{"id":4445,"date":"2023-02-16T09:13:34","date_gmt":"2023-02-16T09:13:34","guid":{"rendered":"https:\/\/www.karotidnahirurgija.com\/?page_id=4445"},"modified":"2023-02-24T09:29:50","modified_gmt":"2023-02-24T09:29:50","slug":"19-lezije-kranijalnih-nerava-u-karotidnoj-hirurgiji","status":"publish","type":"page","link":"https:\/\/www.karotidnahirurgija.com\/?page_id=4445","title":{"rendered":"19. LEZIJE KRANIJALNIH NERAVA U KAROTIDNOJ HIRURGIJI"},"content":{"rendered":"

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\n\"\"<\/a><\/p>\n

<\/p>\n

LEZIJE KRANIJALNIH NERAVA U
KAROTIDNOJ HIRURGIJI<\/h1>\n

<\/a><\/h1>\n

\n

It is worse than immoral. It is a mistake.
(of Americas involvement in Vietnam, Dean Acheson)<\/em><\/p>\n

Wisdom lives in the Future and from there it speaks to us.
Paul Valery<\/em><\/p>\n<\/div>\n

\n

Karotidne arterije<\/strong> su u bliskom odnosu sa okolnim kranijalnim nervima. Rekostrukcija karotidne arterije dovodi nas u kontakt sa kranijalnim nervima. Da se ovaj kontakt ne bi pretvorio u koliziju sa lezijom nerva moraju se imati u vidu ove anatomske \u010dinjenice:<\/p>\n

Ramus<\/b><\/i> <\/b><\/i>marginalis<\/b><\/i> <\/b><\/i>mandibulae<\/b><\/i> <\/b><\/i>nervi<\/b><\/i> <\/b><\/i>facialis<\/b><\/i> <\/b><\/i>ide paralelno sa donjom ivicom mandibule. Naj\u010de\u0161\u0107e se povredi pritiskom ekartera kojim asistent podi\u017ee angulus<\/i> <\/i>mandibulae<\/i>. Postoperativno se konstatuje funkcionalni ispad m.mentalis<\/i>-a i delimi\u010dna pareza donje usne.<\/p>\n

Nervus<\/b><\/i> <\/b><\/i>auricularis<\/b><\/i> <\/b><\/i>magnus<\/b><\/i> <\/b><\/i>se pojavljuje ispod dorzolateralne ivice sterno- kleidomastoidnog mi\u0161i\u0107a, u njenom srednjem delu. Kre\u0107e se lu\u010dno prema u\u0161noj \u0161koljci i lobanji. Zavr\u0161ava se deobom na prednju i zadnju granu. Senzitivna vlakna inervi\u0161u donji deo obraza, u\u0161nu \u0161koljku i potiljak. Naj\u010de\u0161\u0107e se povredi nepa\u017eljivom disekcijom u gornjem polu operativne incizije, u nivou povr\u0161ne fascije vrata.<\/p>\n

Nervus<\/b><\/i> <\/b><\/i>glossopharyngeus<\/b><\/i> <\/b><\/i>pojavljuje se na bazi lobanje kroz foramen<\/i> <\/i>jugulare<\/i>, a zatim se spu\u0161ta put lateralno. Neposredno ispod stilofaringealnog mi\u0161i\u0107a prolazi izme\u0111u unutra\u0161nje karotidne arterije i unutra\u0161nje jugularne vene, a lateralno od n.vagus<\/i>-a. U daljem toku ide napred prema bazi jezika. Prekriven je hipoglosalnim mi\u0161i\u0107em. Nervus<\/i> <\/i>glossopharyngeus<\/i> <\/i>daje senzornu i motornu inervaciju farinksa. Njegova senzorna vlakna provode senzacije \u010dula ukusa i dodira zadnje tre\u0107ine jezika i faringealne mukoze. Njegova motorna vlakna inervi\u0161u mi\u0161i\u0107e elevatore farinksa i larinksa, reguli\u0161u\u0107i akt gutanja.<\/p>\n

