腰椎间盘突出症的体感诱发电位诊断及法医学意义

发布时间：2018-06-27 07:46

本文选题：体感诱发电位 + 腰椎间盘突出症　；参考：《中国医科大学》2004年硕士论文

【摘要】： 前言在临床法医学鉴定中，经常涉及腰椎间盘突出症(Lumbosacral Disc Herniation，LDH)后遗功能障碍评定的问题，由于被鉴定人特殊的心理作用，常常夸大或伪装病情，使主观性较大的临床体格检查更不可信，影像学检查虽为客观的检查手段，但它们终究是一种形态学检查，对于适应性和代偿性有很大个体差异的人体来说，有时虽然有形态学上的改变，却可能无功能上的异常。因此，如何客观的评价受累神经根的功能状态是临床法医学的重要研究课题之一。神经电生理学检查手段可了解神经根的功能状态，弥补了影像学的不足。肌电图和神经传导速度作为传统的电生理检查手段，对神经根性损伤的诊断价值有限。近年来，应用体感诱发电位(Somatosensory Evoked Potential，SEP)判断神经根功能进而诊断LDH，已受到国内外众多学者的重视。体感诱发电位是对躯体感觉系统的任意一点包括从皮肤节段到外周神经干、脊髓神经后根等，给予适当形式刺激后，在该系统特定通路上的任何部位均可检出与刺激有相对固定的时间间隔和特定形式的生物电反应。SEP有特定的解剖学基础，能有效地显示感觉系统的异常改变，是一种灵敏可靠的功能学检测手段。而神经根是SEP传导通路的一部分，故SEP的改变能在一定程度上反映神经根的功能状态。国外自80年代以来就已开始应用SEP评价神经根功能状态的研究，国内自90年代以来临床方面才有一些报道，而法医学方面尚未见相关报道。目前对于SEP诊断LDH的应用价值尚有争议。为此，本文对60例LDH患者行胫后神经体感诱发电位(Posterior Tibial Nerve Somatosensory Evoked Potential，PTNSEP)和皮节体感诱发电位(Dermatomal Somatosensory Evoked Potential，DSEP)检查，并以30例正常人作为对照，寻求客观稳定的观察指标，进一步探讨SEP对神经根功能状态评定的价值，以期为临床法医学鉴定提供客观依据。试验对象与方法试验对象:LDH患者60例，作为试验组，均具有典型的单侧LDH临床表现，无其它神经系统疾病史和体征。其中u一4椎间盘突出8例，M一5 椎间盘突出28例，巧S1椎间盘突出24例。选取健康者30例，作为正常对照组。试验方法:Keypoint型体感诱发电位仪，方波脉冲刺激，波宽0.Zlns，刺激强度使该神经支配的肌肉出现肉眼可见的轻度收缩为宜，或为感觉闭值的3倍，刺激频率为2.3Hz，叠加240次，带通500一2000Hz，刺激电极为鞍形表面电极，负极在近端，记录电极和参考电极均为针电极，皮肤电阻小于 SKQ。同侧小腿置地线。受试对象在安静的检查室内，，取卧位，全身肌肉放松。室温在22一24”C。DSEP检查方法:刺激电极:M:内躁上方;巧足背第三拓趾关节;sl:足跟外侧。记录电极:Cz’(C:正中后2.scm)，参考电极:Fz。主要观察指标:Nl、P1波是否消失，N1、Pl峰潜伏期及其两侧差值 (Interside Lateney Differenee，ILD)。异常判定的标准:(1)Nl或Pl波消失或平坦;(2)Nl或Pl峰潜伏期超过正常参考值3倍标准差;(3)ILD一N1 或ILD一P1超过正常参考值3倍标准差;(4)Nl一Pl波幅低于健侧或对照组的50%或消失、平坦。凡具备上述任何一项，即可判断为异常。PTNSEP 检查方法:刺激电极:内跺，记录电极:C3’(Cz向左旁开Zcm，向后Zcm)、 C4’(Cz向右旁开Zem，向后Zem)、T12棘突、胭窝。参考电极:Fz、骼峙、内侧膝点。主要观察指标:胭窝电位(Ng)、腰部电位(N22)及皮层电位(玛8) 峰潜伏期，Ng一N22、N22一玛8峰间潜伏期(Inte甲eak Uteney，IPL)。异常判定的标准:(1)N22或玛8峰潜伏期超过正常参考值3倍标准差;(2)IPL Ng一N22超过正常参考值3倍标准差;(3) N22或玛8波幅低于健侧的 50%，或消失、平坦。凡具备上述任何一项，即可判断为异常。结果 1.60例患者DSEP检查显示56例(93.3%)异常，U一4椎间盘突出以L4 DSEP异常为主，但其中1例同时有匕DSEP和51 DSEP异常;拼一5 椎间盘突出以巧DSEP异常为主，但其中3例同时有51 DSEP异常;巧S1 椎间盘突出以51 DSEP异常为主，但其中1例同时有肠DSEP异常。DSEP 异常主要表现为Nl、Pl峰潜伏期及ILD一Nl和ILD一P1延长，与对照组相比有显著差异(p0.001)，Nl波幅下降或平坦、消失，NI一Pl波幅下降。 2.60例患者PTNSEP检查只有26例(43.3%)异常，其中腰部电位均异常，而皮层电位24例异常，2例正常。Ng峰潜伏期和IPL N22一玛8与对照组相比无显著差异(p0.05)。PrNSEP异常主要表现为N22和，玛8峰潜伏期、IPL Ng一N22延长，与对照组相比有显著差异(p0 .001)，N22、玛8波幅下降。 3.经CT或MRI检查证实的60例LDH患者中，U一4椎间盘突出8 例，其中PTNSEP异常4例，M DSEP异常7例，拼一5椎间盘突出28例， PTNSEP异常12例，匕DSEP异常26例，巧51椎间盘突出24例，PTNSEP 异常10例，51 DSEp异常23例。DSEp异常率明显高于PTNSEp异常率(p 0 .001)。结论 1 .DSEP中，NI、Pl、ILD一Nl及ILD一PI是诊断LDH的比较客观稳定的观察指标，其中ILD一Nl和ILD一P1个体间的差异小，是比较好的观察指标，多指标同时观察可提高其阳性率。 2.PTNSEP中，N22、玛8、IPL
[Abstract]:Preface
