臺灣博碩士論文加值系統

周邊神經遭切斷後，若沒施以適當處理，可能會造成神經瘤形成，使得神經無法順利再生。矽膠管內置顯微手術是目前研究周邊神經再生的一種重要模式，歷年來有許多的研究投入，使得這種模式越趨成熟，也取得不少成果，而接近臨床的使用。但中醫中藥是否在促進神經再生上可佔一席地，鮮有人加以研究。從中醫古籍上記錄可知痿症的臨床表現與神經切斷後的症狀有許多地方類似，暗示二種情況可能有同樣的基本原因。在臨床治療痿症上，中醫提出補益的療法，以補氣、補血、補陰、補陽加以治療。本研究計劃之重點首先以矽膠管來接合截斷1 cm之大鼠坐骨神經。而在六個星期的實驗期中，分別餵食大鼠整體療方及四物湯。結果顯示：成功率整體療方組為88.9%、四物湯組為56%、控制組為70%，整體療方組再生神經軸突數、神經內膜面積、軸突面積百分比比控制組有明顯意義 (p＜0.05) ，顯示整體療方對大鼠坐骨神經再生有促進作用。

Because of formation of neuroma, dissected peripheral nerve cannot regenerate properly. To solve this problem, the emplacement of silicone rubber tubes through the microscopic surgery to repair dissected nerves is suggested. Reviewing the literature of Chinese medicine, there are few studies investigating the effects of Chinese medical prescriptions on the impairment of injured peripheral nerves. However, there are several physiological similarities between flaccidity commonly seen in Chinese medicine and the condition after cutting the peripheral nerve. It is believed that both the symptoms could be with the same basic causes. To cure the flaccidity, drugs for replenishing Qi, drugs for replenishing blood, drugs for replenishing Yin, and drugs for replenishing Yang are used in Chinese medicine. In the present study, Si-Wu-Tang, a Chinese formula to replenish blood was fed to the rats, whose sciatic nerves had been dissected for 1 cm and repaired with silicone rubber tubes for six weeks of implantation. In addition, a Chinese prescription containing the mixture of drugs for replenishing the Qi, the blood, the Yin and the Yang was also tested to clarify the actual role of Chinese medicine for tonicity on nerve regeneration. As a result, it was found that the success percentages of regeneration occurred in the groups of the mixture, the Si-Wu-Tang and the control were 88.9?%, 56% and 70%, respectively. The mixture group also had significant larger axon number, endoneurial area, percentage of axon area in endoneurial area as compared to the controls (P＜0.05). This finding demonstrated that the mixture containing the drugs for replenishing the Qi, the blood, the Yin and the Yang can promote the devolopment of microstruture in regenerated nerve.

目 錄
第一章 前言 1
第二章 文獻回顧 2
2.1 神經細胞 2
2.1.1 神經細胞組織 2
2.1.1.1 神經細胞 2
2.1.1.2 細胞體 3
2.1.1.3 樹狀突 3
2.1.1.4 軸突 3
2.1.1.5 胞突結合（synapse） 3
2.1.2 神經膠質細胞（neuroglia） 4
2.1.3 神經纖維(nerve fiber) 4
2.1.4 髓鞘化纖維（myelinated fiber） 4
2.1.5 無髓鞘纖維（unmyelinated fiber） 5
2.1.6 神經束 5
2.2 神經細胞生理 5
2.3 神經細胞損傷 6
2.4 神經再生(regeneration) 8
2.4.1 電顯觀察 9
2.4.2 Wallerian degeneration的電生理變化10
2.5 矽膠管 (slicone tube)11
2.5.1 矽膠管的結構與組成11
2.5.2 生物適應性13
2.5.2.1 組織適應性13
2.5.2.2 對血液的適應性13
2.5.2.3 物理穩定性14
2.6 神經修補的方式及其限度與難處14
2.6.1 端對端神經外膜縫合手術 (End-to-end suturing)14
