随着神经显微外科手术技术迅速发展,外科手术团队治疗理念不断进步,这对术中神经电生理监测技术提出了更高要求。神经电生理监测技术的价值不仅仅限于降低术后神经缺损风险,还可以促进手术方式的不断改进,帮助神经外科医师达到手术治疗的目的,改善手术治疗效果,缩短手术所需时间。术中神经电生理监测可以帮助外科团队及时发现异常,避免不可逆的损伤。神经电生理监测技术包括诱发电位、脑电图和肌电图。麻醉医师除了对神经电生理监测有所掌握外,必须熟知麻醉药物对神经电生理监测的影响,在术中避免应用对神经电生理监测影响大的药物。其次,麻醉深度,麻醉时间和体温等都对神经电生理监测有影响。
With the rapid development of neuromicrosurgical technique, the therapy of surgical team is pro-gressing, which puts forward to the higher requirements of neuroelectrophysiological monitoring. The value of neuroelectrophysiological monitoring is not only limited to reduce the risk of post-operative nerve deficits, but also can promote the continuous improvement of surgical methods, help doctors achieve the goal of surgical treatment, thereby improve operative therapeutic efficacy, and shorten the operation time. Intraoperative neuroelectrophysiological monitoring can help the surgical team find abnormalities and avoid non-reversible. Neuroelectrophysiological monitoring techniques include evoked potentials, EEG and EMG. Anesthesiologists should not only comprehend neuroelectrophysiological monitoring, but also achieve rational anesthetic use so as to avoid the influences on neuroelectrophysiological monitoring, then avoid of drugs. Besides, the depth and duration of anesthesia and body temperature can impact neuroelectrophysiological monitoring.
白江曼,高金贵. 神经外科手术中的电生理监测与麻醉 Electrophysiological Monitoring and Anesthesia in Neurosurgery[J]. 临床医学进展, 2018, 08(03): 301-311. https://doi.org/10.12677/ACM.2018.83051
参考文献References马思远, 乔慧, 贾桂军, 等. 经颅电刺激面神经运动诱发电位在小脑脑桥区肿瘤手术中的应用[J]. 中华神经外科杂志, 2014, 30(4): 356-359.Farqen, K.M. and Friedman, W.A. (2014) The Science of Medical Decision Making: Neurosurgery, Errors, and Personal Cognitive Strategies for Improving Quality of Care. World Neurosurgery, 82, e21-e29.
https://doi.org/10.1016/j.wneu.2014.03.030Strahm, C., Min, K., Boos, N., et al. (2003) Reliability of Peri-operative SSEPs Recordings in Spine Surgery. Spinal Cord, 41, 483-489. https://doi.org/10.1038/sj.sc.3101493韩如泉, 李淑琴. 神经外科麻醉分册[M]. 北京: 北京大学医学出版社, 2010.陈华永, 李丽, 张敬. 右美托咪定对患者镇静效应和血流动力学的影响[J]. 中华神经医学杂志, 2015, 14(5): 516-519.Nuwer, M.R. (2016) Measuring Outcomes for Neurophysiological Intraoperative Monitor-ing. Clinical Neurophysiology, 127, 3. https://doi.org/10.1016/j.clinph.2015.07.005Chang, S.H., Park, Y.G., Kim, D.H., et al. (2016) Monitoring of Motor and Somatosensory Evoked Potentials during Spine Surgery: Intraopera-tive Changes and Postoperative Outcomes. Annals of Rehabilitation Medicine, 40, 470-480.
https://doi.org/10.5535/arm.2016.40.3.470Scibilia, A., Terranova, C., Rizzo, V., et al. (2016) Intraoperative Neurophysiological Mapping and Monitoring in Spinal Tumor Surgery: Sirens or Indispensable Tool? Neurosurgical Focus, 41, E18.
