比目鱼肌Ｈ反射监测在全麻下经皮椎板间入路内窥镜下手术中的应用价值

Application value of intraoperative soleus H-reflex monitoring in assessment of endoscopic interlaminar approach under general anesthesia

中文关键词:  椎板间入路  H反射  经皮椎间孔镜  术中监测

英文关键词:Interlaminar approach  H-reflex  Percutaneous transforaminal endoscopic discectomy  Intraoperative monitoring

中文摘要:

  【摘要】 目的：观察全麻下经皮椎板间入路内窥镜下手术各操作步骤中使用H反射监测S1神经根功能的变化情况，明确该神经电生理参数在监测全麻下脊柱内窥镜手术中的应用价值。方法：14例单侧L5/S1椎间盘突出症（S1神经根损伤）患者被纳入本研究，男7例，女7例；年龄25~53岁；身高160~177cm。均行全麻下经皮椎板间入路内窥镜下单纯髓核摘除术。术前、术中各操作步骤（通道置入、神经根暴露、突出髓核摘除及内窥镜系统退出）及术后分别记录双侧下肢比目鱼肌H反射，测量并对比潜伏期及波幅（基线-负向波峰）等参数，并对结果进行统计学分析。结果：以术前完成全麻插管后、在手术体位所测得的H反射参数作为术中H反射的基线值。术中，患侧H反射波幅自神经根暴露（通道触碰或挤压神经根）阶段开始便出现明显下降（P<0.05），在剥离推移神经根时H反射波幅下降幅度最为明显[平均下降（43.9±20.5）%，P<0.05]，而后虽有回升，但较基线值仍存在统计学差异（P<0.05）；手术结束时，所有患者患侧H反射都得以保留，但波幅仍较基线值下降约（15.1±9.0）%（P<0.05）。术后第2日，所有患者VAS评分（Visual analogue scale）明显好转（术前 vs. 术后：6.4±1.3 vs. 0.6±0.6，P<0.05）；12例患者复测患侧H反射，各项参数相较于术前无明显差异（P>0.05）。2例患者术中出现H反射波幅下降超过85%的情况，在停止操作、放松牵拉神经根后数十秒，H反射都得以部分恢复，术后未出现明显的感觉或运动障碍。结论：比目鱼肌H反射波幅能有效反映经皮椎板间入路内窥镜手术各操作步骤中S1神经根的电生理传导功能，术中应用H反射监测技术可为全麻下脊柱内窥镜手术提供额外的、可靠的辅助监护手段。

英文摘要:

  【Abstract】 Objectives: To investigate the H-reflex in evaluating the change of the function of S1 nerve root in the different operation steps of endoscopic interlaminar approach for L5/S1 disc herniation under general anesthesia, and to identify the application value of H-reflex in intraoperative monitoring spinal endoscopic surgery under general anesthesia. Methods: Fourteen patients with unilateral L5/S1 disc herniation(S1 nerve root injury) were included in this study(male/female, 7/7; age, 25-53 years old; height 160-177cm), and all patients underwent percutaneous endoscopic interlaminar approach for L5/S1 disc herniation under general anesthesia. Bilateral soleus H-reflexs were recorded at pre-operation, intra-operation(channel placement, nerve root exposure, removal of nucleus pulposus and endoscope system exit) and post-operation. The latency and the baseline-to-negative amplitude of H-reflex were measured. The results were analyzed by SPSS 12.0. 　Results: The H-reflex recorded after anesthesia and placing the intraoperative position was defined as the baseline parameter. The amplitude of H-reflex on the involved side reduced significantly during the nerve root exposure(P<0.05), especially in the separation of adhesive nerve root[falling by an average of (43.9±20.5)%, P<0.05], and then the amplitude recovered, but still was statistically significant difference compared with the baseline value(P<0.05). At the end of surgery, the H-reflexes of all patients were preserved, but still lower than the baseline value which decreased by (15.1±9.0)%(P<0.05). At the second day after surgery, all patients had significantly improved VAS score(preoperative vs. postoperative: 6.4±1.3 vs. 0.6±0.6, P<0.05), and there was no difference of the amplitudes of H-reflex on the involved side in 12 patients between the pre-and post-operation(P>0.05). In this study, two patients had significant reduced H-reflex(more than 85%) during the operation, and the partial recoveries of the H-reflex in these patients were found after stopping the operation for several seconds. All these two patients had no obvious sensory or motor dysfunction after surgery. Conclusions: In this study, the amplitude of soleus H-reflex can reflect the function of S1 nerve root during the different operation steps of endoscopic interlaminar approach under general anesthesia effectively. Therefore, the clinical application of H-reflex monitoring technology can provide additional and reliable methods to protect the nerve root during the spinal endoscopy surgery under general anesthesia.