摘要
目的探讨术中神经电生理监测在健侧颈7(C_(7))神经移位手术治疗上肢痉挛性偏瘫中的应用价值。方法回顾性分析2022年7月至2023年11月于苏州大学附属第一医院神经外科(6例)和南京大学医学院附属鼓楼医院神经外科(4例)接受健侧C_(7)神经移位术治疗上肢痉挛性偏瘫的患者资料。术中均行实时自由肌电图(f-EMG)、Trigger刺激、体感诱发电位(SSEP)和经颅电刺激运动诱发电位(Tce-MEP)监测并定位C_(5)~C_(8)神经, 同时观察双侧诱发电位的波幅和潜伏期变化。术后记录双上肢的感觉、运动及肌张力变化情况。结果术中10例患者f-EMG均出现不同程度的牵拉反应, 并初步定位C_(5)~C_(8)神经。Trigger刺激结果显示, 刺激C_(5)~C_(8)神经均可有效诱发相应靶肌肉的复合肌肉动作电位(CMAP), 10例患者CMAP均为阳性的包括C_(5)(三角肌)、C_(6)(肱二头肌)、C_(7)(肱三头肌、桡侧腕短伸肌、尺侧腕屈肌)、C_(8)(大鱼际肌+小鱼际肌群), 其诱发CMAP的潜伏期依次为(52.5±6.4)ms、(55.0±3.3)ms、(65.5±4.4)ms、(83.0±4.8)ms、(84.5±5.0)ms和(127.0±8.2)ms;刺激C_(5)~C_(8)神经时诱发靶肌肉CMAP阳性者比例和10例患者CMAP均为阳性的CMAP潜伏期的差异均有统计学意义(均P<0.05)。SSEP结果显示, 10例患者在C_(7)神经离断前后患侧SSEP均无反应;离断C_(7)神经后, 10例患者的健侧SSEP波幅下降均>50%, 其中2例潜伏期改变>10%。Tce-MEP结果显示, 10例患者在C_(7)神经离断前后患侧Tce-MEP均无反应;离断C_(7)神经后, 2例患者健侧Tce-MEP的CMAP消失(波幅下降>50%), 刺激阈值增加。10例患者的手术均顺利完成, 手术时长[M(Q1, Q3)]为344.0(308.8, 545.0)min, 住院时长为(14.3±0.9)d。术后患侧上肢感觉及运动均较术前无改变, 肌张力较术前均缓解;术后健侧出现上肢背侧及食指、中指感觉障碍者10例(术中健侧上肢SSEP波幅下降均>50%), 上肢运动肌力下降者2例(均为术中上肢SSEP监测显示潜伏期改变>10%、Tce-MEP刺激阈值增加的患者), 神经根痛者3例。结论上肢痉挛性偏瘫行健侧C_(7)神经移位术中监测实时f-EMG和Trigger刺激可准确定位C_(5)~C_(8)神经, 监测SSEP和Tce-MEP有助于预测术后健侧上肢的感觉和运动功能状态, 改善患者症状。
ObjectiveTo investigate the value of intraoperative neurophysiological monitoring in contralateral cervical 7(C_(7))nerve transfer surgery for treatment of upper limb spastic hemiplegia.Methods This retrospective dual-center study included consecutive patients with spastic hemiparesis of one upper limb who underwent contralateral C,nerve transfer surgery at the Department of Neurosurgery the First Affiliated Hospital of Soochow University(6 cases)and the Department of Neurosurgery,Nanjing Drum Tower Hospital,the Affiliated Hospital of Nanjing University Medical School(4 cases)between July 2022 and November 2023.During the procedure,real-time free muscle electromyography(f-EMG),trigger stimulation,somatosensory evoked potentials(SSEP),and transcranial electric motor-evoked potentials(Tce-MEP)were used to monitor and identify C_(5)-C_(8) nerves,while monitoring the amplitude and latency changes of bilateral evoked potentials.Postoperatively,the changes in somatosensation,motor function,and muscle tone in both upper limbs were recorded.Results During the procedure,f-EMG of 10 patients showed different degrees of traction response,and the C_(5)-C_(8) nerves were initially identified.During the trigger stimulation,electrical stimulation of C_(5)-C_(8) nerves induced compound muscle action potentials(CMAPs)in all 10 patients for their respective target muscles.The CMAP of 10 patients for each amplitude for all muscles showed the positivity of 10/10,the latency as follows,C_(5) nerve(deltoid):52.5±6.4 ms;C_(6) nerve(biceps brachi):55.0±3.3 ms;C_(7) nerve(triceps brachii,musculus extensor carpi radialis and flexor carpi ulnaris):65.5±4.4 ms,83.0±4.8 ms and 84.5±5.0 ms;C_(8) nerve(thenar and hypothenar muscle):127.0±8.2 ms,respectively.The proportion of CMAP positivity induced by stimulating C_(5)-C_(8) nerves in corresponding muscle groups and the CMAP latency of 10 patients who had positive CMAP were statistically significant(all P<0.05).SSEP recordings revealed no responses in the 10 patients on either side of C_(7) nerve roots during the pre-resection phase.After C_(7) nerve root resection,SSEP amplitude reductions were observed in all 10 patients on the healthy side,with amplitude decreases exceeding 50%,and 2 patients showing significant changes in latent period>10%.The results of Tce-MEP measurements showed no responses on the affected side for C,nerve root resection in 10 patients both before and after surgery.Postoperatively,Tce-MEP amplitude reductions exceeding 50%were observed in 2 patients on the healthy side,with concomitant increases in stimulation thresholds.The surgical procedure was successfully performed in all 10 patients,with a total surgery duration of 344.0(308.8,545.0)minutes and an average hospital stay of 14.3±0.9 days.Postoperatively,no significant changes were observed in sensory or motor function on the affected side compared to preoperative conditions,with muscle relaxation improving as well.On the healthy side,10 patients exhibited posterior arm and finger-to-hand sensation deficits(with SSEP amplitude reductions exceeding 50%during surgery),while 2 patients demonstrated upper limb strength reduction(observed as Tce-MEP monitoring showing latency changes>10%,along with increased stimulation thresholds).A total of 3 patients experienced postoperative neuropathic pain.Conclusions The f-EMG and trigger stimulation can be employed for accurate localization of the C_(5)-C_(8) nerves during contralateral C_(7) nerve transfer in cases of upper limb spastic hemiplegia.The SSEP and Tce-MEP examinations may provide valuable insights into prediction of postoperative sensory and motor functional status of the contralateral upper limb,thereby aiding in symptom management and improving patient outcomes.
作者
季骋远
刘浩
倪红斌
王中
陈罡
虞正权
刘建刚
Ji Chengyuan;Liu Hao;Ni Hongbin;Wang Zhong;Chen Gang;Yu Zhengquan;Liu Jiangang(Department of Neurosurgery,the First Affiliated Hospital of Soochow University,Suzhou 215000,China;Department of Neurosurgery,Nanjng Drum Tower Hospital,the Affiliated Hospital of Nanjing University Medical School,Nanjing 210000,China)
出处
《中华神经外科杂志》
北大核心
2025年第7期704-710,共7页
Chinese Journal of Neurosurgery
基金
江苏省基础研究计划(自然科学基金)(BK20241797)。
关键词
偏瘫
痉挛
神经移位
监测
手术中
诱发电位
运动
诱发电位
躯体感觉
治疗结果
Paresis
Spasm
Nerve transfer
Monitoring,intraoperative
Evoked potentials,motor:Evoked potentials,somatosensory:Treatment outcome
