不同肌松水平对术中脊髓神经电生理监测的影响  

Influence of different neuromuscular blockade levels on intraoperative spinal cord monitoring

作　　者：于琳琳[1] 王军[1] 马越[2] 郭向阳[1] 

机构地区：[1]北京大学第三医院麻醉科,北京100191 [2]北京大学第三医院神经电生理监测室,北京100191

出　　处：《首都医科大学学报》2017年第3期357-360,共4页Journal of Capital Medical University

摘　　要：目的比较不同肌松水平[4个成串刺激(train of four stimulation,TOF)的T1分别为5%~15%基础值和45%~55%基础值水平]对脊柱手术中脊髓神经电生理监测结果的影响,探讨安全有效的电生理监测麻醉方案。方法选择行术中脊髓神经电生理监测的择期脊柱手术病人23例。采用丙泊酚和瑞芬太尼全凭静脉麻醉,阿曲库铵维持肌松,监测拇内收肌TOF指示肌松水平,监测体感诱发电位(somatosensory evoked potentials,SEP)和运动诱发电位(motor evoked potentials,MEP)评判脊髓功能。分别记录神经肌肉阻滞水平1(neuromuscular blockade level 1,NMB_1)(T1为5%~15%基础值)和NMB_2水平(T1为45%~55%基础值)时SEP和MEP的波幅和潜伏期,同时记录经颅电刺激时病人是否出现剧烈体动和自主呼吸。结果不同肌松水平的SEP波幅和潜伏期之间差异均无统计学意义(P>0.05)。同一监测部位不同肌松水平的MEP潜伏期差异无统计学意义(P>0.05),左上肢和右下肢不同肌松水平的MEP波幅则差异有统计学意义(P<0.05)。NMB2水平时的经颅电刺激时剧烈体动发生率明显高于NMB1水平时(P<0.05)。两个肌松水平经颅电刺激时均无自主呼吸产生。结论肌松剂的使用在行神经电生理监测的脊柱手术中并非完全禁忌,TOF的T1在45%~55%基础值的肌松水平可能是高风险脊髓手术较理想的肌松水平。Objective To compare the effects of different muscle relaxation levels （T1 response of the train-of-four （TOF） stimulation 5%-15% versus T1 response 45%-55% of baseline） the electrophysiological monitoring of the spinal cord during the spinal cord surgery, and then to explore the reasonable anesthesia program matched with electrophysiological monitoring.Methods Twenty-three patients undergoing selective spinal surgery with electrosurgical monitoring were enrolled in this study. Total intravenous anesthesia using propofol plus remifentanil and muscle relaxation provided by atracurium were maintained. Somatosensory evoked potentials （SEP） and motor evoked potentials （MEP） were used to monitor the spinal cord function, and TOF stimulation at adductor pollicis muscle represented the muscle relaxation.The amplitude and latency of SEP and MEP were recorded at the level of NMB1 （T1 5% to 15% base） and NMB2 level （T1 45% to 55% base）. Spontaneous breathing and severe motor motility under transcranial electrical stimulation were also recorded.Results There were no significant differences between the amplitudes and the latencies of SEP at different NMB levels（P〉0.05）. The latencies of MEP were similar under different muscle relaxation levels（P〉0.05）. The amplitudes of MEP had significant difference on the left upper limbs and the right lower limbs, whereas not on the left upper limbs and the right lower limbs. The incidence of severe motility at NMB2 level was much higher than that at NMB1 level （P〈0.05）. No spontaneous breathing was detected.Conclusion The use of muscle relaxant is not contraindicated during spinal surgeries that need intraoperative neurophysiology monitoring. For high risk spinal surgery, T1 response at 45%-55% of baseline may be the appropriate neuromuscular blockade level.

关 键 词：脊髓功能监测 神经肌肉阻滞 体感诱发电位 运动诱发电位 

分 类 号：R614[医药卫生—麻醉学]