浅谈喉返神经显露在基层医院甲状腺手术的临床体会

目的探讨甲状腺手术中喉返神经显露的意义及技巧。方法选取2016年1月～2018年2月在我科行甲状腺手术的患者85例,随机分为观察组42例和对照组43例。对照组患者术中不显露喉返神经,观察组患者术中常规行喉返神经显露,观察比较两组患者术中出血量、手术时间、引流总量、喉返神经损伤情况。结果两组患者术中出血量比较,差异无统计学意义(P0.05);但观察组的手术时间较对照组显著延长,引流总量较对照组显著增多,差异均有统计学意义(P0.05);两组患者的喉返神经损伤率比较,观察组显著低于对照组,差异有统计学意义(P0.05)。结论甲状腺手术中常规显露喉返神经,在直视下得到有效保护,降低喉返神经的损伤发生率,值得在基层医院推广使用。     

甲状腺术中喉返神经显露对暂时性喉返神经损伤发生率的影响

目的:探究甲状腺术中喉返神经显露对暂时性喉返神经损伤发生率的影响。方法:选择我院2016年10月-2018年10月收治的行甲状腺切除术的115例患者为研究对象,按照其入院顺序经随机数字表法分为两组,两组患者均行常规甲状腺切除术。其中,对照组58例患者未显露喉返神经;研究组57例患者常规显露喉返神经,记录并比较两组患者的手术时间、术中出血量、术后引流量、切口长度和住院时间等围术期手术指标,术后1d、4d、7d的甲状旁腺激素(PTH)水平、钙离子(Ca2+)水平,术后暂时性喉返神经损伤、术后声音嘶哑、低钙血症等并发症的发生情况。结果:研究组患者的手术时间、术中出血量、术后引流量均短于(少于)对照组(P0.05),但两组患者的切口长度和住院时间无显著性差异(P0.05);研究组患者术后1d、4d、7d的血清PTH、Ca2+水平均高于对照组(P0.05),暂时性喉返神经损伤、术后声音嘶哑、低钙血症发生率均低于对照组(P0.05)。结论:甲状腺术中喉返神经显露可有效预防暂时性喉返神经和甲状腺功能的损伤,降低术后并发症的发生率,且患者的围术期指标均显著改善。     

大鼠皮质脊髓束神经电信号的记录与分析方法研究

目的：探索皮质脊髓束（CST）电生理信号的采集记录方法,分析描述电信号的特征,从而为通过植入式微电极阵列进行信号采集的记录方法建立一定的实验基础,为将来进一步研究脊髓损伤修复与功能重建提供有价值的神经电生理基础资料。方法：使用神经信号采集处理系统（Cerebus System）,在SD大鼠的脊髓T8节段处的皮质脊髓束内通过插入微电极,记录大鼠皮质脊髓束神经电信号。利用神经信号分析软件Offline Sorter、Neuroexplorer对已存储的信号文件进行波形特点的描述,包括波长、波幅、放电频率、同一电极上记录到的不同放电单元之间的同步性、两根电极上记录到的不同放电单元之间的同步性、放电信号的峰间期（ISI）分析等。结果：长时间稳定记录到连续的皮质脊髓束自发放电信号,一般在同一电极上记录到3~4个来自不同放电单位（细胞）的放电信号。皮质脊髓束自发放电信号的波形呈双向型,波宽为0.6~1.3 ms,波幅为百μV级。在多次实验状态下均能达到很高的信噪比,信号采集效果理想。经快蓝（LFB）染色确认记录电极尖端位于皮质脊髓束内。结论：本实验采用Cere-bus神经信号采集处理系统,利用记录电极可在大鼠的皮质脊髓束内较长时间稳定地记录到较为稳定的微伏级神经电信号,并可进行有意义的神经电信号特征分析,为进一步研究脊髓损伤修复与功能重建提供了有价值的神经电生理基础资料。     

神经监测对甲状腺手术中喉返神经保护作用的Meta分析

目的 既往研究显示,甲状腺手术中应用神经监测以保护喉返神经仍存在争议。本文对比甲状腺手术中应用喉返神经监测与常规解剖暴露的差异,探讨术中喉返神经监测对喉返神经暂时性损伤及永久性损伤的保护作用及临床价值。方法 收集2018年1月至2022年12月PubMed、Embase、Web of Science、中国知网、万方及维普数据库发表的与神经监测对甲状腺手术中喉返神经保护作用相关的文献,使用Stata 14.0软件进行Meta分析。结果 本研究共纳入文献18篇,病例数12 877例,其中神经监测喉组7 718例,常规解剖暴露组5 159例。Meta分析结果显示,在甲状腺手术中,神经监测与常规解剖显露喉返神经相比,能减少喉返神经暂时性损伤(OR=0.524,95%CI:0.370～0.742,P<0.001)及永久性损伤(OR=0.371,95%CI:0.235～0.584,P<0.001)。试验序贯分析显示纳入研究的总样本足够。结论 神经监测在甲状腺手术中对喉返神经暂时性损伤和永久性损伤均具有保护作用,尤其在甲状腺癌复发等2次手术时,对喉返神经保护具有重要临床意义。     