.<\/em><\/p>\n<\/div>\n

\"\"<\/p>\n

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Povr\u0161na nervna stabla koja mogu\u00a0 biti ledirana prilikom pristupa\u00a0 karotidnoj bifurkaciji i\u00a0 unutra\u0161njoj karoti\u010dnoj arteriji<\/em><\/p>\n<\/div>\n

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Uobi\u010dajeno diseciranje karotidnih arterija ne dovodi nas u kontakt sa gloso- faringealnim nervom. Lezije ovog \u017eivca mogu nastati samo prilikom visokog pristupa distalnom delu cervikalne unutra\u0161nje karotidne arterije. Manifestuju se te\u0161ko\u0107ama pri gutanju i o\u0161te\u0107enim senzibilitetom za ukus i dodir jezika i \u017edrela, \u0161to obi\u010dno traje manje od 4 nedelje, zatim se povla\u010di i bez terapije. Le\u010di se polivitaminskom i roborantnom terapijom. Lezija glosofaringealnog nerva se javlja u 0 do 1.5% pacijenata. Najve\u0107a u\u010destalost lezija zapa\u017ea se posle visokog pristupa sa dislokacijom mandibule (42%). Interesantno je da dislokacija mandibule mo\u017ee \u010dak da dovede do povrede kontralateralnog glosofaringealnog \u017eivca. Kod karotidne endarterektomije sa intraluminalnim<\/i> <\/i>shunt<\/i>-om zapa\u017eena je ve\u0107a u\u010destalost lezija glosofaringealnog nerva. Ovo se obja\u0161njava neophodno\u0161\u0107u ne\u0161to distalnije disekcije unutra\u0161nje karotidne arterije da bi se sigurno plasirao shunt.<\/p>\n

Heringov<\/b><\/i> <\/b><\/i>\u017eivac<\/b><\/i> <\/b><\/i>(nervus<\/i> <\/i>sinus<\/i> <\/i>caroticus<\/i>) odvaja se kao grana glosofaringealnog nerva na mestu njegovog ukr\u0161tanja sa unutra\u0161njom karotidnom arterijom. Spu\u0161ta se prate\u0107i njen tok prema karotidnoj bifurkaciji. Heringov \u017eivac prenosi aferentnim putem (ka mozgu) informacije iz baroreceptora i hemoreceptora karotidnog sinusa. Lezija Heringovog \u017eivca mo\u017ee (ali ne mora) da izazove varijacije arterijske tenzije i pulsa. Intraoperatine i rane postoperativne epizode nestabilnosti arterijske tenzije i aritmija se mogu spre\u010diti lokalnom intraoperativnom infiltracijom anestetikom. Postoperativno se mogu javiti paroksizmi hipertenzije, glavobolje, crvenila ko\u017ee lica i\/ili respiratorna depresija. Ako o\u010dekujemo ovakve komplikacije, uz lokalnu infiltraciju anestetikom, mo\u017eemo u blizini Heringovog nerva postaviti tanak kateter koji ostaje za postoperativnu instilaciji Novocaina, ako je neophodno na osnovu monitoringa.<\/p>\n<\/div>\n

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\u00a0<\/em><\/p>\n

Nervus<\/b><\/i> <\/b><\/i>hypoglossus<\/b><\/i> <\/b><\/i>le\u017ei normalno na 2-4cm kranijalno od karotidne bifurkacije, ukr\u0161taju\u0107i spolja\u0161nju i unutra\u0161nju karotidnu arteriju. Na njega se mora obratiti pa\u017enja. Njegova identifikacija se ne mo\u017ee izbe\u0107i ako se radi o visoko polo\u017eenoj karotidnoj bifurkaciji ili ako se arterijska lezija prostire visoko du\u017e karotidne arterije.<\/p>\n

N.<\/i> <\/i>hypoglossus<\/i><\/strong> <\/i>prolazi izme\u0111u unutra\u0161nje jugularne vene i unutra\u0161nje karotidne arterije. Potom skre\u0107e put medijalno. Pravi \u201ckrivinu\u201d da bi ukr\u0161taju\u0107i karotidne arterije dospeo do jezika. Ova \u201ckrivina\u201d je bitan detalj. Ona je zategnuta u pravcu karotide bifurkacije, nadole i put lateralno, sternokleidomastoidnom granom spolja\u0161nje karotidne arterije.<\/p>\n

