神经监测技术在结节性甲状腺肿手术中的临床应用

Clinical significance of applying intraoperative neuromonitoring technology in subtotal thyroidectomy of patients with nodular goiter

目的探讨术中神经监测技术（intraoperative neuromonitoring，IONM）在结节性甲状腺肿行甲状腺次全切除手术中的临床应用。方法分析2014年1月至2017年10月期间解放军总医院和解放军总医院第一附属医院普通外科收治的83例结节性甲状腺肿患者，采用随机数字表法分为传统组38例和监测组45例，传统组肿块最大径〉7cm9例，4-7cm 29例，均压迫气管，压迫食道1例；监测组肿块最大径〉7cm 15例，4—7cm30例，均压迫气管，压迫食道2例。2组术前均常规行喉镜检查未提示声带运动异常。2组均在全麻下行甲状腺患侧叶次全切除术，传统组术中不使用IONM，监测组术中使用IONM。结果所有患者均顺利完成手术，传统组术中共暴露RLN18根，术后5例出现声音嘶哑，喉镜检查提示患侧声带运动减弱；监测组使用IONM均顺利获得V1信号，术中共暴露RLN21根，术毕获得V2信号与V1信号比较无明显降低．术后无患者出现声音嘶哑。传统组和监测组在RLN损伤率方面差异存在统计学意义（R0．05，P=0．04），传统组在RLN损伤率方面高于监测组。结论在结节性甲状腺肿行甲状腺次全切除手术中可使用IONM判读神经功能以避免术中发生误损伤。

Objective To investigate the clinical effect of intra-operative recurrent laryngeal nerve（RLN） monitoring in subtotal thyroidectomy of patients with nodular goiter. Methods The clinical data of 83 patients with nodular goiter admitted from Jan. 2014 to Oct. 2017 were analyzed. They were divided into non-monitoring group （38 cases） and the monitoring group （45 cases）. 9 patients had masses with a maximum diameter larger than 7 cm and 29 patients had masses with maximum diameter between 4 and 7 cm in the non-monitoring group. Among the 38 masses compressing trachea, one case also had esophagus compression. In the monitoring group, the maximal diameter of mass was larger than 7 cm in 15 cases and 4 to 7 cm in 30 cases. All the 32 cases had trachea compression and 2 cases had esophagus compression. All patients underwent routine laryngoscopy preoperatively, suggesting no RLN paralyses. Both groups underwent subtotal thyroidectomy under general anesthesia. Results In non-monitoring group, there were 18 cases with RLN exposed. Five patients had hoarseness after operation, and laryngoscopy showed weakened ipsilateral vocal cord. In the monitoring group, all patients successfully received the surgery and signals V1 were obtained during nerve monitoring. A total of 21 RLN were exposed intraoperatively. Signals V2 were obtained postoperatively, and they showed no significant reduction as compared to signals V1 and no hoarseness occurred. Incidence of RLN injury in monitoring group was significantly lower than that in non-monitoring group （P〈0.05, P=0.04）. The rate of RLN injury in the non-monitoring group was higher than that in the monitoring group. Conclusion In the surgery for nodular goiter, intra-operative RLN monitoring can be applied to determine neural function and can effectively reduce the risk of RLN injury.