本文選題：術(shù)中監(jiān)護 + 體感誘發(fā)電位　； 參考：《北京協(xié)和醫(yī)學院》2015年博士論文

【摘要】：在脊柱外科手術(shù)中,體感誘發(fā)電位可以減低手術(shù)風險,已廣泛應用于術(shù)中脊髓功能監(jiān)護,是近年來脊髓監(jiān)護中最常應用的電生理技術(shù)。然而,由于多重因素的影響,術(shù)中體感誘發(fā)電位存在著變異性；另外,體感誘發(fā)電位受各種噪聲的干擾,信噪比非常低,使得誘發(fā)腦電的識別和特征提取比較困難。因此,體感誘發(fā)電位的檢測以及術(shù)中體感誘發(fā)電位變異性一直是臨床監(jiān)護中非常困難的一個問題。本文針對術(shù)中體感誘發(fā)電位變異性影響因素的多樣性及各因素之間錯綜復雜的聯(lián)系,利用灰色理論對影響體感誘發(fā)電位變異性的主要非手術(shù)因素進行多因素分析；針對體感誘發(fā)電位的信噪比低的特性以及術(shù)中監(jiān)護實時性的要求,將限制性二階盲源分離算法應用于體感誘發(fā)電位信噪比的提高；在此基礎上,利用支持向量回歸的非線性特征,提出了體感誘發(fā)電位異常動態(tài)預警模型,提高了術(shù)中監(jiān)護的可靠性。主要研究內(nèi)容和結(jié)論如下：(1)系統(tǒng)地分析人體測量學指標和人體生理參數(shù)對術(shù)中體感誘發(fā)電位的影響。首先,運用統(tǒng)計分析方法分析了各階段SEP波峰潛伏期和波幅的變化率與身高、體質(zhì)量、年齡的相關性,結(jié)果顯示SEP的變化和身高、體質(zhì)量、年齡這些人體測量學指標沒有顯著關系,如果體感誘發(fā)電位發(fā)生變化,不需要再考慮病人的體質(zhì)量、身高、年齡帶來的影響,這對脊髓側(cè)凸矯形手術(shù)術(shù)中誘發(fā)電位監(jiān)護的正確操作具有重要的指導意義；運用灰色關聯(lián)度分析了矯形手術(shù)過程中SEP波峰潛伏期和波幅的變化率與五個生理因素(重點考慮非手術(shù)因素包括血壓、心律、體溫、動脈二氧化碳分壓、麻醉等對術(shù)中SEP變化的影響)變化率的相關程度,結(jié)果顯示各生理參數(shù)的變化對SEP有不同程度的影響,提示術(shù)中應監(jiān)測術(shù)中SEP波形及各生理參數(shù)的變化,排除術(shù)中生理參數(shù)變化造成的監(jiān)護誤診,提高了術(shù)中監(jiān)護可靠性。(2)通過建立大鼠脊髓損傷模型,評價限制性二階盲辨識快速提取方法的性能。針對體感誘發(fā)電位的特征對傳統(tǒng)二階盲辨識算法進行改進,并利用重物下降大鼠脊髓損傷模型模擬脊髓挫傷,驗證新算法對脊髓損傷的判別能力,將處理結(jié)果與傳統(tǒng)平均疊加處理結(jié)果比較得出,限制性二階盲辨識方法可以提取出清晰的單次SEP信號波形,能夠很好地測量信號的潛伏期和幅值,與傳統(tǒng)平均疊加方法相比,提取體感誘發(fā)電位的效果更好,提取的誘發(fā)電位潛伏期和幅值對脊髓損傷的響應比平均疊加方法更快更顯著,不僅降低了提取時間,還將有助于為脊髓損傷早期預警提供更多信息。(3)建立體感誘發(fā)電位異常動態(tài)預警模型。綜合考慮影響術(shù)中體感誘發(fā)電位變化的非手術(shù)因素,利用支持向量回歸的非線性特征,建立術(shù)中體感誘發(fā)電位動態(tài)預測模型,對監(jiān)護基線進行動態(tài)調(diào)整,并給出一定置信度下的置信區(qū)間。體感誘發(fā)電位動態(tài)預測模型很好的擬合出了體感誘發(fā)電位的潛伏期和峰值,預測趨勢線與實際觀測值基本一致,在可接受的誤差范圍內(nèi)得到了比較滿意的預測結(jié)果,在99%置信水平下,大部分實際觀察值都落在預測區(qū)域范圍內(nèi)。這不僅增加了術(shù)中監(jiān)護的可靠性,而且降低了由于非手術(shù)因素帶來的監(jiān)護誤差。針對影響術(shù)中體感誘發(fā)電位監(jiān)護可靠性的關鍵問題,本研究系統(tǒng)分析影響術(shù)中體感誘發(fā)電位的非手術(shù)因素,重點探討了主要因素與術(shù)中體感誘發(fā)電位變異性的關系,并通過動物實驗驗證了體感誘發(fā)電位單次提取技術(shù)對脊髓損傷的動態(tài)跟蹤能力,綜合考慮影響術(shù)中體感誘發(fā)電位變異性的非手術(shù)因素以及動態(tài)監(jiān)護的必要性,建立了體感誘發(fā)電位異常動態(tài)預警模型。本課題的研究能夠提高術(shù)中體感誘發(fā)電位監(jiān)護的可靠性,如果本研究成果應用于臨床監(jiān)護,可以隨時了解脊髓功能狀態(tài),及早發(fā)現(xiàn)神經(jīng)功能損傷并確定損傷部位及其誘因,及時采取措施糾正不正當?shù)氖中g(shù)操作,降低病人痛苦,將會使損傷得以恢復或者使損傷達到最低限度,避免出現(xiàn)不可逆的神經(jīng)功能損害；同時,由于有效避免了脊髓功能損傷,使得治療、護理、康復費用有所降低,減輕了患者的費用負擔。
[Abstract]:In spinal surgery, somatosensory evoked potential can reduce the risk of operation and has been widely used in the intraoperative monitoring of spinal cord function. It is the most commonly used electrophysiological technique in spinal cord monitoring in recent years. However, due to the influence of multiple factors, the somatosensory evoked potential exists variability in the operation, and the somatosensory evoked potential is disturbed by various noises. Therefore, the detection of somatosensory evoked potential and the variability of somatosensory evoked potential in the operation have been a very difficult problem in clinical monitoring. The diversity of factors affecting the variability of somatosensory evoked potential in the operation and the complexity of the factors are complicated in this paper. The main non operative factors that affect the somatosensory evoked potential variability are analyzed by the grey theory. In view of the low signal-to-noise ratio of somatosensory evoked potential and the requirement of real-time monitoring in the operation, the restrictive two order blind source separation algorithm is applied to the enhancement of the signal to noise ratio of the somatic induced generation potential. On this basis, Using the nonlinear characteristics of support vector regression, an abnormal dynamic early-warning model of somatosensory evoked potential is proposed, which improves the reliability of intraoperative monitoring. The main contents and conclusions are as follows: (1) systematic analysis of the effects of anthropometric parameters and human physiological parameters on the somatosensory evoked potential in the operation. First, the statistical analysis method is used. The correlation between the variation of SEP wave peak latency and wave amplitude with height, body mass and age showed that there was no significant relationship between SEP and height, body mass and age. If somatosensory evoked potential was changed, the effects of body mass, height and age, this pair of ridges were not needed. The correct operation of evoked potential monitoring in the operation of scoliosis orthopedics has important guiding significance. Using grey correlation analysis, the changes of SEP wave peak latency and amplitude in orthopedic surgery and five physiological