Presecanjem i ligiranjem sternokleidomastoidne<\/strong> gran\u010dice koja obi\u010dno ima i prate\u0107u venicu dobija se mogu\u0107nost medijalnog pomeranja n.hypoglossusa,<\/i> <\/i>bez njegovog dodirivanja Posle toga se mo\u017ee preparisati unutra\u0161nja karotidna arterija sve do njenog ulaska u foramen<\/i> <\/i>caroticum<\/i>.<\/p>\n

U visini \u201ckrivine\u201d n.hypoglossus-a<\/strong> obi\u010dno nastaje jedna njegova bo\u010dna grana koja inervi\u0161e m.omohyoideus<\/i>. U svom daljem toku ova grana se spaja sa drugim cervikalnim nervima koji grade mre\u017eu zvanu ansa<\/b><\/i> <\/b><\/i>cervicalis<\/b><\/i> <\/b><\/i>profunda<\/b><\/i>. Ovaj nervni splet treba sa\u010duvati, ako je mogu\u0107e, ali ne na \u0161tetu kvaliteta arterijske rekonstrukcije. Najbolje je izbegavati dodirivanje n.hypoglossus<\/i>-a i njegovih tipi\u010dnih i atipi\u010dnih grana.<\/p>\n

R. <\/i>descendens<\/i> <\/i>n.hypoglossi<\/i><\/strong> <\/i>obi\u010dno se odvaja od glavnog nervnog stabla iznad nivoa \u201ckrivine\u201d, pa se mo\u017ee sa\u010duvati. Ona dalje prati unutra\u0161nju, a zatim zajedni\u010dku karotidnu arteriju, prema grudnom ko\u0161u. Presecanje ove grane n.hypoglossus<\/i>-a ne ostavlja neurolo\u0161ke konsekvence koje bi se mogle registrovati klini\u010dkim pregledom.<\/p>\n<\/div>\n

\"\"<\/p>\n

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Kranijalni nervi sa kojima se mo\u017ee do\u0107i u koliziju prilikom disekcije karotidnih arterija<\/em><\/p>\n<\/div>\n

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Postavljanje \u201cautomatskog ekartera\u201d<\/strong> i razdvajanje ivica rane zate\u017ee sternokleidomastoidnu granu spolja\u0161nje karotidne arterije. Tako se pravi dodatna trakcija u predelu \u201ckrivine\u201d nerva; indirektno ga pozle\u0111uju\u0107i. Zato je postavljanje ekartera u pravu poziciju mogu\u0107e tek posle reseciranja sternokleidomastoidnih krvnih sudova i \u201cosloba\u0111anja\u201d n.hypoglossus<\/i>-a.<\/p>\n

Lezija n.hypoglossus-a<\/strong> se manifestuje devijacijom jezika na o\u0161te\u0107enu stranu, ako je jednostrana. Obostrana lezija n.hypoglossus-a opisana je kod simultane rekonstrukcije obe karotidne arterije. Zato se istovremeni zahvati na obe karotidne arterije izbegavaju.<\/p>\n

O\u0161te\u0107enje n.hypoglossusa<\/i> <\/i><\/strong>dovodi do nemogu\u0107nosti kontrolisanja jezika, ali i insuficijencije akta gutanja, \u0161to obi\u010dno traje manje od 4 nedelje, zatim se povla\u010di i bez terapije. Le\u010di se polivitaminskom i roborantnom terapijom. U le\u017ee\u0107oj poziciji pacijenta mo\u017ee do\u0107i do zapadanja jezika i\/ili hrane, sa obstrukcijom gornjih respiratornih puteva i asfiksijom.<\/p>\n

Posle bu\u0111enja iz anestezije ovi pacijenti se mogu na\u0107i u \u017eivotnoj opasnosti. Oni su klini\u010dki potpuno budni, ali ne mogu da di\u0161u. Privremena pareza \u017eivca registruje se postoperativno u oko 8,5% slu\u010dajeva, sa poblj\u0161anjem u roku od nekoliko nedelja. Spre\u010dava se suptilnom operativnom tehnikom.<\/span> <\/span><\/p>\n

