研究中国人术中喉返神经监测肌电信号的正常值范围

目的:应用术中神经监测技术(intraoperative neuromonitoring IONM),探讨国人喉返神经肌电信号的正常值范围。方法:烟台毓璜顶医院甲状腺外科自2009年11月到2012年1月对300例甲状腺开放手术行术中喉返神经实时监测,术中一根回路电极斜行刺入同侧切口外缘直径约2 cm范围皮肤,两根记录电极斜行刺入环甲肌,手持刺激探针垂直刺激神经,发出"嘟嘟嘟"提示音,同时监测仪显示器显示肌电波形,并记录潜伏期及波幅值。结果:285例(386条)清晰显示肌电波形;15例未引出肌电波形,其中10例因机器故障和麻醉因素造成假阴性,5例因肿瘤浸润环甲肌,无法插入记录电极造成。无永久性喉返神经损伤,暂时性神经损伤2例,术后1月内恢复。V1 95%可信区间482.66～574.28μV,R1 95%可信区间521.85～615.05μV,V2 95%可信区间440.92～531.84μV,R2 95%可信区间489.25～582.05μV,T可信区间19.88～20.12ms。结论:明确喉返神经肌电信号正常值范围,为识别、确认喉返神经及通过肌电信号判断神经功能完整性提供依据,降低喉返神经损伤率,利于判断喉返神经非离端性损伤,并寻找损伤原因。     

中耳手术面神经定位的研究进展

近年来,随着手术显微镜和电钻的问世,中耳手术面神经损伤率大大降低,但即使是非常有经验的医生也不可避免地有损伤面神经的机会,尤其是当患者为再次手术,或合并感染、胆脂瘤等使正常解剖标志改变、模糊或移位,或先天性畸形者,都会增加手术损伤面神经的机会.本文主要是针对中耳手术面神经定位的研究进展做简要的综述.中耳手术面神经的定位主要是依靠中耳面神经的解剖学标志,例如匙突、砧骨短突、水平半规管、二腹肌脊、鼓索神经等.随着影像学的高速发展,特别是高分辨率CT以及CT的多平面重建(MPR)和曲面重建(CPR)等,对面神经的定位有明显的指导意义.同时熟悉面神经的畸形以及面神经监测技术的开展,对面神经的定位也有一定的帮助.了解国际上中耳手术面神经定位的研究进展,对于面神经的定位、降低中耳术后面神经损伤的概率有着十分重要的意义.     

麻醉闭环自动控制系统的研究进展

正随着医学科学的不断发展,麻醉技术也在不断改进,在追求确保患者安全的同时,也重视医疗质量和成本的控制。传统的静脉、吸入麻醉药物的给药方式没有反馈控制,麻醉医生根据手术刺激程度和病人的生理状态等监测指标来进行药物调整。由于临床环境的复杂性和患者个体的差异性,即使是临床技能高和经验丰富的麻醉医生也难免发生给药过多而导致心血管或神经损伤等事件,或是药物不足而发生术中知晓。因此研究人员把临床麻醉和自动控制技术、设备     

砷中毒和P物质在神经损伤中作用的研究进展

砷中毒可引起神经系统损伤,P物质作为广泛存在于神经系统的一种神经递质,在各种伤害性刺激信息的传递、调控和痛敏形成、发展中发挥着重要的作用.本文综述了两者在神经系统损伤过程中的相关机制,以期更好的了解砷中毒所致的神经损伤的机理.     

