三种诱发电位术中监测脊髓功能的实验研究

目的：观察常用麻醉药物及控制性降血压对猴皮层体感诱发电位（ＣＳＥＰ）、脊髓体感诱发电位（ＳＳＥＰ）和经颅磁刺激运动诱发电位（ＭＥＰ）的影响，评价诱发电位术中监测的作用及影响因素。方法：选用１０只健康猴直接模拟脊柱手术中的麻醉及控制性降压等操作，诱发电位监测。结果：ＣＳＥＰ受多种麻醉药物及控制性降压影响，特别是氯胺酮和异氟醚；ＳＳＥＰ受影响最小。结论：单独使用ＣＳＥＰ监测必须与麻醉密切配合，否则既不稳定又不可靠，ＳＳＥＰ是最佳监测方法     

皮层体感诱发电位（CSEP）在脊柱手术中的监护作用

作者总结了４８例脊柱手术的ＣＳＥＰ监护结果，介绍了术中ＣＳＥＰ的变化及脊髓损伤的指标。提示术中损伤脊髓的危险操作其大小依次是脊柱凹侧撑开，椎板下穿入Ｌｕｑｕｅ钢线，胸椎ＣＤ椎板钩放则驼背截骨较安全。除非已有胸椎椎管狭窄，否则，凿椎板时损伤脊髓机会较少，Ｈａｒｉｎｇｔｏｎ钩及腰段ＣＤ钩的放置及前路椎间盘切除最安全。     

异丙酚对上肢正中神经体感诱发电位的影响

麻醉药物对体感诱发电位(ＳＥＰ)波形存在不同程度的影响,以致干扰术中监测神经病变的效果。本研究通过观察单次静脉注射不同剂量异丙酸对上肢正中神经ＳＥＰ(ＭＮＳＥＰ)波形的变化,了解异丙酚对ＳＥＰ监测的影响情况,为术中进行ＳＥＰ监测时选择合理的麻醉药物及对波形的正确分析提供依据。资料与方法一般资料　30例择期行神经外科手术患者,术前ＭＮＳＥＰ检测无异常,ＡＳＡⅠ～Ⅱ级,男女性别不限,年龄16～68岁,随机分成三组,每组10人。麻醉方法　入室前30分钟肌注阿托品05ｍｇ、苯巴比妥钠01ｇ。入室后记录ＭＮＳＥＰ波形两次。于踝部大…     

皮层体感诱发电位（CSEP）对静压型脊髓损伤术中监护的实验研究

皮层体感诱发电位（ＣＳＥＰ）对静压型脊髓损伤术中监护的实验研究△沈宁江王书成卢传新术中监护脊髓功能预防医源性脊髓损伤，是当前脊柱外科的研究课题之一。１９７８年Ｅｎｇｌｅｒ〔１〕报道体感诱发电位（ＳＥＰ）在脊柱手术中的监护作用，９０年代以来国外应用逐...     

SCEP监测在脊柱外科手术中的应用

１９９０年３月～１９９２年１２月对５５例脊柱外科手术患者进行了脊髓诱发电位（ＳＣＥＰ）术中监测，无１例出现不可逆的神经损伤并发症。术前脊髓神经功能正常组２７例中有２例出现了电位波幅明显变化。２５例术前伴有不全截瘫，在脊髓减压后出现振幅增大、潜时加快的电位图象，术后患者神经功能障碍有了明显的改善。３例完全性截瘫者，术中脊髓诱发电位波幅消失，但在减压后有１例出现了电位波幅，术后截瘫得到了部分恢复。在硬膜外放置刺激及记录电极线记录ＳＣＥＰ的方法可得到大而稳定的电位波幅，能够准确地反应出脊髓功能的即时变化。     

