(yán)格創(chuàng)面止血，留置引流條，縫合掌腱膜層及全層縫合切口皮膚。將所切除的肌腱周圍滑膜組織送病理檢查。

三、術(shù)后處理

術(shù)后24h內(nèi)拔除引流條，在醫(yī)生指導(dǎo)下進(jìn)行手指的屈曲和背伸活動，防止肌腱黏連，夜間將患側(cè)肢體抬高減輕腫脹；術(shù)后14d傷口拆線；口服甲鈷胺片3周；手術(shù)4～6周后完全正?；顒?。

四、療效判斷標(biāo)準(zhǔn)

術(shù)后3個月以Kelly標(biāo)準(zhǔn)評價手術(shù)效果，優(yōu)：癥狀完全消失；良：癥狀明顯緩解；一般：癥狀輕度減輕或者持續(xù)；差：癥狀不變或加重。并進(jìn)行神經(jīng)電生理檢測。

五、統(tǒng)計學(xué)分析

采用SPSS統(tǒng)計學(xué)軟件，使用配對樣本t檢驗分析，P＜0．05為差異有統(tǒng)計學(xué)意義。

結(jié) 果

共計46例患者（50側(cè)）獲得3個月以上的臨床隨訪，術(shù)后隨訪時間平均為4．6個月，術(shù)后第1天手麻、脹痛癥狀均有不同程度減輕，夜間麻醒癥狀消失。手術(shù)切口愈合良好，沒有出現(xiàn)感染、長期不愈合等并發(fā)癥，無瘢痕攣縮，術(shù)后3～12個月無復(fù)發(fā)。所有患者術(shù)后未出現(xiàn)正中神經(jīng)、掌淺弓、正中神經(jīng)返支損傷等并發(fā)癥。

術(shù)中可見周圍滑膜組織明顯增生，壓迫正中神經(jīng)，術(shù)后病理檢查顯示：正中神經(jīng)周圍纖維結(jié)締組織水腫變性，滑膜組織增生，淋巴細(xì)胞、漿細(xì)胞浸潤（圖1、2）。

圖1 滑膜組織明顯增生

圖2 纖維結(jié)締組織水腫變性，滑膜組織增生，淋巴細(xì)胞、漿細(xì)胞浸潤

術(shù)前電生理檢測顯示正中神經(jīng)運(yùn)動、感覺傳導(dǎo)速度無明顯減低，分別為（48．32±3．68）m／s、（46．32±3．68）m／s；術(shù)后3個月行神經(jīng)電生理檢查50側(cè)，正中神經(jīng)運(yùn)動、感覺傳導(dǎo)速度分別是（51．64±2．70）m／s、（50．11±3．47）m／s，較術(shù)前加快，差異有統(tǒng)計學(xué)意義（t＝－6．095、－2．935，P均＜0．05）；正中神經(jīng)運(yùn)動遠(yuǎn)端潛伏期由（4．38±0．40）ms縮短為（3．47±0．27）ms，感覺遠(yuǎn)端潛伏期由（5．12±0．36）ms縮短為（4．14±0．31）ms，差異有統(tǒng)計學(xué)意義（t＝15．895、16．011，P均＜0．05）（表1）。

按照Kelly標(biāo)準(zhǔn)，術(shù)后優(yōu)32側(cè)，夜間痛、手指麻木完全消失；良14側(cè)，夜間痛、手指麻木較前明顯緩解，未完全消失；一般4側(cè)；差0側(cè)，優(yōu)良率為96%（表2）。

表1 術(shù)前、術(shù)后正中神經(jīng)電生理比較（±s）

表1 術(shù)前、術(shù)后正中神經(jīng)電生理比較（±s）

組別 運(yùn)動傳導(dǎo)速度（m／s）運(yùn)動遠(yuǎn)端潛伏期（ms）感覺傳導(dǎo)速度（m／s）感覺遠(yuǎn)端潛伏期（ms）術(shù) 前 48．32±3．68 4．38±0．40 46．32±3．68 5．12±0．36術(shù) 后 51．64±2．70 3．47±0．27 50．11±3．47 4．14±0．31