味觉神经损伤与再生对动物味觉功能影响的研究进展

味觉的感受器是味蕾,来源于味蕾的味觉信号通过味觉神经传递到味觉中枢神经系统。鼓索神经和舌咽神经是支配舌面味蕾的两大主要味觉神经,它们分别支配着前舌和后舌的味蕾。味觉神经损伤可以引起所支配的味蕾萎缩、退化、消失,进而导致部分味觉功能受损,受损的味觉功能则可以在味觉神经再生后得到恢复。味觉神经交叉再生支配大鼠模型是研究中枢神经系统可塑性变化的重要平台。味觉神经交叉再生支配后,动物的行为学反应和味觉神经的电生理特性都发生了很大的变化。本文综述味觉神经损伤、再生以及味觉神经交叉支配对动物味觉功能的影响,并对味觉神经交叉再生支配动物模型以后的研究方向进行展望。味觉神经损伤、再生和交叉再生支配的研究不仅有助于揭示味觉神经系统可塑性变化的机制,也将为临床上寻找治疗味觉障碍患者的方法和技术提供理论基础和新的思路。     

脂肪干细胞对神经创伤修复的研究进展

在医学上,神经系统对神经损伤的自我修复能力往往有限。因此,探索有效修复损伤神经的方法已经成为近年来的研究热点。研究发现脂肪干细胞对各类损伤神经都有一定的修复作用,可作为修复神经损伤的种子细胞。脂肪干细胞不仅具有干细胞的特性而且还具有自身的优点;首先它属于成体细胞,来源于中胚层,具有多种分化的潜能;其次免疫原性较低,易于取材;另外脂肪干细胞移植后的风险较低,因此被认为是修复神经损伤的优秀种子细胞。就脂肪干细胞的特性及脂肪干细胞在神经创伤修复方面的研究进展和存在的问题进行综述。     

原发性干燥综合征患者神经系统病变的临床研究

目的：探讨原发性干燥综合征患者合并神经系统损害的发生率,并分析其出现外周和中枢神经系统受累的临床特点。方法：共纳入34例原发性干燥综合征患者,进行神经系统查体,头MRI、脑脊液化验以及电生理检查。结果：34例患者有15例出现神经系统症状,其中11例表现为外周神经受累,分别为3例颅神经受累,6例多发神经病变,1例多发单神经炎,1例怀疑小纤维神经病;4例为中枢神经受累,分别为．1例患者头和脊髓多发脱髓鞘病变,2例大脑单个灶性病变,1例脑干病变。患者间免疫学检查未见显著差异。结论：原发性干燥综合征患者合并神经系统病变的发生率约为44．1％,外周神经损伤尤其是感觉神经损伤更常见,未发现特异性神经系统改变。与不伴神经系统病变的原发性干燥综合征患者相比较,未发现显著的差异以及能够辅助诊断的实验室检查结果。     

神经系统中的嘌呤信号

三磷酸腺苷(ATP)作用于嘌呤受体(P2受体),引起离子通道开放或通过第二信使调节神经细胞功能,不仅参与了特殊感觉、神经元与神经胶质细胞相互作用等生理活动,而且参与了神经损伤修复和疼痛等病理过程.神经系统中的嘌呤信号系统研究,不仅为解释神经系统生理功能及其病理过程提供了新的思路,而且为治疗神经系统损伤和疼痛等疾病开辟了新的希望.     

神经影像与转化神经科学专栏——序言

正神经系统是人体最重要的系统之一,其结构损伤或功能紊乱将导致多种精神和神经系统疾病。神经影像和神经调控技术相辅相成,对认识精神和神经系统疾病的神经病理机制并针对性地调控神经系统活动以治疗相应疾病有重要作用。"神经影像与转化神经科学"专栏着眼于加强神经影像和神经调控技术的转化和应用,既介绍了弥散张量成像、脊髓成像等前沿神经影像方法,也关注神经影像在精神分裂症、偏头痛、膝骨关节炎、肠易激综合征等疾病中的应用,还概述了非侵入性神经电刺激对缓解疼痛的作用。[1]     