脊柱脊髓手术中皮层体感诱发电位（CSEP）监护的临床研究

目的：通过开展皮层体感诱发电位（ＣＳＥＰ）术中监护脊髓功能的临床研究，有效的预防医原性脊髓损伤，杜绝截瘫的发生。方法：６０例手术患者按Ｆｒａｎｋｅｌ分级术前属Ｂ级１１例，Ｃ级１９例，Ｄ级１２例，Ｅ级１８例，ＣＳＥＰ术中连续动态监测。作者经实验研究并结合临床提出ＣＳＥＰ术中监护临界值为：Ｄ、Ｅ级患者术中波幅较麻醉后下降不超过５０％，潜伏期延长不超过７０％；Ｂ、Ｃ级患者术中波幅较麻醉后下降不超过４０％，潜伏期延长不超过５０％。结果：４５例未达到监护临界值，术后无脊髓损伤。超过临界值发出警告１５例，其中１３例接受警告术后脊髓功能无损害，２例不顾警告继续手术，术后发生完全性截瘫。结论：ＣＳＥＰ术中监护脊髓损伤准确可靠，值得推广应用。     

脊髓急,慢性损伤CSEP的变化：（附127例报告）

１９８０年～１９９２年９月对１２７例急、慢性脊髓损伤行皮层体感诱发电位（ＣＳＥＰ）检查。急性脊髓损伤７７例，全瘫３９例，不全瘫３８例，伤后２周内做减压复位及内固定。术后１～１２个月作ＣＳＥＰ检查与术前对比，３９例全瘫中的２６例ＣＳＥＰ完全消失，瘫痪也无恢复；１３例术前有严重异常的ＣＳＥＰ，７例ＣＳＥＰ及部分皮肤感觉有恢复，余６例无变化。３８例不全瘫，术前有异常的ＣＳＥＰ，术后瘫痪及ＣＳＥＰ都有不同程度恢复。慢性脊髓损伤５０例，术前ＣＳＥＰ均有异常改变，治疗后除２例颈椎病的症状及ＣＳＥＰ无变化外，其余病例都有不同程度的恢复。作者还分析了在急、慢性脊髓损伤者检测ＣＳＥＰ中一些不可靠的原因及影响因素。     

脊髓损伤皮层体感诱发电位（CSEP）术中监护的实验研究

目的：通过开展皮层体感诱发电位（ＣＳＥＰ）术中监护脊髓损伤的实验研究，以确定脊髓损伤的临界值并有效的评价预后，为临床应用提供依据。方法：２８只中国家犬随机分成４组，用ＡｌｅｎＷＤ法致脊髓轻度、重度和完全性损伤，术中ＣＳＥＰ动态监测，并观察伤后１～３个月脊髓组织学改变、ＣＳＥＰ和功能恢复情况。结果：脊髓损伤ＣＳＥＰ术中监护临界值为，伤后２分钟Ｐ１潜伏期较术前延长不超过１．５倍，波幅下降不超过５０％；伤后１０分钟Ｐ１潜伏期较术前延长不超过１．８倍，波幅下降不得超过５５％。波幅变化灵敏，其恢复早于形态学及功能变化。结论：ＣＳＥＰ术中监护脊髓损伤较准确可靠，并能评价其预后。     

先天性心脏病心内直视手术对血浆内皮素的影响

目的　探讨先天性心脏病（ＣＨＤ） 围术期血浆内皮素（ＥＴ） 的变化。　方法　将６７ 例行心肺转流术（ＣＰＢ）的ＣＨＤ 患儿按疾病种类不同分为３ 组,室间隔缺损（ＶＳＤ） 组、肺动脉高压（ＰＨ） 组和肺动脉狭窄（ＰＳ） 组;１０ 例正常儿童为对照组。对前３ 组手术前后血浆ＥＴ 变化进行动态观测。　结果　ＰＨ 组和ＰＳ组术前ＥＴ 值即有升高,术后７ 天仍较对照组为高;ＣＰＢ３０ 分钟时各组ＥＴ 值均较术前为低;术前血浆ＥＴ 值与ＰＳ和ＰＨ 程度呈线性相关;ＰＳ组ＣＰＢ 时间和主动脉阻断时间与术后１ 小时ＥＴ 值明显相关。　结论　ＣＨＤ 患儿手术前、后血浆ＥＴ 值均有变化,血浆ＥＴ 水平可作为监测肺动脉压力变化及ＣＨＤ 手术预后的指标之一。     

