摘要
目的
1.评估运动神经监测仪在术中对喉返神经进行识别、保护和对其病变部位进行定位的意义;2.建立喉返神经术中监测诱发肌电的正常参数值和相关检测数据;3.确定喉返神经术中监测的阈刺激和最佳刺激量;4.模拟手术损伤,应用运动神经监测仪对喉返神经损伤部位进行定位和功能监测;5.手术中对病人的喉返神经进行实时监测,为临床的诊断与治疗提供相关参考资料。
材料与方法
一.动物实验部分:
(一).实验仪器:采用美敦力-施美德公司(Medtronic, USA)生产的术中运动神经监测仪(NIM-Response and NIM-Pulse system)和EMG加固型专用带电极气管导管。刺激强度(Stimulus Inteasity)分别取0.2mA、0.4mA、3.0mA,刺激速率(Velocity Rate)设置为4次/秒,刺激时间(Duration)为100μS,刺激过滤器为3.10mS,事件阈值(Event Threshold)为100~100μV,时间刻度50mS,垂直刻度为500μV。
1.实验动物:健康成年犬40只,体重14~18公斤/只,雌雄不限,用3%戊巴比妥每公斤体重30mg腹腔内注射全麻,气管内插入NIM~(TM)EMG专用气管插管(美国XOMED公司生产),手术暴露双侧喉返
第二军医大学博士论文
神经、环约后肌,甲状软骨板中下三分之一处做一snnn、3~骨窗,
基寡甲灼肌及环为侧机.
2.正常值监浏:40只(so侧)分别用刺激电流童为0.ZmA、
0 .4碱刺激双侧喂返神经,记录电极分别里于气管内擂管甲村肌表面、
环钓侧肌、环村后肌,了解各种电流喇激后诱发杯电的始潜伏期、峰
潜伏期、波福、时程的变化,探讨阅利激和最佳刺激强度,建立正常
数据值范围。
模拟手术损伤的实验研究:针对临床上常见的手术损伤类型,分
为5组:即结扎组、钳夹组、3毗(本实验机器最大电流刺激量)电
流刺激组、喉返神经切断后端一端吻合组、喉返神经切断空白对照组,
除空白对照组2只犬外,其余每组均为5只,所有实验动物均取右侧
喉返神经作为实验侧,随机分组对比研究。(1):结扎组用4号丝线在
右侧喉返神经入喉处下方1 .scm处直接结扎喉返神经干;(2):柑夹组
用中号止血钳夹一齿为度,持续10秒钟后松开,(3):3毗电流刺激
组用机器最大的输出电流3mA连续刺激喉返神经10秒钟后,休息1
分钟,再次用0 ZlnA和0.4mA电流刺激后观察其运动神经监浏诱发
肌电变化月4):神经吻合组在切断喉返神经后即刻行显微外科喉返神
经端一端吻合术;(5):神经切断组切断喉返神经Zcm以上,不做任何
处理,为失神经空白对照组。所有动物的左侧喉返神经解刹后作为正
常对照。在损伤前、损伤后即刻、损伤后1个月分别进行甲朽肌、环
钓侧肌和环钓后肌各肌的静息电位、0.2mA、0.4祖A#.J激强度的始潜
伏期、峰潜伏期、波幅、时程的变化,依次对各种不同电刺激强度的
第二军医大学博士论文
数据和各种记录方法的数据分别进行对比研究,了解各种损伤对喉返
神经功能的影响,将结果进行统计学分析.
结
果
1.犬用)0.ZmA以上电流刺激喉返神经时,均能引出诱发肌
电改变,0.4以刺激时能引出高大、稳定、重复性好的诱发肌电反应,
刺激量进一步增大时波幅增高较小或不明显。
2.甲钓肌组、环约侧肌组、环钓后肌组喉返神经运动诱发肌电
术中静息电位、峰潜伏期、波幅、时程左右两侧对比P>0 .05,差异
无显著性意义。
3.甲钓肌组、环钓侧肌组、环钓后肌组喉返神经运动诱发电
位比较:
甲钓肌组的始潜伏期和时程与环构侧肌组和环钓后肌组对比
P> 0.05,差异无显著性意义,而峰潜伏期和波幅甲构肌组均明显少于
环柏侧肌组和环构后肌组P< 0.01,差异有极显著性意义.提示环钓侧
肌组和环约后肌组灵敏性更高,考虑原因为甲构肌组是通过将电极呈
于声带表面,而环构侧从组和环钓后肌组均是将记录电极直接插入记
录肌组肉内,因而后二者能直接记录大量运动单位肌电活动的原因.