Poseban<\/span> <\/span>problem<\/span> <\/span>su<\/span> <\/span>reoperacije,<\/span> <\/span>gde<\/span> <\/span>se<\/span> <\/span>disekcija<\/span> <\/span>odvija<\/span> <\/span>kroz<\/span> <\/span>o\u017eiljno<\/span> <\/span>tkivo,<\/span> <\/span>pa<\/span> <\/span>se<\/span> <\/span>nervi<\/span> <\/span>te\u017ee<\/span> <\/span>identi<\/span>fi<\/span>kuju.<\/span><\/p>\n<\/div>\n

\"\"<\/p>\n

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Kranijalni nervi sa kojima se mo\u017ee do\u0107i u koliziju prilikom disekcije karotidnih arterija<\/em><\/p>\n<\/div>\n

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Nervus<\/b><\/i><\/span> <\/b><\/i><\/span>vagus<\/b><\/i><\/span> <\/b><\/i><\/span>mo\u017ee<\/span> <\/span>da<\/span> <\/span>strada<\/span> <\/span>ako<\/span> <\/span>se<\/span> <\/span>klemovanje<\/span> <\/span>karotidnih<\/span> <\/span>arterija<\/span> <\/span>izvodi<\/span> <\/span>\u201cna<\/span> <\/span>slepo\u201d,<\/span> <\/span>po\u0161to<\/span> <\/span>se<\/span> <\/span>pru\u017ea<\/span> <\/span>zadnjom<\/span> <\/span>stranom<\/span> <\/span>unutra\u0161nje<\/span> <\/span>i<\/span> <\/span>zajedni\u010dke<\/span> <\/span>karotidne<\/span> <\/span>arterije.<\/span> <\/span>Ne<\/span> <\/span>treba<\/span> <\/span>insistirati<\/span> <\/span>na<\/span> <\/span>potpunom<\/span> <\/span>odvajanju<\/span> <\/span>arterije<\/span> <\/span>i<\/span> <\/span>nerva,<\/span> <\/span>ako<\/span> <\/span>nije<\/span> <\/span>neophodno,<\/span> <\/span>jer<\/span> <\/span>se<\/span> <\/span>i<\/span> <\/span>to<\/span> <\/span>mo\u017ee<\/span> <\/span>zavr\u0161iti<\/span> <\/span>njegovom<\/span> <\/span>lezijom.<\/span> <\/span>Na<\/span> <\/span>drugoj<\/span> <\/span>strani,<\/span> <\/span>ako<\/span> <\/span>se<\/span> <\/span>nerv<\/span> <\/span>uop\u0161te<\/span> <\/span>ne<\/span> <\/span>odvoji<\/span> <\/span>od<\/span> <\/span>arterije,<\/span> <\/span>mo\u017ee<\/span> <\/span>stradati<\/span> <\/span>pri<\/span> <\/span>postavljanju<\/span> <\/span>kleme.<\/span> <\/span>Zato<\/span> <\/span>je<\/span> <\/span>najbolje<\/span> <\/span>da<\/span> <\/span>se<\/span> <\/span>nerv<\/span> <\/span>odvoji<\/span> <\/span>od<\/span> <\/span>arterije<\/span> <\/span>tamo<\/span> <\/span>gde<\/span> <\/span>\u0107e<\/span> <\/span>biti<\/span> <\/span>postavljena<\/span> <\/span>proksimalna<\/span> <\/span>i<\/span> <\/span>distalna<\/span> <\/span>klema.<\/span> <\/span>Me\u0111utim,<\/span> <\/span>i<\/span> <\/span>ovo<\/span> <\/span>mo\u017ee<\/span> <\/span>biti<\/span> <\/span>problem<\/span> <\/span>ako<\/span> <\/span>se<\/span> <\/span>radi<\/span> <\/span>o<\/span> <\/span>reoperaciji,<\/span> <\/span>zbog<\/span> <\/span>o\u017eiljka.<\/span><\/p>\n