https://doi.org/10.3171/2016.5.FOCUS16141许文强, 沈炳华, 倪淑芹, 等. 皮层体感诱发电位联合经颅电刺激运动诱发电位在颈胸椎管内占位手术中的应用[J]. 中华临床医师杂志(电子版), 2011, 5(8): 2384-2386.Nuwer, M.R., Emerson, R.G., Galloway, G., Legatt, A.D., Lopez, J., Minahan, R., Yamada, T., Goodin, D.S., Armon, C., Chaudhry, V., Gronseth, G.S. and Harden, C.L. (2012) Evidence-Based Guideline Update: Intraoperative Spinal Monitoring with Somatosensory and Transcranial Electrical Motor Evoked Potentials—Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Clinical Neurophysiology Society. Neurology: Official Journal of the American Academy of Neurology, 8, No. 8.Croft, T.J., Brodkey, J.S. and Nulsen, F.E. (1972) Reversible Spinal Cord Trauma: A Model for Electrical Monitoring of Spinal Cord Function. Journal of Neurosurgery, 36, 402-406. https://doi.org/10.3171/jns.1972.36.4.0402Tamaki, T. and Kubota, S. (2007) History of the Development of Intraoperative Spinal Cord Monitoring. European Spine Journal, 16, S140-S146. https://doi.org/10.1007/s00586-007-0416-9Deletis, V. and Sala, F. (2008) In Intraoperative Neurophysio-logical Monitoring of the Spinal Cord during Spinal Cord and Spine Surgery: A Review Focus on the Corticospinal Tracts. Clinical Neurophysiology, 119, 248-264.
https://doi.org/10.1016/j.clinph.2007.09.135Devlin, V.J., Anderson, P.A., Schwartz, D.M., et al. (2006) In-traoperative Neurophysiologic Monitoring: Focus on Cervical Myelopathy and Related Issues. Spine J, 6, 212S-224S. https://doi.org/10.1016/j.spinee.2006.04.022Huang, S.L., Qi, H.G., Liu, J.J., et al. (2016) Alarm Value of Somatosensory Evoked Potential in Idiopathic Seoliosis Surgery J1. World Neurosurgery, 92, 397-401. https://doi.org/10.1016/j.wneu.2016.05.054刘海雁, 朱泽章, 史本龙, 等. 体感诱发电位联合运动诱发电位在Chiari畸形伴脊椎侧凸后路矫形手术中的应用价值[J]. 中国脊柱脊髓杂志, 2016, 26(4): 299-303.Ginsburg, H.H., Shetter, A.G. and Raudzens, P.A. (1985) Postoperative Paraplegia with Preserved In-troperative Somatoensory Evoked Potentials: Case Report. Journal of Neurosurgery, 63, 296-300.
https://doi.org/10.3171/jns.1985.63.2.0296Hilibrand, A.S., Schwartz, D.M., Sethuraman, V., et al. (2004) Comparison of Trans-Cranial Electric Motor and Somatosensory Evoked Potential Monitoring during Cervical Spine Surgery. The Journal of Bone and Joint Surgery. American Volume, 86, 1248-1253. https://doi.org/10.2106/00004623-200406000-00018Epstein, N.E., Danto, J. and Nardi, D. (1993) Evalua-tion of Intraoperative Somatosensor-Yevoked Potential Monitoring during 100 Cervical Operations. Spine, 18, 737-747. https://doi.org/10.1097/00007632-199305000-00011史琤莉, 周倩, 张明铭, 等. 术中经颅电刺激运动诱发电位监测评估颅内动脉瘤术后运动功能[J]. 中南大学学报(医学版), 2012, 37(3): 244-249.Sala, F., et al. (2006) Motor Evoked Potential Monitoring Improves Outcome after Surgery for Intramedullary Spinal Cord Tumors: A Historical Control Study. Neurosurgery, 58, 1129-1143.Koht, A. and Sloan, T.B. (2016) Intraoperative Moni-toring: Recent Advances in Motor Evoked Potentials. Anesthesiology Clinics, 34, 525-535. https://doi.org/10.1016/j.anclin.2016.04.006MacDonald, D.B., Al Zayed, Z., Khoudeir, I., et al. (2003) Monitoring Scollosis Surgery with Combined Multiple Pulse Transonmial Electric Motor and Cortical Sornatesenso-ry-Evoked Potentials