2.6.2 神經束縫合術 (Fascular suturing)14
2.6.3 神經移植手術 (Nerve grafting)15
2.6.4 生物性神經管移植手術 (Nerve bridging — biological
materials)15
2.6.5 生物材料神經管移植手術 (Nerve bridging — synthetic
materials)15
2.7 神經管中神經再生過程的描述16
2.8 配合神經管的使用以增加神經再生成功率的幾種方式17
2.8.1 神經管中內填不同的生長激素17
2.8.2 內填血管17
2.8.3 電刺激18
2.8.4 內填Schwann cell18
2.9 方藥分析18
2.9.1 整體療方與補陽還五湯18
2.9.2 補陽還五湯在神經再生上的研究19
2.9.3 四物湯19
2.9.4 四物湯對神經再生的作用20
2.10 痿証20
2.10.1 痿病的概念20
2.10.2 痿病與坐骨神經截斷21
2.10.2.1 肢體癱瘓21
2.10.2.2 四肢拘急22
2.10.2.3 肢體麻木不仁23
2.10.2.4 四肢瘦削24
2.10.2.5 皮毛枯搞25
2.10.3 痿病歷代研究概況26
2.10.3.1《內經》奠定了痿病的理論基礎26
2.10.3.2 《難經》五痿傳變論26
2.10.3.3《針灸甲乙經》奠定針刺治療痿病的基礎26
2.10.3.4 朱丹溪痿病多因說27
2.10.3.5 《景岳全書》元氣敗傷致痿論27
2.10.3.6 《証治匯補》辨痿施治最為詳全27
2.10.4 痿病的病因病機28
2.10.5 痿病治療概要29
2.10.5.1 清金保肺法29
2.10.5.2 補益肝腎，壯筋健骨法29
2.10.5.3 清熱利濕法29
2.10.5.4 補益脾胃法30
2.10.5.5 溫化寒濕法30
2.10.5.6 填精補髓法30
2.10.5.7 溫腎助陽法31
2.10.5.8活血化瘀法31
第三章材料方法32
3.1 材料32
3.1.1 矽膠32
3.1.2 中藥方劑32
3.1.3 日常食物32
3.1.4 組織染色所使用的Toluidine blue33
3.2 方法34
3.2.1 實驗動物模式34
3.2.2 實驗分組35
3.3 電生理檢測35
3.4 神經固定、脫水、包埋、切片及染色37
3.4.1 神經固定37
3.4.1.1 前固定(Pre-fixation)37
3.4.1.2 後固定(Post-fixation)37
3.4.2 脫水37
3.4.3 包埋39
3.4.4 切片39
3.4.5 染色39
3.5 組織學定性分析(Qualitative histology)39
3.6 組織學定量分析(Quantitative histology)40
3.7 統計方法41
第四章 結果42
4.1 大白鼠外觀42
4.1.1 毛色42
4.1.2 重量42
4.1.3 手術傷口42
4.1.4 足趾自殘42
4.1.5 足踝傷口44
4.1.6 足趾缺損情況合併足踝傷口45
4.1.7 行動46
4.2 矽膠管觀察46
4.3 切片觀察 49
4.4 神經再生的成功率53
4.5 定量分析53
4.5.1 再生神經之基本資料 53
4.5.2 再生神經切片之統計分析54
4.5.2.1 再生神經全部面積57
4.5.2.2 再生神經內膜面積58
4.5.2.3 再生神經軸突數目59
4.5.2.4 再生神經軸突面積60
4.5.2.5 再生神經軸突密度61
4.5.2.6 再生神經軸突面積百分比62
4.5.2.7 再生血管數目63
4.5.2.8 再生血管面積64
4.5.2.9 再生血管神經百分比 65
4.5.3 再生神經軸突直徑分布66
4.5.3.1 正常組再生神經軸突直徑66
4.5.3.2 控制組再生神經軸突直徑66
4.5.3.3 整體療方組再生神經軸突直徑66
4.5.3.4 四物湯組再生神經軸突直徑66
4.6 電生理紀錄 66
4.6.1 再生神經電生理之基本資料66
4.6.2 電生理之統計分析68
4.7 再生神經所支配之肌肉(腓腸肌)切片69
4.7.1 正常組69
4.7.2 控制組70
4.7.3 整體療方組71
4.7.4 四物湯組72
第五章討論73
第六章結論77
參考文獻78
附錄85
英文摘要99
謝詞 100
圖 目 錄
3.1矽膠管神經縫合手術 34
圖3.2誘發電位儀36
圖3.3電生理檢測圖示36
圖3.4神經肌肉複合動作電位38
圖3.5選取再生神經中段之神經組織38
圖4.1實驗動物(C4)之腳趾自殘情況43
圖4.2實驗動物 (C8)腳踝傷口情況嚴重44
圖4.3實驗動物(C5)腳踝傷口情況45
圖4.4實驗動物(F5)足趾缺損合併足踝傷口情況45
圖4.5實驗動物(F4)無足趾缺損且無足踝傷口情況46
圖4.6實驗動物(F3)再生神經成功的於矽膠管中接合了截斷坐骨
神經的兩斷端47
圖4.7實驗動物(M6)再生神經成功的於矽膠管中接合了截斷坐骨
神經的兩斷端48
圖4.8實驗動物(C7)再生神經成功的於矽膠管中接合了截斷坐骨
神經的兩斷端49
圖4.9正常坐骨神經用Toluidine blue染色50
圖4.10再生神經橫切面(C9)於顯微鏡下51
圖4.11再生神經橫切面(C9)於顯微鏡下(油鏡)51
圖4.12再生神經橫切面(F8)於顯微鏡下52
圖4.13再生神經橫切面(F3)於顯微鏡下(油鏡)52
圖4.14再生神經橫切面(M4)於顯微鏡下(油鏡)53
圖4.15再生神經的全部面積三組之比較57
圖4.16再生神經內膜面積三組之比較58
圖4.17再生神經平均軸突數三組之比較59
圖4.18再生神經軸突平均面積三組之比較60
圖4.19再生神經軸突密度三組之比較61
圖4.20再生神經軸突面積百分比三組之比較62
圖4.21再生血管數目三組之比較63
圖4.22再生血管面積三組之比較64
圖4.23再生血管面積百分比四組之比較65
圖4.24正常組(C7)腓腸肌切片(scale bar =100 μm)68
圖4.25控制組(C3)腓腸肌切片(scale bar =100 μm)69
圖4.26整體療方組(M3)腓腸肌切片(scale bar =100 μm)70
圖4.27四物湯組(F6)腓腸肌切片(scale bar =100 μm)71
表 目 錄
表4.1實驗動物體重變化情形43
表4.2動物自殘情況44
