术中经颅电刺激运动诱发电位和皮层体感诱发电位联合监护与唤醒试验判断脊髓功能

目的 探讨术中经颅电刺激运动诱发电位(TES-MEP)和皮层体感诱发电位(CSEP)联合监护与唤醒试验判断脊髓功能的作用.方法 2006年7月至2010年3月中山大学附属第一医院脊柱外科脊柱手术中同时实施TES-MEP和CSEP联合监护426例,并对术中出现阳性和仔细检查后原因不明或纠正手术操作后仍没有恢复的23例进行唤醒试验.根据术中联合监护和唤醒试验结果,分别与术后脊髓功能进行比较.结果 联合监护阳性64例(15%),其中51例与脊髓功能符合,另13例不符合.假阳性占3.1%(13/426).本组无假阴性.联合监护判断脊髓功能灵敏度为100%(51151),特异度96.5%(362/375),约登指数0.965.23例唤醒试验中,8例阳性均与脊髓功能符合,没有假阳性.而15例阴性中,与脊髓功能符合9例,不符合6例.唤醒试验判断脊髓功能的灵敏度为57.1%(8/14)、特异度100%(9/9)、约登指数0.571.结论 TES.MEP和CSEP联合监护为目前脊柱外科手术监护的理想选择和首选方法,唤醒试验可用于联合监护真假阳性鉴别的检测.     

术中经颅电刺激运动诱发电位和皮层体感诱发电位联合监护与唤醒试验判断脊髓功能

目的 探讨术中经颅电刺激运动诱发电位(TES-MEP)和皮层体感诱发电位(CSEP)联合监护与唤醒试验判断脊髓功能的作用.方法 2006年7月至2010年3月中山大学附属第一医院脊柱外科脊柱手术中同时实施TES-MEP和CSEP联合监护426例,并对术中出现阳性和仔细检查后原因不明或纠正手术操作后仍没有恢复的23例进行唤醒试验.根据术中联合监护和唤醒试验结果,分别与术后脊髓功能进行比较.结果 联合监护阳性64例(15%),其中51例与脊髓功能符合,另13例不符合.假阳性占3.1%(13/426).本组无假阴性.联合监护判断脊髓功能灵敏度为100%(51151),特异度96.5%(362/375),约登指数0.965.23例唤醒试验中,8例阳性均与脊髓功能符合,没有假阳性.而15例阴性中,与脊髓功能符合9例,不符合6例.唤醒试验判断脊髓功能的灵敏度为57.1%(8/14)、特异度100%(9/9)、约登指数0.571.结论 TES.MEP和CSEP联合监护为目前脊柱外科手术监护的理想选择和首选方法,唤醒试验可用于联合监护真假阳性鉴别的检测.     

多模式神经电生理监测在椎管内占位手术中的应用

目的　探讨体感诱发电位(CSEP)、经颅电刺激运动诱发电位(TES-MEP)与自由及激发肌电图（EMG）多模式联合监测技术在脊柱椎管内占位手术中应用的价值。 方法　对47例脊柱椎管内占位患者(颈椎4例,胸椎14例,胸腰段13例,腰椎13例,骶椎3例)行占位病变切除术中采用CSEP+TES-MEP+自由EMG+激发EMG监护。 结果　①CSEP和 TES-MEP：监测成功率各为100%和93.6%;阳性率分别为19.1%和17.0%;联合监测假阴性率及假阳性率均为0%;10例诱发电位阳性均与手术操作有关,8例及时报警采取措施后渐恢复,2例MEP阳性未能恢复,术后肌力下降;6例CSEP改善,术后症状好转。②自由和激发EMG：34例患者术中出现自由EMG,其中1例马尾神经严密包裹病变的患者,术后小便功能异常,术后渐恢复。 结论　①椎管内占位术中联合运用CSEP和TES-MEP监测,排除各种干扰因素后,能准确地反映术中脊髓功能状况;②术中自由及激发EMG监测可准确探查和鉴别占位病变神经组织分布,实时反映神经受激惹情况,预防医源性神经损伤。     

脊柱外科手术中脊髓功能的监护

脊柱外科手术中,由于加压、推移力、内固定器械置入等外加因素造成对神经的压迫,可能导致脊髓功能的损伤.脊髓监护可以及时发现手术中的不当操作和可能出现的损伤并及早进行纠正和补救,因而有效地降低脊柱外科手术中脊髓功能的损伤.术中脊髓监护技术经过几十年的发展,由传统的唤醒方法发展到今天比较完善的诱发电位监护技术.回顾了脊髓监护技术的发展及其在脊柱外科手术中的应用,并介绍了近年来脊髓监护领域研究的新进展.     