factors (focusing on non operative factors including blood pressure, heart rhythm, body temperature, arterial carbon dioxide partial pressure, anesthesia, etc.) are used in the operation. The effect of the change of SEP) the correlation of the change rate, the results showed that the changes of the physiological parameters had different influence on the SEP. It was suggested that the changes of the SEP waveform and the physiological parameters should be monitored during the operation, the monitoring misdiagnosis caused by the changes of physiological parameters during the operation and the reliability of the intraoperative monitoring should be eliminated. (2) the model of spinal cord injury was established by establishing the rat spinal cord injury model, Evaluate the performance of the limited two order blind identification fast extraction method. According to the characteristics of the somatosensory evoked potential, the traditional two order blind identification algorithm is improved, and the spinal cord contusion is simulated by the model of the spinal cord injury of the weight loss rat, and the discriminant ability of the new algorithm for spinal cord injury is verified. The results are compared with the traditional average superposition treatment results. It is concluded that the restricted two order blind identification method can extract a clear single SEP signal waveform, and can measure the latency and amplitude of the signal very well. Compared with the traditional average superposition method, the effect of extracting the somatosensory evoked potential is better. The evoked potential latency and amplitude response to the spinal cord injury is faster and more faster than the average superposition method. Significantly, it not only reduces the time of extraction, but also helps to provide more information for early warning of spinal cord injury. (3) establish an abnormal dynamic early warning model of somatosensory evoked potential. Take into account the non operative factors that affect the changes of somatosensory evoked potential in the operation, and use the non linear characteristics of support vector regression to establish the dynamic preconditioning potential of the somatosensory evoked potential in the operation. The model is used to dynamically adjust the monitoring baseline and give confidence interval under certain confidence. The dynamic prediction model of somatosensory evoked potential can fit the latent period and peak of somatosensory evoked potential well, and the forecast trend line is basically consistent with the actual observation value, and a satisfactory prediction result is obtained within the acceptable error range. At the 99% confidence level, most of the actual observation values fall within the range of the prediction area. This not only increases the reliability of the intraoperative monitoring, but also reduces the monitoring error caused by the non operative factors. This study systematically analyzes the effect of the somatosensory evoked potential in the operation for the key problems affecting the monitoring reliability of the somatosensory evoked potential during the operation. The relationship between the main factors and the variability of somatosensory evoked potential was emphatically discussed, and the dynamic tracking ability of the single extraction technique of somatosensory evoked potential for spinal cord injury was verified by animal experiments, and the non operative factors affecting the variability of somatosensory evoked potential in the operation and the necessity of dynamic monitoring were considered. An abnormal dynamic early warning model of somatosensory evoked potential can be used to improve the reliability of the monitoring of somatosensory evoked potential in the operation. If the results of this study are applied to clinical monitoring, the functional state of the spinal cord can be understood at any time, the damage of the nerve function can be found early and the location and cause of the injury can be determined, and the measures to correct the dishonesty in time should be taken. Operation, reducing the patient's pain, will make the injury recover or minimize the damage and avoid irreversible nerve function damage. At the same time, the cost of treatment, nursing and rehabilitation will be reduced and the cost burden of the patient is reduced because of the effective avoidance of spinal cord injury.
【學位授予單位】：北京協(xié)和醫(yī)學院
【學位級別】：博士
【學位授予年份】：2015
【分類號】：R687.3

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