全髖關(guān)節(jié)置換術(shù)中神經(jīng)損傷及神經(jīng)電生理監(jiān)測(cè)技術(shù)的研究進(jìn)展

孔祥朋 柴偉 倪明 李想 王巖

（中國人民解放軍總醫(yī)院骨科，北京100853）

全髖關(guān)節(jié)置換術(shù)中神經(jīng)損傷及神經(jīng)電生理監(jiān)測(cè)技術(shù)的研究進(jìn)展

孔祥朋 柴偉 倪明 李想 王巖*

（中國人民解放軍總醫(yī)院骨科，北京100853）

全髖關(guān)節(jié)置換術(shù)（total hip arthroplasty,THA）是目前開展最早、數(shù)量最多的關(guān)節(jié)置換手術(shù)。術(shù)后神經(jīng)損傷是一種較為少見的并發(fā)癥，嚴(yán)重影響患者預(yù)后。現(xiàn)有文獻(xiàn)表明，復(fù)雜髖關(guān)節(jié)置換術(shù)中多模式神經(jīng)電生理監(jiān)測(cè)可有效預(yù)測(cè)及預(yù)防下肢周圍神經(jīng)損傷。本文從神經(jīng)損傷發(fā)生率、神經(jīng)應(yīng)用解剖、預(yù)后、危險(xiǎn)因素、術(shù)中神經(jīng)電生理監(jiān)測(cè)原理及國內(nèi)外研究等方面對(duì)THA術(shù)中神經(jīng)損傷及神經(jīng)電生理監(jiān)測(cè)技術(shù)的相關(guān)研究進(jìn)展進(jìn)行綜述。

關(guān)節(jié)成形術(shù)，置換，髖；神經(jīng)損傷；監(jiān)測(cè)，手術(shù)中；誘發(fā)電位；電生理學(xué)

神經(jīng)損傷對(duì)于人工全髖關(guān)節(jié)置換術(shù)（total hip arthroplasty,THA）來說，是一種災(zāi)難性并發(fā)癥。神經(jīng)損傷主要涉及坐骨神經(jīng)及股神經(jīng)[1]。初次THA神經(jīng)損傷發(fā)生率為0.21%～2.8%，其中，先天性髖關(guān)節(jié)發(fā)育不良（developmental dysplasia of the hip,DDH）患者THA神經(jīng)損傷發(fā)生率為5.2%[2-4]。

1 神經(jīng)損傷預(yù)后

Pekkarinen等[5]報(bào)道，4339例髖關(guān)節(jié)置換患者中，共發(fā)生27例坐骨神經(jīng)損傷，8例完全恢復(fù)，7例部分恢復(fù)，12例殘留永久性嚴(yán)重功能障礙。Farrell等[6]報(bào)道大多數(shù)THA術(shù)后坐骨神經(jīng)損傷患者下肢肌力無法完全恢復(fù)。單純腓總神經(jīng)較坐骨神經(jīng)易恢復(fù)，感覺障礙優(yōu)于運(yùn)動(dòng)障礙。同坐骨神經(jīng)比較，股神經(jīng)損傷預(yù)后相對(duì)較好[7,8]。Simmons等[9]報(bào)道15例拉鉤導(dǎo)致股神經(jīng)牽拉傷均完全恢復(fù)；髖臼側(cè)骨水泥壓迫造成的股神經(jīng)損傷經(jīng)手術(shù)取出水泥后，大部分患者獲得完全恢復(fù)。當(dāng)考慮血腫、螺釘、骨水泥等機(jī)械因素壓迫時(shí)，應(yīng)及時(shí)手術(shù)解除壓迫[10]。對(duì)于肢體延長造成神經(jīng)損傷，學(xué)者意見尚未統(tǒng)一，Sakai和Silbey[11]認(rèn)為，更換假體或減少股骨頸長度可有效治療坐骨神經(jīng)損傷，而Unwin和Scott[12]認(rèn)為，應(yīng)及時(shí)屈曲髖膝關(guān)節(jié)，緩解神經(jīng)張力，密切觀察。