外伤性颈椎间盘突出伴脊髓损伤的围手术期治疗(附18例报告)

目的:探讨外伤性颈椎间盘突出伴脊髓损伤的围手术期治疗方法.方法:手术治疗外伤性颈椎间盘突出伴脊髓损伤患者18例,围术期根据病情分别给予激素冲击、脱水剂、神经营养及高压氧舱治疗等综合处理.结果:术后平均随访11.8个月.13例患者术后症状消失,其余5例患者症状明显改善.神经功能按Frankel 分级:B级转为C级1例; B级转为D级2例;C级转为D级2例;C级转为E级1例;D级转为E级12例.未出现脊髓损伤感染及内固定物松动等并发症.结论:对外伤性颈椎间盘突出伴脊髓损伤的患者,采用颈前路减压内固定手术治疗,辅以激素冲击治疗,以及神经营养药、高压氧舱治疗和功能锻炼,可取得较好疗效.     

前路减压植骨内固定治疗胸腰椎骨折

目的:探讨胸腰椎骨折的前路减压植骨内固定的临床疗效.方法:采用前路减压自体髂骨植骨内固定术治疗胸腰椎骨折14例,其中10例合并不全瘫.结果:术后随访3个月～2 a,平均1 a,14例病人脊柱畸形矫正满意,生理曲度恢复,植骨均达到骨性融合.10例术前有脊髓功能损伤患者术后有1～3级的神经功能恢复,无内固定松动、断钉、断板等发生.结论:前路手术安全可靠,椎管减压彻底,可重建脊柱的稳定性,恢复脊柱的生理曲度.     

多模式神经电生理在脊柱手术中的监护应用

脊柱术手术中有很多因素会导致脊柱手术对神经的损伤,甚至是脊髓的损伤.多模式的术中神经电生理监护就是尽可能的减少脊柱手术的风险,和传统的方法比较,更易为患者和手术医生接受,能使手术的损伤显著的降低.本文对目前国内外的发展和应用做综述如下.     

锁定板前路置入治疗颈胸段脊柱骨折脱位

背景：前路治疗颈胸段脊柱骨折脱位有关中长期临床效果及钢板置入后脊髓神经功能的报道很少。 目的：观察锁定板前路置入治疗颈胸段脊柱骨折脱位的可行性及疗效。 方法：回顾性分析2007-01/2011-01湘雅医院一附院脊柱外科收治的颈胸段脊柱骨折脱位患者12例,均采用前路减压、植骨、锁定板置入内固定治疗。 结果与结论：全部患者获随访一两年,均获得骨性融合,融合时间为4~8个月,无螺钉松动、脱落及锁定板断裂等并发症发生。锁定钢板置入前Frankel A级2例,置入后2例脊髓损伤无恢复;置入前B级4例,置入后恢复至C级2例,D级2例;置入前C级3例,置入后恢复至D级1例,E级2例;置入前D级3例,恢复至E级。1例置入后出现暂时性声音嘶哑,置入后3~6个月恢复。提示颈胸段前路减压、植骨、锁定钢板置入内固定对颈胸段脊柱脊髓损伤具有较好的疗效,锁定钢板有助于植骨节段融合、重建和稳定颈胸段脊柱。     

多模式神经电生理监测在脊柱手术中报警因素分析

目的:分析多模式神经电生理监测在脊柱手术中的各种报警因素,减少假阳性报警。方法:对243例不同类型脊柱手术病例进行体感诱发电位(Somatosensory Evoked Potentials,SSEPs)、运动诱发电位(Motor Evoked Potentials,MEPs)、自由肌电图(free-run,EMG)、四联刺激肌肉收缩试验(Train of four Twitch test,TOF)等多模式神经电生理监测,实时记录各种报警事件、血压、出血量、体温、麻醉药物及术后的感觉运动功能。结果:243例病例术中SSEPs预警率46.9%(114/243),MEPs预警率28.0%(68/243),EMG预警率72.8%(177/243)。经分析排除假阳性后总的真实报警率68.7%(167/243),其中SSEPs报警率23.9%(58/243),MEPs报警率12.8%(31/243),EMG报警率32%(78/243)。所有术后均无严重的神经系统并发症。结论:在脊柱手术中常发生各种报警事件,其中大部分是由于外界各种干扰因素造成的"假阳性"事件,若不加以分析判断均予以报警会严重干扰手术进程。因此神经电生理监测医生要仔细分析各种因素排除干扰,以提高脊髓功能监测结果的准确性。     

