神经电生理检测对小脑脑桥角区肿瘤术后面神经功能的预测价值

Predictive value of neurophysiological monitoring in facial nerve function after cerebellopontine angle tumor surgery

目的 探讨术前及术中神经电生理检测指标对小脑脑桥角（CPA）区肿瘤术后面神经功能的预测价值.方法 回顾性分析2016年8月至2017年3月首都医科大学附属北京天坛医院神经外科收治的58例CPA区肿瘤患者的临床资料.患者术前均行瞬目反射及面神经F波检测,对瞬目反射的R1波潜伏期及F波的平均潜伏期结果进行分级.术中均采用面肌运动诱发电位（FMEP）保护面神经功能,记录FMEP波幅的比值.依据House-Brackmann（H-B）评分标准分别于术前1d、术后1周、3个月及6个月评估面神经功能.采用多因素Lotistic回归分析术后面神经功能的影响因素.结果 58例CPA区肿瘤患者均经乙状窦后入路切除肿瘤,其中55例获得肿瘤全切除（94.8％）,3例肿瘤行次全切除.单因素Logistic回归分析显示,术后1周、3个月及6个月面神经功能结局良好组患者的瞬目反射结果优于结局不良组（均P＜0.05）.术后6个月面神经功能结局良好组的F波反应检测结果优于结局不良组（P＜0.05）.术后3个月及6个月面神经功能结局良好组的肿瘤最大径小于结局不良组[（31.9±10.2）mm、（31.9±9.3）mm对比（37.8±9.7）mm、（40.0±10.0）mm]（均P＜0.05）.术后1周、3个月及6个月面神经功能结局良好组的FMEP波幅比值高于结局不良组[（84.6±21.3）％、（83.0±19.0）％、（81.0±19.1）％对比（66.2±27.0）％、（63.4±29.0）％、（59.6±31.2）％]（均P＜0.05）.多因素Logistic回归分析显示,FMEP波幅比值为预测术后1周、3个月及6个月面神经功能结局的独立预测因素,差异有统计学意义（P＜0.05）.肿瘤最大径为3个月及6个月面神经功能的独立预测因素（P＜0.05）;瞬目反射结果分级是术后6个月面神经功能的独立预测因素（P＜0.05）.ROC曲线分析,FMEP波幅比值预测术后1周、3个月及6个月面神经功能良好的截点值分别为89.2％、58.2％、58.2％;曲线下面积分别为0.709、0.706、0.713.结论 瞬目反射及肿瘤最大径对术后远期面神经功能有一定的预测价值.FMEP波幅比值对术后面神经功能有良好的预测价值,波幅比值＞60％预测术后远期面神经功能结局良好.

 Objective To investigate the predictive value of preoperative and intraoperative electrophysiological parameters in facial nerve （FN） function after cerebellopontine angel （CPA） tumor surgery.Methods A total of 58 patients with CPA tumor underwent operations from August 2016 to March 2017 at Department of Neurosurgery,Beijing Tiantan Hospital,Capital Medical University and were enrolled into this retrospective study.Preoperative blink reflex （BR） and FN F wave response were tested in all patients.The R1 component latency and mean F wave latency were determined.Intraoperative facial motor evoked potentials （FMEP） was applied to monitor the FN function and the amplitude ratio of FMEP was documented.According to the House-Brackmann （H-B） grading system,the functional classification of FN was determined preoperatively,at 1 week,3 months and 6 months postoperatively.Multiple logistic regression analysis was applied to explore the predictor of postoperative FN function.Results A total of 58 cases of CPA tumor underwent microsurgical excisions by retrosigmoid approach.Total and subtotal resections were performed in 55 （94.8%） and 3 cases,respectively.Single factor Logistic regression analysis showed that the results of blink reflex in patients with good FN outcome were better than those in the group with poor outcome at 3 follow-up time points （P 〈 0.05）.The results of F wave response in patients with good FN outcome were better than those in poor outcome group at 6 months post operation （P 〈 0.05）.At 3 and 6 months post surgery,the maximal tumor diameters in the good outcome group were （31.9 ± 10.2） mm and （31.9 ± 9.3） mm,respectively,which were smaller than those in the poor outcome group [（37.8 ±9.7） mm and （40.0 ± 10.0） mm,respectively] （both P 〈0.05）.At 1 week,3 and 6 months post surgery,the FMEP amplitude ratios in the good outcome group were （84.6 ±21.3）%,（83.0 ± 19.0）% and （81.0 ± 19.1）%,respectively,which were higher than those in the poor outcome group [（66.2 ± 27.0） %,（63.4 ± 29.0） % and （59.6 ± 31,2） %] （all P 〈 0.05）.Multivariate Logistic regression analysis showed that FMEP amplitude ratio was the independent predictor of FN outcome at 1 week,3 and 6 months post operation （P 〈 0.05）.The maximal tumor diameter was the independent predictor of FN outcome at 3 and 6 months post operation （P 〈 0.05）.BR classification was the independent predictor of FN outcome at 6 months after operation （P 〈 0.05）.ROC （receiver operating characteristic） curve analysis showed that the FMEP amplitude ratio cut-off values of 89.2% [AUC （area under the curve） =0.709],58.2% （AUC =0.706） and 58.2% （AUC =0.713） predicted good FN function at 1 week,3 and 6 months after surgery,respectively.Conclusions BR and maximal tumor diameter have certain predictive values for postoperative FN function.The FMEP amplitude ratio is a valuable predictor for postoperative FN function and its value of at least 60% is predictive of favorable long-term postoperative FN function.