不同手术方式对分化型甲状腺癌患者预后的影响

目的：探讨不同手术方式对分化型甲状腺癌患者临床治疗的效果及其预后的影响。方法：回顾性分析了2005.02-2012.07入住我院的60例分化型甲状腺癌患者的临床资料,采用如下三种不同的治疗方式：甲状腺切除术联合双侧中央区颈淋巴结清扫手术;保留对侧喉返神经入喉处甲状腺组织的甲状腺次全切除术联合单侧改良颈淋巴结清扫手术;保留对侧喉返神经入喉之处甲状腺组织的甲状腺次全切除手术联合双侧改良颈淋巴结清扫手术。结果：（1）上述三组患者术后,患者的甲状旁腺的功能低下之间均存在显著的统计学差异（P〈0.01）,三组喉返神经损伤的发生率之间也存在显著的统计学差异（P〈0.01）;本组60例患者均获10-172个月（平均为93.5±10.2）的随访,上述三种手术方式下患者的癌症复发率分别为77.8%、4.5%及45.0%,三组具有显著的统计学差异（P〈0.01）;生化治愈率分别为27.8%、95.5%及50.0%;平均生存时间分别为（92.3±12.5）个月、（105.8±14.5）个月及（112.3±20.9）个月。（2）三组患者术后生存质量总得分分别为（122±9）、（118±8）及（125±9）分。结论：与甲状腺切除术联合双侧中央区颈淋巴结清扫手术进行对比,保留对侧喉返神经入喉处甲状腺组织的甲状腺次全切除术联合单侧改良颈淋巴结清扫手术与保留对侧喉返神经入喉之处甲状腺组织的甲状腺次全切除手术联合双侧改良颈淋巴结清扫手术在生存时期、术后生存质量两个方面不具显著性差异。     

Wistar大白鼠血红蛋白的抽样测试与统计分析

对 6～ 8周龄Wistar大白鼠大样本随机抽样 ,眼底静脉丛取血 ,用氰化高铁血红蛋白光电比色法测血红蛋白 ,经统一分析 ,结果 ,♂ : X±SD =1 2 8 4 0± 1 1 55,μ±S x =1 2 8 4 0± 0 89,μ的可信区间估计为 1 2 6 65～ 1 3 0 1 5(可信度 95% )和 1 2 6 1 0～ 1 3 0 70 (可信度 99% ) ,正常值范围估计为 1 0 6 79～1 52 90 (含 95%总本 )和 1 0 0 3 7～ 1 59 4 8(含 99%总体 ) ;♀ : X±SD =1 2 8 79± 1 1 2 9,μ±S x =1 2 8.79± 0 87;μ的可信区间估计 1 2 7 0 8～ 1 3 0 50 (可信度 95% )和 1 2 6 53～ 1 3 1 0 4 (可信度 99% ) ,正常值范围估计 1 0 8 4 6～ 1 52 1 8(含 95%总体 )和 1 0 1 96～ 1 58 2 5(含 99%总体 ,单位均为 g/L ,性别间无显著性差异。结果可作为科研、教学等的大白鼠血红蛋白正常值的参考。     

BALB/c小鼠血小板抽样测试与统计分析

调查了BALB c小鼠血液血小板的正常参考值范围。随机抽样BALB c小鼠 98例 ,雄性 5 0只 ,雌性 48只 ,显微镜计数法 ,按统计学原理分析 ,并对总体正常值范围估计。结果表明 ,♂ : X±SD =3 1 7 5 8± 72 0 8,μ±S X =3 1 7 5 8± 1 0 1 9,μ的可信区间估计为 3 0 0 5 0～ 3 3 4 66(90 %可信度 )、2 97 1 1～ 3 3 8 0 5(95 %可信度 )和 2 90 2 9～ 3 44 87(99%可信度 ) ,正常值范围综合估计为 1 94 92～ 41 4 95 (含 90 %总体 )、1 80 87～ 42 5 9(含 95 %总体 )和 1 5 8 67～ 45 9 62 (含 99%总体 ) ;♀ : X±SD =2 85 2 3± 71 71 ,μ±S X =2 85 2 3± 1 0 3 5 ,μ的可信区间估计为 2 67 88～ 3 0 2 5 8(90 %可信度 )、2 64 44～ 3 0 6 0 2 (95 %可信度 )和2 5 7 5 1～ 3 1 2 95 (99%可信度 ) ,正常值范围综合估计为 1 68 64～ 3 81 3 6(含 90 %总体 )、1 5 3 5 9～ 3 93 0 1(含 95 %总体 )和 1 2 8 3 6～ 42 6 65 (含 99%总体 ) ,单位为× 1 0 9 L。性别间有差异 ,P <0 0 5。本结果可为科研、教学工作提供参考。     