U<\/span> <\/span>slu\u010daju<\/span> <\/span>disekcije<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>zbog<\/span> <\/span>restenoze<\/span> (<\/span>redo <\/i><\/span>operacija)<\/span> <\/span>najbolje<\/span> <\/span>je<\/span> <\/span>prvo<\/span> <\/span>zauzdati<\/span> <\/span>zajedni\u010dku<\/span> <\/span>karotidnu<\/span> <\/span>arteriju<\/span> <\/span>ne\u0161to<\/span> <\/span>proksimalnije<\/span> <\/span>od<\/span> <\/span>dela<\/span> <\/span>koji<\/span> <\/span>je<\/span> <\/span>u<\/span> <\/span>o\u017eiljku.<\/span> <\/span>Potom<\/span> <\/span>se<\/span> <\/span>nervus<\/i><\/span> <\/i><\/span>vagus <\/i><\/span>odvaja,<\/span> <\/span>a<\/span> <\/span>o\u0161tra<\/span> <\/span>disekcija<\/span> <\/span>nastavlja<\/span> <\/span>put<\/span> <\/span>distalno.<\/span> <\/span>Posebno<\/span> <\/span>treba<\/span> <\/span>biti<\/span> <\/span>oprezan<\/span> <\/span>kod<\/span> <\/span>elektrokoagulacije<\/span> <\/span>ili<\/span> <\/span>ligiranja<\/span> <\/span>zbog<\/span> <\/span>manjih<\/span> <\/span>krvarenja<\/span> <\/span>u<\/span> <\/span>blizini<\/span> <\/span>vagusa.<\/span><\/p>\n

Lezija<\/span> <\/span>n.vagusa<\/i><\/span> <\/i><\/span>se<\/span> <\/span>postoperativno<\/span> <\/span>manifestuje<\/span> <\/span>promuklo\u0161\u0107u<\/span> <\/span>sa<\/span> <\/span>paralizom<\/span> <\/span>ili<\/span> <\/span>parezom<\/span> <\/span>ipsilateralne<\/span> <\/span>glasne<\/span> <\/span>\u017eice.<\/span> <\/span>Diferencijalno<\/span> <\/span>dijagnosti\u010dki<\/span> <\/span>se<\/span> <\/span>promuklost<\/span> <\/span>mo\u017ee<\/span> <\/span>javiti<\/span> <\/span>i<\/span> <\/span>zbog<\/span> <\/span>edema<\/span> <\/span>ili<\/span> <\/span>hematoma<\/span> <\/span>vokalnih<\/span> <\/span>plika<\/span> <\/span>zbog<\/span> <\/span>ote\u017eane<\/span> <\/span>endotrahealne<\/span> <\/span>intubacije<\/span> <\/span>Posle<\/span> <\/span>karotidne<\/span> <\/span>endarterektomije<\/span> <\/span>se<\/span> <\/span>lezija<\/span> <\/span>vagusa<\/span> <\/span>mo\u017ee<\/span> <\/span>o\u010dekivati<\/span> <\/span>u<\/span> <\/span>oko<\/span> <\/span>2%<\/span> <\/span>pacijenata,<\/span> <\/span>zavisno<\/span> <\/span>od<\/span> <\/span>dijagnosti\u010dkih<\/span> <\/span>kriterijuma.<\/span> <\/span>Privremeni<\/span> <\/span>de<\/span>fi<\/span>citi<\/span> <\/span>u<\/span> <\/span>inervacionom<\/span> <\/span>podr\u010dju<\/span> <\/span>n.vagus<\/i><\/span>-a<\/span> <\/span>je<\/span> <\/span>\u010de\u0161\u0107i<\/span> <\/span>ako<\/span> <\/span>se<\/span> <\/span>radi<\/span> <\/span>rutinska<\/span> <\/span>laringolo\u0161ka<\/span> <\/span>kontrola<\/span> <\/span>pokretljivosti<\/span> <\/span>glasnih<\/span> <\/span>\u017eica.<\/span> <\/span>\u010ce\u0161\u0107e<\/span> <\/span>povrede<\/span> <\/span>nervusa<\/span> <\/span>vagusa<\/span> <\/span>javljaju<\/span> <\/span>se<\/span> <\/span>kod<\/span> <\/span>visokog<\/span> <\/span>pristupa<\/span> <\/span>distalnoj<\/span> <\/span>cervikalnoj<\/span> <\/span>unutra\u0161njoj<\/span> <\/span>karotidnoj<\/span> <\/span>arteriji<\/span> <\/span>sa<\/span> <\/span>subluksacijom<\/span> <\/span>ili<\/span> <\/span>luksacijom<\/span> <\/span>mandibule,<\/span> <\/span>kao<\/span> <\/span>i<\/span> <\/span>kod<\/span> <\/span>reoperacija<\/span> <\/span>zbog<\/span> <\/span>restenoze<\/span> <\/span>ili<\/span> <\/span>psudoaneurizme<\/span> <\/span>karotidne<\/span> <\/span>arterije.<\/span><\/p>\n

