CAJ | 학술논문

目的研究在痉挛型脑瘫患者选择性脊神经后根切断术(SPR)中的肌电监测技术与标准.方法在89例痉挛型脑瘫患者SPR中,采用50 Hz方波电脉冲,分别刺激L3-S1神经后根小束,分别于双侧三角肌、长收肌、股直肌、股二头肌、胫骨前肌和腓肠肌内、外侧头记录自由肌电反应及触发肌电反应,同时观察下肢肌肉痉挛性收缩活动.对肌电反应向对侧、乃至远隔神经支配节段明显扩散的3+级和4+级神经后根小束,及引起下肢或足趾肌肉收缩活动的相对低阈值的神经后根小束进行选择性切断.术后观察下肢肌张力的改善程度,并对下肢感觉、运动及排便功能进行评估.结果触发肌电反应的出现明显滞后于自由肌电反应,观察自由肌电反应更能及时的判断"异常的"神经小束.89例患儿的372根神经后根被选择性切断,其中324根(83.5%)腰神经后根的出现3+～4+级肌电反应的神经小束被选择性切断;48根(12.9%)神经后根的神经小束根据"相对低阈值"被选择性切断.所有患儿术后下肢肌张力明显降低,未出现明显的下肢感觉、运动及排便功能障碍.结论 SPR中,肌电监测所出现的向对侧和(或)远隔节段扩散的持续的肌肉动作电位反应,是判定"异常"神经后根小束并进行选择性切断的有效并可重复的客观标准.
목적 연구재경련형뇌탄환자선택성척신경후근절단술(SPR)중적기전감측기술여표준.방법 재89례경련형뇌탄환자SPR중,채용50 Hz방파전맥충,분별자격L3-S1신경후근소속,분별우쌍측삼각기、장수기、고직기、고이두기、경골전기화비장기내、외측두기록자유기전반응급촉발기전반응,동시관찰하지기육경련성수축활동.대기전반응향대측、내지원격신경지배절단명현확산적3+급화4+급신경후근소속,급인기하지혹족지기육수축활동적상대저역치적신경후근소속진행선택성절단.술후관찰하지기장력적개선정도,병대하지감각、운동급배편공능진행평고.결과 촉발기전반응적출현명현체후우자유기전반응,관찰자유기전반응경능급시적판단"이상적"신경소속.89례환인적372근신경후근피선택성절단,기중324근(83.5%)요신경후근적출현3+～4+급기전반응적신경소속피선택성절단;48근(12.9%)신경후근적신경소속근거"상대저역치"피선택성절단.소유환인술후하지기장력명현강저,미출현명현적하지감각、운동급배편공능장애.결론 SPR중,기전감측소출현적향대측화(혹)원격절단확산적지속적기육동작전위반응,시판정"이상"신경후근소속병진행선택성절단적유효병가중복적객관표준.
Objective To evaluate the clinical application of intraoperative electrophysiological monitoring in lumbosacral selective posterior rhizotomy for spastic cerebral palsy. Methods Total 372 dorsal roots of 89 patients underwent selective posterior rhizotomy at a single medical center. The dorsal roots from L3 to S1 were divided into rootlets and stimulated with a 1-second 50 Hz train. Motor responses were recorded by electomyography. Rootlets were assigned according to the extent of abnormal electrophysiological propagation, and grades of 3 + to 4 + were cut. If no electrical response was observed, the second criterion is the behavioral response (that is, muscle contraction in the legs or toes) assessed by the physical therapist, when rootlets were stimulated at the lowest threshold with a 1-second 50 Hz train. Results The rootlets of 340 dorsal roots were assigned according to the extent of abnormal electrophysiological propagation ,324 (83. 5% ) roots were assigned the maximally abnormal response of grade 3 + (76, 22. 4% ) or 4 + (248, 72. 9% ) in EMG monitoring and were cut. For no electrical response was observed, according to the second criterion, 48 roots were partially cut. It was also be found that free running EMG occurred earlier than stimulus triggered EMG, and identified "abnormal" rootlets on free running EMG monitoring was more easily and quickly than on stimulus triggered EMG. During the postoperative 2 weeks in hospital , there was a significant decrease in lower-limb spasticity and an increase in range of movement in all patients, and no one case occurred obvious loss of muscle strength, abnormity of sensory,or deterioration of bladder/bowel control. Conclusions The spread of electromyography response to the contra lateral limb and/or upper extremity remains a valid criterion to define a "abnormal" posterior nerve rootlet that feeds into a disinhibited spinal circuit involved in uncontrolled spasticity. Intraoperative electrophysiological monitoring is reproducible and reliable for selection of "abnormal" rootlets.