表2 術(shù)后臨床療效評價（Kelly）

討 論

滑膜增生型CTS是臨床上較為常見的疾病，多發(fā)于40～60歲的女性。腕管是腕掌部的一個骨纖維管，拇長屈肌和4根屈指淺肌腱、4根屈指深肌腱及正中神經(jīng)通過此管進(jìn)入手部。腕管由腕骨和腕橫韌帶構(gòu)成。正常腕管內(nèi)壓為20～30mmHg，腕關(guān)節(jié)在完全屈伸位時腕管內(nèi)壓力升至94～110mmHg。正中神經(jīng)傳導(dǎo)速度的正常范圍是MNCV＝53．7m／s、SNCV＝57．5m／s［3］。X 線片可了解腕骨部位有無骨、關(guān)節(jié)病理改變。在臨床上，開放手術(shù)行腕橫韌帶切開、正中神經(jīng)松解被認(rèn)為是治療的金標(biāo)準(zhǔn)［4］。而近年來隨著內(nèi)窺鏡的普及和微創(chuàng)外科理念的深入，有很多患者接受了內(nèi)窺鏡微創(chuàng)治療［5－6］。然而內(nèi)窺鏡治療的原理是切斷腕橫韌帶從而減輕對正中神經(jīng)的壓迫作用，無法進(jìn)行腕管內(nèi)滑膜的切除及正中神經(jīng)的外膜松解。所以對于滑膜增生、滑膜的炎性反應(yīng)刺激正中神經(jīng)所引起的CTS，則需要通過開放手術(shù)進(jìn)行腕橫韌帶的切斷、滑膜的切除及正中神經(jīng)外膜松解，從根本上解決正中神經(jīng)受到壓迫和刺激的所有因素［7］。本組病例主要為中老年患者，與年輕患者相比較，中老年患者少有腕管內(nèi)骨性突起或外生腫物壓迫，大多為腕部長期勞損和免疫性、代謝性疾病患者，腕管內(nèi)肌腱、滑膜增生、肥厚，容積變小，壓力增高。其表現(xiàn)為由于組織缺血、缺氧，炎性物質(zhì)釋放而產(chǎn)生較為嚴(yán)重的正中神經(jīng)支配區(qū)疼痛癥狀。同時由于血流的淤滯、手指活動的減少，腕管內(nèi)滑膜的充血、腫脹會在夜間明顯加重，而在白天減輕，從而出現(xiàn)夜間麻木、脹痛等癥狀明顯加重，甚至出現(xiàn)夜間麻醒病史。對于此類CTS患者腕管徹底減壓的治療意義尤其重要。該病在病變的初期表現(xiàn)為正中神經(jīng)的水腫和充血，逐漸由于壓迫性缺血而造成神經(jīng)內(nèi)的纖維化、神經(jīng)軸突壓縮和髓磷脂鞘的消失，最后神經(jīng)組織轉(zhuǎn)為纖維組織，其神經(jīng)內(nèi)管消失并被膠原組織代替，成為不可逆的改變導(dǎo)致肌肉組織在失去神經(jīng)營養(yǎng)時出現(xiàn)局部萎縮的現(xiàn)象［8］。CTS分為3個時期。早期：腕橫韌帶肥厚，單純卡壓，癥狀較輕，無正中神經(jīng)病理形態(tài)改變；中期：多由長期卡壓，慢性損傷，代謝性疾病所致腕管內(nèi)肌腱、滑膜及神經(jīng)水腫，纖維增生，出現(xiàn)無菌性炎癥引起的神經(jīng)癥狀，此時正中神經(jīng)病變是可逆的，減壓后可恢復(fù)正常；晚期：運(yùn)動和感覺均明顯減退，正中神經(jīng)纖維化，部分脫髓鞘變和軸突退行變，此時為不可逆損害。因此，提高CTS療效的關(guān)鍵是早診斷、早治療。尤其是老年患者，腕管內(nèi)滑膜增生組織長期刺激，神經(jīng)受卡壓后，神經(jīng)變性出現(xiàn)早，術(shù)后神經(jīng)水腫恢復(fù)慢。

