【作者】 王强；

【导师】 岳树源；

【作者基本信息】 天津医科大学 ， 临床医学（专业学位）， 2020， 硕士

【摘要】 目的:为不断改善前庭神经鞘瘤手术面神经功能保留效果,探讨术后面神经功能预后的影响因素,评估面神经监测在前庭神经鞘瘤手术中对面神经保护及术后面神经功能预测的应用价值。方法:回顾性收集了于2016年9月至2018年9月,在天津医科大学总医院神经外科住院手术治疗的72例前庭神经鞘瘤患者临床资料,通过纳入和排除标准筛选后,共60例纳入研究。对60例患者进行临床资料收集,包括术前MRI、CT扫描,按Koos标准将肿瘤分为1-4级,查体重点检查面神经功能及后组颅神经功能。术中使用电生理监护仪,对60例前庭神经鞘瘤(术后病理证实)患者通过自发及诱发肌电图对面神经实施监测。观测记录术中自发肌电反应(A trains)有无出现,术末以不同强度电流刺激面神经脑干端和内听道端,记录诱发动作电位刺激阈值。术后回顾手术录像,记录患者的手术入路、肿瘤切除程度及颅神经保留情况;随访记录患者术后早期(即刻或转天早晨、1周)、远期(6个月)的面神经功能,按照House-Brackmann(H-B)分级系统,将H-B等级为I-III级者定义为面神经功能保留,将H-B IV-VI级者定义为面神经功能不良,比较影响两组患者面神经功能的可能影响因素以及其与面神经监测结果可能存在的相关性,结果采用~2检验、连续性校正~2检验或spearman相关检验分析,将P<0.05认定为差异存在统计学意义的标准进行统计分析。结果:1.60例患者均通过乙状窦后入路,术中肿瘤全切率达91.7%(55/60),面神经解剖保留率为93.3%(56/60)。2.对面神经解剖保留的56例前庭神经鞘瘤患者的面神经监测结果进行统计学分析,术后1周面神经功能不良者23例,其中出现A trains者19例,校正~2=5.357,P=0.021,差异有统计学意义。3.患者术后6个月面神经功能与术末面神经脑干端直接电刺激的刺激阈值进行spearman相关性分析,r=0.781,P<0.05,结果提示两者存在相关性。4.单因素分析患者年龄、性别、肿瘤侧别、肿瘤质地与患者术后面神经功能,差异无统计学意义;肿瘤的分级与患者术后面神经功能进行spearman相关性分析,r=0.656,P<0.05,结果提示两者存在相关性。5.将患者术后迟发性面瘫的发生与术中自由肌电图监测过程中有无A trains出现进行统计学分析,~2=0.083,P>0.05,差异无统计学意义;将患者术后迟发性面瘫的发生与否与术末面神经脑干端直接电刺激的刺激阈值进行spearman相关性分析,r=0.224,P>0.05,结果提示两者无明显相关性。结论:1.前庭神经鞘瘤术中行自发及诱发肌电图联合应用,能精确定位面神经,减少手术操作中面神经损伤的概率,对术后面神经解剖保留和功能保留有着重要意义;2.术中监测A trains出现者,术后早期面神经功能损伤概率更高;3.术末面神经脑干端刺激阈值越低者,术后面神经功能预后越佳;4.术前肿瘤大小是影响患者术后面神经功能的重要因素,肿瘤分级越高,术后面神经功能预后越差;5.对于肿瘤巨大、膜性界面不清、面神经分离困难者,即使术末面神经脑干端直接电刺激未引出动作电位,术后即刻并非都出现严重面瘫(H-B V级以上);6.术中面神经监测结果如A trains的出现及术末面神经脑干端刺激阈值与迟发性面瘫的发生差异无统计学意义,难以预测术后迟发性面瘫的发生;7.面神经监测作为前庭神经鞘瘤以及颅底、脑干手术中神经功能保护的重要辅助工具已达成共识,但影响患者术后面神经功能的首要因素仍是术者娴熟的手术技巧及丰富的临床经验。更多还原

