پديد آورندگان :
افتخار واقفي، حسن دانشگاه علوم پزشكي افضليپور كرمان - گروه علوم تشريح , رايگان، پرويز دانشگاه علوم پزشكي افضليپور كرمان - گروه علوم تشريح , شمس آرا، علي دانشگاه علوم پزشكي افضليپور كرمان - گروه علوم تشريح , بابايي، عليرضا دانشگاه علوم پزشكي افضليپور كرمان - گروه علوم تشريح
چكيده فارسي :
زﻣﯿﻨﻪ و ﻫﺪف: ﻋﻀﻠﮥ دﯾﺎﻓﺮاﮔﻢ ﮐﻪ ﻣﺴﺌﻮل ﻋﻤﻞ دم ﻣﯽﺑﺎﺷﺪ، از اﻋﺼﺎب ﻓﺮﻧﯿﮏ راﺳﺖ و ﭼﭗ، ﻋﺼﺐ ﻣﯽﮔﯿﺮد. ﻋﺼﺐ ﻓﺮﻧﯿﮏ ﯾﮏ ﻋﺼﺐ ﻣﺨﺘﻠﻂ اﺳﺖ ﮐﻪ ﻗﺴﻤﺖﻫﺎي ﻣﺘﻌﺪدي از ﻣﺪﯾﺎﺳﺘﻦ را ﺗﻐﺬﯾﻪ ﻣﯽﮐﻨﺪ. ﻋﺼﺐ ﻓﺮﻧﯿﮏ ﺳﻤﺖ راﺳﺖ از ﺳﻤﺖ ﭼﭗ ﮐﻮﺗﺎﻫﺘﺮ اﺳﺖ. اﯾﻦ دو ﻋﺼﺐ ﻣﺴﯿﺮ ﻣﺘﻔﺎوﺗﯽ را ﺗﺎ رﺳﯿﺪن ﺑﻪ دﯾﺎﻓﺮاﮔﻢ ﻃﯽ ﻣﯽﮐﻨﻨﺪ. در اﯾﻦ ﺑﺮرﺳﯽ، ﻣﻨﺸﺄ، ﻣﺴﯿﺮ و ﻣﺠﺎورات اﻋﺼﺎب ﻓﺮﻧﯿﮏ راﺳﺖ و ﭼﭗ ﻣﻮرد ﻣﻄﺎﻟﻌﻪ ﻗﺮار ﮔﺮﻓﺘﻪ، ﺑﺎ ﮔﺰارشﻫﺎي اراﺋﻪ ﺷﺪه در ﮐﺘﺎبﻫﺎي ﻣﺮﺟﻊ ﻣﻘﺎﯾﺴﻪ ﮔﺮدﯾﺪ و وارﯾﺎﺳﯿﻮنﻫﺎي ﻣﺸﺎﻫﺪه ﺷﺪه
را ﮔﺰارش ﻧﻤﻮدهاﯾﻢ. ﻣﻮاد و روش ﻫﺎ: اﯾﻦ ﻣﻄﺎﻟﻌﻪ ﺑﺮ روي 22 ﺟﺴﺪ ﻣﺮد و 2 ﺟﺴﺪ زن اﻧﺠﺎم ﺷﺪ. وﺳﺎﯾﻞ ﻣﻮرد اﺳﺘﻔﺎده اﺑﺰار ﺳﺎده ﺗﺸﺮﯾﺢ ﺑﻮد. از ﻣﺘﺮ ﻧﻮاري ﺑﺮاي اﻧﺪازهﮔﯿﺮي ﻃﻮل ﻗﺪ و ﻃﻮل ﺗﻨﻪ و ﺑﺮاي ﻣﺸﺎﻫﺪة ﺷﺎﺧﻪﻫﺎي رﯾﺰ اﻋﺼﺎب، از اﺳﺘﺮﯾﻮﺳﮑﻮپ اﺳﺘﻔﺎده ﮔﺮدﯾﺪ. ﻃﻮل ﻫﺮ ﻋﺼﺐ، ﻣﺠﺎورات در ﻧﻮاﺣﯽ ﻣﺨﺘﻠﻒ، ﺷﺎﺧﻪﻫﺎي ﺟﺪا ﺷﺪه و رﺷﺘﮥ اﻧﺘﻬﺎﯾﯽ ﻫﺮ ﺳﻤﺖ از ﻣﺒﺪأ ﺗﺎ اﻧﺘﻬﺎ ﻣﻮرد ارزﯾﺎﺑﯽ ﻗﺮار ﮔﺮﻓﺖ. ﺑﻪ وﺟﻮد ﯾﺎ ﻋـﺪم وﺟﻮد ﻋﺼﺐ ﻓﺮﻧﯿﮏ ﻓـﺮﻋﯽ ﻧﯿﺰ ﺗﻮﺟﻪ ﺷﺪ. ﺟﻬـﺖ ارزﯾﺎﺑﯽ آﻣﺎري، ﭘﺎراﻣﺘـﺮﻫﺎي ﻣﺮﺑﻮﻃﻪ در ﺟﺪاوﻟﯽ ﺛﺒﺖ ﮔﺮدﯾﺪ. ﺑﺎ اﺳﺘﻔـﺎده از ﺑﺮﻧﺎﻣﻪ ﻧﺮم اﻓﺰاري 16 SPSS، ﻣﯿﺎﻧﮕﯿﻦ ﯾﺎﻓﺘﻪﻫﺎ اﻧﺪازهﮔﯿﺮي ﺷﺪ. ﺳﭙﺲ ﻣﯿﺎﻧﮕﯿﻦ ﻫﺮ ﮐﺪام از اﻧﺪازهﻫﺎ ﺑﺎ ﯾﮑﺪﯾﮕﺮ ﻣﻘﺎﯾﺴﻪ
ﮔﺮدﯾﺪ. ﯾﺎﻓﺘﻪ ﻫﺎ: در اﯾﻦ ﭘﮋوﻫﺶ، وارﯾﺎﺳﯿﻮنﻫﺎي ﻣﺘﻌﺪدي در اﻋﺼﺎب ﻓﺮﻧﯿﮏ راﺳﺖ و ﭼﭗ ﻧﺴﺒﺖ ﺑﻪ آﻧﭽﻪ در ﻣﻮارد ﻗﺒﻠﯽ ذﮐﺮ ﮔﺮدﯾﺪه ﺑﻮد، ﻣﺸﺎﻫﺪه ﮔﺮدﯾﺪ. در ﻣﻮاردي ﻣﺎﻧﻨﺪ ﻣﺴﯿﺮ ﻋﺼﺐ از ﮔﺮدن ﺑﻪ ﻗﻔﺴﻪ ﺳﯿﻨﻪ و ﻣﺠﺎورت ﺑﺎ ﻋﻀﻠﻪ ﻧﺮدﺑﺎﻧﯽ ﻗﺪاﻣﯽ، ﻋﺒﻮر از ﺳﻮراخﻫﺎي دﯾﺎﻓﺮاﮔﻢ، ﺗﻌﺪد ﺷﺎﺧﻪﻫﺎي ﻋﺼﺐ ﻓﺮﻧﯿﮏ راﺳﺖ و ﭼﭗ، ﻃﻮل ﻋﺼﺐ و وﺟﻮد ﯾﺎ ﻋﺪم وﺟﻮد ﻋﺼﺐ ﻓﺮﻧﯿﮏ ﻓﺮﻋﯽ، ﺗﻔﺎوتﻫﺎي ﻗﺎﺑﻞ ﻣﻼﺣﻈﻪاي ﻣﺸﺎﻫﺪه ﮔﺮدﯾﺪ. ﻧﺘﺎﯾﺞ ﻣﺎ ﻧﺸﺎن داد ﮐﻪ اﻓﺰاﯾﺶ ﻃﻮل ﺗﻨﻪ، ﺑﺎ اﻓﺰاﯾﺶ ﻃﻮل اﻋﺼﺎب ﻓﺮﻧﯿﮏ راﺳﺖ و ﭼﭗ راﺑﻄﻪاي ﻣﺴﺘﻘﯿﻢ و ﺻﻌﻮدي دارد. ﺑﺎ در ﻧﻈﺮ ﮔﺮﻓﺘﻦ ﺗﻌﺪاد ﺟﺴﺪﻫﺎي ﻣﻮرد ﻣﻄﺎﻟﻌﻪ، ﺑﺮرﺳﯽ ﻣﺎ ﻧﺸﺎن داد ﮐﻪ درﺻﺪ وﺟﻮد ﻋﺼﺐ ﻓﺮﻧﯿﮏ ﻓﺮﻋﯽ در ﺟﻤﻌﯿﺖ