CTS手術(shù)治療的主要目的是通過探查針對所見病變，采取相應(yīng)措施，以增加腕管容積或減少腕管內(nèi)容物體積，從而達(dá)到減少腕管內(nèi)壓力，解除正中神經(jīng)受壓的目的［9］。本組所選擇的63例（75側(cè)）患者均為腕橫韌帶壓迫相對較輕，腕管內(nèi)滑膜增生較重的患者，其中46例患者（50側(cè)）獲得3個月以上的臨床隨訪。如表1所示，術(shù)前電生理檢查顯示神經(jīng)傳導(dǎo)速度降低相對較輕，而臨床癥狀重，有明顯的夜間麻醒病史。術(shù)中見明顯的滑膜增生肥厚（圖1），通過切開肥厚的腕橫韌帶，清除滑膜增生組織，增大腕管內(nèi)容積而起到減壓的目的。術(shù)后正中神經(jīng)運(yùn)動、感覺傳導(dǎo)速度較術(shù)前改善，運(yùn)動遠(yuǎn)端潛伏期、感覺遠(yuǎn)端潛伏期較術(shù)前縮短（表1）。術(shù)后隨訪顯示，患者癥狀明顯好轉(zhuǎn)，優(yōu)良率為92%（表2）。

內(nèi)窺鏡視下腕管松解術(shù)是近年來治療CTS的一種新的方法，由于其切口小，局麻下就可以完成，所以被廣大的患者所接受。但是，由于這種手術(shù)方法只能完成對于腕橫韌帶的切斷，無法行腕管內(nèi)廣泛的滑膜清除及正中神經(jīng)的松解，所以手術(shù)的范圍受到了很大的限制，常常因為腕橫韌帶的松解不完全、滑膜清理不夠徹底，而需要再次手術(shù)。此外內(nèi)窺鏡下腕管松解術(shù)還易于造成尺動脈、掌淺弓及第三指總神經(jīng)損傷。這些因素都限制了內(nèi)窺鏡的使用［8，10］。

總結(jié)本組46例（50側(cè)）滑膜型CTS患者住院資料：滑膜型CTS臨床上以夜間痛、麻木、握物無力、橈側(cè)三個半指掌側(cè)感覺異常為主。神經(jīng)電生理檢查提示：神經(jīng)源性損害，神經(jīng)傳導(dǎo)速度減慢，但是降低并不明顯，行腕橫韌帶切開減壓、腕管內(nèi)滑膜切除、正中神經(jīng)松解治療可以取得良好的效果。

［1］劉華，董暉，杜永軍．腕管綜合征治療分析［J］．國際骨科學(xué)雜志，2011，32（6）：400－401．

［2］林泉，劉志剛，于光．正中神經(jīng)返支卡壓及易損傷部位的解剖學(xué)基礎(chǔ)［J］．中國臨床解剖學(xué)雜志，2005，23（1）：76－78．

［3］顧雁浩，張凱莉，朱藝，等．探討腕管綜合征電生理分期的定量指標(biāo)［J］．中華手外科雜志，2004，20（3）：145－147．

［4］顧玉東，王澍寰，侍德．手外科手術(shù)學(xué)［M］．上海：復(fù)旦大學(xué)出版社，2010：530－531．

［5］陳彬，楊小輝，首家保，等．改良內(nèi)窺鏡微創(chuàng)治療腕管綜合征的療效觀察［J］．現(xiàn)代中西醫(yī)結(jié)合雜志，2012，21（4）：371－372．

［6］史其林，薛峰，王金武，等．腕管綜合征在內(nèi)窺鏡視下手術(shù)與常規(guī)手術(shù)的療效比較［J］．中華手外科雜志，2000，16（3）：26－29．

［7］顧玉東，陳德松，史其林，等．腕管綜合征128例分析［J］．中華手外科雜志，2006，22（5）：283－285．

［8］孟國成，陳立科，陳四華，等．三種手術(shù)方式治療腕管綜合征的臨床優(yōu)劣分析［J］．中華手外科雜志，2011，27（4）：246－247．

［9］郭建平，李立森，王玉發(fā)，等．老年腕管綜合征的診治［J］．中國老年學(xué)雜志，2006，26（12）：1718－1719．

［10］顧玉東，史其林，孫貴新．內(nèi)窺鏡下松解腕管綜合征的神經(jīng)并發(fā)癥［J］．中華手外科雜志，2003，19（3）：151－152．

Surgical treatment of synovial hyperplasia carpal tunnel syndrome

LiJianqiang，JiangBaoguo，Chen Jianhai，F(xiàn)uZhongguo，WangTianbing．DepartmentofTraumaandOrthopedics，PekingUniversity People′sHospital，PekingUniversitytrafficMedicineCenter，Beijing100044，China