应用连续小波变换提取脊柱手术中脊髓功能特征参数的研究

在脊柱外科手术中,为防止脊髓神经功能损伤进行术中脊髓功能监护十分必要。本研究以特发性脊柱侧弯矫形手术中脊髓功能的电生理监护特征参数提取技术为目标,试图解决监护参数在时域参数变异性较大、容易受干扰的问题。运用连续小波变换方法对手术中采集的体感诱发电位分析处理,提取信号在时频域的三个新的特征参数。通过本研究表明,在脊柱手术监护中,运用连续小波变换获得的时频域特征参数比单纯在时域分析参数具有更小的变异系数。因此时频域特征分析参数比单纯时域的幅值和潜伏期分析更稳定和可靠。在脊柱手术中如果应用时频监护参数可能会更有效地避免脊髓损伤。     

Intraoperative monitoring of spinal cord function in spinal and spinal cord surgery

It has become essential to monitor spinal cord function during operations which may involve the risk of stretching, compressing, or injuring the spinal cord, or compromise its blood supply. The recordings of sensory and motor functions include the spinal cord-evoked potential (SCEP), motor-evoked potential (MEP), and somatosensory-evoked potential (SEP). Each of these recordings is not sufficient as a single modality to evaluate the integrity of spinal cord function, so they are used in combination. In particular, to prevent and detect early motor disturbance, the MEP is widely used, which has the advantages of the lowest invasiveness and greatest case of setting. Although spinal cord monitoring is conducted by surgeons, anesthetists, and medical technologists, it should preferably be performed by those routinely engaged in neurophysiological examinations including intraoperative monitoring. Its success depends largely on good coordination and mutual trust between surgeons, anesthesiologists, operative nurses, and clinical engineers, as well as the development of individual expertise.     

椎管内肿瘤手术方式的研究

椎管内肿瘤是中枢神经系统的罕见肿瘤,放化疗以及针对基因改变和分子生物学的靶向治疗在治疗椎管内肿瘤的应用与研究不够完善,手术切除仍是临床上最有效的方法。但由于脊髓及其发出的神经与肿瘤解剖关系紧密,并且都在空间相对狭小的椎管内,手术切除易造成一定的神经功能缺陷,同时,追求完全切除肿瘤并保持脊柱的稳定性具有挑战性。随着临床实践和手术技术的进步,手术器械的不断更新,以及神经生理学监测技术的术中应用的加强,椎管内肿瘤的手术治疗得到了迅速发展。本文综述了近年来相关文献中椎管内肿瘤的外科治疗方法,为临床手术治疗的选择提供参考。     

Neurophysiological characteristics of spinal arteriovenous malformations

The aim of the study was to identify the clinical and neurophysiological pattern of deficits in spinal arteriovenous malformations (AVM) to allow an early diagnosis which is the prerequisite for effective treatment by early surgery or embolization. Among 26 patients with myelographic signs of a spinal AVM, selective spinal angiography disclosed 20 cases with a dural AV-fistula (dAVF) and 6 patients with an intradural AV-malformation (iAVM). Although the main pathogenetic factor in both disorders may be different, clinical and neurophysiological findings proved to be of limited value in differential diagnosis. Clinical symptoms presented by the patients were a variable combination of lower motor neuron lesion, sphincter disturbance, sensory transverse lesion and partly additional signs of upper motor neuron involvement. Electromyography invariably showed an increased rate of polyphasia and frequently pathological spontaneous activity usually in several myotomes. Normal sensory conduction velocity of the sural nerve contrasted with almost regularly pathological SEP's after tibial nerve stimulation. The distribution if clinical and neurophysiological findings suggests rather widespread lesions of the lower cord and/or cauda equina, frequently at a lower level than the angiographically localized shunt. This suggests a vascular myelopathy on the basis of insufficient venous drainage at least for the frequent dural AV-anomaly.     

Effects of repeated administration of low doses of cisplatin on the rat nervous system

Cisplatin is a very effective antineoplastic drug. To date its major toxic dose-limiting effect is peripheral neuropathy. Whereas the clinical and neurophysiological features of cisplatin-induced neuropathy are fairly well known, its pathogenesis is still unclear. We treated a group of Wistar rats with low doses of cisplatin for 70 days in order to evaluate the light-microscopic and ultrastructural changes induced by chronic cisplatin administration in the spinal cord, spinal ganglia and peripheral nerves. Although the most striking pathological alterations were observed in the spinal ganglia neurons, initial axonal neuropathy was also demonstrated, whereas the spinal cord neurons were completely normal. Our findings further support the hypotheses that spinal ganglion neurons are the primary target of cisplatin peripheral neurotoxicity and that peripheral nerve damage is secondary to this neuronopathy.     

