肌萎缩侧索硬化症患者针电极肌电图肌肉选择的优化

Optimization of muscle selection for needle electromyographyin amyotrophic lateral sclerosis

目的比较不同体区的不同肌肉的诊断敏感性,优化肌萎缩侧索硬化症(amyotrophic lateral sclerosis,ALS)患者针电极肌电图肌肉选择的方案;同时比较El Escorial标准(revised El Escorial criteria,rEEC)和Awaji criteria标准(AwC)的诊断效能。方法收集就诊于西安交通大学第一附属医院神经内科的ALS患者198例,采用rEEC和AwC诊断标准进行诊断分级。针电极肌电图分别检测延髓、颈髓、胸髓和腰骶髓4个体区支配的肌肉。结果肌肉敏感性的分布在ALS患者体区(无论有无临床受累)和无临床受累体区基本一致:延髓体区的舌肌敏感性(54.7%vs.39.2%)最高,其后依次是斜方肌(44.2%vs.30.2%)、口轮匝肌(33.2%vs.20.7%),而胸锁乳突肌(20%vs.13.2%)最低;颈髓体区的第一骨间肌(93.8%vs.77.3%)和拇短展肌(92.8%vs.72.7%)敏感性高于肱二头肌(82%vs.50%)和三角肌(82%vs.45.4%);胸髓体区的胸10脊旁肌(86.5%vs.85.3%)敏感性高于腹直肌(49.5%vs.49.3%);腰骶髓体区的胫前肌(74.6%vs.46.3%)敏感性高于腓肠肌(53.4%vs.19.7%)。在延髓起病组中,肌肉敏感性依次是延髓、颈髓、胸髓、腰骶髓体区;上肢起病组中,肌肉敏感性依次是颈髓、胸髓、腰骶髓、延髓体区;下肢起病组中,肌肉敏感性依次是腰骶髓、胸髓、颈髓区、延髓体区。采用AwC标准时确诊的阳性率(75.3%)明显高于采用rEEG标准时的确诊阳性率(24.2%),差异具有统计学意义(McNemar检验P<0.001)。结论优化的肌电图方案为延髓区选择舌肌,颈髓区选第一骨间肌,胸髓区选胸10椎旁肌,腰骶髓区选胫前肌。如果临床受累肌肉为非优化方案的肌肉,建议加做受累肌肉的肌电图,以提高诊断灵敏度。临床诊断时选用AwC诊断标准,早期确诊,早期治疗。

Objective To compare the diagnostic sensitivity of muscles in different regions on electromyography(EMG)to optimize and the muscle selection of needle electromyography in amyotrophic lateral sclerosis(ALS).To compare the diagnostic performance of revised El Escorial criteria(rEEC)and Awaji criteria(AwC)in ALS.Methods Totally 198 ALS patients were recruited from ALS Clinic of The First Affiliated Hospital of Xi'an Jiaotong University and diagnosed with rEEC and AwC diagnostic criteria.Needle EMG was detected in muscles of bulbar,cervical,thoracal,and lumbosacral regions.Results The muscle sensitivity in ALS regions(with or without clinical involvement)was consistent with that in the regions without clinical involvement.The diagnostic sensitivity of muscles were presented as follows:tongue(54.7%vs.39.2%),trapezius(44.2%vs.30.2%),lower orbicularis oris(33.2%vs.20.7%),sternocleidomastoid(20%vs.13.2%)in bulbar region,the first dorsal interosseus(93.8%vs.77.3%),abductor pollicis brevis(92.8%vs.72.7%),biceps(82%vs.50%),deltoid(82%vs.45.4%)in cervical region,thoracic paraspinal muscle 10(86.5%vs.85.3%)and rectus abdominis(49.5%vs.49.3%)in thoracal region,the tibialis anterior(74.6%vs.46.3%),and gastrocnemius(53.4%vs.19.7%)in lumbosacral region.The diagnostic rate at AwC standard(75.3%)was significantly higher than that at rEEG standard(24.2%)(McNemar test P<0.001).Conclusion The muscles of clinical affected region should be detected first,followed by the non-affected region in clinically suspected ALS.The tongue in bulbar region,the first dorsal interosseus in cervical region,thoracic paraspinal muscle 10 in thoracal region,tibialis anterior in lumbosacral region are recommended to detect in EMG protocol.The AwC criteria are suggested in ALS clinical diagnosis.