Burkholder Lee M, Houlden David A, Midha Rajiv, Weiss Erin, Vennettilli Marco
Division of Neurosurgery and Neuroscience Research Program, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Ontario, Canada.
J Neurosurg. 2003 Mar;98(3):607-10. doi: 10.3171/jns.2003.98.3.0607.
Peripheral nerve graft repair after severe brachial plexus injury is futile if there is degeneration of motor fibers in the proximal nerve stump to which the graft must be attached. Traditional intraoperative neurophysiological assessment methods like nerve action potential (NAP) and somatosensory evoked potential (SSEP) monitoring have been used to evaluate proximal nerve stump integrity, but these methods do not allow evaluation of the integrity of motor fibers back to the anterior horn cell. Consequently, the authors used transcranial electrical stimulation and recorded neurogenic motor evoked potentials (MEPs) directly from the brachial plexus in a patient undergoing surgical repair of a complete upper brachial plexus injury (Erb palsy) to assess the functional continuity of motor fibers. In addition, selected elements of the brachial plexus were directly stimulated, and NAPs were recorded. Finally, SSEPs were recorded from the scalp after stimulation of selected elements of the brachial plexus. Neurogenic MEPs were present from the medial cord of the brachial plexus, but not the middle or upper trunk; NAPs were present from the lateral and posterior cords after middle trunk stimulation, but absent after upper trunk stimulation; and SSEPs were present after medial cord stimulation but absent after stimulation of the upper and middle trunks. For the first time, neurogenic MEPs were coupled with NAPs and SSEPs to evaluate successfully the functional status of motor fibers back to the anterior horn cell for accurate localization of the lesion sites.
如果必须将移植体附着的近端神经残端中的运动纤维发生了变性，那么严重臂丛神经损伤后的周围神经移植修复将是徒劳的。传统的术中神经生理学评估方法，如神经动作电位（NAP）和体感诱发电位（SSEP）监测，已被用于评估近端神经残端的完整性，但这些方法无法评估运动纤维回到前角细胞的完整性。因此，作者在一名接受完全性上臂丛神经损伤（Erb麻痹）手术修复的患者中，使用经颅电刺激并直接从臂丛神经记录神经源性运动诱发电位（MEP），以评估运动纤维的功能连续性。此外，直接刺激臂丛神经的选定部位，并记录NAP。最后，在刺激臂丛神经的选定部位后，从头皮记录SSEP。神经源性MEP存在于臂丛神经的内侧束，但不存在于中间或上干；中间干刺激后，外侧和后束出现NAP，但上干刺激后未出现；内侧束刺激后出现SSEP，但上干和中间干刺激后未出现。神经源性MEP首次与NAP和SSEP相结合，成功评估了运动纤维回到前角细胞的功能状态，以准确确定病变部位。