Changes in nociceptive flexion reflex threshold across the menstrual cycle in healthy women

OBJECTIVE: We assessed the influence of changes in steroid hormones across the menstrual cycle on the spinal nociceptive reflex. METHOD: We studied in 14 healthy women during the follicular and luteal phase the nociceptive flexion reflex (RIII reflex), an objective neurophysiological method that allows exploring possible abnormal functioning of the pain-control system. The basal body temperature (BBT) was used to evaluate the different phases of the ovarian cycle. The menstrual distress questionnaire (MDQ) was also applied for monitoring somatic and psychological symptoms during the cycle. RESULTS: During the luteal phase, the threshold of the RIII reflex (Tr) and the psychophysical threshold for pain (Tp) were both significantly reduced compared with the follicular phase. Moreover, the reflex threshold in the luteal phase was negatively correlated to the total MDQ score of the recording day. CONCLUSIONS: A higher sensitivity to pain stimuli was observed during the luteal phase of the menstrual cycle, which probably results from a reduction in the inhibitory descending control on spinal nociceptive flexion reflex. Complex neuromodulatory interactions of ovarian steroids with other systems of neurotransmission (especially serotonergic) may account for these observations.     

Learning from the spinal cord

The graceful control of multiarticulated limbs equipped with slow, non-linear actuators (muscles) is a difficult problem for which robotic engineering affords no general solution. The vertebrate spinal cord provides an existence proof that such control is, indeed, possible. The biological solution is complex and incompletely known, despite a century of meticulous neurophysiological research, celebrated in part by this symposium. This is frustrating for those who would reanimate paralysed limbs either through promoting regeneration of the injured spinal cord or by functional electrical stimulation. The importance of and general role played by the spinal cord might be more easily recognized by analogy to marionette puppets, another system in which a brain (the puppeteer's) must cope with a large number of partially redundant actuators (strings) moving a mechanical linkage with complex intrinsic properties.     

Locomotor recovery after thoracic spinal cord lesions in cats, rats and humans

More than a hundred years of extensive studies have led to the development of clinically valid animal models of spinal cord injury (SCI) used to investigate neurophysiological mechanisms, pathology and potential therapies. The cat and rat models of SCI were found particularly useful due to several behavioral responses that correspond to clinical symptoms seen in patients. This review concentrates on recovery of motor behavior in the rat and cat models of thoracic spinal cord injury. At the beginning an outline of the general concept of neural control of locomotion: the existence of a spinal network producing the locomotor activity and the supraspinal and sensory inputs that influence this network is presented. Next, the severity of functional impairment in relation to the extent and precise location of lesions at the thoracic level in cats and rats is described. Finally, the impact of animal studies on the treatment of SCI patients and the possibility that a spinal network producing the locomotor activity also exists in humans is discussed.     

The Role of Spinal Manipulation in Modifying Central Sensitization

Central sensitization (CS) is characterized by adaptations to the central nervous system resulting in decreased sensory thresholds and widespread hypersensitivity. CS is often difficult to manage, with current treatment strategies primarily consisting of medication, pain science education, cognitive behavioral therapy, and graded exercise intervention. Spinal manipulation represents a potential alternative treatment for CS because of its centrally acting neurophysiological mechanisms. However, experimental trials utilizing spinal manipulation in persons with CS often lack the controls or methodology required to determine the technique's effect on meaningful clinical outcomes. This paper summarizes the mechanistic and experimental evidence on spinal manipulation for centrally mediated pain and hypersensitivity, and offers recommendations for future study considerations in this topic area.     

Universal stereotaxic apparatus DB-2-59 (second model)

Summary The authors describe a new model of a universal stereotaxic instrument, intended for the neurophysiological and neuromorphological investigations in the area of the brain and spinal cord of cats, rabbits, and small monkeys. The instrument is supplied with two micromanipulators operating in the system of rectangular and equatorial coordinates. The stand of the device is capable of being turned around 360°, together with the fixated animal and inserted electrodes. The head-holder may be tilted. The instrument is provided with an automatic heating device and an adjustment for the fixation of the spinal column.(Presented by Active Member AMN SSSR V. V. Parin) Translated from Byulleten' Éksperimental'noi Biologii i Meditsiny, Vol. 51, No. 5, pp. 113–115.