from the Lower and Upper Extremities. Spine, 28, 194-203. https://doi.org/10.1097/00007632-200301150-00018Costa, P., Bruno, A., Bomanino, M., et al. (2007) So-matosensory and Motor Evoked Potential Monitoring during Spine and Spinal Cord Surgery. Spinal Cord, 45, 86-91. https://doi.org/10.1038/sj.sc.3101934Jameson Leslie, C., Sloan, T.B., et al. (2012) Neurophysiologic Mon-itoring in Neurosurgery. Anesthesiology Clinics, 30, 311-331. https://doi.org/10.1016/j.anclin.2012.05.005Shine, T.S., Harrison, B.A., De Ruyter, M.L., et al. (2008) Motor and Somatosensory Evoked Potentials: Their Role in Predicting Spinal Cord Ischemia in Patients Undergoing Thoracoabdominal Aortic Aneurysmrepair with Regional Lumbar Epidural Cooling. Anesthesiology, 108, 580-587. https://doi.org/10.1097/ALN.0b013e318168d921Tamkus, A.A., Rice, K.S. and Kim, H.L. (2014) Differen-tial Rates of False-Positive Findings in Transcranial Electric Motor Evoked Potential Monitoring When Using Inhala-tional Anesthesia versus Total Intravenous Anesthesia during Spine Surgeries. The Spine Journal, 14, 1440-1446. https://doi.org/10.1016/j.spinee.2013.08.037Shida, Y., Shida, C., Hiratsuka, N., et al. (2012) High-Frequency Stimulation Restored Motor-Evoked Potentials to the Baseline Level in the Upper Extremities But Not in the Lower Extremities under Sevoflurane Anesthesia in Spine-Surgery. Journal of Neurosurgical Anesthesiology, 24, 113-120.
https://doi.org/10.1097/ANA.0b013e318237fa41Neuloh, G. and Schramm, J. (2004) Monitoring of Motor Evoked Potentials Compared with Somatosensory Evoked Potentials and Microvascular Doppler Ultrasonography in Cerebral Aneurysm Surgery. Journal of Neurosurgery, 100, 389-399. https://doi.org/10.3171/jns.2004.100.3.0389陶晓蓉, 乔慧, 王硕, 等. 颅内前循环动脉瘤术中诱发电位监测效果评估[J]. 中华神经外科杂志, 2010, 26: 1059-1062.Macdonald, D.B. and Janusz, M. (2002) An Ap-proach to Intraoperative Neurophysiologic Monitoring of Thoracoabdominal Aneurysm Surgery. Journal of Clinical Neurophysiology, 19, 43-54.
https://doi.org/10.1097/00004691-200201000-00006谭志彬, 陈谦学, 等. 神经电生理监测在颅内动脉瘤夹闭术中的应用研究[J]. 临床和实验医学杂志, 2016, 14(15): 1408-1411.Hammett, T.C., Boreham, B., Quraishi, N.A., et al. (2013) Intraoperative Spinal Cord Monitoring during the Surgical Correction of Scoliosis Due to Cerebral Palsy and Other Neuromuscular Disorders. European Spine Journal, 22, S38-S41. https://doi.org/10.1007/s00586-012-2652-xLiu, H.Y., Zhu, Z.Z., Shi, B.L., et al. (2016) Use of Soma-tosensory Evoked Potentials and Transcranial Electric Motor Evoked Potentials in Surgical Correction of Scoliosis Secondary to Chiari Malformation. Chinese Journal Spinal Cord, 26, 299-303.Thirumala, P.D., Huang, J., Thia-garajan, K., et al. (2016) Diagnostic Accuracy of Combined Multimodality Somatosensory Evoked Potential and Transcranial Motor Evoked Potential Intraoperative Monitoring in Patients with Idiopathic Scoliosis. Spine, 41, E1177-E1184. https://doi.org/10.1097/BRS.0000000000001678Eager, M., Shimer, A., Jahangiri, F.R., et al. (2011) Intraoperative Neurophysiological Monitoring IONM, Lessons Learned from 32 Case Events in 2069 Spine Cases. American Journal of Electroneurodiagnostic Technology, 51, 247-263.Malhotra, N.R. and Shaffrey, C.I. (2010) Intraoperative Electrophysiological Monitoring in Spine Surgery. Spine, 35, 2167-2179. https://doi.org/10.1097/BRS.0b013e3181f6f0d0Hagihira, S. (2015) Changes in the Electroencephalogram during Anaesthesia and Their Physiological Basis. British Journal of Anaesthesia, 115, i27-i31. https://doi.org/10.1093/bja/aev212临床指南. Depth of Anaesthesia Monitors-Bispectral Index (BIS). 