尺神经松解前后肌电生理变化的意义
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摘要
目的:通过对肘管综合征患者进行神经-肌电图检测其入院手术前、手术松解前、手术松解后神经传导速度(Never Conduction Velocity, NCV)等的变化情况,并分析术前神经电生理各项指标与疾病严重程度、手术治疗近期疗效的相关性,以探讨神经-肌电图检测在肘管综合征的诊断、治疗中的应用指导意义,为早期诊断肘管综合征、改进该病的手术治疗方法并最终减少手术创伤、改善手术预后提供科学依据。
方法:于2010年7月～2011年7月,选取在新疆医科大学第一附属医院显微修复重建外科住院并行尺神经松解前置术治疗肘管综合征患者和此期间在上海复旦大学附属华山医院手外科住院并行尺神经松解前置术治疗肘管综合征患者共计45例为研究对象,利用神经-肌电图检测手段通过:(1)一组独立样本的t检验和Spearman秩相关比较患者术前神经-肌电图检测测得的尺神经运动神经传导速度、潜伏期、波幅与正常水平的差异并分析各指标与疾病严重程度的相关性;(2)利用微移技术法定位检测的卡压部位并比较其与术中观察到的实际卡压部位以评价术前神经-肌电图检测定位诊断的准确性;(3)应用配对资料的t检验,分析神经松解前后测到的尺神经传导速度、潜伏期及波幅改变情况,探讨这两项操作对尺神经短期功能恢复的影响;(4)评价术后短期疗效3月与术前尺神经传导速度、潜伏期及波幅的相关关系,最终来评价神经电生理监测在肘管综合征的诊断、治疗中的指导意义。
结果:45例研究对象有38例在术后3月获得短期随访,随访率84.4%无长期随访;(1)38例研究对象尺神经传导速度、潜伏期及波幅平均值分别为:24.52±11.43(m/s),10.68±6.51(ms)及3.42±3.17(mv);与正常人相比,肘管综合征病人尺神经传导速度减慢,潜伏期延长,波幅降低。(2)尺神经传导速度与疾病严重程度呈负相关,而潜伏期和波幅与疾病严重程度呈正相关。(3)神经-肌电图检测中微移技术法定位检测肘管综合征卡压部位的定位正确率达到83.64%,再次证实了该项技术在肘管综合征中的应用优势。(4)松解术后,尺神经传导速度较松解前增快,潜伏期较松解前缩短,波幅较松解前升高。重度肘管综合征各项指标差异无明显统计学意义,中度肘管综合征各项指标中运动传导速度差异有有统计学意义,而波幅和潜伏期无显著变化,轻度肘管综合征中各项指标有高度的统计学意义,(5)术后3月的评价疗效,大部分患者78.94%获得了较为满意的疗效(疗效优者14例,良者14例),但仍有少部分人(10.53%)疗效较差。
结论:(1)术前应用神经-肌电图检测检查技术有助于肘管综合征的诊断、判断疾病严重程度及预后,并可较准确地进行术前病变部位定位;(2)术中松解后可用神经-肌电图检测尺神经功能的改善情况能直观、客观的早期判断手术松解效果,(3)肘管综合征患者手术疗效与术前神经损伤程度有关,在重度肘管综合征手术松解后若电生理检测指标改善不明显提示临床医师可同期进行功能重建术。(4)作为一种简单、无创、客观的检查方法,肌电生理检查可为患者及临床医师提供真实的依据,对术后康复有指导意义,应该在肘管综合征的诊治中广泛应用。
Objectives: Through to cubital tunnel syndrome patients with EMG detection before operation, the operation admission releasable before peration, after neurolysis and nerve conduction velocity(Never Conduction Velocity, NCV)and other changes, and analysis of preoperative neurophysiological indices and severity of illness, operation treatment efficacy of correlation, in order to explore the EMG detection in the diagnosis of cubital tunnel syndrome, therapeutic application of guiding significance for the early diagnosis of cubital tunnel syndrome, the disease, improved operation treatment method and eventually reduce the operation, improve the prognosis of traumatic operation to provide a scientific basis.
