面肌痉挛显微血管减压术中不同听力保护策略的疗效:一项随机对照研究

Effect of different hearing protection strategies in microvascular decompression for hemifacial spasm:a randomized controlled study

目的探讨不同听力保护策略在面肌痉挛显微血管减压术(HFS-MVD)中的治疗效果。方法设计一项随机对照试验,前瞻性纳入2015年12月至2018年10月于中日友好医院神经外科行脑干听觉诱发电位(BAEPs)监测下HFS-MVD患者360例。术前采用随机数字表法分为"单纯等待组"、"温盐水灌注组"和"尼莫地平灌注组",每组120例。当术中BAEPs发生听力受损报警(Ⅰ~Ⅴ波潜伏期延迟超过1 ms或Ⅴ波波幅下降超过50%)时,按照术前分组进行干预,并将术中BAEPs的变化分为4型:稳定保持Ⅰ型(未报警,未施加干预),稳定恢复Ⅱ型,部分受损Ⅲ型,完全受损Ⅳ型。所有患者术后行听力检查(纯音测听和言语识别率)明确听力受损情况。比较3种干预措施,3种BAEPs分型(Ⅰ型因未施加干预,不纳入分析)和术后听力受损结果。结果本组146例患者实施了干预措施,单纯等待组47例,温盐水灌注组50例,尼莫地平灌注组49例,3组患者的Ⅱ、Ⅲ、Ⅳ型占干预总数的构成比比较,差异有统计学意义(P<0.05)。单纯等待组与温盐水灌注组的分型构成比比较,差异有统计学意义(χ^(2)=8.754,P=0.013)。单纯等待组、温盐水灌注组与尼莫地平灌注组比较,差异均无统计学意义(χ^(2)=6.119、0.247,P=0.047、0.884)。3组患者术后听力功能占干预总人数的构成比比较,差异无统计学意义(P>0.05)。结论 HFS-MVD术中联合电生理监测发现听力损害时,立即暂停手术并采用温热生理盐水回填术区,重新建立脑脊液环境,是一种简便而又相对有效的听力挽救手段。

Objective To investigate the therapeutic effects of different hearing protection strategies in microvascular decompression for hemifacial spasm(HFS-MVD).Methods A randomized controlled trial was designed to include 360 patients with HFS-MVD under the monitoring of brainstem auditory evoked potentials(BAEPs)in Neurosurgery Department of China-Japan Friendship Hospital from December 2015 to October 2018.Before surgery,random digital table method was performed and patients were divided into"simple waiting group","warm saline perfusion group"and"Nimodipine perfusion group",120 cases in each group.When the hearing loss alarm occurs in BAEPs during the operation(the latency ofⅠ-Ⅴwave delayed more than 1 ms or the amplitude of wave V decreases more than 50%),the intervention was performed according to the preoperative grouping.The changes of BAEPs during the operation were divided into four types:stable maintenance typeⅠ(no alarm,no intervention),stable recovery typeⅡ,partial damage typeⅢ,and complete damage typeⅣ.All patients underwent postoperative hearing examinations(pure tone audiometry and speech discrimination score)to confirm the hearing loss.Results The intervention measures were implemented in 146 patients in this group,including 47 patients in simple waiting group,50 patients in warm saline perfusion group and 49 patients in Nimodipine perfusion group.The difference of composition ofⅡ,Ⅲ,Ⅳfor total interventions among three groups was considered statistically significant(P<0.05).The difference of type and composition ratio between the simple waiting group and the warm saline perfusion group was considered statistically significant(χ^(2)=8.754,P=0.013).The difference of Nimodipine perfusion group and simple waiting group or warm saline perfusion group was no significant difference(χ^(2)=6.119,0.247;P=0.047,0.884).There was no significant difference of postoperative hearing function to the total number of interventions among three groups(P>0.05).Conclusion When hearing damage occurs by combined electrophysiological monitoring during MVD operation,immediately suspending the operation and using warm normal saline to backfill the operation area,which re-establishes the cerebrospinal fluid environment,is a simple and relatively effective rescue method.