اﯾﺮاﻧﯽ ﺣﺪود 30 درﺻﺪ ﻣﯽﺑﺎﺷﺪ. ﻧﺘﯿﺠﻪ ﮔﯿـﺮي: در اﯾﻦ ﺑﺮرﺳﯽ ﺿﻤﻦ ﺑﺪﺳﺖ آﻣﺪن ﻧﺘﺎﯾﺞ ﯾﮑﺴﺎن از ﺗﺤﻘﯿﻘﺎت ﻗﺒﻠﯽ، در ﻋﯿﻦ ﺣﺎل ﯾﺎﻓﺘﻪﻫﺎي ﻣﺘﻔﺎوﺗﯽ ﻧﯿﺰ ﭘﯿﺮاﻣﻮن ﻣﻘﺎﯾﺴﻪ ﻣﺴﯿﺮ، ﺷﺎﺧﻪﻫﺎ، ﻃﻮل و وﺟﻮد ﻋﺼﺐ ﻓﺮﻧﯿﮏ ﻓﺮﻋﯽ اراﺋﻪ ﮔﺮدﯾﺪ. ﻣﺠﺎورات اﯾﻦ ﻋﺼﺐ از اﯾﻦ ﺟﻬﺖ ﺣﺎﺋﺰ اﻫﻤﯿﺖ اﺳﺖ ﮐﻪ در ﺑﺮﺧﯽ ﻣﻮارد ﻣﺜﻼ ًدر ﺑﯽﺣﺴﯽﻫﺎ و ﺑﻼك ﮐﺮدن اﻋﺼﺎب در ﻧﺎﺣﯿﮥ ﺳﻮﭘﺮاﮐﻼوﯾﮑـﻮﻻر و ﻣﺎ ﺑﯿﻦ ﻋﻀﻼت اﺳﮑﺎﻟـﻦ اﯾﻦ ﻋﺼﺐ ﻧﯿﺰ دﭼﺎر ﺑﯽﺣﺴﯽ ﻣﯽﺷﻮد. ﻫﻤﭽﻨﯿﻦ ﻣﺠﺎورت ﻧﺰدﯾﮏ اﯾﻦ ﻋﺼﺐ ﺑﺎ ورﯾﺪ ﺗﺤﺖ ﺗﺮﻗﻮهاي در ﻋﻤﻞﻫﺎي ﺟﺮاﺣﯽ ﻣﺮﺑﻮط ﺑﻪ اﯾﻦ ورﯾﺪ ﻣﺎﻧﻨﺪ ﮐﺎﻧﺎلﮔﺬاري ﺑﺴﯿﺎر ﺣﺎﺋﺰ اﻫﻤﯿﺖ ﻣﯽﺑﺎﺷﺪ. ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ اﯾﻦ ﻣﻮﺿﻮع ﮐﻪ ﻋﺼﺐ ﻓﺮﻧﯿﮏ ﺗﻨﻬﺎ ﻋﺼﺐ ﺣﺮﮐﺘﯽ دﯾﺎﻓﺮاﮔﻢ ﻣﯽﺑﺎﺷﺪ، آﮔﺎﻫﯽ ﻻزم در ﻣﻮرد ﻧﺤﻮة ﭘﺨﺶ ﺷﺪن ﺷﺎﺧﻪﻫﺎي اﻧﺘﻬﺎﯾﯽ اﯾﻦ ﻋﺼﺐ در ﻋﻀﻠﮥ دﯾﺎﻓﺮاﮔﻢ ﺣﺎﺋﺰ اﻫﻤﯿﺖ ﻣﯽﺑﺎﺷﺪ، ﺑﺨﺼﻮص ﺗﻮﺟﻪ ﺑﻪ اﯾﻦ ﻧﮑﺘﻪ ﮐﻪ اﮐﺜﺮ ﺟﺮاﺣﯽﻫﺎي ﺗﻮراﮐﺲ و ﻣﺪﯾﺎﺳﺘﻦ ﺑﻪ ارﺗﺒﺎﻃﺎت و ﻣﺠﺎورات اﺣﺸﺎء ﺑﺎ اﯾﻦ ﻋﺼﺐ ارﺗﺒﺎط ﻣﯽﯾﺎﺑﺪ.
چكيده لاتين :
Introduction & Objective: Diaphragmatic muscle that is responsible for the inhalation, innervations by right and left phrenic nerves. This nerve is a complex and feeds several part of mediastinum. The right phrenic is shorter than the left phrenic and arrived to diaphragm by traveling a different path than the left phrenic. In this study, we evaluated the origin, direction and right and left phrenic nerves and compared them with those offered in reference books and variations have been reported.
Materials & Methods: This study was performed on 22 male and 2 female cadavers. We used simple dissect tools and observed tiny branches by the stereoscope. We evaluated the length of each nerve, relations in various areas, division of branches and terminal fibers. The presence or absence of accessory phrenic nerve was also assessed. For Statistical evaluation, the relevant parameters were recorded in tables. Mean (average) was measured by SPSS 16, and then the average of the sizes were compared.