【Abstract】 Objectives In order to improve the surgical facial nerve function of vestibular schwannoma,to investigate the prognostic factors of postoperative nerve function,and to evaluate the value of facial nerve monitoring in opposite nerve protection and prediction of postoperative nerve function in vestibular schwannoma surgery.Methods Clinical data of 72 patients with vestibular schwannoma hospitalized in the department of neurosurgery,general hospital of Tianjin medical university from September 2016 to September 2018 were retrospectively collected,and after screening by inclusion and exclusion criteria,a total of 60 patients were included in the study.The clinical data of 60 patients were collected,including preoperative MR、CT scanning,and the tumor was divided into 1-4 levels according to the Koos standard,and the facial nerve function and the posterior group cranial nerve function were examined emphatically by physical examination.Using electrophysiological monitor during operation,60 patients with vestibular schwannoma(postoperative pathological confirmation)were monitored by free-EMG and trigger-EMG.During the operation,spontaneous EMG(A trains)was observed and recorded.At the end of the operation,the brain stem and inner auditory canal were stimulated with different intensity current,and the threshold of evoked action potential stimulation was recorded.Postoperative surgical videos were reviewed to record the surgical approach,tumor resection degree and cranial nerve retention of the patients.Follow-up of patients with postoperative 1day,1 week and 6 months of facial nerve function,according to the House-Brackmann(H-B)classification system,the I-III grade of H-B was defined as facial nerve function retention,and the IV-VI grade as facial nerve dysfunction,then we compared the possible influencing factors of facial nerve function in the two groups and their possible correlation with facial nerve monitoring results.The results were analyzed by Chi-square test,Chi-square test of continuity correction or spearman correlation test,and P<0.05 was identified as the standard of statistically significant difference.Results 1.60 patients underwent retrosigmoid sinus approach.The total resection rate of intraoperative tumor was 91.7%(55/60)and the anatomical retention rate of facial nerve was 93.3%(56/60).2.By analyzing the results of facial nerve monitoring in 56patients with vestibular schwannoma preserved by facial nerve anatomy,there were23 cases of facial nerve dysfunction 1 week after operation,of which 19 were A trains,and the correction~2=5.357,P=0.021,the difference was statistically significant.3.By Spearman correlation analyzing,there was a correlation between facial nerve function and the stimulation threshold of direct electrical stimulation at the brain stem end of the facial nerve at the end of the operation,~2=0.781,P<0.05.4.The age,gender,tumor profile,tumor texture and postoperative facial nerve function of the patients were not statistically significant by single factor analysis,and there was a correlation between tumor grade and postoperative facial nerve function(r=0.656,P<0.05).5.There was no significant difference between the occurrence of delayed facial paralysis and A trains during free electromyography,~2=0.083,P=0.773>0.05.By spearman correlation analysis,there was no correlation between the incidence of delayed facial paralysis and the stimulation threshold of direct electrical stimulation at the end of the operation,r=0.224,P>0.05.Conclusions 1.The combination of free-EMG and trigger-EMG can accurately locate facial nerve,reduce the probability of facial nerve injury during operation of vestibular schwannoma,and play an important role in the preservation of anatomy and function of posterior nerve.2.Early postoperative facial nerve function injury probability is higher in patients with intraoperative monitoring A trains.3.The lower the nerve stimulation intensity at the end of operation,the better the prognosis of nerve function after operation.4.Preoperative tumor size is an important factor affecting the postoperative nerve function of patients.the higher the tumor grade,the worse the prognosis of postoperative nerve function.5.For those with large tumor,unclear membrane interface and difficulty in facial nerve separation,direct electrical stimulation at the end of brain stem did not lead to action potential,not all of them developed severe facial paralysis(above grade H-B V)immediately after operation.6.Intraoperative facial nerve monitoring such as the occurrence of A trains,the intensity of stimulation at the end of the brain stem is not statistically significant for the occurrence of delayed facial paralysis,and it is difficult to predict the occurrence of delayed facial paralysis after operation.7.Facial nerve monitoring has reached a consensus as an important auxiliary tool for the protection of nerve function in vestibular schwannoma and skull base and brain stem surgery,but the primary factor affecting postoperative nerve function is the skilled surgical skills of the operator.更多还原