2016.Schetinin, V. and Jakaite, L. (2017) Extraction of Features from Sleep EEG for Bayesian Assessment of Brain Development. PLoS ONE, 12, eo174027. https://doi.org/10.1371/journal.pone.0174027Askhonov, U., Gafurov, B. and Ashanov, G. (2016) EEG Features of Dyskinesias, Complicated by Levodopa Therapy in Patients with Parkinson’s Disease. Parkinsonism and Related Disorders, 1, e143.
https://doi.org/10.1016/j.parkreldis.2015.10.600Abdul Awal, M., Lai, M.M., et al. (2016) EEG Background Features That Predict Outcome in Term Neonates with Hypoxic Ischaemic Encephalopathy: A Structured Review. Clinical Neurophysiology, 127, 285-296.
https://doi.org/10.1016/j.clinph.2015.05.018Alfei, E., Raviglione, F., Franceschetti, S., et al. (2014) Seizures and EEG Features in 74 Patients with Genetic-Dysmorphic Syndromes. American Journal of Medical Genetics Part A, 164, 3154-3161.
https://doi.org/10.1002/ajmg.a.36746Banoub, M., Tetzlaff, J.E. and Schubert, A. (2003) Pharmacologic and Physiologic Influences Affecting Sensory Evoked Potentials: Implications for Perioperative Monitoring. Anesthesiology, 99, 716-737.
https://doi.org/10.1097/00000542-200309000-00029Tolekis, J.R. (2005) Introperative Monitoring Using Somatosensory Evoked Potentials: A Position Statement by the American Society of Neurophysiological Monitoring. Journal of Clinical Monitoring and Computing, 19, 241-258.
https://doi.org/10.1007/s10877-005-4397-0Mpimbaza, A., Ndeezi, G., Staedke, S., et al. (2008) Comparison of Buccal with Rectal Diazepam in the Treatment of Prolonged Seizures in Ugandan Children: A Randomized Clinical Trial. Pediatrics, 121, e58-e64.
https://doi.org/10.1542/peds.2007-0930Riviello, J.J., Claassen, J., LaRoche, S.M., et al. (2013) Treatment of Status Epilepticus: An International Survey of Experts. Neurocritical Care, 18, 193-200. https://doi.org/10.1007/s12028-012-9790-1Momen, A.A., Azizi Malamiri, R., Nikkhah, A., et al. (2015) Efficacy and Satety of Intramuscular Midazolam versus Rectal Diazepam in Controlling Status Epilepticus in Children. European Journal of Paediatric Neurology, 19, 149-154. https://doi.org/10.1016/j.ejpn.2014.11.007Horst, H.J. and Brouwer, O.F. (2004) Burst Suppression on Amplitude-Integrated Electroencephalogram May Be Induced by Midazolam: A Report on Three Cases. Acta Paediatrica, 93, 559-563.See, J.J., Lew, T.W., Kwek, T.K., et al. (2007) Anaesthetic Management of Awake Craniotomy for Tumour Resection. Annals of the Academy of Medicine, Singapore, 36, 319-325.程灏, 王德祥, 韩如泉. 脑功能区胶质瘤手术唤醒麻醉中持续或间断输注舒芬太尼的影响[J]. 中国康复理论与实践, 2009, 15(7): 679-680.Gram, M., Erlenwein, J., Petzke, F., et al. (2017) Pre-diction of Postoperative Opioid Analgesia Using Clinical-Experimental Parameters and Electroencephalography. Eu-ropean Journal of Pain, 21, 264-277.