脊柱术后病人硬膜外自控镇痛的临床观察

硬膜外自控镇痛 (ＰＣＥＡ)是目前临床应用行之有效的镇痛方法。探讨其镇痛疗效及安全性 ,旨在为脊柱术后病人临床应用ＰＣＥＡ进行镇痛提供参考 ,现总结如下。资料与方法ＡＳＡⅠ～Ⅱ级择期脊柱手术病人 ,均在硬膜外麻醉下行脊柱手术及术后用ＰＣＥＡ ,年龄 16～ 6 3岁。随机分为Ａ组(芬太尼 布比卡因 ) ,Ｂ组 (吗啡 布比卡因 ) ,每组 30例。术前常规用药 ,于Ｔ9～Ｌ2 穿刺 ,术中麻醉平面维持在Ｔ5～Ｓ4节段 ,手术结束前 15分钟给首剂量 ,保留硬膜外导管实施ＰＣＥＡ。脊柱术后病人采用美国雅培电脑注射镇痛泵镇痛。用药方法按ＬＣＰ模式 …     

体感诱发电位用于脊柱手术中脊髓功能的监测

目的评估体感诱发电位(SEP)用于脊柱手术中脊髓监测的可行性，以及皮质体感诱发电位(CSEP)与皮质下体感诱发电位(Sub—CSEP)监测的适应证。方法42例脊柱手术患者，年龄6～68岁，咪唑安定、丙泊酚及维库溴铵静脉诱导，安氟醚吸入维持麻醉．术中均应用CSEP和Sub—CSEP监测脊髓功能。结果CSEP受麻醉影响较大，Sub—CSEP波形稳定，全组7例诱发电位出现异常，其中3例与临床相符，4例为假阳性，无假阴性发生，准确率为90．5％。结论CSEP适于麻醉深度的监测，Sub—CSEP是脊柱手术中脊髓功能监测较为理想的方法。     

经颅电刺激运动诱发电位和皮层体感诱发电位在脊柱侧凸手术中联合监护的观察研究

目的 探讨脊柱侧凸手术中经颅电刺激运动诱发电位(transcranial electrical stimulation motor evoked potential,TES-MEP)和皮层体感诱发电位(cortical somatosensory evoked potential,CSEP)联合监护的可行性和应用价值.方法 2006年7月至2008年4月,在脊柱侧凸手术中同时记录双侧胫前肌、足(足母)短屈肌TES-MEP和双侧胫后神经CSEP 76例.实施全静脉麻醉49例,七氟烷(吸入浓度＜1%)+异丙芬复合麻醉27例.对各麻醉组的TES-MEP检出结果 进行四格表χ2检验,并对术中两种电位的真、假阳性和真、假阴性结果 进行相关的指数统计分析.结果 TES-MEP和CSEP成功检出率均为96.1%,而两种麻醉组的TES-MEP检出率差异无统计学意义.术中诱发电位阳性11例,其中9例为真阳性,均与手术操作不当直接有关.CSEP、TES-MEP、联合监护的灵敏度分别为75.0%、87.5%和100%,特异度分别为98.5%、98.5%和97.0%,约登指数分别为0.74、0.86和0.97.结论 实施异丙芬静脉麻醉为主,辅以七氟烷吸入浓度＜1%的复合麻醉,也是联合监护切实町行的麻醉方案;联合监护对脊髓功能监测的敏感性和准确性明显高于单一的TES-MEP或CSEP监护.     