In the identification of clinical forensic medicine, it is often involved in the assessment of the sequela of Lumbosacral Disc Herniation (LDH). Because of the special psychological effect of the identified person, it often exaggerates or disguises the condition, making the subjective clinical physical examination more unbelievable, although the imaging examination is an objective examination, but it is an objective examination. After all, they are a morphological examination. For the human body with a large individual difference in adaptability and compensation, there are sometimes morphological changes, but there may be no functional abnormalities. Therefore, how to objectively evaluate the functional state of the involved nerve roots is one of the most important research topics in clinical forensic medicine.
Neuroelectrophysiological examination can be used to understand the functional state of nerve roots and make up for the lack of imaging. Electromyography and nerve conduction velocity are used as a traditional electrophysiological examination, and the diagnostic value of nerve root injury is limited. In recent years, Somatosensory Evoked Potential (SEP) is used to judge the function of nerve root. The diagnosis of LDH has been paid much attention by many scholars at home and abroad. The somatosensory evoked potential (somatic evoked potential) is an arbitrary point of the somatosensory system, including the trunk of the skin to the peripheral nerve, the dorsal root of the spinal nerve and so on. After the proper form of stimulation, there is a relatively fixed time interval and specific stimulation at any part of the system on the specific pathway of the system. The form of bioelectrical reaction.SEP has a specific anatomical basis and can effectively display the abnormal changes of the sensory system. It is a sensitive and reliable means of functional detection. The nerve root is part of the SEP conduction pathway, so the change of SEP can reflect the power state of the nerve root to a certain extent. Foreign countries have been applied since 80s. SEP evaluation of the state of nerve root function has been reported in China since 90s, but there has been no related reports in the field of forensic medicine. At present, the value of the application of SEP in the diagnosis of LDH is still controversial. For this reason, 60 cases of LDH patients were treated with the tibial nerve somatosensory evoked potential (Posterior Tibial Nerve Somatosensory Evoked Poten). TiAl, PTNSEP) and skin somatic somatosensory evoked potential (Dermatomal Somatosensory Evoked Potential, DSEP) examination, and 30 normal people as control, seek objective and stable observation index, further explore the value of SEP to evaluate the functional state of nerve root, so as to provide an objective basis for clinical forensic identification.
Test object and method
Participants: 60 patients with LDH, as the experimental group, all had typical unilateral LDH.
There were no other neurological diseases and signs. Among them, u 4 had disc herniation in 8 cases, M 5.
28 cases of intervertebral disc herniation and 24 cases of S1 intervertebral disc herniation were selected. 30 healthy subjects were selected as normal pairs.