：WangTianbing，Email：wantianbing＠m(xù)edmail．com．cn

BackgroundCarpal tunnel syndrome is the most common compressive peripheral neuropathy，which is a couple of clinical syndromes caused by the oppression of the median nerve in the carpal tunnel．The tough of the transverse carpal ligament and thickness of its edge are the major factors in the oppression of the median nerve．Under normal circumstances，there is a large amount of tendon synovial in the carpal tunnel，which plays a role of nutrition and lubrication to the nerve．However，the tendon synovial hyperplasia，or even congestion and edema can cause or aggravate the oppression of the median nerve．Also，it will cause an inflammatory stimulate to the nerve．The major clinical manifestations of carpal tunnel syndrome are numbness and pain of three and a half fingers of the radial side．Usually，the pain radiates to the hand and forearm，accompanied with dysfunction of thumb opposition，thenar muscle atrophy and decreased grip and pinch strength．But in the synovial hyperplasia carpal tunnel syndrome，because of increased congestion at night and reflux disorder，there will be a significant night pain and numbness，which sometimes even makes the patients awake at a fixed time at night．These are the typical symptoms of synovial hyperplasia carpal tunnel syndrome．When the patients wake up，many will activate the fingers and wrists to relieve the pain，which promotes the synovial reflux in the carpal tunnel and reduces the pressure of carpal tunnel．As such reasons，there will be a phenomenon that clinical manifestations in the resting state do not fully meet the electrophysiological examination after activity．Patients who were diagnosed as synovial hyperplasia carpal tunnel syndrome were admitted to our hospital．We performed transverse carpal ligament release，carpal tunnel decompression，synovial tissue removal and median nerve release．The purpose of this study is to describe clinical characteristics of synovial hyperplasia carpal tunnel syndrome andanalyzes the outcome of treatment method adopted in this study．MethodsThere were 63patients（75 sides，left of 27cases and right of 48cases；51cases of one－side and 12cases bilateral；16males and 47females；aged 40－82years，mean 62years old；course of disease differ from 3months to 8years）included in the group．The time between onset of symptoms to treatment time differed from 3weeks to 2years．The etiology of the disease was as follows：49cases caused by chronic injury，14cases caused by autoimmune diseases（mostly bilateral）such as rheumatoid arthritis，gout，Sjogren syndrome and so on．There was no patient with a history of wrist trauma，fracture or dislocation．Also，there was no wrist tumor．The main symptoms of patients were wrist pain，numbness，weakness of grip and pinch and wake up at night caused by pain，which may radiated to the elbow and shoulder and had a relief by shaking the involved hands．The examination is as follows：wrist Tinel sign positive，paresthesia of three and a half fingers of the radial side and thenar muscle atrophy．The preoperative neurophysiological testing includes median nerve motor conduction velocity，sensory conduction velocity，motor distal latency and sensory distal latency．All patients

