Tomazini Martins Rodrigo, Elstner Kristen E, Skulina Christian, Rodriguez-Acevedo Omar, Read John W, Rowe Dominic B, Ibrahim Nabeel
Hernia Institute Australia, Sydney, NSW, Australia.
Department of Neurology, Macquarie University Hospital, Sydney, NSW, Australia.
Front Surg. 2019 Apr 9;6:16. doi: 10.3389/fsurg.2019.00016. eCollection 2019.
Pre-operative botulinum toxin A (BTA) injection of the lateral obliques aims to facilitate the closure of large ventral hernia defects and decrease the risk of repair breakdown during the critical healing phase. The exact duration of post-operative BTA effect and top-up timing in cases at high risk of recurrence remains uncertain. This study was designed to assess the value of electromyography (EMG) in determining the appropriate time for BTA top-up. 56 patients underwent ventral hernia repair with pre-operative BTA infiltration of the lateral obliques. Eleven patients at high risk of recurrence considered suitable for BTA top-up were assessed post-operatively with both functional computed tomography (CT) and EMG. CT assessed segmental contractility of each muscle layer. Single-point EMG assessed the activity of individual muscle layers bilaterally in the anterior axillary line. CT showed (i) variable contractility of anterior and posterior muscle segments ; (ii) absent or incomplete muscle paralysis in over half of all segments; (iii) on progress scans; and (iv) non-uniform pattern of change in BTA effect between the anterior and posterior muscle. EMG demonstrated modest voluntary activity in most muscle layers. Compared to standard of reference (CT), EMG showed moderate sensitivity (0.62), poor specificity (0.48), poor accuracy (0.57), and incorrect grading in 71% of true positive results. As BTA effect wanes, single-point EMG cannot reliably determine functional muscle status. A novel finding is that BTA-induced paralysis of the abdominal muscles may be remarkably non-uniform in degree, distribution and duration.
术前向腹外斜肌注射A型肉毒杆菌毒素（BTA）旨在促进大型腹疝缺损的闭合，并降低关键愈合阶段修复失败的风险。对于复发风险高的病例，术后BTA作用的确切持续时间和补充注射时机仍不确定。本研究旨在评估肌电图（EMG）在确定BTA补充注射合适时间方面的价值。56例患者接受了腹疝修补术，术前对腹外斜肌进行了BTA浸润。11例被认为适合进行BTA补充注射的高复发风险患者在术后接受了功能计算机断层扫描（CT）和EMG评估。CT评估了各肌肉层的节段收缩性。单点EMG评估了双侧腋前线各肌肉层的活动。CT显示：（i）前后肌肉节段的收缩性各异；（ii）超过半数的节段存在肌肉麻痹缺失或不完全的情况；（iii）在随访扫描中；（iv）前后肌肉之间BTA效应的变化模式不均匀。EMG显示大多数肌肉层存在适度的自主活动。与参考标准（CT）相比，EMG显示出中等灵敏度（0.62）、较差的特异性（0.48）、较差的准确性（0.57），并且在71%的真阳性结果中分级错误。随着BTA效应减弱，单点EMG无法可靠地确定肌肉功能状态。一个新发现是，BTA诱导的腹肌麻痹在程度、分布和持续时间上可能非常不均匀。