Lezije<\/span> <\/span>parasimpati\u010dkih<\/span> <\/span>vlakana<\/span> <\/span>vagusa<\/span> <\/span>za<\/span> <\/span>visceralnu<\/span> <\/span>autoregulaciju<\/span> <\/span>se<\/span> <\/span>klini\u010dki<\/span> <\/span>ne<\/span> <\/span>manifestuju,<\/span> <\/span>ako<\/span> <\/span>su<\/span> <\/span>unilateralne.<\/span><\/p>\n

Nervus<\/b><\/i><\/span> <\/b><\/i><\/span>laryngeus<\/b><\/i><\/span> <\/b><\/i><\/span>superior<\/b><\/i><\/span> <\/b><\/i><\/span>nastaje<\/span> <\/span>iz<\/span> <\/span>nodoznog<\/span> <\/span>gangliona.<\/span> <\/span>Spu\u0161ta<\/span> <\/span>se<\/span> <\/span>koso<\/span> <\/span>iza<\/span> <\/span>unutra\u0161nje<\/span> <\/span>i<\/span> <\/span>spolja\u0161nje<\/span> <\/span>karotidne<\/span> <\/span>arterije.<\/span> <\/span>Iza<\/span> <\/span>gornje<\/span> <\/span>tireoidne<\/span> <\/span>arterije<\/span> <\/span>skre\u0107e<\/span> <\/span>prema<\/span> <\/span>larinksu.<\/span> <\/span>Mo\u017ee<\/span> <\/span>biti<\/span> <\/span>lediran<\/span> <\/span>pri<\/span> <\/span>zauzdavanju<\/span> <\/span>spolja\u0161nje<\/span> <\/span>karotidne<\/span> <\/span>i<\/span> <\/span>gornje<\/span> <\/span>tireoidne<\/span> <\/span>arterije,<\/span> <\/span>ako<\/span> <\/span>se<\/span> <\/span>ono<\/span> <\/span>izvodi<\/span> <\/span>tupom<\/span> <\/span>disekcijom.<\/span><\/p>\n