conservative treatment like preoperative non－steroidal anti－inflammatory drugs，local physical therapy and carpal tunnel drug injections．The treatment received a varying relief but soon the symptoms recurred，which affected the quality of life of patients so much that they came to the hospital to receive surgery．All patients underwent severing of transverse carpal ligament，synovial removal of the carpal tunnel and release of the median nerve．Procedures：All patients were narcotized with brachial plexus anesthesia，and then we will make the patient supine，limb abduction．Use the tourniquet and turn the pressure at 300mmHg．Disinfection and drape routinely，and then make an arc－shaped incision between the midpoint of thenar crease to the wrist crease line，which is 3cm long．After cutting the skin，subcutaneous tissue and fascia layer of the palm，cut the transverse carpal ligament at the level of the wrist crease line．We should cut the transverse carpal ligament proximally under direct vision．In the process，we should prevent damage to the underlying median nerve until the transverse carpal ligament is fully cut．At the midpoint thenar crease and beyond care should be taken to avoid damage to the recurrent branch of the median nerve．During the operation，we can see：the transverse carpal ligament thickened；median nerve is compressed under the transverse carpal ligament；the nerve becomes flat and the outer membrane thickened；the color of the compressed part is dark；visible neurovascular interruption；nerve surrounded by scars；flexor digitorum deep tendons and flexor digitorum superficial tendons are wrapped by a large amount of synovial tissue．After cutting the transverse carpal ligament，separate the median nerve and decide whether to release the outer membrane according to degree of nerve entrapment and hyperplasia．If releasing the outer membrane of nerve is decided，release the hyperplasia tissue around the nerve using microsurgical scissors，cut the involved out membrane of median nerve longitudinally until soft normal nerve is revealed，which means a complete release．Protect the median nerve strictly；separate the flexor digitorum deep tendons and flexor digitorum superficial tendons；carefully remove the hyperplastic lesions of synovial tissue．Loose the tourniquet，stanch strictly，indwell drainage strip，suture the fascia layer of the palm and then make a full thickness suture．The resected synovial tissue surrounding the tendon should be sent to receive a pathologic examination．Postoperative treatment：Drainage strip should be removed within 24hours after surgery；do the finger flexion and dorsiflexion activities under the guidance of a doctor to prevent tendon adhesions；elevate the affected limb at night to reduce swelling；stitches the wound 14days after surgery；take methycobal for 3weeks；exercise normally 4－6weeks after surgery．Clinical criteria：We use the Kelly standard to evaluate the effect of treatment 3months after surgery．The details are as follows：excellent：the symptoms disappeared completely；good：the symptoms were relieved significantly；general：symptoms become mild or continued；poor：symptoms unchanged or be worse．All patients received neurophysiological testing during follow－up．Statistical Analysis：The data is statistically analyzed using SPSS software．We use two independent samples t－test analysis and makeP＜0．05significant differences．ResultsThere are a total of 46patients（50sides）who received a more than 3months clinical follow－up and the average time of follow－up is 4．6months．The symptoms of hand numbness，pain all hada varying relief and the symptom of anesthesia at night disappeared．The Incision healed well，and there was no long－term complications such as infection and nonunion．There was no scar contracture．No one complained of recurrence 3－12months after operation．No patient was present with injury of median nerve，the superficial palmar arch or recurrent branch of the median nerve．During the operation，we can see the synovial tissue hyperplasia around the median nerve，which cause the compression of the median nerve．The postoperative pathological examination shows edema and degeneration of the fibrous connective tissue around the median nerve，hyperplasia of the synovial tissue，infiltration of the lymphocyte and plasma cells．Preoperative electrophysiological tests showed there is no significant reduction of median nerve motor or sensory conduction velocity，（48．32±3．68）m／s and（46．32±3．68）m／s，respectively．There are 50sides which received electrophysiological tests 3months after operation and the tests showed that the median nerve motor and sensory conduction velocities were bigger than the preoperative velocities，（51．64±2．70）m／s and （50．11±3．47）m／s，respectively．There is a significant difference（t＝－6．095，－2．935，allP＜0．05）．The median nerve motor distal latency of（4．38±0．40）ms is reduced to （3．47±0．27）ms，and the sensory distal latency of（5．12±0．36）ms is reduced to （4．14±0．31）ms，with a significant difference（t＝15．895，16．011，allP＜0．05）．According to the Kelly standard，there are 32sides of excellent，whose night pain and numbness of the fingers disappeared completely；there are 14sides of good，whose night pain，numbness of the fingers relieved significantly than before but not completely disappeared；there are 4sides of general and no side of poor．Over all，the proportion of excellent is 92%．ConclusionsAs a summary，from the data of this 46 patients（50sides）with synovial hyperplasia carpal tunnel syndrome，we can see that the main clinical manifestations of synovial hyperplasia carpal tunnel syndrome are pain，numbness and inability to grip at night，paresthesia of three and a half fingers in the radial sides．The neurophysiological examinations show neurogenic damage，mild decrease of nerve conduction velocity．The way of transverse carpal ligament revering，synovial removal within the carpal tunnel and median nerve release therapy can achieve a good result．

Carpal tunnel syndrome； Nerve electrophysiological examination； Carpal transverse ligament severing；Median nerve release

2014－03－11）

（本文編輯：李靜）

10．3877／cma．j．issn．2095－5790．2014．02．007

衛(wèi)生公益性行業(yè)科研專項（201002014）；教育部創(chuàng)新團(tuán)隊（IRT1201）

100044 北京大學(xué)人民醫(yī)院創(chuàng)傷骨科 北京大學(xué)交通醫(yī)學(xué)中心

王天兵，Email：wangtianbing＠m(xù)edmail．com．cn

李建強(qiáng)，姜保國，陳建海，等．滑膜增生型腕管綜合征的手術(shù)治療［J／CD］．中華肩肘外科電子雜志，2014，2（2）：103－108．