神经电生理在颅内动脉瘤夹闭术中联合颅内压、脑灌注压监测的应用效果研究

摘要 目的：探讨神经电生理在颅内动脉瘤夹闭术中联合颅内压（ICP）、脑灌注压（CPP）监测的应用效果。方法：选取2018年12月～2020年1月我院进行开颅手术治疗的颅内动脉瘤患者60例,采用简单随机化分组方法分为两组,每组30例。对照组实施颅内动脉瘤夹闭手术,观察组在对照组基础上,术中应用神经电生理、ICP、CPP监测。比较两组动脉瘤夹闭情况,术后第1 d新发神经功能缺损情况,术前、术后1 d、术后3个月格拉斯哥昏迷评分（GCS）、美国国立卫生研究院脑卒中量表（NIHSS）评分及术后3个月预后优良率。结果：两组动脉瘤均完全夹闭,观察组术后第1 d新发神经功能缺损率6.67%（2/30）低于对照组的26.67%（8/30）（P＜0.05）;术后1 d观察组GCS评分高于对照组,NIHSS评分低于对照组（P＜0.05）;排除失访病例后,观察组术后3个月GOS分级、mRS分级优良率分别为88.89%、88.89%,与对照组的88.00%、84.00%比较,差异无统计学意义（P＞0.05）。结论：采用神经电生理联合ICP、CPP监测,能够实时掌握颅内动脉瘤夹闭术患者脑组织血流情况,根据监测结果及时采取相应干预措施,可预防不可逆的脑缺血改变,改善术后早期患者意识状态,减少术后早期神经功能缺损的发生。     

Intraoperative monitoring of the abducens nerve in extended endonasal endoscopic approach: A pilot study technical report

BackgroundTo determine the reliability and usefulness of intraoperative monitoring of the abducens nerve during extended endonasal endoscopic skull base tumor resection.MethodsWe performed abducens nerve intraoperative monitoring in 8 patients with giant clival lesions recording with needle electrodes sutured directly into the lateral rectus muscles of the eye to evaluate spontaneous electromyographic activity and triggered responses following stimulation of the abducens nerves.ResultsA total of 16 abducens nerves were successfully recorded during endoscopic endonasal skull base surgeries. Neurotonic discharges were seen in two patients (12% [2/16] abducens nerves). Compound muscle action potentials of the abducens nerves were evoked with 0.1–4 mA and maintained without changes during the neurosurgical procedures. No patient had new neurological deficits or ophthalmological complications post-surgery.ConclusionsIntraoperative monitoring of the abducens nerve during the extended endonasal endoscopic approach to skull base tumors appears to be a safe method with the potential to prevent neural injury through the evaluation of neurotonic discharges and triggered responses.     

Clinical Utility and Limitations of Intraoperative Monitoring of Visual Evoked Potentials

Objectives

During surgeries that put the visual pathway at risk of injury, continuous monitoring of the visual function is desirable. However, the intraoperative monitoring of the visual evoked potential (VEP) is not yet widely used. We evaluate here the clinical utility of intraoperative VEP monitoring.

Methods

We analyzed retrospectively 46 consecutive surgeries in 2011-2013. High luminance stimulating devices delivered flash stimuli on the closed eyelid during intravenous anesthesia. We monitored VEP features N75 and P100 and took patients'' preoperative and postoperative visual function from patient charts. Postoperative ophthalmologic workup was performed in 25 (54%) patients and preoperatively in 28 (61%) patients.

Results

VEP recordings were feasible in 62 of 85 eyes (73%) in 46 patients. All 23 eyes without VEP had impaired vision. During surgery, VEPs remained stable throughout surgery in 50 eyes. In 44 of these, visual function did not deteriorate and three patients (6 eyes) developed hemianopia. VEP decreased transiently in 10 eyes and visual function of all was preserved. VEPs were lost permanently in 2 eyes in two patients without new postoperative visual impairment.

Conclusions

Satisfactory intraoperative VEP monitoring was feasible in all patients except in those with severe visual impairment. Preservation of VEPs predicted preserved visual function. During resection of lesions in the visual cortex, VEP monitoring could not detect new major visual field defects due to injury in the posterior visual pathway. Intraoperative VEPs were sensitive enough to detect vascular damage during aneurysm clipping and mechanical manipulation of the anterior visual pathway in an early reversible stage. Intraoperative VEP monitoring influenced surgical decisions in selected patients and proved to be a useful supplement to the toolbox of intraoperative neurophysiological monitoring.     

