经颅电刺激前阴部神经强直刺激可增强小儿神经外科手术中运动诱发电位的幅度。
Tetanic stimulation of the pudendal nerve prior to transcranial electrical stimulation augments the amplitude of motor evoked potentials during pediatric neurosurgery.
机构信息
Departments of1Central Operation.
2Neurosurgery, and.
出版信息
J Neurosurg Pediatr. 2021 Apr 23;27(6):707-715. doi: 10.3171/2020.10.PEDS20674. Print 2021 Jun 1.
OBJECTIVE
Reportedly, tetanic stimulation prior to transcranial electrical stimulation (TES) facilitates elicitation of motor evoked potentials (MEPs) by a mechanism involving increased corticomotoneuronal excitability in response to somatosensory input. However, the posttetanic MEP following stimulation of a pure sensory nerve has never been reported. Furthermore, no previous reports have described posttetanic MEPs in pediatric patients. The aim of this study was to investigate the efficacy of posttetanic MEPs in pediatric neurosurgery patients and to compare the effects on posttetanic MEP after tetanic stimulation of the sensory branch of the pudendal nerve versus the standard median and tibial nerves, which contain a mixture of sensory and motor fibers.
METHODS
In 31 consecutive pediatric patients with a mean age of 6.0 ± 5.1 years who underwent lumbosacral surgery, MEPs were elicited by TES without tetanic stimulation (conventional MEPs [c-MEPs]) and following tetanic stimulation of the unilateral median and tibial nerves (mt-MEPs) and the sensory branch of the pudendal nerve (p-MEP). Compound muscle action potentials were elicited from abductor pollicis brevis (APB), gastrocnemius (Gc), tibialis anterior (TA), and adductor hallucis (AH) muscles. The success rate of monitoring each MEP and the increases in the ratios of mt-MEP and p-MEP to c-MEP were investigated.
RESULTS
The success rate of monitoring p-MEPs was higher than those of mt-MEPs and c-MEPs (87.5%, 72.6%, and 63.3%, respectively; p < 0.01, adjusted by Bonferroni correction). The mean increase in the ratio of p-MEP to c-MEP for all muscles was significantly higher than that of mt-MEP to c-MEP (3.64 ± 4.03 vs 1.98 ± 2.23, p < 0.01). Subanalysis of individual muscles demonstrated significant differences in the increases in the ratios between p-MEP and mt-MEP in the APB bilaterally, as well as ipsilateral Gc, contralateral TA, and bilateral AH muscles.
CONCLUSIONS
Tetanic stimulation prior to TES can augment the amplitude of MEPs during pediatric neurosurgery, the effect being larger with pudendal nerve stimulation than tetanic stimulation of the unilateral median and tibial nerves. TES elicitation of p-MEPs might be useful in pediatric patients in whom it is difficult to elicit c-MEPs.
目的
据报道，经颅电刺激（TES）前的强直刺激通过增加感觉传入引起的皮质运动神经元兴奋性，从而促进运动诱发电位（MEPs）的引出。然而，刺激纯感觉神经后的强直后 MEPs 从未被报道过。此外，以前的报告中也没有描述过儿科患者的强直后 MEPs。本研究旨在探讨强直刺激对儿科神经外科患者 MEPs 的影响，并比较刺激阴部感觉支与标准正中神经和胫神经后强直后 MEPs 的效果，因为前两者包含感觉和运动纤维的混合物。
方法
在 31 例平均年龄为 6.0±5.1 岁的连续行腰骶部手术的儿科患者中，通过 TES 引出无强直刺激的 MEPs（常规 MEPs [c-MEPs]）和单侧正中神经和胫神经（mt-MEPs）及阴部感觉支（p-MEPs）的强直刺激后 MEPs。从拇短展肌（APB）、腓肠肌（Gc）、胫骨前肌（TA）和拇展肌（AH）中引出复合肌肉动作电位。研究了监测每种 MEPs 的成功率以及 mt-MEP 和 p-MEP 与 c-MEP 的比值增加情况。
结果
监测 p-MEPs 的成功率高于 mt-MEPs 和 c-MEPs（分别为 87.5%、72.6%和 63.3%；p<0.01，经 Bonferroni 校正）。所有肌肉 p-MEP 与 c-MEP 的比值平均增加均显著高于 mt-MEP 与 c-MEP 的比值（3.64±4.03 比 1.98±2.23，p<0.01）。对个体肌肉的亚分析表明，双侧 APB 以及同侧 Gc、对侧 TA 和双侧 AH 肌肉的 p-MEP 与 mt-MEP 比值增加存在显著差异。
结论
TES 前的强直刺激可增强儿科神经外科期间 MEPs 的振幅，刺激阴部神经的效果大于单侧正中神经和胫神经的刺激。在难以引出 c-MEPs 的儿科患者中，TES 引出 p-MEPs 可能有用。
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