体感诱发电位在脊柱手术中的监测作用

目的：探讨脊柱外科手术中体感诱发电位监护技术的准确性。方法：对78例颈、胸椎手术患者术中采用皮层体感诱发电位(cortical somatosensory evoked potential，CSEP)术中监测，记录术前、术中、术后各个重要手术步骤的CSEP变化，根据不同阶段诱发电位的变化与术后临床脊髓功能改变相结合，判断CSEP的准确性。结果：78例患者中，CSEP未达到监护界值71例，术后无脊髓损伤；5例患者术中CSEP达到预警标准，告诫手术医生，注意手术操作，术后无脊髓损伤；另外，出现假阳性和假阴性各1例，术后恢复亦良好。结论：排除各种干扰因素后体感诱发电位可较准确地对脊髓的功能状况进行监测，是较准确的脊柱外科手术监护技术。     

同时应用皮层及皮层下诱发电位监测脊柱矫形手术的观察

目的 寻求一种新的监护方法,以提高脊柱矫形手术监测效果。方法 对95例脊柱矫形手术同时进行皮层诱发电位(Cortical somalosensory evoked potential,CSEP)及皮层下诱发电位(Sub cortica somatosensory evoked potential,Sub CSEP)监测。结果 皮层诱发电位受麻药的影响较大,皮层下诱发电位受麻药的影响较小。结论 两者同时监测,可以早期预告脊髓损伤,这对脊柱矫形手术术中监测是较为理想的方法。     

皮层下体感诱发电位监测脊柱侧凸手术的临床研究

目的：研究皮层下体感诱发电位对脊柱侧凸矫正手术监测的准确性,提高术中预防神经损伤的有效性。方法：对４１例脊柱侧凸患者于矫正术中采用皮层下体感诱发电位和皮层体感诱发电位监测脊髓功能。结果：皮层下体感诱发电位波形稳定可靠,很少受麻醉的影响;皮层体感诱发电位受麻醉影响较大,波幅几乎可消失。全组５例皮层下体感诱发电位出现异常,其中２例与临床相符,３例为假阳性;无假阴性发生。准确率为９２７％。结论：应用体感诱发电位术中监测脊髓功能,皮层下体感诱发电位是目前较理想的方法。     

皮层体感诱发电位(CSEP)临护胸椎及胸椎管手术的临床研究

目的　通过开展皮层体感诱发电位 (CSEP)术中监护脊髓功能的临床研究 ,有效的预防医源性脊髓损伤 ,杜绝截瘫的发生。方法　 4 6例手术患者按 Frankel分级术前属 B级 6例 ,C级 14例 ,D级 15例 ,E级 11例 ,CSEP术中连续动态监测。监护临界值为 :D、E级患者术中波幅较麻醉后下降不超过 4 0 %。结果　 2 5例未达到监护临界值 ,术后无脊髓损伤。超过临界值发出警告 2 1例 ,其中 2 0例接受警告术后脊髓功能无损害 ,1例不顾警告继续手术 ,术后发生完全性截瘫。结论CSEP术中监护脊髓损伤准确可靠 ,值得推广应用。     

颈椎手术中皮层体感诱发电位(CSEP)监护的临床研究

目的：通过开展皮层体感诱发电位（CSEP）术中监护脊髓功能的临床研究，有效的预防医源性脊髓损伤。杜绝截瘫的发生。方法：71例手术患者按Frankel分级术前属B级5例，C级24例，D级27例。E级15例，CSEP术中连续动态监测。作者经实验研究并结合临床提出CSEP术中监护临界值为，D、E级患者术中波幅较麻醉后下降不超过50%；B，C级患者术中波幅较麻醉后下降不超过40%，结果：39例未达到监护临界值，术后无脊髓损伤，超过临界值发出警告32例，其中31例接受警告术后脊髓功能无损害。1例不顾警告继续手术。术后发生完全性截瘫。结论：CSEP术中监护脊髓损伤准确可靠。值得推广应用。     

Multimodal intraoperative monitoring (MIOM) during cervical spine surgical procedures in 246 patients