甲状腺全切除术与半切除术治疗甲状腺癌的临床效果分析

目的:比较甲状腺全切除术与半切除术治疗甲状腺癌的临床效果。方法:选取我院收治的90例甲状腺癌患者,对所有患者行甲状腺全切除术或近全切除术,同时应用I131以及甲状腺激素抑制治疗作为辅助治疗,并对所有患者进行随访。结果:两组患者的术中出血量、喉返神经显露率比较差异无统计学意义(P0.05),观察组的手术切口以及手术时间均明显长于对照组(P0.01),甲状旁腺显露率高于对照组(P0.01)。两组患者暂时性、永久性喉返神经损伤,暂时性、永久性甲状旁腺功能低下发生率比较差异无统计学意义(P0.05)。复发率为13.33%(6/45),观察组无复发,两组患者术后复发率比较差异具有统计学意义(P0.05)。结论:甲状腺全切除术治疗甲状腺癌的效果优于半切除术,且能够有效降低术后复发率。     

痉挛性肌张力增高的神经外科治疗

目的:分析总结在周围神经肌电监测指导下行缩窄神经术降低痉挛性高肌张力,改善关节强直的临床疗效。方法:对16例关节强直患者术中在周围神经肌电监测指导下,在显微镜下行神经缩窄术,其中脑性瘫痪患者9例,脑炎后遗症患者2例,中毒性脑病1例,脑外伤后遗症患者1例,颈髓损伤患者1例,脑积水患者1例,烟雾病伴脑梗死患者1例。用表面肌电(surface electro myo graphy,s EMG)及改良的Ashworth(Modified A shworth Scale,MAS)肌张力分级标准对强直肢体肌张力评定。结果:所有患者的痉挛肢体肌张力明显下降,症状显著改善。肌电信号均方根值术前与术后比较,采用配对样本的T检验分析,P值0.001,差异有统计学意义。术后感觉障碍发生率为12.5%(2/16),术后肌力明显减低发生率为18.8%(3/16),随访期间完全恢复。结论:术中在周围神经肌电监测指导下,显微镜下行神经缩窄术治疗痉挛性关节强直是有效的外科治疗方法,效果确切。     

瑞芬太尼辅助颈丛神经阻滞用于甲状腺手术麻醉70例观察

目的探讨瑞芬太尼辅助颈丛神经阻滞用于甲状腺手术麻醉的可行性及效果。方法选择70例甲状腺肿大在Ⅱ°以内,既往无明显心、肺疾患的甲状腺手术患者,行双侧颈丛神经阻滞,术中持续输注小剂量瑞芬太尼,以0.05μg.kg-1.min-1为基础剂量,并根据病人的反应增减剂量,最大不超过0.1μg.kg-1.min-1。观察术中患者血压、心率、脉搏氧饱和度的变化,评价术中疼痛及呼吸抑制、肌强直等不良反应的情况。结果所有病例术中血压、心率、脉搏氧饱和度均保持平稳,镇痛效果优53例,良17例;其中2例有轻度呼吸抑制（SpO2〈92%）,经停药、给氧处理后迅速恢复正常,其余患者麻醉过程SpO2保持在95%以上。所有患者均无肌强直等不良反应发生。结论术中注意加强呼吸管理,常规面罩吸氧,小剂量瑞芬太尼辅助颈丛神经阻滞麻醉下行甲状腺手术是安全、有效的。     

Voice changes after thyroidectomy: role of the external laryngeal nerve.