Povreda<\/span> <\/span>spolja\u0161nje<\/span> <\/span>grane<\/span> <\/span>gornjeg<\/span> <\/span>laringealnog<\/span> <\/span>nerva<\/span> <\/span>se<\/span> <\/span>klini\u010dki<\/span> <\/span>manifestuje<\/span> <\/span>brzim<\/span> <\/span>zamorom<\/span> <\/span>glasa,<\/span> <\/span>nemogu\u0107no\u0161\u0107u<\/span> <\/span>fonacije<\/span> <\/span>vi\u0161ih<\/span> <\/span>tonova<\/span> <\/span>i<\/span> <\/span>slabljenjem<\/span> <\/span>re<\/span>fl<\/span>eksa<\/span> <\/span>ka\u0161lja.<\/span> <\/span>Laringoskopski<\/span> <\/span>se<\/span> <\/span>registruje<\/span> <\/span>afunkcija<\/span> <\/span>ili<\/span> <\/span>disfunkcija<\/span> <\/span>m.cricothyroideus<\/i><\/span>-a.<\/span> <\/span>Povreda<\/span> <\/span>unutra\u0161nje<\/span> <\/span>grane<\/span> <\/span>gornjeg<\/span> <\/span>laringealnog<\/span> <\/span>nerva<\/span> <\/span>dovodi<\/span> <\/span>do<\/span> <\/span>poreme\u0107aja<\/span> <\/span>akta<\/span> <\/span>gutanja,<\/span> <\/span>\u0161to<\/span> <\/span>obi\u010dno<\/span> <\/span>traje<\/span> <\/span>manje<\/span> <\/span>od<\/span> <\/span>6<\/span> <\/span>nedelja,<\/span> <\/span>zatim<\/span> <\/span>se<\/span> <\/span>povla\u010di<\/span> <\/span>i<\/span> <\/span>bez<\/span> <\/span>terapije.<\/span> <\/span>Le\u010di<\/span> <\/span>se<\/span> <\/span>polivitaminskom<\/span> <\/span>i<\/span> <\/span>roborantnom<\/span> <\/span>terapijom.<\/span><\/p>\n

Nervus<\/b><\/i><\/span> <\/b><\/i><\/span>laryngeus<\/b><\/i><\/span> <\/b><\/i><\/span>recurrens<\/b><\/i><\/span> <\/b><\/i><\/span>se<\/span> <\/span>odvaja<\/span> <\/span>od<\/span> <\/span>nervus<\/i><\/span>-a.<\/span>vagus<\/i><\/span>-a<\/span> <\/span>intratorakalno<\/span> <\/span>i<\/span> <\/span>kre\u0107e<\/span> <\/span>retrogradno<\/span> <\/span>(<\/span>recurrens<\/i><\/span>)<\/span> <\/span>put<\/span> <\/span>kranijalno.<\/span> <\/span>Nalazi<\/span> <\/span>se<\/span> <\/span>izme\u0111u<\/span> <\/span>traheje<\/span> <\/span>i<\/span> <\/span>jednjaka<\/span> <\/span>u<\/span> <\/span>svom<\/span> <\/span>cervikalnom<\/span> <\/span>delu,<\/span> <\/span>ali<\/span> <\/span>nije<\/span> <\/span>tako<\/span> <\/span>blizak<\/span> <\/span>arteriji<\/span> <\/span>kao<\/span> <\/span>n.vagus<\/i><\/span>.<\/span><\/p>\n

    \n
  • Desni<\/b><\/span> <\/b><\/span>rekurentni<\/span> <\/span>laringealni<\/span> <\/span>\u017eivac<\/span> <\/span>odvaja<\/span> <\/span>se<\/span> <\/span>od<\/span> <\/span>stabla<\/span> <\/span>vagusnog<\/span> <\/span>\u017eivca<\/span> <\/span>ispod<\/span> <\/span>desne<\/span> <\/span>subklavijalne<\/span> <\/span>arterije.<\/span> <\/span>Vra\u0107a<\/span> <\/span>se<\/span> <\/span>ukr\u0161taju\u0107i<\/span> <\/span>njenu<\/span> <\/span>prednju<\/span> <\/span>stranu.<\/span><\/li>\n
  • Levi<\/b> <\/b>rekurentni \u017eivac pravi sli\u010dnu petlju oko luka aorte, iza ligamentum<\/i>-a arteriosum<\/i>-a.<\/li>\n<\/ul>\n

    Oba rekurentna \u017eivca vra\u0107aju se prema larinksu du\u017e \u017eljeba izme\u0111u jednjaka i traheje. Njihova lezija je mogu\u0107a ako se \u201cluta\u201d pri preparisanju. Posebno na levoj strani gde je karotidna arterija ne\u0161to dublje polo\u017eena. Zato se savetuje identifikacija i zauzdavanje zajedni\u010dke karotidne arterije, \u0161to je najlak\u0161e, a zatim preparisanje put kranijalno uz samu arteriju.<\/p>\n