表4.3再生神經組織資料55
表4.4再生神經之組織資料比較及檢定結果56
表4.5再生神經電生理之基本資料66
表4.6電生理各項數值之組間比較及檢定結果67

參考文獻
1.Lundborg G, Dahlin LB, Danielsen NP, Hansson HA, and Larsson K. Reorganization and Orientation of Regenerating Nerve Fibers, Perineurium, and Epineurium in Preformed Mesothelial Tubes-An Experimental Study on the Sciatic Nerve of Rats. Journal of Neuroscience Research 1981; 6: 265-281
2.Junqueira LC, and Carneiro J. Basic Histology. 3rd edition: Nerve Tissue. Chapter 9.
3.Schlaepfer WW, and Micko S. Chemical and structural changes of neurofilaments in transected rat sciatic nerve: The Journal of Cell Biology. 1978; 78: 369-377
4.Dandon DN. Pathology of the Peripheral nerve. Chapter 13. 1976: 702-727
5.Stoll G, and Muller HW. Nerve injury, axonal degeneration and neural regeneration:Brain Pathology. 1999, 9(2), 13-25
6.William DF, and Press CRC. Biocompatibility of Clinical Implant Materials, Volume 2. Silicone rubbers for medical applications, Chapter 4. 1981; 80-91
7.Kern SF, Anderson RC, and Harris PN. Observations on the toxicity of methyl-silicone: Journal. American. Pharmacology. 1949; 38: 575
8.McGregor RR. Toxicology of silicones, Bull. Dow Corning Center Aid Med. Res.1960; 2(4): 15
9.MacDonald WE. Inc. The subacute oral toxicity to the rat of certain polydimethylsiloxanes, Arch. Ind. 1960; 21(6): 514
10.Rowe VK, Spencer HC, and Bass SL. Toxicological studies on certain commercial silicones, J. Ind. Hyg. Toxicol. 1948; 30: 332
11.Cruickshank CND, Hooper C, Lewis HB, and Mcdougall JD. The toxicity of rubbers and plastics used in transfusion-giving sets: Journal Clinical Pathology. 1990; 13(1): 42
12.Carreri AR, Gale JW, Young WP, and Dickie HA. Plastic sponge prosthesis following recession in pulmonary tuberculosis: Journal Thorac. Surg. 1952; 24:587
13.Braley S. Use of silicones in plastic surgery, Arch. Otolaryng. 1963; 78:669
14.Mullison EQ. Silicones as artificial internal tissue and organ substitutes, Ann. N.Y. Acad. Sci. 1964; 120: 540
15.Geha S, Salaymeth TM, Davis LG, and Bane EA. Replacement of the aortic valve with molded autogenous grafts grown in response to implanted Silastic: Journal Thorac. Cardiovasc. Surg. 1970; 60: 661
16.Kern SF, Anderson RC, and Harris PN. Observations on the Toxicity of Methyl-Silicone. 1949: 575-576
17.Smahel J. Histology of the capsules causing constrictive fibrosis around breast implants, Br. J. Plast. Surg. 1977; 30: 324
18.Wilfingseder P, Hoinkes G, Mikuz G, and Propst A. Constrictive Fibrosis Post Augmentation Mammaplasty, Conf. on Mechanical Properties of Biomaterials, Keele, England. 1978
19.Wilflingseder T, Propst A, and Mickuz G. Constrictive fibrosis following silicone implants, Br. J. Plast. Surg. 1977; 30: 324