Hitherto voice changes have been regarded as an infrequent complication of thyroidectomy and damage to the recurrent laryngeal nerve has been given as their major cause. Voice function was assessed in 325 patients after thyroidectomy. Permanent changes occurred in 35 (25%) after subtotal thyroidectomy and in 19 (11%) after lobectomy. The commonest cause of voice change appeared to be injury to the external laryngeal nerves on one or both sides. Damage to the recurrent laryngeal nerve, which was routinely identified and protected, was rarely a cause. When the external laryngeal nerves were identified and preserved, permanent voice changes occurred in only 5% of cases; this was similar to the incidence of 3% in controls after endotracheal intubation alone. The course of the external laryngeal nerve is variable, and consequently mass ligation of the vessels at the top of the upper pole will damage it in a high proportion of cases. To minimise this serious complication these nerves should be identified and protected as well as the recurrent nerves and voice function should be assessed early in the postoperative period by laryngoscopy and by a speech therapist.     

Specificity of esophageal electrode recordings of posterior cricoarytenoid muscle activity

Esophageal electrodes have been used for recording the electromyographic (EMG) activity of the posterior cricoarytenoid muscle (PCA). To determine the specificity of this EMG technique, esophageal electrode recordings were compared with intramuscular recordings in eight anesthetized mongrel dogs. Intramuscular wire electrodes were placed in the right and left PCA, and the esophageal electrode was introduced through the nose or mouth and advanced into the upper esophagus. On direct visualization of the upper airway, the unshielded catheter electrode entered the esophagus on the right or left side. Cold block of the recurrent laryngeal nerve (RLN) ipsilateral to the esophageal electrode was associated with a marked decrease in recorded activity, whereas cold block of the contralateral RLN resulted only in a small reduction in activity. After supplemental doses of anesthesia were administered, bilateral RLN cold block essentially abolished the activity recorded with the intramuscular electrodes as well as that recorded with the esophageal electrode. Before supplemental doses of anesthesia were given, especially after vagotomy, the esophageal electrode, and in some cases the intramuscular electrodes, recorded phasic inspiratory activity not originating from the PCA. Therefore, one should be cautious in interpreting the activity recorded from esophageal electrodes as originating from the PCA, especially in conditions associated with increased respiratory efforts.     

Transplantation of Olfactory Ensheathing Cells to Evaluate Functional Recovery after Peripheral Nerve Injury

Olfactory ensheathing cells (OECs) are neural crest cells which allow growth and regrowth of the primary olfactory neurons. Indeed, the primary olfactory system is characterized by its ability to give rise to new neurons even in adult animals. This particular ability is partly due to the presence of OECs which create a favorable microenvironment for neurogenesis. This property of OECs has been used for cellular transplantation such as in spinal cord injury models. Although the peripheral nervous system has a greater capacity to regenerate after nerve injury than the central nervous system, complete sections induce misrouting during axonal regrowth in particular after facial of laryngeal nerve transection. Specifically, full sectioning of the recurrent laryngeal nerve (RLN) induces aberrant axonal regrowth resulting in synkinesis of the vocal cords. In this specific model, we showed that OECs transplantation efficiently increases axonal regrowth.OECs are constituted of several subpopulations present in both the olfactory mucosa (OM-OECs) and the olfactory bulbs (OB-OECs). We present here a model of cellular transplantation based on the use of these different subpopulations of OECs in a RLN injury model. Using this paradigm, primary cultures of OB-OECs and OM-OECs were transplanted in Matrigel after section and anastomosis of the RLN. Two months after surgery, we evaluated transplanted animals by complementary analyses based on videolaryngoscopy, electromyography (EMG), and histological studies. First, videolaryngoscopy allowed us to evaluate laryngeal functions, in particular muscular cocontractions phenomena. Then, EMG analyses demonstrated richness and synchronization of muscular activities. Finally, histological studies based on toluidine blue staining allowed the quantification of the number and profile of myelinated fibers.All together, we describe here how to isolate, culture, identify and transplant OECs from OM and OB after RLN section-anastomosis and how to evaluate and analyze the efficiency of these transplanted cells on axonal regrowth and laryngeal functions.     