2 神經(jīng)損傷危險(xiǎn)因素

坐骨神經(jīng)不完全性損傷最常見的原因是牽拉或挫傷、下肢延長，4 cm或15%或?yàn)樯窠?jīng)延長的極限距離[13,14]。神經(jīng)損傷與下肢延長無明顯關(guān)系，而與手術(shù)操作和手術(shù)難度有關(guān)[15-17]。在CroweⅣ型DDH患者中，由于脫位位置較高，臀中肌、臀小肌、闊筋膜張肌、關(guān)節(jié)囊短縮，強(qiáng)行延長肢體可造成神經(jīng)血管急性牽拉傷。其他危險(xiǎn)因素包括女性、骨關(guān)節(jié)炎、類風(fēng)濕性關(guān)節(jié)炎、后入路、髖關(guān)節(jié)屈曲內(nèi)旋位融合。Nercessian等[18]報(bào)道，7133例患者中，59%為女性，但神經(jīng)損傷患者中女性比例達(dá)到71%。目前女性神經(jīng)損傷發(fā)生率高于男性的確切原因尚未明確，可能跟女性懷孕后血管神經(jīng)走形變化有關(guān)[19]。Adrian等[20]報(bào)道，42例THA，其中，22例選擇后外側(cè)入路，20例選擇直接外側(cè)入路，二者神經(jīng)損傷發(fā)生率比較，差異無統(tǒng)計(jì)學(xué)意義，而通過神經(jīng)電生理監(jiān)測(cè)發(fā)現(xiàn)4例直接外側(cè)入路患者神經(jīng)損傷，無臨床癥狀。

3 神經(jīng)電生理監(jiān)測(cè)技術(shù)

目前，術(shù)中神經(jīng)電生理監(jiān)測(cè)已廣泛應(yīng)用于脊柱外科、神經(jīng)外科、甲狀腺外科手術(shù)[21,22]。術(shù)者可獲得實(shí)時(shí)、可靠、精確、客觀的術(shù)中信息，以更好的判斷脊髓、神經(jīng)根功能。術(shù)中神經(jīng)電生理監(jiān)測(cè)手段包括肌電圖（electomyogram,EMG）、運(yùn)動(dòng)誘發(fā)電位（motor evoked potential,MEP）、體感誘發(fā)電位（somatosensory evoked potential,SEP）。誘發(fā)電位系刺激周圍神經(jīng)，通過向心傳導(dǎo)引起中樞神經(jīng)的電活動(dòng)，成為體感誘發(fā)電位，或相反，刺激中樞神經(jīng)，通過神經(jīng)傳導(dǎo)，引起周圍神經(jīng)元的電活動(dòng)，刺激大腦皮質(zhì)的運(yùn)動(dòng)區(qū)，通過脊髓內(nèi)椎體束傳導(dǎo)在上肢或下肢的肌肉接受肌肉活動(dòng)電位者稱運(yùn)動(dòng)誘發(fā)電位[23]。

3.1 體感誘發(fā)電位

體感誘發(fā)電位指在頭皮接受大腦皮質(zhì)電位活動(dòng)，記錄生物電活動(dòng)波形的方法，可監(jiān)護(hù)體感通路上從外周神經(jīng)到大腦皮層的功能狀態(tài)。體感誘發(fā)電位異常評(píng)估標(biāo)準(zhǔn)[24]為波幅峰值下降50%和（或）潛伏期延長10%。Kennedy等[25]報(bào)道，波幅峰值下降25%以內(nèi)是可以接受的。