A prospective study of 246 patients who received multimodal intraoperative monitoring during cervical spine surgery between March 2000 and December 2005. To determine the sensitivity and specificity of MIOM techniques used to monitor spinal cord and nerve root function during cervical spine surgery. It is appreciated that complication rate of cervical spine surgery is low, however, there is a significant risk of neurological injury. The combination of monitoring of ascending and descending pathways may provide more sensitive and specific results giving immediate feedback information and/or alert regarding any neurological changes during the operation to the surgeon. Intraoperative somatosensory spinal and cerebral evoked potentials combined with continuous EMG and motor-evoked potentials of the spinal cord and muscles were evaluated and compared with postoperative clinical neurological changes. A total of 246 consecutive patients with cervical pathologies, majority spinal stenosis due to degenerative changes of cervical spine were monitored by means of MIOM during the surgical procedure. About 232 patients presented true negative while 2 patients false negative responses. About ten patients presented true positive responses where neurological deficit after the operation was predicted and two patients presented false positive findings. The sensitivity of MIOM applied during cervical spine procedure (anterior and/or posterior) was 83.3% and specificity of 99.2%. MIOM is an effective method of monitoring the spinal cord functional integrity during cervical spine surgery and can help to reduce the risk of neurological deficit by alerting the surgeon when monitoring changes are observed.

     

The diagnostic value of multimodal intraoperative monitoring (MIOM) during spine surgery: a prospective study of 1,017 patients

A prospective study of 1,017 patients who received MIOM during spine surgery procedures between March 2000 and December 2005. To determine the sensitivity and specificity of MIOM techniques used to monitor spinal cord and nerve roots function during spine surgery. MIOM has become a widely used method of monitoring neural function during spine surgery. Several techniques only monitor either ascending or descending pathways and thus may not provide sensitive or specific results. MIOM aims to monitor both ascending and descending pathways therefore giving immediate feedback information regarding any neurological deficits during the operation. Intraoperative sensory spinal and cortical evoked potentials, combined with monitoring of EMG and motor evoked potentials recorded from the spinal cord and muscles elicited by electrical motor cortex, spinal cord, cauda equina and nerve root stimulation, was evaluated and compared with post-operative clinical neurological changes. One thousand and seventeen consecutive patients underwent a total of 4,731 h of MIOM to evaluate any neural deficits that may have occurred during spine surgery. Of these, 935 were true negative cases, 8 were false negative cases, 66 were true positive cases and 8 were false positive cases, resulting in a sensitivity of 89% and a specificity of 99%. Based on the results of this study, MIOM is an effective method of monitoring the spinal cord functional integrity during spine surgery and therefore can lead to reduction of neurological deficit and consequently improve postoperative results.

     

Multimodal intraoperative monitoring during surgery of spinal deformities in 217 patients

A prospective study was performed on 217 patients who received MIOM during corrective surgery of spinal deformities between March 2000 and December 2005. Aim is to determine the sensitivity and specificity of MIOM techniques used to monitor spinal cord and nerve root function during corrective spine surgery. MIOM is becoming an increasingly used method of monitoring function during corrective spine surgery. The combination of monitoring of ascending and descending pathways may provide more sensitive and specific results giving immediate feedback information regarding any neurological deficits during the operation. Intraoperative somatosensory spinal and cerebral evoked potentials combined with continuous EMG and motor evoked potentials of the spinal cord and muscles were evaluated and compared with postoperative clinical neurological changes. A total of 217 consecutive patients with spinal deformities of different aetiologies were monitored by means of MIOM during the surgical procedure. Out of which 201 patients presented true negative findings while one patient presented false negative and three patients presented false positive findings. Twelve patients presented true positive findings where neurological deficit after the operation was predicted. All neurological deficits in those 12 patients recovered completely. The sensitivity of MIOM applied during surgery of spinal deformities has been calculated of 92.3% and the specificity 98.5%. Based upon the results of this study MIOM is an effective method of monitoring the spinal cord and nerve root function during corrective surgery of spinal deformities and consequently improves postoperative results. The Wake-up test for surgical procedure of spinal deformities became obsolete in our institution.