Methods: from 2010 July to 2011 July, selected in the first affiliated hospital of Xinjiang Medical University microsurgical repair and reconstruction of ulnar nerve neurolysis in parallel preamplifier for treatment of cubital tunnel syndrome patients and this period in Huashan Hospital Affiliated to Fudan University of Shanghai hand surgery hospital anterior transposition of ulnar nerve neurolysis parallel treatment of cubital tunnel syndrome with 45 cases as the research object, using EMG detection means through: (1)a group of independent samples test and Spearman rank correlation comparison in patients with preoperative EMG detection measured ulnar nerve motor nerve conduction velocity, latency, amplitude and normal level difference and the analysis of the indexes and the disease severity; (2)using the micro shift technology orientation method detection of entrapment sites and to compare it with intraoperative observed actual entrapment sites to evaluate preoperative EMG detection and location accuracy of diagnosis; (3)application of paired test, analysis of neurolysis pretest to posttest ulnar nerve conduction velocity, the latency and the amplitude change of situation, these two operation on the ulnar nerve of short-term functional recovery; (4)the evaluation of postoperative short term efficacy(March)and preoperative ulnar nerve conduction velocity, incubation period And the amplitude correlation, ultimately to the evaluation of neurophysiological monitoring in the diagnosis of cubital tunnel syndrome, treatment of guiding significance.
Results: 38 in 45 cases were postoperative March to obtain short-term follow-up, follow-up rate was 84. 4%. No long-term follow-up; 1. 38 cases study of ulnar nerve conduction velocity, the latency and the amplitude average values were: 24.52+11.43 (M/s), 10.68+6.51(MS)and 3.42+3.17(MV); compared with normal subjects, patients with cubital tunnel syndrome ulnar nerve conduction velocity slowing, prolongation of latency, amplitude decreased. 2 ulnar nerve conduction velocity and wave amplitude and disease severity correlated negatively, and latency and disease severity was positively related to. 3 EMG detection in micro shift technology orientation method in detection of cubital tunnel syndrome entrapment sites of correct localization rate reached 83. 64%, once again proved that the technology in the cubital tunnel syndrome application advantage. 4 after neurolysis, ulnar nerve conduction velocity is non-releasable front increased quickly, latency is releasable before shortening, fluctuation is non-releasable front elevation. Severe cubital tunnel syndrome showed no statistically significant differences between the various indicators, moderate cubital tunnel syndrome indicators in the motor conduction velocity differences have statistical significance, but no significant changes in amplitude and latency, mild cubital tunnel syndrome indicators are highly statistically significant, 5 postoperative March evaluation of efficacy, the majority of patients 78.94% to obtain a more satisfactory the efficacy(or curative effect in 14 cases, good in 14 cases), but there are still a few people(10.53%)poor efficacy.
Conclusion: (1)preoperative application of EMG examination technology is helpful to the diagnosis of cubital tunnel syndrome, judging the disease severity and prognosis, and allows for a more accurate preoperative site of lesion location; (2)for releasable upon available EMG detection of ulnar nerve function improvement, can directly objective early judgment of operation solution effect, (3)the cubital tunnel syndrome patients with operation curative effect of preoperative degree of nerve injury, in severe cubital tunnel syndrome after operation for releasable if electrophysiological detection index did not change significantly prompt the clinician can be simultaneously performed function reconstruction.(4)as a simple, noninvasive, objective check method, electrophysiological examination for patients and clinicians to provide the real basis, on postoperative rehabilitation guidance, should be in the cubital tunnel syndrome diagnosis and treatment is widely used.
方法:于2010年7月～2011年7月,选取在新疆医科大学第一附属医院显微修复重建外科住院并行尺神经松解前置术治疗肘管综合征患者和此期间在上海复旦大学附属华山医院手外科住院并行尺神经松解前置术治疗肘管综合征患者共计45例为研究对象,利用神经-肌电图检测手段通过:(1)一组独立样本的t检验和Spearman秩相关比较患者术前神经-肌电图检测测得的尺神经运动神经传导速度、潜伏期、波幅与正常水平的差异并分析各指标与疾病严重程度的相关性;(2)利用微移技术法定位检测的卡压部位并比较其与术中观察到的实际卡压部位以评价术前神经-肌电图检测定位诊断的准确性;(3)应用配对资料的t检验,分析神经松解前后测到的尺神经传导速度、潜伏期及波幅改变情况,探讨这两项操作对尺神经短期功能恢复的影响;(4)评价术后短期疗效3月与术前尺神经传导速度、潜伏期及波幅的相关关系,最终来评价神经电生理监测在肘管综合征的诊断、治疗中的指导意义。