Look at the group.
Test method: Keypoint type somatosensory evoked potential instrument, square wave pulse stimulation, wave width 0.Zlns, thorn.
The intensity of the innervation of the innervated muscle is suitable for the mild contraction of the eye, or for the sensory closure.
3 times the stimulation frequency is 2.3Hz, 240 times superimposed, bandpass 500 2000Hz, and the stimulation electrode is saddle.
The electrode and the reference electrode are all needle electrodes, and the skin resistance is smaller than that of the negative electrode.
SKQ. placed on the same side of the calf. The subjects were lying in place in the quiet examination room.
Loose. Room temperature at 22 one 24 "C.DSEP inspection method: stimulating electrode: M: inside the upper part of the rash; skillful foot back.
Third toe joint; sl: lateral heel. Recording electrode: Cz '(C: median 2.scm), reference electricity.
Fz.: main outcome measures: whether Nl, P1 wave disappeared, N1, Pl peak latency and the difference between two sides.
(Interside Lateney Differenee, ILD). Criteria for anomaly determination: (1) Nl or Pl waves disappear.
Or flat; (2) Nl or Pl peak latency exceeds 3 times the normal reference value standard deviation; (3) ILD N1
Or ILD P1 exceeds 3 times the standard reference value; (4) Nl Pl amplitude is lower than the healthy side or control.
Group 50% or disappear, flat. Any one of these items can be identified as abnormal.PTNSEP.
Examination method: stimulating electrode: internal stamp, recording electrode: C3 "(Cz to left side Zcm, backward Zcm).
C4 "(Cz opens to Zem on the right, backward Zem), T12 spinous process and pit. Reference electrode: Fz, iliac, internal
Main outcome measures: lateral popliteal potential (Ng), lumbar potential (N22) and cortical potential (MA 8).
Peak latency, Ng 1 N22, N22 one Ma 8 peak latency (Inte a eak Uteney, IPL).
Criteria for determination: (1) the peak latency of N22 or Ma 8 exceeds the normal reference value 3 times standard deviation; (2) IPL
Ng N22 exceeds 3 times the normal reference value; (3) the amplitude of N22 or Ma 8 is lower than that of the healthy side.
50%, or disappear, flat. Any one of them can be judged to be abnormal.
Result
In 1.60 patients, DSEP showed abnormal in 56 cases (93.3%), and U 4 in disc herniation.
L4 DSEP abnormality was the main cause, but 1 cases had dagger DSEP and 51 DSEP abnormality; one 5.
Intervertebral disc herniation was dominated by DSEP abnormalities, but 3 of them had 51 DSEP abnormality at the same time; Qiao S1
Disc herniation was dominated by 51 DSEP abnormalities, but 1 of them had abnormal DSEP.DSEP.
The main abnormalities were Nl, Pl peak latency and ILD Nl and ILD P1 extension, compared with the control group.
There was a significant difference (p0.001), the amplitude of Nl decreased or even disappeared, and the amplitude of NI Pl decreased.
Of the 2.60 patients, only 26 (43.3%) had abnormal PTNSEP findings, including waist potentials.
Abnormal, 24 cases of cortical potential abnormalities, 2 cases of normal.Ng peak latency and IPL N22 N22 8.
There was no significant difference between the two groups (P0.05). The.PrNSEP abnormalities were mainly N22 and Ma 8 peaks.
Incubation period, IPL Ng N22 extension was significantly different from the control group (P0.001), N22.
The amplitude of Ma 8 declined.
3. among 60 LDH patients confirmed by CT or MRI examination, U 4 4 disc herniation was 8
Among them, there were 4 cases of PTNSEP abnormality, 7 cases of M DSEP abnormality, and 5 cases of intervertebral disc protrusion 28 cases.
PTNSEP abnormality in 12 cases, dagger DSEP abnormality in 26 cases, coincidence 51 in 24 cases, PTNSEP
Abnormal 10 cases, 51 DSEp abnormal 23 cases.DSEp abnormal rate was significantly higher than PTNSEp abnormal rate (P
0.001).
conclusion
In 1.DSEP, NI, Pl, ILD Nl and ILD PI are more objective and stable for diagnosing LDH.
Among them, the difference between ILD Nl and ILD P1 is small.
The positive rate can be improved by the simultaneous observation of multiple indexes.
In 2.PTNSEP, N22, Ma 8, IPL
【学位授予单位】：中国医科大学
【学位级别】：硕士
【学位授予年份】：2004
【分类号】：D919

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