瞬目反射监测在大型听神经瘤手术中的应用价值

Application value of blink reflex monitoring in large acoustic neuroma surgery

目的探讨大型听神经瘤术中瞬目反射(BR)监测对患者眼睑闭合功能结局的预测价值。方法回顾性分析2020年12月至2021年4月首都医科大学附属北京天坛医院神经外科手术治疗的80例大型听神经瘤(Koos分级≥3级)患者的临床资料。患者术中均行BR监测,并记录术中BR波幅的下降率。分别于术后1周、3个月、6个月依据Terzis区域性量表评价患者的眼睑闭合功能,并将其分为眼睑闭合功能良好组(Terzis量表分级≥4级)和眼睑闭合功能不良组(Terzis量表分级<4级)。采用单因素和多因素logistic回归分析筛选术后眼睑闭合功能结局的影响因素。绘制受试者工作特征(ROC)曲线并计算曲线下面积(AUC),以确定BR的临界值及其对患者眼睑闭合功能结局的预测价值。结果80例患者中,76例(95.0%)引出有效BR波形,其中1例因术中调整麻醉深度未纳入分析。75例患者中,术中有28例(37.3%)面神经与肿瘤粘连紧密难于分离,14例(18.7%)面神经严重变形、菲薄。术后1周、3个月、6个月眼睑闭合功能的良好率分别为58.7%(44/75)、77.3%(58/75)和82.7%(62/75)。单因素分析结果显示,术后1周、3个月、6个月,眼睑闭合功能良好组和功能不良组的面神经形态、BR波幅下降率的差异均有统计学意义(均P<0.05)。术后3个月,两组的面神经分离难度的差异有统计学意义(P<0.05)。多因素logistic回归分析结果显示,BR波幅下降率是术后1周(OR=1.11,95%CI:1.06~1.16)、术后3个月(OR=1.08,95%CI:1.04~1.13)、术后6个月(OR=1.08,95%CI:1.03~1.13)眼睑闭合功能结局的影响因素(均P<0.01);其临界值分别为20.8%、29.4%、51.0%;灵敏度分别为90.3%、94.1%、84.6%,特异度分别为89.7%、83.3%、92.1%。结论术中BR监测结果可有效反映听神经瘤患者术后眼睑闭合功能的结局;BR波幅下降>50%可作为手术中的预警标准。

Objective To investigate the predictive value of intraoperative blink reflex(BR)monitoring for the outcome of eyelid closure in patients with large acoustic neuromas.Methods A retrospective analysis was conducted on the clinical data of 80 patients with large acoustic neuroma who underwent surgical operations at Department of Neurosurgery,Beijing Tiantan Hospital,Capital Medical University from December 2020 to April 2021.Intraoperative BR monitoring was performed in all patients,and the decrease ratio of intraoperative BR amplitude was documented.The eyelid closure function of the patients was evaluated according to Terzis facial grading system at 1 week,3 months,and 6 months after operation,and they were divided into good eyelid closure function group(Terzis grade≥4)and poor eyelid closure function group(Terzis grade<4).Univariate and multivariate logistic regression analyses were used to determine the influencing factors of postoperative eyelid closure function outcome.Receiver operating characteristic(ROC)curves were drawn and the area under the curve(AUC)was calculated to determine the critical value of BR and its predictive value.Results Among the 80 patients,76 patients(95.0%)had BR waveforms,and 1 patient was not included in the analysis due to intraoperative adjustment of anesthesia depth.Among the 75 patients,the facial nerve was closely adhered to the tumor and difficult to separate in 28(37.3%)cases,and the facial nerve was severely deformed and thin in 14(18.7%)cases.The proportions of good eyelid closure function at 1 week,3 months and 6 months after operation were 58.7%(44/75),77.3%(58/75)and 82.7%(62/75),respectively.The results of univariate analysis showed that there were significant differences in the facial nerve morphology and BR amplitude decrease between the good eyelid closure function group and the poor function group at 1 week,3 months,and 6 months after surgery(all P<0.05).The difference in the difficulty of facial nerve separation was statistically significant between the good eyelid closure function group and the poor function group at 3 months after operation(P<0.05).The results of multivariate logistic regression analysis showed that the decrease of BR amplitude was the influencing factor of the outcome of eyelid closure function at 1 week(OR=1.11,95%CI:1.06-1.16),3 months(OR=1.08,95%CI:1.04-1.13),6 months(OR=1.08,95%CI:1.03-1.13)post operation(all P<0.01);the critical values were 20.8%,29.4%,and 51.0%respectively;the sensitivities were 90.3%,94.1%,84.6%respectively;the specificities were 89.7%,83.3%,and 92.1%respectively.Conclusions Intraoperative BR monitoring can effectively reflect the outcome of postoperative eyelid closure function in patients with acoustic neuroma.A decrease in BR amplitude>50%can be used as an early warning standard during surgery.