环约侧肌组和环钓后肌组在0 .ZmA刺激时P>0 .05,差异无显著
性意义。而在0 .4mA电流刺激时峰潜伏期和波幅差异有极显著性意
义,P< 0.01,这与最佳刺激量时环约后肌收缩的机纤维多,收缩力强
有关。
3
第二军医大学博士论文
4.动物实脸中发现当用3毗电流刺激童时,对喂返神经不造
成明显损害.
5.模拟手术损伤后的改变:
右侧噪返神经结扎、柑夹、端一端喻合和空白对照组术后1月检
查,刺激喂返神经近心端均沃有引出运动神经监侧肌电反应,远心端
均能引出诱发从电,但波幅较术前明显下降,手术前后差异均有显著
性意义(P<0 .05)。3毗电流刘激组手术前后运动神经监测肌电波形、
波幅差异无显著性意义,P>O.05.
二、临床部分:
仪器及电流刺激强度和方法同实验动物组。41例颐部手术病人
作为受检者,手术时不用刀‘松剂,将Prass双极记录电极直接插入环
柏后肌,在游离喉返神经后,标准单极刺激电极里于喉返神经上,记
录运动诱发肌电.
临床受检者观察:41例颈部手术病人,术中用运动神经监测仪
监测喉
OBJECTIVE: 1 to identify the recurrent laryngeal nerve and to access its integrity of the nerve with NIM-Response and NIM-Pulse system intraoperationly. 2. setup the storage of normal data or determination of normal limits. 3 to explore the threshold and the best stiraulate-response threshold of the EMG intraoperationly . 4 to imitate the operative damage and to access the electrophysiologic function of the recurrent laryngeal nerve. 5. clinic observation intraoperationly for the patients.
Material and method:
1.Animal experiment:
Instrument: NIM-Response and NIM-Pulse system made of Medtronic-MOMED, USA; stimulus mount 0.2mA, 0.4mA 3.0mA separately; Velocity Rate, 4c/s; duration, 100S; event threshold, 100 ~ 1000V; filter, 3.10mS; time scale, 50mS, vertical scale, 500V
Method:
Normal data group: 40 dogs were measured under general anaesthesia. The stimulator electrode was put on the surface of the recurrent laryngeal nerve and the record electrode were located at the thyroarytenoid muscle,lateral cricoarytenoid muscle and posterior
cricoarytenoid muscle. Comparing the onset latency, peak latency, amplify, duration, probing into the threshold and the best threshold, and setup the storage of normal data or determination of normal limits.
20 dogs were classified randomly into four types, ligature, jaw, 3mA electron current stimulator group (max output current), and end-to-end anastomosis of the recurrent laryngeal nerve. 2 dogs as control group. 3mA electron current stimulator group have no change after the operation. Other groups lost the transmit faction of the current. The threshold was 0.2mA and the best threshold was 0.4mA.
2. Clinic study:
40 patients of neck operation were inspected with NIM-Response and NIM-Pulse system made of Medtronic-MOMED, USA; stimulus mount 0.2mA, 0.4mA could conduct the typical EMG of recurrent laryngeal nerve. It is helpful to locate the RLN and the lesion position in the neck operation.
Conclusion:
1.The main advantage to intraoperative RLN monitoring is in help with the initial identification of the RLN and assessment of the integrity of the nerve at the end of the case. 2.The threshold was 0.2mA, and the best threshold was 0.4mA.
3. 3mA stimulator is still safe and stabilization. There are no influence on the NIM.
引文
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7. Holger K Eltzschig; Matthew Posner; The use of readily available equipment in a simple method for intraoperative monitoring of recurrent laryngeal nerve function during thyroid surgery. Archives of surgery; Apt 2002;137(4):452~458