20.Domanskis EJ, and Owsley JQ. Histological investigation of the etiology of capsule contracture following augmentation mammaplasty, Plast. Recinstr. Surg. 1976; 58: 689
21.Mason RG, Scarborough DE, Saba SR, Brinkhous KM, Ikkenberry LD, Kearney JJ, and Clark HG. Thrombogenicity of some biomedical materials platelet-interface reactions, J. Biomed. Mater. Res. 1969; 3: 615
22.Nose Y. Blood clotting problems in the artificial heart devices, J. Biomed. Mater. Res. 1976; 1: 151
23.Akutsu T, Mitkovitch V, Topaz SR, and Kolff WJ. Silastic sac type of artificial heart and its use in calves, Trans. Am. Soc. Artif. Intern. 1963; 9:281
24.Nose Y, Russell F, Gradel F, and Kantrowitz A. Long term operation of an electronically controlled plastic auxiliary ventricle in conscious dogs, Trans. Am. Soc. Artif. Intern. Organs. 1964; 10: 140.
25.Gradel F, Akutsu T, Chaptai PA, Cottle HR, and Kantrowitz AR. Prolonged arterioarterial pumping in dogs with a mechanical auxiliary ventricle, Ann. Surg. 1966; 163: 347
26.Leininger RI, Merkovitch V, Peters A, and Hawks WA. Changes in properties of plastics during implantation, Trans. Am. Soc. Artif. Int. Organs. 1964; 10: 320
27.Raible DA, Keller DP, Pierie WR, and Loorajian S. Elastomers for use in heart valves, Rubber Chem. Technol. 1966; 39: 1276
28.Boone JL, and Braley SA. Resistance of silicone rubbers to body fluids, Rubber Chem. Technol. 1966; 39: 1293
29.Keen J. Late death due to escape of ball from mitral valve prosthesis, J. Thorac. Cardiovasc. Surg. 1974; 67(2): 202
30.Fields RD, Beau JML, Longo FM, and Ellisman MH. Nerve Regeneration through Artifical Tubular Implants: Neurobiology. 1989; 33: 87-134
31.Hentz VR, Rosen JM, Shao-Jun Xiao, McGill KC, and Abraham G. A comparison of suture and tubulization nerve repair techniques in a primate: The Journal of Hand Surgery. 1991; 16(2):251-260
32.Heumann R, Korsching S, Bandtlow C, and Thorenen H. Changes of never growth factor synthesis in nonneuronal cells in response to sciatic nerve transection: J. Cell Biol. 1987; 104: 1623-1631
33.Taniuchi M, Clark HB, and Johnson EM. Induction of nerve growth factor receptor in Schwann cells after axotomy: Proc. natn. Acad. Sci. U.S.A. 1986; 83: 4094-4098
34.Labrador RO, Buti M, and Navarro X. Influence of collagen and laminin gels concentration on nerve regeneration after resection and tube repair: Experimental Neurology. 1998; 149(1): 243-252
35.Chamberlain IJ, Yannas IV, Arrizabalaga A, Hsu HP, Norregaard TV, and Spector M. Early peripheral nerve healing in collagen and silicone tube implants: myofibroblasts and the cellular response: Biomaterials. 1998; 19(15): 1393-1403