    Lezija ovog \u017eivca je izuzetno retka, a manifestuje se promuklo\u0161\u0107u. Postoperativna promuklost je mnogo \u010de\u0161\u0107e posledica lezije vagusa. Paraliza rekurentnog \u017eivca daje ipsilateralnu nepokretnost glasne \u017eice u paramedijalnoj poziciji. Glas postaje slab i promukao, sa oslabljenim refleksom ka\u0161lja \u0161to obi\u010dno traje manje od 6 nedelja, zatim se povla\u010di, a le\u010di se polivitaminskom terapijom.<\/p>\n

    Nervus<\/b><\/i> <\/b><\/i>phrenicus<\/b><\/i> <\/b><\/i>spu\u0161ta se regionom vrata prednjom stranom prednjeg skalenskog mi\u0161i\u0107a. \u0160to kaudalnije ga pratimo, to medijalnije \u0107emo ga na\u0107i.<\/p>\n

      \n
    • Na desnoj strani se spu\u0161ta du\u017e lateralnog zida desne brahiocefali\u010dne vene, a potom spolja\u0161njom stranom gornje \u0161uplje vene. Zatim du\u017e perikarda lateralne strane perikardne kese dospeva do dijafragme.<\/li>\n
    • Na levoj strani n.phrenicus<\/i> <\/i>ukr\u0161ta na bazi vrata ductus<\/i> <\/i>thoracicus<\/i>. Dospeva<\/li>\n<\/ul>\n

      izme\u0111u subklavijalne arterije i vene do aortnog luka. Potom se du\u017e peri- kardne kese spu\u0161ta do dijafragme.<\/p>\n

      N.phrenicus<\/i> <\/i>je izlo\u017een povredama naro\u010dito pri operacijama na subklavijalnoj arteriji, brahiocefali\u010dnom stablu, a re\u0111e na unutra\u0161njoj jugularnoj veni. Mo\u017ee se ledirati prilikom tuneliziranja za plasiranje grafta kod ektraanatomske i transsternalne rekonstrukcije supraaortalnih stabala.<\/p>\n

      Posledica lezije freni\u010dnog \u017eivca je pareza ili paraliza hemidijafragme. Dijafragma se na kontrolnom rentgenskom snimku zapa\u017ea kao elevirana. Ovo mo\u017ee pridoneti postoperativnim respiratornim komplikacijama (neekspandirano plu\u0107no krlo, atelektaza, pneumonija).<\/p>\n

      Simpati\u010dka<\/b> <\/b>nervna<\/b> <\/b>vlakna<\/b> <\/b>nalaze se u preveretebralnoj fasciji, dorzalno i medijalno u odnosu na neurovaskularnu peteljku karotidne arterije. O\u0161te\u0107enje simpati\u010dkih vlakana, a naro\u010dito gangliona stelatuma mogu\u0107e je pri disekciji vertebrane i subklavijalne arterije<\/p>\n

      Lezija cervikalnog simpati\u010dkog gangliona manifestuje se pojavom Hornerovog sindroma. Klini\u010dki trijas: ptoza, mioza i enoftalmus opisuje se kao Hornerov sindrom. Obi\u010dno se povla\u010di spontano, za nekoliko nedelja. Polivitminska terapija (vitamini B grupe) mo\u017ee da ubrza i\u0161\u010dezavanje Horenerovog sindroma.<\/p>\n<\/div>\n


      \n<\/p>\n","protected":false},"excerpt":{"rendered":"

      LEZIJE KRANIJALNIH NERAVA UKAROTIDNOJ HIRURGIJI It is worse than immoral. It is a mistake.(of Americas involvement in Vietnam, Dean Acheson) Wisdom lives in the Future and from there it speaks to us.Paul Valery Karotidne arterije su u bliskom odnosu sa okolnim kranijalnim nervima. Rekostrukcija karotidne arterije dovodi nas u kontakt sa kranijalnim nervima. Da se […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-4445","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\n19. LEZIJE KRANIJALNIH NERAVA U KAROTIDNOJ HIRURGIJI - KAROTIDNA HIRURGIJA<\/title>\n<meta name=\"description\" content=\"Karotidne arterije su u bliskom odnosu sa okolnim kranijalnim nervima. 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