本文關(guān)鍵詞：異常肌反應(yīng)監(jiān)測(cè)在面肌痙攣顯微血管減壓術(shù)中的定量化分析與改進(jìn)　出處：《北京協(xié)和醫(yī)學(xué)院》2017年博士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 面肌痙攣 顯微血管減壓術(shù) 異常肌反應(yīng) 側(cè)方擴(kuò)散反應(yīng) 術(shù)中神經(jīng)電生理監(jiān)測(cè)

【摘要】：研究背景異常肌反應(yīng)是面肌痙攣患者特有的電生理學(xué)診斷指標(biāo)。在顯微血管減壓術(shù)中進(jìn)行異常肌反應(yīng)監(jiān)測(cè)時(shí),其波形是否消失常被用來評(píng)估減壓的效果是否確切。但在傳統(tǒng)的定性監(jiān)測(cè)方法下,其預(yù)測(cè)的精準(zhǔn)性尚有很大爭(zhēng)議。研究目的通過對(duì)異常肌反應(yīng)誘發(fā)閾值在術(shù)中的變化進(jìn)行定量化的追蹤和記錄,分析傳統(tǒng)的定性監(jiān)測(cè)結(jié)果與術(shù)后患者的臨床結(jié)局間不一致的可能原因,從而提供改進(jìn)異常肌反應(yīng)監(jiān)測(cè)方法的思路。研究方法從2014年1月至2014年6月間,共72例在中日友好醫(yī)院神經(jīng)外科行顯微血管減壓術(shù)治療的特發(fā)性偏側(cè)面肌痙攣患者。術(shù)中采用1～100mA刺激強(qiáng)度的單方波由弱至強(qiáng)輪替誘發(fā)異常肌反應(yīng)。手術(shù)中全程定量記錄患者異常肌反應(yīng)的誘發(fā)閾值和主波波幅,根據(jù)其變化情況將72例患者的異常肌反應(yīng)誘發(fā)閾值的變化分為五種類型:A型(穩(wěn)定消失型)、B型(閾值大幅波動(dòng)型)、C型(閾值小幅波動(dòng)型)、D型(單純波幅下降型)和E型(穩(wěn)定存在型)。作為對(duì)照,同時(shí)模擬傳統(tǒng)的定性監(jiān)測(cè)法將該72例患者術(shù)中異常肌反應(yīng)的變化分為兩型:消失型和未消失型。根據(jù)患者術(shù)后面部痙攣癥狀的殘留情況,將患者分為三組:立即治愈組、延遲治愈組和未愈組。收集患者的術(shù)后隨訪情況,對(duì)比在定量監(jiān)測(cè)法和定性監(jiān)測(cè)法下,兩種不同的分類方式與術(shù)后隨訪結(jié)果的關(guān)系。研究結(jié)果(1)術(shù)后平均隨訪時(shí)長(zhǎng)27個(gè)月。立即治愈44人,延遲治愈24人,未愈4人。(2)定量監(jiān)測(cè)時(shí),各分型的患者人數(shù)分別為:A型(穩(wěn)定消失型)26例,B型(閾值大幅波動(dòng)型)12例,C型(閾值小幅波動(dòng)型)16例,D型(單純波幅下降型)13例,E型(穩(wěn)定存在型)5例。模擬定性監(jiān)測(cè)時(shí),兩個(gè)分類的患者人數(shù)分別為:消失型41例,未消失型31例。(3)按照定量監(jiān)測(cè)分型,立即治愈組內(nèi)44位患者術(shù)中電生理變化的各型分別占比為:A 型 57%(25/44)、B 型 16%(7/44)、C 型 9%(4/44)、D 型 16%(7/44)和E型2%(1/44)。延遲治愈組內(nèi)24位患者術(shù)中電生理變化的各型分別占比為:A型 4%(1/24)、B 型 21%(5/24)、C 型 50%(12/24)、D 型 25%(6/24)和 E 型 0%(0/24)。未愈組內(nèi)4位患者術(shù)中電生理變化的分型均為E型100%(4/4)。三個(gè)臨床結(jié)局組間兩兩比較時(shí),分型構(gòu)成比的差異均有統(tǒng)計(jì)學(xué)意義。(4)按照定性監(jiān)測(cè)分型,立即治愈組內(nèi)44位患者術(shù)中電生理變化的各型分別占比為:消失型66%(29/44),未消失型34%(15/44)。延遲治愈組內(nèi)24位患者術(shù)中電生理變化的各型分別占比為消失型50%(12/24),未消失型50%(12/24)。未愈組內(nèi)4位患者術(shù)中電生理變化的分型占比為:未消失型100%(4/4)。三個(gè)臨床結(jié)局組間兩兩比較時(shí),分型構(gòu)成比的差異均無統(tǒng)計(jì)學(xué)意義。研究結(jié)論(1)采用全程寬幅調(diào)整刺激強(qiáng)度的定量監(jiān)測(cè)方式能夠發(fā)現(xiàn)異常肌反應(yīng)在術(shù)中的多種變化類型,相比傳統(tǒng)的定性監(jiān)測(cè)具有更好的分辨能力。(2)異常肌反應(yīng)誘發(fā)閾值的變化可能反映了患者面神經(jīng)核團(tuán)興奮狀態(tài)的變化,而不是直接反映責(zé)任血管與面神經(jīng)出腦干區(qū)是否處于接觸狀態(tài)。
[Abstract]:Background abnormal muscle reaction (ABR) is a specific electrophysiological diagnostic index for patients with hemifacial spasm. If the abnormal muscle reaction is monitored during microvascular decompression, the disappearance of the waveform is often used to assess the exact effect of decompression. But in the traditional qualitative monitoring method, the accuracy of its prediction is still very controversial. The purpose of the study is to track and record the changes of abnormal muscle response threshold during operation, and to analyze the possible reasons for the inconsistency between the traditional qualitative monitoring results and postoperative clinical outcomes, so as to provide ideas for improving the monitoring method of abnormal muscle response. Methods from January 2014 to June 2014, a total of 72 patients with idiopathic hemifacial spasm treated by microvascular decompression in Department of Neurosurgery, China-Japan Friendship Hospital were studied. The 1 ~ 100mA wave unilateral stimulus intensity from weak to strong rotation induced abnormal muscle response during operation. Patients with abnormal muscle response throughout the operation of the quantitative