Skull base tumors: a comprehensive review of transfacial swing osteotomy approaches

Numerous techniques have been proposed for the resection of skull base tumors, each one unique with regard to the region exposed and degree of technical complexity. This study describes the use of transfacial swing osteotomies in accessing lesions located at various levels of the cranial base. Eight patients who underwent transfacial swings for exposure and resection of cranial base lesions between 1996 and 2002 were studied. The mandible was the choice when wide exposure of nasopharyngeal and midline skull base tumors was necessary, especially when they involved the infratemporal fossa. The midfacial swing osteotomy was an option when access to the entire clivus was necessary. An orbital swing approach was used to access large orbital tumors lying inferior to the optic nerve and posterior to the globe, a region that is often difficult to visualize. Gross total tumor excision was possible in all patients. Six patients achieved disease control and two had recurrences. The complications of cerebrospinal fluid leak, infection, hematoma, or cranial nerve damage did not occur. After surgery, some patients experienced temporary symptoms caused by local swelling. The aesthetic result was considered good. Transfacial swing osteotomies provide a wide exposure to tumors that occur in the central skull base area. Excellent knowledge of the detailed anatomy of this region is paramount to the success of this surgery. The team concept is essential; it is built around the craniofacial surgeon and an experienced skull base neurosurgeon.     

Intraoperative motor evoked potentials monitoring in spinal neurosurgery.

Neurological damage may follow even a technically accurate spinal surgery. The intraoperative monitoring of neurological functions put at risk by the operation is a method utilized to correctly identify the topography of neural structures and to avoid surgical insults. SEPs monitoring is 20 year old, and only recently direct motor tract monitoring has become possible. Transcranial electrical motor cortex stimulation with single pulses or with short trains of stimuli and recording of the evoked responses from the spinal epidural space (D-waves) and from limb muscles is a reliable and safe technique for monitoring corticospinal tract activity even under general anesthesia. The method has a solid theoretical experimental background. Its clinical application has demonstrated high sensitivity and specificity. Intraoperative MEPs monitoring is nowadays considered indispensable during spinal neurosurgery.     

经鼻内镜手术进展

颅底手术正随着经鼻内镜手术的发展而发生着转变。经鼻内镜手术最初开发于鼻窦手术,但其适应症已逐渐扩大到其它领域,可以用于治疗大量的疾病。经鼻内镜手术的主要优点是：它利用天然的孔道来处理大量的颅内、鼻窦病变,避免了皮肤切口、面部骨瓣切口、脑回缩等直接开颅所不可避免的后遗症。与传统的神经外科手术相比,发病率和死亡率下降,并间接减少了住院时间和管理成本。本文就经鼻内镜手术的进展进行综述。在综述中阐述了经鼻内镜手术的适应症和基本原则,以及显露、特别是重建技术的进展,这些进展要求在可接受的并发症前提下达到更广泛的切除;讨论了经鼻内镜手术的局限性,尤其是,虽然这种手术往往是“微创”,但它并不是完全没有并发症;展望了经鼻内镜手术的适应症会不断拓宽,并发症会越来越少的美好未来。     

经鼻内镜手术进展

颅底手术正随着经鼻内镜手术的发展而发生着转变。经鼻内镜手术最初开发于鼻窦手术,但其适应症已逐渐扩大到其它领域,可以用于治疗大量的疾病。经鼻内镜手术的主要优点是:它利用天然的孔道来处理大量的颅内、鼻窦病变,避免了皮肤切口、面部骨瓣切口、脑回缩等直接开颅所不可避免的后遗症。与传统的神经外科手术相比,发病率和死亡率下降,并间接减少了住院时间和管理成本。本文就经鼻内镜手术的进展进行综述。在综述中阐述了经鼻内镜手术的适应症和基本原则,以及显露、特别是重建技术的进展,这些进展要求在可接受的并发症前提下达到更广泛的切除;讨论了经鼻内镜手术的局限性,尤其是,虽然这种手术往往是"微创",但它并不是完全没有并发症;展望了经鼻内镜手术的适应症会不断拓宽,并发症会越来越少的美好未来。     

