论文部分内容阅读
背景:由于听神经瘤缓慢地膨胀性生长,听神经的解剖位置发生很大的变化,手术中面神经的损伤不可避免。目的:总结120例听神经瘤患者术中面神经功能监测的临床经验,了解面神经监测的方法学、准确性、实用性以及术中监测和面神经预后的关系,实现解剖保留面神经功能。设计:自身对照观察。单位:解放军总医院神经外科。对象:于1996-05/2000-02选择解放军总医院神经外科收治的听神经瘤患者120例为研究对象,小型听神经瘤(直径<2cm)3例,中型听神经瘤(直径>2cm)9例,大型听神经瘤(直径>3cm)的108例,其中包括双侧听神经瘤1例,复发性听神经瘤1例;手术采用枕下乳突后入路119例,经迷路入路1例。方法:术中使用美国Viking-Ⅳ型多导术中监测仪监测自发和诱发面肌肌电图。监测面神经功能时,记录电极置于眼囵匝肌、口囵匝肌或上唇方肌上,监测三叉神经运动支时,记录电极置于咀嚼肌上;监测副神经时,电极置于斜方肌上。听觉脑干诱发电位测定:记录电极为正极,置于额区中线(脑电图10～20分类系统),记录出的波形呈向上的偏转(正),参考电极A1或A2,接地电极置于额极中线(相当于鼻根部);记录电极均为针电极并用胶布固定。一般刺激强度为80～90nHL,对侧耳用40nHL的噪声。通过术中监测解剖保留面神经。术后复查CT(必须有增强扫描)或MRI,了解肿瘤的切除程度;术后患者面神经功能的H-B评分(术后2周,6～9个月复诊时再次评分)。主要观察指标:手术前后听神经瘤患者面神经功能的H-B评分。结果:纳入患者120例,均进入结果分析。①面神经解剖保留117例;1例听神经瘤因面神经呈羽状位于肿瘤的后方,开始切除肿瘤时没有给予电刺激而未能保留,后行面-舌下神经吻合术。2例面神经不慎拉断后两残端足够长且没有张力,故修整后用7-0可吸收线行面神经端-端吻合,术后6个月H-B分级为IV～V级。②术后2周面神经功能的H-B评分为Ⅰ级10例,Ⅱ级57例,Ⅲ级44例,Ⅳ级4例,Ⅴ级2例,Ⅵ级3例。③术后9个月面神经功能的H-B评分为Ⅰ级94例,Ⅱ级18例,Ⅲ级4例,Ⅳ级1例,Ⅴ级1例,Ⅵ级2例。结论:通过术中监测自发肌电图结合单极恒压电刺激诱发肌电图可以精确判断面神经的位置,损伤较机械刺激小,面神经的解剖保留率高,且电刺激量由大到小,距离由远及近,定位准确、及时,并可判断面神经预后。
Background: Due to the slow expansion of acoustic neuroma growth, the anatomic location of the auditory nerve undergoes considerable changes and the facial nerve damage during surgery is inevitable. OBJECTIVE: To summarize the clinical experience of facial nerve function monitoring in 120 patients with acoustic neuroma and to understand the methodology, accuracy and practicability of facial nerve monitoring, as well as the relationship between intraoperative monitoring and facial nerve prognosis and to preserve facial nerve function. Design: self-control observation. Unit: PLA General Hospital Neurosurgery. PARTICIPANTS: A total of 120 patients with acoustic neuroma admitted to the Department of Neurosurgery, Chinese PLA General Hospital from May 1996 to May 2000 were selected as the study object. Three patients with small acoustic neuroma (diameter <2cm), 9 patients with medium acoustic neuroma (diameter> 2cm) Acoustic neuroma (diameter> 3cm) in 108 cases, including bilateral acoustic neuroma in 1 case, recurrent acoustic neuroma in 1 case; operation after the suboccipital papillae in 119 cases, lost in 1 case. Methods: Intraoperative use of the United States Viking-Ⅳ type of multi-guided intraoperative monitoring of spontaneous and induced facial muscle EMG. When monitoring facial nerve function, the recording electrode was placed on the orbicularis muscle, the orbicularis oris muscle, and the recording electrode was placed on the masticatory muscle while monitoring the trigeminal motor branch. When monitoring the accessory nerve, the electrode was placed on the trapezius on. Auditory Brainstem Evoked Potentials: The recording electrodes are positive and placed in the forehead midline (EEG 10-20 classification system). The recorded waveform is deflected upward (positive), reference electrode A1 or A2, and the ground electrode is placed Frontal center line (equivalent to the nasal root); recording electrodes are needle electrodes and fixed with tape. The general stimulus intensity of 80 ~ 90nHL, contralateral ear with 40nHL of noise. Facial nerve was preserved through intraoperative monitoring and dissection. Postoperative recanalization CT (must have an enhanced scan) or MRI, to understand the extent of tumor resection; postoperative patients with facial nerve function H-B score (2 weeks after surgery, 6 to 9 months re-evaluation score). MAIN OUTCOME MEASURES: H-B score of facial nerve function in patients with acoustic neuroma before and after surgery. Results: 120 patients were enrolled in the analysis of the results. ① facial nerve anatomy retained 117 cases; 1 case of acoustic neuroma was facial femur was located in the posterior of the tumor, began to excision of the tumor without giving electrical stimulation failed to retain, after the line - sublingual nerve anastomosis. 2 cases of facial nerve inadvertently pulled off the two stumps long enough and no tension, so after dressing with 7-0 absorbable line facial nerve end-to-end anastomosis, 6 months after the H-B grade IV ~ V grade. ② The H-B scores of facial nerve function in 2 weeks after operation were 10 grade Ⅰ, 57 grade Ⅱ, 44 grade Ⅲ, 4 grade Ⅳ, 2 grade Ⅴ, and 3 grade Ⅵ. ③ The H-B score of facial nerve in 9 months after operation was 94 grade Ⅰ, 18 grade Ⅱ, 4 grade Ⅲ, 1 grade Ⅳ, 1 grade Ⅴ, and 2 grade Ⅵ. Conclusion: Electromyography can be used to accurately determine the location of facial nerve through intraoperative monitoring of spontaneous EMG combined with unipolar constant voltage electrical stimulation. Compared with mechanical stimulation, facial nerve can retain more anatomic retention rate and the electrical stimulation volume from large to small, Distance from near and far, accurate positioning, timely, and can determine the prognosis of facial nerve.