https://doi.org/10.1002/ejp.921Fradorf, J., Huhn, R., Weber, N.C., et al. (2010) Sevoflurane-Induced Pre-conditioning: Impact of Protocol and Aprotinin Administration on Infarct Size and Endothelial Nitricoxide Synthase Phosphoryation in the Rat Heart in Vivo. Anesthesiology, 113, 1289-1298. https://doi.org/10.1097/ALN.0b013e3181f97fecSymons, J.A. and Myles, P.S. (2006) Myocardial Protection with Volatile Anaesthetic Agents during Coronary Artery Bypass Surgery, a Meta-Analysis. British Journal of Anaesthesia, 97, 127-136. https://doi.org/10.1093/bja/ael149Duffy, C.M. and Matta, B.F. (2000) Sevoflu-rance and Anesthesia for Neurosurgery: A Review. Journal of Neurosurgical Anesthesiology, 12, 128-140. https://doi.org/10.1097/00008506-200004000-00012夏莉, 杨鹏举, 马祥云, 等. 全凭静脉麻醉与静–吸复合麻醉下对脑干肿瘤手术中神经电生理监测的影响[J]. 中国实用神经疾病杂志, 2016, 19(18): 33-35.朱娟, 朱明慧, 何帆. 全凭静脉麻醉与静–吸复合麻醉下腰椎手术中神经电生理监测的比较[J]. 临床麻醉学杂志, 2014, 30(12): 1149-1151.Sloan, T.B. (2002) Anesthetics and the Brain. Anesthesiology Clinics of North America, 20, 265-292.
https://doi.org/10.1016/S0889-8537(01)00002-5Liu, E.H., Wong, H.K., Chia, C.P., et al. (2005) Effects of Isoflurane and Propofol on Cortical Somatosensory Evoked Potentials during Comparable Depth of Anaesthesia as Guided by Bispectral Index. British Journal of Anaesthesia, 94, 193-197. https://doi.org/10.1093/bja/aei003Fung, N.Y., Hu, Y., Irwin, M.G., et al. (2008) Comparison between Sevoflurane/Remifentanil and Propofol/Remifentanil Anaesthesia in Providing Conditions for Somatosensory Evoked Potential Monitoring during Scoliosis Corrective Surgery. Anaesthesia and Intensive Care, 36, 779-785.Lo, Y.L., Dan, Y.F., Tan, Y.E., et al. (2006) Intraoperative Motor-Evoked Potential Monitoring in Scoliosis Surgery: Comparison of Desflurane/Nitrous Oxide with Propofol Total Intravenous Anesthetic Regimens. Journal of Neurosurgical Anesthesiology, 18, 211-214. https://doi.org/10.1097/01.ana.0000211007.94269.50Kawaguchi, M., Sakamoto, T., Inoue, S., et al. (2000) Low Dose Propofol as a Supplement to Ketamine-Based Anesthesia during Intraoperative Monitoring of Motor-Evoked Potentials. Spine, 25, 974-979.
https://doi.org/10.1097/00007632-200004150-00013Malcharek, M.J., Loeffler, S., Schiefer, D., et al. (2015) Transcranial Motor Evoked Potentials during Anesthesia with Desflurane versus Propofol—A Prospective Randomized Trial. Clinical Neurophysiology, 126, 1825-1832.
