甲状腺术中不同肌电阈值下喉返神经损伤后功能恢复的比较

Functional recovery after recurrent laryngeal nerve injury on different electromyography thresholds during thyroid surgery

目的 探讨甲状腺术中采用不同肌电阈值时喉返神经损伤后功能恢复的差异.方法2014年12月至2015年12月12只实验猪接受喉返神经牵拉伤前瞻性研究,连续监测记录24条喉返神经电生理功能损伤及恢复过程,其中12条神经于肌电信号振幅下降50%时解除牵拉,12条神经于肌电信号振幅下降70%时解除牵拉,记录振幅下降时间、潜伏期变化,以及神经功能恢复的程度与所需时间.回顾性分析2016年7月至12月1119例在吉林大学中日联谊医院甲状腺外科行接受甲状腺癌根治术患者的术中神经监测及术后喉镜检查情况,其中男性237例,女性882例,平均年龄45.2岁.结果动物研究中,喉返神经牵拉后振幅下降50%平均时间为（59±4）s,潜伏期延长（8±4）%,均于解除牵拉力10 min内逐渐恢复;振幅下降70%平均时间为（75±6）s,潜伏期延长（11±5）%,解除牵拉后20 min,肌电振幅恢复至基线水平的（43±23）%.临床研究中,术中监测1632条喉返神经,64例神经损伤机制明确,其中牵拉伤占62.5%（40/64）,热损伤占12.5%（8/64）,压迫伤占23.4%（15/64）,钳夹伤占1.6%（1/64）.喉返神经肌电信号振幅下降50%~〈70%时,术后声带运动异常比例为8.8%（6/68）,振幅下降≥70%时为37.2%（19/51）,信号丢失时为5/13.结论甲状腺术中喉返神经肌电振幅下降≥50%前解除损伤诱因,术后神经功能有望完全恢复,可避免术后发生声带运动异常.

Objective To discuss the functional recovery after recurrent laryngeal nerve injury （ RLNI ） on different electromyography thresholds during thyroid surgery. Methods The prospective experimentally were induced in 12 acute recurrent laryngeal traction animals （ porcine ） from December 2014 to December 2015, the amplitude and latency of electromyography, even time course during RLNI and recovery of 24 recurrent laryngeal nerves （ RLN ） were continuous intraoperative neuromonitoring （ IONM ） , including 12 RLN releasing traction after 50% amplitude decrease （ AD） and other 12 RLN after 70% AD. The IONM data and postoperative laryngoscopy result of 1119 thyroid cancer patients, involved 237 male and 882 female, aged 45. 2 years in average, who underwent thyroidectomy in Department of Thyroid Surgery, China-Japan Union Hospital Affiliated to Jilin University from July to December in 2016 were analyzed retrospectively. Results The porcine model of traction lesion showed that the time of 50% AD was （59±4） s, latency increase （LI） was （8± 4）%, was recovered in 10 minutes; the time of 70% AD was （75±6）s, LI was （11±5）% , was recovered （43±23）% of baseline even during 20 minutes. Among the IONM of 1632 recurrent laryngeal nerves in clinic, the mechanism of 64 RLNI is clear, including traction injury accounted for 62. 5% （40/64）, thermal injury was 12. 5% （8/64）,compression injury was 23. 4%（15/64）,clamp injury was 1. 6% （1/64）. When 50%≤AD 〈70% （8. 8%）, the rate of abnormal vocal fold movement （ AVCM） was 8. 8% （ 6/68） , while AD≥70% （ 37. 2%） , the rate of AVCM was 37. 2%（ 19/51） , but LOS was 5/13. Conclusion Releasing the injury before AD≥50% in surgery, is a more effective indicator to avoid postoperative AVCM and promote nerve function recovery.