recording evoked threshold and main wave amplitude will change according to the change of abnormal muscle response evoked threshold in 72 patients were divided into five types: type A (stable type and B type (disappeared) threshold volatility type), C type (small amplitude wave type threshold D (simple type), decreased amplitude type) and type E (stable type). As a control, the changes of the abnormal muscle reaction in the 72 patients were divided into two types: disappearing and undisappearing. According to the residual postoperative facial spasm symptoms, the patients were divided into three groups: immediate cure group and delayed cure group and cured group. The postoperative follow-up of patients was collected, and the relationship between two different classification methods and follow-up results was compared under quantitative monitoring and qualitative monitoring. The results of the study (1) were followed up for an average of 27 months. Immediately cure 44, delayed cure 24 people, 4 people. (2) in quantitative monitoring, the number of patients in each classification is A type (stable vanishing type), 26 cases, B type (large threshold fluctuation type), 12 cases, C type (threshold small fluctuation type) 16 cases, D type (simple amplitude decreasing type) 13 cases, E type (stable existence type) 5 cases. In the simulated qualitative monitoring, the number of two classified patients were 41 cases of disappearing type and 31 cases without disappearing type. (3) according to the quantitative monitoring typing, the electrophysiological changes of 44 patients in the immediate cure group accounted for 57% A (25/44), B 16% (7/44), C type 9% (4/44), D 16% (7/44) and E type 2% (1/44) respectively. The proportion of intraoperative electrophysiological changes in 24 patients in the delayed cure group accounted for: A type 4% (1/24), B type 21% (5/24), C type 50% (12/24), D type 25% (6/24) and E type 0% (0/24). Not within the group in 4 patients, intraoperative electrophysiological changes were all divided into E type 100% (4/4). The difference in the composition ratio of the three clinical outcome groups was statistically significant when compared with 22 of the clinical outcome groups. (4) according to the classification of qualitative monitoring, the proportion of the various types of electrophysiological changes in the 44 patients in the immediate cure was 66% (29/44) and 34% (15/44) without disappearing type. The different types of electrophysiological changes in 24 patients in the delayed cure group were 50% (12/24) and 50% (12/24) without disappearing type. No group 4 patients with intraoperative electrophysiological change type accounted for 100%: not fade away (4/4). There was no statistically significant difference in the proportion of the three clinical outcomes between the 22 groups. Conclusion: (1) using the quantitative monitoring method of whole range wide adjustment of stimulus intensity, we can find various types of abnormal muscle response in operation, and have better resolution than traditional qualitative monitoring. (2) the change of threshold evoked by abnormal muscle response may reflect the change of facial nerve nucleus's excitatory state, rather than directly reflecting whether the responsible vessel and facial nerve stem brain area are in contact state.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R651.3

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