36.Voinesco F, Glauser L, Kraftsik R, and Barakat-Walter I. Local administration of thyroid hormones in silicone chamber increases regeneration of rat transected sciatic nerve: Experimental Neurology. 1998; 150(1): 69-81
37.Azzouz M, Kenel PF, Warter J-M, Poindron P, and Borg J. Enhancement of mouse sciatic nerve regeneration by the long chain fatty alcohol, N-Hexacosanol: Experimental Neurology. 1996; 138(2): 189-197
38.Trigg DJ, O''Grady KM, Bhattacharyya T, Reinke M, and Toriumi DM. Peripheral nerve regeneration : comparison of laminin and acidic fibroblast growth factor. American Journal of Otolaryngology. 1998; 19(1): 29-32
39.Chen YS. Effect of fibrin on nerve regeneration in a silicone chamber: Journal of the Formosan Medical Association. 1992; 91 Suppl 3: S246-50
40.Woolley AL, Hollowell JP, and Rich KM. Fibronectin-laminin combination enhances peripheral nerve regeneration across long gaps: Otolaryngology-Head and Neck Surgery. 1990; 103: 509-517
41.Smith MS, and Browne JD. The effect of endothelial cell growth factor on peripheral nerve regeneration: Otolaryngology-Head & Neck Surgery. 1998; 118(2): 178-182
42.Whitworth IH, Brown RA, Dore CJ, Anand P, Green CJ, and Terenghi G. Nerve growth factor enhances nerve regeneration through fibronectin grafts: Journal of Hand Surgery-British Volume. 1996; 21(4): 514-522
43.Wells MR, Kraus K, Batter DK, Blunt DG, Weremowitz J, Lynch SE, Antoniades HN, and Hansson HA. Gel matrix vehicles for growth factor application in never gap injuries repaired with tubes: a comparison of Biomatrix, collagen, and methylcellulose: Experimental Neurology. 1997; 146(2): 395-402
44.Wang JZ, Bai DC, Rao CM, Li WG, Gao MT, Wang XQ, and Wu YJ. Effects of 2.5 s mouse never growth factor on regeneration of injured sciatic nerves in mice and rats: Acta Pharmacologica Sinica. 1997; 18(6): 501-504
45.Hall S. Axonal regeneration through acellular miscle grafts: Journal og Anatomy. 1997; 190 (1): 57-71
46.Kakinoki R, Nishijima N, Ueba Y, Oka M, Yamamuro T, and Nakamura T. Never regeneration over a 25 mm gap in rat sciatic nerves using tubes containing blood vessels: the possibility of clinical application: International Orthopaedics. 1997; 21(5): 332-336
47.Francel PC, Francel TJ, Mackinnon SE, and Hertl C. Enhancing nerve regeneration across a silicone tube conduit by using interposed short-segment nerve grafts: Journal of Neuroaurgery. 1997; 87(6): 887-892
48.Francel PC, Francel TJ, Mackinnon SE, and Hertl C. Enhancing nerve regeneration across a silicone tube conduit by using interposed short-segment nerve grafts: Journal of Neurosurgery. 1997; 87(6): 887-892
49.Lauto A, Trickett R, Malik R, Dawes JM , and Owen ER. Laser-activated solid protein bands for peripheral nerve repair: an vivo study: Lasers in Surgery & Medicine. 1997; 21(2): 1997.