高频超声与喉镜检查对甲状腺癌侵犯喉返神经的术前评价价值分析

目的:比较高频超声与喉镜检查对甲状腺癌侵犯喉返神经(recurrent laryngeal nerve,RLN)的术前评价价值。方法:选择2012年2月到2019年8月在本院进行诊治的甲状腺癌患者207例,采用高频超声与喉镜进行术前评估侵犯喉返神经情况,记录超声特征并判断诊断价值(以病理检查作为金标准)。结果:在207例甲状腺癌患者中,术后病理学证实喉返神经侵犯52例(侵犯组),转移率为25.1%。侵犯组的性别、年龄、发病位置、体重指数、病程等与非侵犯组患者对比差异无统计学意义(P0.05)。侵犯组超声显示病灶形态、内部回声、边界、钙化、晕环等特征与非侵犯组对比差异有统计学意义(P0.05),主要表现为侵犯组的病灶形态不规则、无晕环、无钙化、边界不清晰、内部高超声均显著高于非侵犯组(P0.05)。侵犯组的峰值强度(Peak intensity,PI)值高于非侵犯组患者(P0.05),两组达峰时间(Peak time,TP)与AUC值对比差异无统计学意义(P0.05)。在207例患者中,高频超声判断为喉返神经侵犯43例,喉镜判断为喉返神经侵犯39例,高频超声与喉镜检查对甲状腺癌侵犯喉返神经的术前诊断敏感性为97.7%和97.4%,特异性为93.9%和91.7%,高频超声诊断的敏感性和特异性比喉镜检查稍优。ROC曲线显示高频超声诊断的AUC为0.903,喉镜检查的AUC为0.860。结论:高频超声与喉镜检查对甲状腺癌侵犯喉返神经的术前评价的应用价值相当,均有很高的敏感性与特异性,能准确反映患者侵犯喉返神经的情况。     

Electrophysiologic identification and evaluation of stylohyoid and posterior digastricus muscle complex.

PURPOSE: To identify the function of stylohyoid and posterior digastricus (STH-PD) muscle complex by the EMG techniques. METHODS: Unaffected sides of the faces of 30 patients with facial paralysis or hemifacial spasm were investigated. A concentric needle electrode was inserted to the STH-PD muscle complex and another concentric needle electrode was inserted to the orbicularis oris (OO) muscle. Simultaneous recording were obtained from two muscles using electrical stimulation (ES) (in 25 cases) and magnetic coil stimulation (MS) (in 15 cases); and both in 10 cases. Afterwards, the function of STH-PD was studied such as whistling, lip pursing, swallowing, jaw opening and closing. RESULTS: (1) The motor latency of compound muscle action potential (CMAP) of the STH-PD muscle was shorter than that of OO. (2) When the facial nerve was stimulated more distally than the stylomastoid foramen, the CMAP elicited from the STH-PD muscle complex immediately disappeared. (3) Ipsilateral MS was able to elicit the motor evoked potential (MEP) from STH-PD either at intracranially (half of cases) or at the extracranially. While OO muscle was always stimulated intracranially by MS. (4) The STH-PD muscle complex could not be basically recruited by the mimicry except lip pursing. The main recruitment were provided by swallowing and jaw opening. Cortical MS were facilitated during swallowing (5) Late reflex responses appeared in the STH-PD muscle complex during infraorbital-trigeminal and facial nerve ES. CONCLUSION: The STH-PD muscle complex is identified electrophysiologically. Although it is innervated by the facial nerve, its functions are mainly related with jaw opening and oropharyngeal swallowing. However, it is activated by the lip pursing.     

The interaction between breathing and swallowing in healthy individuals

In this article, we aimed at investigating the interaction between breathing and swallowing patterns in normal subjects. Ten healthy volunteers were included in the study. Diaphragm EMG activity was recorded by a needle electrode inserted into the 7th or 8th intercostal space. Swallowing was monitored by submental EMG activity, and laryngeal vertical movement was recorded by using a movement sensor. A single voluntary swallow was initiated during either the inspiration or expiration phases of respiration, and changes in EMG activity were evaluated. When a swallow coincided with either inspiration or expiration, the duration of the respiratory phase was prolonged. Normal subjects were able to voluntarily swallow during inspiration. During the inspiration phase with swallowing, diaphragmatic activity did not ceased and during the expiration phase with swallowing, there was a muscle activity in the diaphragm muscle.     

The accuracy of needle electrode placement by trainees in selected forearm muscles using verification by neuromuscular ultrasound

IntroductionAnatomic landmarks alone may not always be sufficient to accurately guide electromyography (EMG) electrode needle placement.MethodsSenior residents and fellows (n = 11) targeted 4 forearm muscles with anatomic landmarks alone versus with audiovisual EMG feedback. Accuracy of EMG needle placement was verified using neuromuscular ultrasound imaging.ResultsWhile relatively large and superficial FCR muscle was sampled at a rate of 100% with and without audiovisual EMG feedback, accuracy of deeper and/or smaller forearm muscles (FPL, EIP, and SUP) diminished significantly without audiovisual EMG feedback.DiscussionOur study suggests that in clinical scenarios in which an electrodiagnostician relies on anatomic landmarks alone to target small and deep muscles, the risk of misplacement of needle electrode is increased. Consideration for neuromuscular ultrasound to augment training and/or real time guidance in EMG practice may be appropriate.