体外循环心脏手术围术期脑损伤监测进展

脑损伤是体外循环心脏手术的严重并发症之一,目前患病人数在全球范围内呈逐年增高的趋势,并且临床上应用的脑保护措施效果并不确切,因此有效的神经系统监测关系到外科手术的成败和病人的预后。本文从术中脑组织氧供需平衡、栓子的监测、生化标志物和术后神经功能监测四个方面综述目前脑损伤监测的新进展。     

颧根与侧颅底重要结构的解剖学测量

目的：通过测量颧根与侧颅底各重要结构间的距离关系,为临床侧颅底外科手术治疗提供定位参考。方法：取成人颅骨标本50例（去颅盖标本8例,整颅42例）100侧,用游标卡尺、圆规和直尺测量颧根与侧颅底重要结构的距离。结果：实验测得左右侧颧根与外耳门前缘中点、乳突尖、茎突、翼突外侧板根部、舌下神经管外口、茎乳孔、颈静脉孔外缘、颈动脉管外口后缘、棘孔、卵圆孔、破裂孔的距离分别为22.30±2.84mm和22.02±3.27mm、40.37±3.21mm和40.56±3.54mm、32.53±2.78mm和32.92±2.68mm、35.13±3.14mm和35.19±2.74mm、49.29±2.88mm和48.98±2.87mm、32.92±2.44mm和33.05±2.61mm、35.15±2.86mm和34.68±3.13mm、33.17±2.78mm和33.17±2.72mm、28.83±2.62mm和28.68±2.63mm、31.15±2.76mm和31.49±2.73mm、43.67±3.32mm和44.15±3.02mm,左右侧数据无差异（P〉0.05）。结论：颧根可以作为侧颅底外科手术的定位标志,为直视条件下经颞下等入路的侧颅底外科手术提供解剖学依据。     

Improved Intraoperative Visualization of Nerves through a Myelin-Binding Fluorophore and Dual-Mode Laparoscopic Imaging

The ability to visualize and spare nerves during surgery is critical for avoiding chronic morbidity, pain, and loss of function. Visualization of such critical anatomic structures is even more challenging during minimal access procedures because the small incisions limit visibility. In this study, we focus on improving imaging of nerves through the use of a new small molecule fluorophore, GE3126, used in conjunction with our dual-mode (color and fluorescence) laparoscopic imaging instrument. GE3126 has higher aqueous solubility, improved pharmacokinetics, and reduced non-specific adipose tissue fluorescence compared to previous myelin-binding fluorophores. Dosing and kinetics were initially optimized in mice. A non-clinical modified Irwin study in rats, performed to assess the potential of GE3126 to induce nervous system injuries, showed the absence of major adverse reactions. Real-time intraoperative imaging was performed in a porcine model. Compared to white light imaging, nerve visibility was enhanced under fluorescence guidance, especially for small diameter nerves obscured by fascia, blood vessels, or adipose tissue. In the porcine model, nerve visualization was observed rapidly, within 5 to 10 minutes post-intravenous injection and the nerve fluorescence signal was maintained for up to 80 minutes. The use of GE3126, coupled with practical implementation of an imaging instrument may be an important step forward in preventing nerve damage in the operating room.     

高流量颅外内血管搭桥技术在颅底肿瘤手术中的应用进展

颅底肿瘤尤其是侵及颈内动脉等颅内主供血血管的肿瘤治疗一直是神经外科的难题,由于此类肿瘤与重要血管的关系密切,手术风险极大,导致治愈率底下。而颅外内血管搭桥技术通过重建颅内血运,可以有效提升此类肿瘤的全切率。本文回顾了高流量颅外内血管搭桥技术的历史进展、探讨了颅外内血管搭桥技术辅助切除颅底肿瘤的意义所在,复习文献归纳了该技术应用的适应症、术中注意事项及其疗效与争议,旨在为其临床推广应用提供更多的参考依据。熟练及合理地应用颅外内血管搭桥技术,制定个体化的治疗方案,复杂颅底肿瘤的治愈率将会得到进一步提升。