https://doi.org/10.1016/j.clinph.2014.11.025Belso, N., Kui, R., Szegesdi, I., et al. (2011) Propofol and Fentanyl Induced Perioperative Anaphylaxis. British Journal of Anaesthesia, 106, 283-284. https://doi.org/10.1093/bja/aeq384Ubags, L.H., Kalkman, C.J., Been, H.D., et al. (1997) The Use of Ketamine or Etomidate to Supplement Sufentanil/N2O Anesthesia Does Not Disrupt Monitoring of Myogenic Transcranial Motor Evoked Responses. Journal of Neurosurgical Anesthesiology, 9, 228-233. https://doi.org/10.1097/00008506-199707000-00005IAu, H.Y., Zeng, H.Y., Cheng, H., et al. (2012) Comparison of the Effects of Etomidate and Propofol Combined with Remifentanil and Guided by Comparable BIS on Transcranial Electrical Motor-Evoked Potentials during Spinal Surgery. Journal of Neurosurgical Anesthesiology, 24, 133-138. https://doi.org/10.1097/ANA.0b013e31823dfb2eVan Dongen, E.P., Ter Beek, H.T., Schepens, M.A., et al. (1999) Within Patient Variability of Myogenic Motorevoked Potentials to Multipulse Transcranial Electrical Stimulation during Two Levels of Partial Neuromuscular Blockade in Aortic Surgery. Anesthesia & Analgesia, 88, 22-27.Sloan, T.B. (2013) Muscle Relaxant Use during Intraoperative Neurophysiologic Monitoring. Journal of Clinical Monitoring and Computing, 27, 35-46. https://doi.org/10.1007/s10877-012-9399-0Cai, Y.R., Xu, J., Chen, L.H., et al. (2009) Electromyographic Monitoring of Facial Nerve under Different Levels of Neuromuscular Blockade during Middle Ear Microsurgery. Chinese Medical Journal, 122, 311-314.徐成明, 李玉兰, 刘映龙, 等. 无肌松药全身麻醉下进行脊柱手术的临床研究[J]. 临床麻醉学杂志, 2012, 28(7): 646-648.Maurtua, M.A., Deogaokar, A., Bakri, M.H., et al. (2008) Dosing of Remifentanil to Prevent Movement during Craniotomy in the Absence of Neuromuscular Blockade. Journal of Neurosurgical Anesthesiology, 20, 221-225.
https://doi.org/10.1097/ANA.0b013e3181806c4aCarollo, D.S., Nossaman, B.D. and Ramadhyani, U. (2008) Dexmedetomidine: A Clinical Applications. Current Opinion in Anesthesiology, 21, 457-461. https://doi.org/10.1097/ACO.0b013e328305e3efLi, Y., Meng, L., Qiao, H., et al. (2016) Effects of Dexmedetomidine on Motor- and Somatosensory-Evoked Potentials in Patients with Thoracic Spinal Cord Tumor: A Randomized Controlled Trial. BMC Anesthesiology, 16, 51.
https://doi.org/10.1186/s12871-016-0217-yBala, E., Sessler, D.I., Nair, D.R., et al. (2008) Motor and Somatosensory Evoked Potentials Are Well Maintained in Patients Given Dexmedetomidine during Spine Surgery. Anesthesiology, 109, 417-425.
https://doi.org/10.1097/ALN.0b013e318182a467Chen, Z., Lin, S. and Shao, W. (2015) Effects on Somatosensory and Motor Evoked Potentials of Senile Patients Using Different Doses of Dexmedetomidine during Spine Surgery. Irish Journal of Medical Science, 184, 813-818.He, L., Xu, J.M. and Dai, R.P. (2012) Dexmedetomidine Reduces the Incidence of Fentanyl-Induced Cough: A Double-Bind, Randomized, and Placebo-Controlled Study. Upsala Journal of Medical Sciences, 117, 18-21.
https://doi.org/10.3109/03009734.2011.629749张蕴辉, 高金贵, 张山. 右美托咪定对颅脑损伤患者全麻下开颅术时的脑保护作用[J]. 中华麻醉学杂志, 2015, 35(1): 30-32.Wang, A.C., Than, K.D., Etame, A.B., et al. (2009) Impact of Anesthesia on Transcranial Electric Motor Evoked Potential Monitoring during Spine Surgery: A Review of the Literature. Neurosurgical Focus, 27, E7.
https://doi.org/10.3171/2009.8.FOCUS09145