50.Rusovan A, Kanje M, and Mild KH. The Stimulatory Effect of Magnetic Fields on Regeneration of the Rat Sciatic Nerve is Frequency Dependent: Experimental neurology. 1992; 116: 81-84
51.Rochkind S, Nissan M, Barr-Nea L, Razon N, Schwartz M, and Bartal A. Response of Peripheral Nerve to He-Ne Laser: Experimental Studies: Lasers in Surgery and Medicine. 1987; 7: 441-443
52.Kerns JM, and Lucchinetti C. Electrical Field Effects on Crushed Nerve Regeneration: Experimental Neurology. 1992; 117: 71-80
53.Kanje M, Rusove A, Sisken B, and Lundborg G. Pretreatment of Rats With Pulsed Electromagnetic Fields Enhances Regeneration of the Sciatic Nerve: Bioelectromagnetics. 1993; 14 : 353-359
54.aebischer P, Valentini RF, Dario P, Domenici C, and Galletti PM. Piezoelectric guidance channels enhance regeneration in the mouse sciatic nerve after awotomy. Brain Research. 1987; 436:165-168
55.Ansselin AD, Fink T, and Davey DF. Peripheral nerve regeneration through nerve guides seeded with adult Schwann cells: Neuropathology & Applied Neurobiology. 1997; 23(5): 387-398
56.Bryan DJ, Wang KK, and Chakalis-Haley DP. Effect of Schwann cells in the enhancement of peripheral —nerve regeneration: Journey of Reconstructive Microsurgery. 1996; 12(7): 439-446
57.Gondre M, Burrola P, and Weinstein DE. Accelerated nerve regeneration mediated by Schwann cells expressing a mutant from of the POU protein SCIP: Journal of Cell Biology. 1998; 141(2): 493-501
58.Guest JD, Rao A, Olson L, Bunge MB, and Bunge RP. The ability of human Schwann cell grafts to promote regeneration in the ransected nude rat spinal cord: Experimental Neurology. 1997; 148(2): 502-522
59.梁翠微，和鄭有順。補陽還五湯藥理研究與臨床應用新進展：實用中西醫結合雜誌 1997; 10(19): 1865-1867
60.石關桐，李義凱，和石印玉。補陽還五湯對周邊神經損傷後腓腸積及血粘度的影響實驗研究。中國中醫骨傷科雜誌 2000; 4(2): 4-7
61.陳奇。中藥名方藥理學與應用：台北南天書局。1993：283-285，464-466
62.李濟仁。痿病通論：人民衛生出版社。1995:1-77
63.朱扣云，葉丹，陶明龍。溫腎降濁湯對大白鼠實驗性腎功能衰竭的研究。上海中醫藥雜誌。1995；8：24-25
64.Conn HJ. Methods for testing stains. In: Biological Stains, pp. 290-291. The Williams & Wilkins Company, Baltimore, Maryland.
65.Rosen JM, Pham HN, Abraham G, Harold L, and Hentz VR. Artificial nerve graft compared to autograft in a rat model. J. of Rehabilitation Research and Development. 1989; 26: 1-14
66.Bonner J, and Armati PJ. Microwave assisted staining of nerve and muscle biopsy tissue. Biotechnic and Histochemistry 1991; 66: 236-238
67.Amillo S, Yanez R, and Barrios RH. Nerve regeneration in different types of grafts: experimental study in rabbits. 1995; 16: 621-630
68.Aldini NN, Perego G, Cella GD, Maltarello MC, Fini M, Rocca M, and Giardino R. Effectiveness of a bioabsorbable conduit in the repair of peripheral nerves: Biomaterials 1996; 17(10): 959-962
69.Lunbdog G and Kanje M. Bioartificial nerve grafts, Scand. J. Plast. Reconstr. Hand Surg. 1996 ; 30: 105-110
70.徐邵東，黃東明，和陸松青。補陽還五湯對周圍神經斷裂吻合術後功能恢復的療效觀察；新中醫。1998; 6: 20-21
71.石關桐，李義凱，和石印玉。補陽還五湯對周邊神經損傷修復的實驗研究；中國中醫骨傷科雜誌 1997; 5(5): 1-3
72.Chen YS, Hsieh CL, Tasi CC, Lai TY, and Lin JG. Nerve Regeneration Through Multiple-Lumen Silicone Rubber Guides Filled With Different Growth Stimulants: China Medical College Journal. 1999; 8(3): 83-92
73.Almgren GK. Revascularization of free peripheral nerve grafts. An experimental study in the rabbit. Acta Orthop Scand 1974; 154: 4-97
74.Weiss P, Taylor AV: Repair of peripheral nerve by grafts of frozendried nerve. Proc Soc Exp Biol Med. 1943; 52: 326-328
75.Weiss P, Taylor AC: Further experimental evidence against neurotropism in nerve regeneration. J Exp Zool. 1944; 95: 233-257