Boston Shoulder Institute, Massachusetts General Hospital, Boston, MA, USA.
Department of Anesthesiology, Brigham & Women's Hospital, Boston, MA, USA.
J Shoulder Elbow Surg. 2014 Oct;23(10):1473-80. doi: 10.1016/j.jse.2014.04.003. Epub 2014 Jun 18.
We used intraoperative neuromonitoring to define the stages of the Latarjet procedure during which the nerves are at greatest risk.
Thirty-four patients with a mean age of 28.4 years were included. The Latarjet procedure was divided into 9 defined stages. Bilateral median and ulnar somatosensory evoked responses and transcranial motor evoked potentials from all arm myotomes were continuously monitored. A "nerve alert" was defined as averaged 50% amplitude attenuation or 10% latency prolongation of ipsilateral somatosensory evoked responses and transcranial motor evoked potentials. For each nerve alert, the surgeon altered retractor placement, and if there was no response to this, the position of the operative extremity was then changed.
Of 34 patients, 26 (76.5%) had 45 separate nerve alert episodes. The most common stages of the procedure for a nerve alert to occur were glenoid exposure and graft insertion. The axillary nerve was involved in 35 alerts; the musculocutaneous nerve, in 22. Of the 34 patients, 7 (20.6%) had a clinically detectable nerve deficit postoperatively, all correlated with an intraoperative nerve alert. All cases involved the axillary nerve, and all resolved completely from 28 to 165 days postoperatively. Prior surgery and body mass index were not predictive of a neurologic deficit postoperatively. However, total operative time (P = .042) and duration of the stage of the procedure in which the concordant nerve alert occurred (P = .010) were statistically significant predictors of a postoperative nerve deficit.
The nerves, in particular the axillary and musculocutaneous nerves, are at risk during the Latarjet procedure, especially during glenoid exposure and graft insertion.
我们使用术中神经监测来确定 Latarjet 手术过程中神经最容易受损的阶段。
共纳入 34 例平均年龄为 28.4 岁的患者。将 Latarjet 手术分为 9 个定义明确的阶段。连续监测双侧正中神经和尺神经体感诱发电位以及所有上肢肌节的经颅运动诱发电位。“神经警示”定义为同侧体感诱发电位和经颅运动诱发电位的平均振幅衰减 50%或潜伏期延长 10%。对于每个神经警示，外科医生都会改变牵开器的位置，如果对此没有反应，则改变手术肢体的位置。
在 34 例患者中，有 26 例（76.5%）出现了 45 次单独的神经警示事件。最常见的手术阶段发生神经警示是肩盂暴露和移植物插入。腋神经在 35 次警示中受到影响，肌皮神经在 22 次警示中受到影响。在 34 例患者中，有 7 例（20.6%）术后出现可察觉的神经功能缺损，均与术中神经警示相关。所有病例均涉及腋神经，所有病例均在术后 28 至 165 天内完全恢复。既往手术和体重指数不是术后神经缺损的预测因素。然而，总手术时间（P=0.042）和发生协同神经警示的手术阶段持续时间（P=0.010）是术后神经缺损的统计学显著预测因素。
神经，特别是腋神经和肌皮神经，在 Latarjet 手术过程中容易受损，尤其是在肩盂暴露和移植物插入时。