Results: In this study, we observed several variations on the left and right phrenic nerves from what
was reported in the previous cases. Considerable differences were observed, in cases such as the pathway
nerve of the neck to the chest and the presence of the anterior scalene muscle, passes through the
diaphragmatic foramina, a multiple of right and left phrenic nerve branches, the presence or absence of
accessory nerve and the phrenic nerve length. Our results showed that the increase in the length of the
trunk, and ascending correlation to the left and right phrenic nerve elongation. With respected to the
number of cadaver in this study, we showed that there is an accessory nerve in about 30% of the Iranian
population.
Conclusions: In this evaluation, we provided the different results about the pathway, branches, length and presence of accessory phrenic nerve. However, we found the same results of previous research. The neighborhood of this the nerve is important as in some cases, such as anesthesia and nerve block in the supraclavicular region or between scalenus muscles, the phrenic nerve also suffers from anesthesia. Also, the close proximity of this nerve and infraclavicular vein is very important in surgical operation related to this vein like canal catheter insertion. Since, the phrenic nerve is the only motor nerve of diaphragm, is important to be aware about how to spread the terminal branches of the nerve in the diaphragmatic muscle. Especially considering the fact that most of surgeries in the thoracic and mediastineum is associated with Communications and the organs adjacent to this nerve.