结果:45例研究对象有38例在术后3月获得短期随访,随访率84.4%无长期随访;(1)38例研究对象尺神经传导速度、潜伏期及波幅平均值分别为:24.52±11.43(m/s),10.68±6.51(ms)及3.42±3.17(mv);与正常人相比,肘管综合征病人尺神经传导速度减慢,潜伏期延长,波幅降低。(2)尺神经传导速度与疾病严重程度呈负相关,而潜伏期和波幅与疾病严重程度呈正相关。(3)神经-肌电图检测中微移技术法定位检测肘管综合征卡压部位的定位正确率达到83.64%,再次证实了该项技术在肘管综合征中的应用优势。(4)松解术后,尺神经传导速度较松解前增快,潜伏期较松解前缩短,波幅较松解前升高。重度肘管综合征各项指标差异无明显统计学意义,中度肘管综合征各项指标中运动传导速度差异有有统计学意义,而波幅和潜伏期无显著变化,轻度肘管综合征中各项指标有高度的统计学意义,(5)术后3月的评价疗效,大部分患者78.94%获得了较为满意的疗效(疗效优者14例,良者14例),但仍有少部分人(10.53%)疗效较差。
结论:(1)术前应用神经-肌电图检测检查技术有助于肘管综合征的诊断、判断疾病严重程度及预后,并可较准确地进行术前病变部位定位;(2)术中松解后可用神经-肌电图检测尺神经功能的改善情况能直观、客观的早期判断手术松解效果,(3)肘管综合征患者手术疗效与术前神经损伤程度有关,在重度肘管综合征手术松解后若电生理检测指标改善不明显提示临床医师可同期进行功能重建术。(4)作为一种简单、无创、客观的检查方法,肌电生理检查可为患者及临床医师提供真实的依据,对术后康复有指导意义,应该在肘管综合征的诊治中广泛应用。
Objectives: Through to cubital tunnel syndrome patients with EMG detection before operation, the operation admission releasable before peration, after neurolysis and nerve conduction velocity(Never Conduction Velocity, NCV)and other changes, and analysis of preoperative neurophysiological indices and severity of illness, operation treatment efficacy of correlation, in order to explore the EMG detection in the diagnosis of cubital tunnel syndrome, therapeutic application of guiding significance for the early diagnosis of cubital tunnel syndrome, the disease, improved operation treatment method and eventually reduce the operation, improve the prognosis of traumatic operation to provide a scientific basis.
Methods: from 2010 July to 2011 July, selected in the first affiliated hospital of Xinjiang Medical University microsurgical repair and reconstruction of ulnar nerve neurolysis in parallel preamplifier for treatment of cubital tunnel syndrome patients and this period in Huashan Hospital Affiliated to Fudan University of Shanghai hand surgery hospital anterior transposition of ulnar nerve neurolysis parallel treatment of cubital tunnel syndrome with 45 cases as the research object, using EMG detection means through: (1)a group of independent samples test and Spearman rank correlation comparison in patients with preoperative EMG detection measured ulnar nerve motor nerve conduction velocity, latency, amplitude and normal level difference and the analysis of the indexes and the disease severity; (2)using the micro shift technology orientation method detection of entrapment sites and to compare it with intraoperative observed actual entrapment sites to evaluate preoperative EMG detection and location accuracy of diagnosis; (3)application of paired test, analysis of neurolysis pretest to posttest ulnar nerve conduction velocity, the latency and the amplitude change of situation, these two operation on the ulnar nerve of short-term functional recovery; (4)the evaluation of postoperative short term efficacy(March)and preoperative ulnar nerve conduction velocity, incubation period And the amplitude correlation, ultimately to the evaluation of neurophysiological monitoring in the diagnosis of cubital tunnel syndrome, treatment of guiding significance.
Results: 38 in 45 cases were postoperative March to obtain short-term follow-up, follow-up rate was 84. 4%. No long-term follow-up; 1. 38 cases study of ulnar nerve conduction velocity, the latency and the amplitude average values were: 24.52+11.43 (M/s), 10.68+6.51(MS)and 3.42+3.17(MV); compared with normal subjects, patients with cubital tunnel syndrome ulnar nerve conduction velocity slowing, prolongation of latency, amplitude decreased. 2 ulnar nerve conduction velocity and wave amplitude and disease severity correlated negatively, and latency and disease severity was positively related to. 3 EMG detection in micro shift technology orientation method in detection of cubital tunnel syndrome entrapment sites of correct localization rate reached 83. 64%, once again proved that the technology in the cubital tunnel syndrome application advantage. 4 after neurolysis, ulnar nerve conduction velocity is non-releasable front increased quickly, latency is releasable before shortening, fluctuation is non-releasable front elevation. Severe cubital tunnel syndrome showed no statistically significant differences between the various indicators, moderate cubital tunnel syndrome indicators in the motor conduction velocity differences have statistical significance, but no significant changes in amplitude and latency, mild cubital tunnel syndrome indicators are highly statistically significant, 5 postoperative March evaluation of efficacy, the majority of patients 78.94% to obtain a more satisfactory the efficacy(or curative effect in 14 cases, good in 14 cases), but there are still a few people(10.53%)poor efficacy.
