侧方扩散反应监测在面肌痉挛微血管减压术中的作用

Effect of intraoperative electrophysiological monitoring of later spread response to microvascular decompression for hemifacialspasm

目的分析侧方扩散反应监测在面肌痉挛微血管减压术中的作用。方法结合遵义医学院附属医院2016年1月～2017年8月采用侧方扩散反应(Later spread response,LSR)监测下行显微血管减压术治疗的38例原发性面肌痉挛患者资料,术前均行面神经诱发电位、3D-TOF-MRA、3D-FIESTA序列检查明确诊断、同时排除颅内占位等继发性因素,LSR监测下由同一术者行显微血管减压术,结合术中LSR波形变化情况明确责任血管、有效评估减压效果。术后随访6个月,观察并评估术后恢复情况。结果 37例手术开始前记录到LSR波形,其中Teflon棉垫离面神经的压迫血管后消失26例; 4例垫入Teflon棉后LSR波形复现,重新探查、调整棉片位置后波形消失; 3例剪开硬脑膜、释放脑脊液后消失; 1例患者探及小脑前下动脉与面神经贴近伴行后即予适量Teflon棉垫离,LSR波幅下降小于50%,关闭硬脑膜前再次探查面神经全程发现遗漏责任血管并予有效隔离,LSR波消失。3例至手术结束时,LSR波幅下降均大于75%,但未完全消失。术后随访6个月,治愈32例(86. 49%),明显缓解4例(10. 81%),部分缓解1例(2. 70%)。1例患者术前曾外院使用肉毒素注射治疗,未引出LSR。结论面肌痉挛微血管减压术中结合LSR监测波形变化反馈责任血管对面神经的激惹情况,对于术中精准识别责任血管、避免责任血管遗漏及客观评估减压效果具有重要指导意义。

Objective To analyze the effectof intraoperative electrophysiological monitoring of later spread response(LSR)to microvascular decompression for hemifacialspasm.Methods A retrospective analysis was made on 38 patients suffered with hemifacial spasm who underwent intraoperative electrophysiological monitoring of LSR during microvascular decompression surgery between January 2016 to August 2017 in Affiliated Hospital of Zunyi Medical University.All patients underwent facial nerve evoked potentials,3D-TOF-MRA,3D-FIESTA sequence examination toconfirm the diagnosis,while excluding secondary factors such as intracranial tumors.All Those who under intraoperative electrophysiological monitoring of LSR during microvascular decompression treatment from same surgeon,the relationship between the changes in LSR and surgical outcome was analysed.According to intraoperative LSR waveform changes or disappearance, we can make sure the clear offending vessel,and effectively assess the effect of decompression. Postoperative follow-up of 6 months to observe postoperative recovery.Results The characteristic LSR was observed in 37 out of 38 cases before operation.LSR disappeared after decompression with Teflon pad in 26 cases.LSR waves reappeared in 4 cases after decompression with Teflon pad,and the waveform disappeared after adiusting the position of the Teflon pad.The waveform of 3 cases were disappeared after dilatation of dura and cerebrospinal fluid.Observed anteriorinferior cerebellar artery and facial nerve close to accompany in one case,the LSR amplitude decreased less than 50% after the decompression with Teflon pad,before the closure of the dura,the whole zone of the facial nerve was explored again and the missing offendingvessel were identified, after isolated effectively,The LSR wave disappeared at last.By the end of surgery,the amplitude of LSR decreased by more than75%,but not completely disappeared in 3 cases.32patients (86.49%)were perfectly recovered from their HFS,4 patients(10.81%)were significantly relieved,one(2.70%)partially relieved after six months followed up.One patient had been treated with botulinum toxin in the other hospital before the surgery and no LSR was recorded.Conclusion Intraoperative electrophysiological monitoringof LSR during microvascular decompression for hemifacialspasm can dynamically reflect the irritability of the facial nerve against the offending vessel.It is of important guiding significance for the surgeon to identify offending vessel,avoiding leakage of offending vessel and effectively assess degree of decompression.