异常肌反应监测在面肌痉挛显微血管减压术中的定量化分析与改进

发布时间：2017-12-27 05:18

本文关键词：异常肌反应监测在面肌痉挛显微血管减压术中的定量化分析与改进　出处：《北京协和医学院》2017年博士论文　论文类型：学位论文

【摘要】：研究背景异常肌反应是面肌痉挛患者特有的电生理学诊断指标。在显微血管减压术中进行异常肌反应监测时,其波形是否消失常被用来评估减压的效果是否确切。但在传统的定性监测方法下,其预测的精准性尚有很大争议。研究目的通过对异常肌反应诱发阈值在术中的变化进行定量化的追踪和记录,分析传统的定性监测结果与术后患者的临床结局间不一致的可能原因,从而提供改进异常肌反应监测方法的思路。研究方法从2014年1月至2014年6月间,共72例在中日友好医院神经外科行显微血管减压术治疗的特发性偏侧面肌痉挛患者。术中采用1～100mA刺激强度的单方波由弱至强轮替诱发异常肌反应。手术中全程定量记录患者异常肌反应的诱发阈值和主波波幅,根据其变化情况将72例患者的异常肌反应诱发阈值的变化分为五种类型:A型(稳定消失型)、B型(阈值大幅波动型)、C型(阈值小幅波动型)、D型(单纯波幅下降型)和E型(稳定存在型)。作为对照,同时模拟传统的定性监测法将该72例患者术中异常肌反应的变化分为两型:消失型和未消失型。根据患者术后面部痉挛症状的残留情况,将患者分为三组:立即治愈组、延迟治愈组和未愈组。收集患者的术后随访情况,对比在定量监测法和定性监测法下,两种不同的分类方式与术后随访结果的关系。研究结果(1)术后平均随访时长27个月。立即治愈44人,延迟治愈24人,未愈4人。(2)定量监测时,各分型的患者人数分别为:A型(稳定消失型)26例,B型(阈值大幅波动型)12例,C型(阈值小幅波动型)16例,D型(单纯波幅下降型)13例,E型(稳定存在型)5例。模拟定性监测时,两个分类的患者人数分别为:消失型41例,未消失型31例。(3)按照定量监测分型,立即治愈组内44位患者术中电生理变化的各型分别占比为: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)。延迟治愈组内24位患者术中电生理变化的各型分别占比为: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)。未愈组内4位患者术中电生理变化的分型均为E型100%(4/4)。三个临床结局组间两两比较时,分型构成比的差异均有统计学意义。(4)按照定性监测分型,立即治愈组内44位患者术中电生理变化的各型分别占比为:消失型66%(29/44),未消失型34%(15/44)。延迟治愈组内24位患者术中电生理变化的各型分别占比为消失型50%(12/24),未消失型50%(12/24)。未愈组内4位患者术中电生理变化的分型占比为:未消失型100%(4/4)。三个临床结局组间两两比较时,分型构成比的差异均无统计学意义。研究结论(1)采用全程宽幅调整刺激强度的定量监测方式能够发现异常肌反应在术中的多种变化类型,相比传统的定性监测具有更好的分辨能力。(2)异常肌反应诱发阈值的变化可能反映了患者面神经核团兴奋状态的变化,而不是直接反映责任血管与面神经出脑干区是否处于接触状态。
[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.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R651.3

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