电生理监测下小切口选择性脊神经背根切断术治疗下肢痉挛型瘫痪的研究  

Selective dorsal rhizotomy with small incision under electrophysiological monitoring in lower limb spasticity

作　　者：蒲珂[1] 韩国庆 刘鑫 朱志中[3] 李庆国[1] Pu Ke;Kan Quoqing;Liu Xin;Zhu Zhizhong;Li Qingguo(Department of Neurosurgery,Tianjin Huanhu Hospital,Tianjin 300222,China;Department of Neurophysiology,Tianjin Huanhu Hospital,Tianjin 300222,China;Department of Rehabilitation Medicine,Tianjin Huanhu Hospital,Tianjin 300222,China)

机构地区：[1]天津市环湖医院神经外科,天津300222 [2]天津市环湖医院神经电生理科,天津300222 [3]天津市环湖医院康复医学科,天津300222

出　　处：《中华神经医学杂志》2024年第5期458-463,共6页Chinese Journal of Neuromedicine

摘　　要：目的探讨电生理监测下小切口选择性脊神经背根切断术治疗下肢痉挛型瘫痪的效果及安全性。方法选择自2019年1月至2023年12月天津市环湖医院神经外科收治的20例因颅脑损伤等原因造成的下肢痉挛型瘫痪患者进入研究。术前将Ashworth痉挛量表分级为1+级以上肌群确定目标肌群。术中切除L1棘突下半部分及L2棘突上半部分,显露马尾神经。应用双极刺激器对马尾神经逐根进行电刺激,确定目标肌群的感觉神经,随后给予成串的电刺激,若未见对侧肌群收缩则切断50%、若出现对侧肌群收缩则切断75%。通过粗大运动功能测试量表-66(GMFM-66)、粗大运动功能分级系统(GMFCS)和Ashworth痉挛量表评估、比较患者术前及术后半年时运动功能及肌张力分级。观察患者术后早期及半年内并发症发生情况。结果20例患者目标肌群最常见为腓肠肌(内外侧头)(20例),其次为股二头肌(12例)和大腿内收肌群(9例)。GMFCS分级1~4级患者术中切断的神经数依次为(5.40±1.84)根、(9.50±6.36)根、(11.67±5.86)根、(14.00±5.66)根,差异有统计学意义(F=5.506,P=0.009)。20例患者术前与术后半年目标肌群的Ashworth痉挛量表分级差异有统计学意义(P<0.05),平均秩次提示术后半年患者目标肌群的Ashworth量表分级明显优于术前。此外,患者术后半年的GMFM-66总评分及主要关节活动度评分亦明显优于术前,差异有统计学意义(P<0.05)。并发症方面,15例患者术后早期出现发热,18例患者存在切口疼痛,1例患者出现可逆性下肢感觉减退,随访终末(术后0.5~4.0年)时症状均消失。所有患者均未出现下肢肌力减退、尿便障碍及脊柱畸形。结论本研究所采用的电生理监测下小切口选择性脊神经背根切断术能有效减少手术创伤,缓解因颅脑损伤造成的下肢痉挛型瘫痪,且手术安全性高。Objective To investigate the efficacy and safety of selective dorsal rhizotomy with small incision under electrophysiological monitoring in lower limb spasticity.Methods Twenty patients with lower limb spasticity due to craniocerebral injury admitted to Department of Neurosurgery,Tianjin Huanhu Hospital from January 2019 to December 2023 were selected.Target muscles(Ashworth Scale graded 1+or higher)were identified preoperatively.Intraoperatively,the lower L1 spinous process and the upper L2 spinous process were resected to expose the cauda equina nerves.A bipolar stimulator was applied to electrically stimulate the cauda equina nerves root by root to identify the sensory nerves of the target muscles;subsequently,strings of electrical stimulation were given,50%cauda equina nerves were cut off if no contraction of the contralateral muscles was seen,and 75%were cut off if contraction of the contralateral muscles was noted.Motor function and muscle tension were assessed and compared before and 6 months after surgery by Gross Motor Function Measure(GMFM)-66,Gross Motor Function Classification System(GMFCS),and Ashworth spasticity scale.Complications early after surgery and 6 months after surgery were observed.Results The most common targeted muscles in these 20 patients included the gastrocnemius(the medial and lateral side,n=20),followed by the biceps femoris(n=12)and the adductor muscles of thigh(n=9).Number of nerves intraoperatively cut in patients with GMFCS grading 1-4 was 5.40±1.84,9.50±6.36,11.67±5.86,and 14.00±5.66,respectively,with significant differences(F=5.506,P=0.009).Grading of Ashworth spasticity scale of the target muscles before surgery in these 20 patients showed significant difference compared with that at 6 months after surgery(P<0.05),and average rank indicated that Ashworth spasticity scale of target muscles 6 months after surgery was graded obviouly better than that before surgery.In addition,the GMFM-66 total scores and major joint motion scores of the patients 6 months after surgery were

关 键 词：神经背根切断术 电生理监测 椎板切除 下肢痉挛型瘫痪 

分 类 号：R651.11[医药卫生—外科学]