Hoving M A, van Kranen-Mastenbroek V H J M, van Raak E P M, Spincemaille G H J J, Hardy E L M, Vles J S H
Department of Neurology, University Hospital Maastricht, P. Debyelaan 25, Postbus 5800, 6202 AZ Maastricht, The Netherlands.
Clin Neurophysiol. 2006 Jul;117(7):1508-17. doi: 10.1016/j.clinph.2006.04.014. Epub 2006 Jun 8.
To evaluate feasibility and utility of the soleus H-reflex and tibialis anterior flexor reflex (FR) in identifying spinal cord neuronal response to intrathecal baclofen (ITB) in children with severe spastic cerebral palsy.
During a randomized, double-blind, placebo-controlled dose-escalation test treatment, maximum H amplitude/maximum M amplitude (H/M ratio) and FR parameters were bilaterally recorded at baseline and 2-3 h after intrathecal bolus administration of placebo and increasing doses of baclofen until both an improvement in the individual treatment goal(s) and a one-point reduction on the Ashworth scale were observed.
Electrophysiological data of 14 children were studied. The H-reflex was feasible in 13 children, the FR threshold area in 9 and the FR, elicited with supramaximal stimulation, in only one child. After ITB, the H/M ratio significantly decreased (left: 0.67+/-0.47 to 0.15+/-0.18, P=0.005; right: 0.55+/-0.32 to 0.14+/-0.19, P=0.002) without placebo effect. FR threshold area after ITB, only decreased significantly in children not taking oral baclofen (left: 146+/-53 to 41+/-54 mV ms, P=0.000; right: 156+/-80 to 66+/-48 mV ms, P=0.002).
This is the first randomized, double-blind, placebo-controlled dose-escalation study in spastic children demonstrating the soleus H-reflex to be a feasible and objective measure to quantify the decreasing motoneuron excitability in response to ITB bolus administration. Only in children not taking oral baclofen, FR threshold area can also be used as an objective outcome measure, yet feasibility is limited.
We suggest introducing the H-reflex as the electrophysiological gold standard for the evaluation of the effect of ITB in spastic children.
评估比目鱼肌H反射和胫前肌屈肌反射（FR）在识别重度痉挛型脑瘫患儿鞘内注射巴氯芬（ITB）后脊髓神经元反应方面的可行性和实用性。
在一项随机、双盲、安慰剂对照的剂量递增试验治疗期间，在基线以及鞘内推注安慰剂和递增剂量的巴氯芬后2 - 3小时，双侧记录最大H波幅/最大M波幅（H/M比值）和FR参数，直至观察到个体治疗目标出现改善且Ashworth量表评分降低1分。
研究了14名儿童的电生理数据。13名儿童的H反射可行，9名儿童的FR阈值面积可行，仅1名儿童在超强刺激下引出FR。注射ITB后，H/M比值显著降低（左侧：从0.67±0.47降至0.15±0.18，P = 0.005；右侧：从0.55±0.32降至0.14±0.19，P = 0.002），无安慰剂效应。仅在未服用口服巴氯芬的儿童中，注射ITB后FR阈值面积显著降低（左侧：从146±53降至41±54 mV·ms，P = 0.000；右侧：从156±80降至66±48 mV·ms，P = 0.002）。
这是首次针对痉挛型儿童进行的随机、双盲、安慰剂对照的剂量递增研究，证明比目鱼肌H反射是一种可行且客观的测量方法，可用于量化鞘内注射巴氯芬推注后运动神经元兴奋性的降低。仅在未服用口服巴氯芬的儿童中，FR阈值面积也可作为客观的结局指标，但可行性有限。
我们建议将H反射作为评估ITB对痉挛型儿童疗效的电生理金标准。