Conclusion: (1)preoperative application of EMG examination technology is helpful to the diagnosis of cubital tunnel syndrome, judging the disease severity and prognosis, and allows for a more accurate preoperative site of lesion location; (2)for releasable upon available EMG detection of ulnar nerve function improvement, can directly objective early judgment of operation solution effect, (3)the cubital tunnel syndrome patients with operation curative effect of preoperative degree of nerve injury, in severe cubital tunnel syndrome after operation for releasable if electrophysiological detection index did not change significantly prompt the clinician can be simultaneously performed function reconstruction.(4)as a simple, noninvasive, objective check method, electrophysiological examination for patients and clinicians to provide the real basis, on postoperative rehabilitation guidance, should be in the cubital tunnel syndrome diagnosis and treatment is widely used.
引文
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[26] IlkahaniM, JahanbakhshSM, Eghtesadi-Arghip, etal. Accuracy of soma to sensory evoked potential sindagnosis of mildi diopathic carpal tunnel syndrome[J]. Clin Neuro Neurosurg, 2005, 108(1): 40-44
[27] Zhang Kai-li, Segmental detdction of motor evoked potential in the diagnosis of thoracic outlet syndrome[J], Chin J Hand Surg October 2005 Vol 21 NO. 5
[28] WU Baofan, Determination of the trauma location in compressive neuropathy by inching test[J]; Journal of Clinical Electroneurophysiology(China), February 2001, Vol. 10, No. 1
[29] b: Shefner JM. Cudkowicz ME. Zhang H. et al. Revised statistical motor unit number estimation in the Celecoxib/AI[J]. S trial. Muscle Nerve, 2007; 35(2): 228-234
[30] Kwon O, Lee KW. Reproducibility of statistical motor unit number estimates in amyotrophic lateral sclerosis; comparisons between size-and number-weighted modifications[J]. Muscle Never. 2004; 29(2): 211-217
[31] Alberecht E. Kuntzer T. Number of Edb motor units estimated using an adapted multiple point stimulation method: normal valuse and longitudinal studies in ALS and peripheral neuropathies[J]. Clin Neurophysiol. 2004; 115(3): 557-563
[32] Jillapalli D. Bradshaw DY, Shefner JM Motor unit number estimation in the evaluation of focal conduction block [J]Muscle Nerve, 2003; 27(6): 676-681
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[35] TONG Zhi-Hong, YANG Weri-Dong, WANG Su-Ping, Appl ication of electro physiolog ical exa mination to cubital tunnel syndrome[J], Chinese Journal of Clinical Rehabilitation, April 15 2003 Vol. 7 No. 7
[36] Yilmaz N, Akdemir G, Gezici AR, Basmaci M, Ergungor MF, Asalanturk Y, Beskonakli E, Electrophysiological and clinical assessment of response to surgery in carpal tunnel[J]. Ucar D. Int J Neurosci. 2010 Apr; 120(4): 261-4.
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[38] Park GY. Kim JM. Lee SM. The ultrasonographic and electrodiagnostic findings of ulnar neuropathy at the elboe[J]. Arch Phys Med Rehabil. 2004; 85(6): 1000-1005
[39] Staub F. Dombert T. Assmus H. Carpal tunnel syndrome in haemodialysis patients: analysis of clinical and electrophysiological findings in 268 patients(395 hands) [J] Handchir Mikrochir Plast Chir. 2005; 37(3): 150-157
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[42]俞永林顾玉东沈丽英等,周围神经卡压与神经根型颈椎病的神经肌电图鉴别. [J]中国临床神经科学2001; 9(2): 166-171
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[45] VOS E. J. , MULLENDER M. G. , INGEN SCHENAU G. J. Electromechanical delay in the vastus lateralis muscle during dynamic isometric contractions[J]. European Journal of Applied Physiology, 1990, 60(6): 467-471.
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[50] XU Hong-bing, HUANG Gong-yi, YANG Shu-hua, Application of Somatosensory Evoked Potentials(SEP)in the Diagnosis of Sevre Carpal Tunnel Syndrome[J]; ChinJ Neuroimmunol & Neurol 2008, Vol 15. (6)453-457
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