3.2 運(yùn)動(dòng)誘發(fā)電位

由于神經(jīng)損傷或受壓時(shí)，感覺通道和運(yùn)動(dòng)傳導(dǎo)束的損害程度可能不一致，運(yùn)動(dòng)誘發(fā)電位可彌補(bǔ)體感誘發(fā)電位缺陷，客觀全面地反應(yīng)脊髓功能。采用表面電極或針狀電極，單極記錄或雙極記錄，禁用于兒童、癲癇患者、安裝心臟起搏器患者、血管性腦出血和低氧造成的腦損傷患者，對(duì)于應(yīng)用此法的患者，先行腦電圖檢查也是必要的[26]。常用的刺激方法包括經(jīng)顱電刺激及磁刺激。根據(jù)信號(hào)接收部位的不同，分為脊髓運(yùn)動(dòng)誘發(fā)電位（spinal MEP,SMEP），神經(jīng)運(yùn)動(dòng)誘發(fā)電位（neural MEP,NMEP）和肌肉運(yùn)動(dòng)誘發(fā)電位（muscle MEP,MMEP）。肌肉運(yùn)動(dòng)誘發(fā)電位異常評(píng)估標(biāo)準(zhǔn)為全或無。肌肉運(yùn)動(dòng)誘發(fā)電位高電壓刺激會(huì)引起小幅度肌肉收縮，需與手術(shù)醫(yī)生溝通后操作。神經(jīng)運(yùn)動(dòng)誘發(fā)電位異常評(píng)估標(biāo)準(zhǔn)[23]為潛伏期延長10%和波幅下降80%，無需中斷手術(shù)，可增加刺激頻率，從而增加監(jiān)測(cè)陽性率。

3.3 肌電圖

神經(jīng)肌肉在興奮時(shí)，發(fā)生生物電的變化，將其引導(dǎo)出來加以放大即為肌電圖，將針電極刺入骨骼肌可引出肌電圖，其可實(shí)時(shí)監(jiān)測(cè)并及時(shí)將陽性結(jié)果反饋給手術(shù)醫(yī)生。肌電圖分為自發(fā)肌電圖和誘發(fā)肌電圖兩種[25]。前者被動(dòng)記錄肌肉的電活動(dòng)，而不干預(yù)，后者通過電極釋放微量電流，由其支配肌肉的電極記錄電活動(dòng)。脊柱外科手術(shù)中通過誘發(fā)肌電圖確定內(nèi)固定與神經(jīng)根的相對(duì)位置，如果誘發(fā)肌電圖連續(xù)爆發(fā)可疑波形，提示內(nèi)固定過于靠近神經(jīng)根[26]。肌電圖異常評(píng)估標(biāo)準(zhǔn)[23]為連續(xù)性爆發(fā)波形，停止操作后短時(shí)間內(nèi)仍不恢復(fù)。

3.4 麻醉對(duì)神經(jīng)電生理監(jiān)測(cè)的影響

人工全髖關(guān)節(jié)置換術(shù)理論上全身麻醉、硬膜外麻醉、腰麻或者腰硬外聯(lián)合阻滯麻醉都可達(dá)到麻醉效果，所以麻醉方式、麻醉藥物、麻醉深度、肌松劑的使用，血壓、體溫、血氧飽和度、二氧化碳分壓等也關(guān)系到監(jiān)測(cè)的準(zhǔn)確性及靈敏度[26]。異丙酚靜脈麻醉基本不影響監(jiān)測(cè)，而過量的瑞芬太尼則有抑制作用；在不影響監(jiān)測(cè)及增強(qiáng)麻醉效果的前提下，可代償使用利多卡因。各種類型吸入性烷類麻醉藥物和肌松藥對(duì)下肢手術(shù)監(jiān)測(cè)影響較大，尤其是運(yùn)動(dòng)誘發(fā)電位。肌松藥可有效阻斷神經(jīng)肌肉接頭興奮的傳遞，從而達(dá)到松弛肌肉的目的，按作用時(shí)間分為長效、短效兩種。肌松效果顯著干擾運(yùn)動(dòng)誘發(fā)電位，對(duì)由于CroweⅣ型髖關(guān)節(jié)發(fā)育不良患者術(shù)中不可避免地需要使用肌松藥以延長肢體。如使用運(yùn)動(dòng)誘發(fā)電位，則必須使用超短時(shí)效、短時(shí)效肌松藥，方可最大程度上減少肌松藥物對(duì)其干擾，等待肌松藥物代謝可能會(huì)延長手術(shù)時(shí)間，這限制了運(yùn)動(dòng)誘發(fā)電位在DDH患者關(guān)節(jié)置換中的應(yīng)用。

3.5 其他干擾因素

手術(shù)室各種電場(chǎng)、磁場(chǎng)均會(huì)影響神經(jīng)電生理監(jiān)測(cè)，比如手術(shù)床、麻醉劑、電刀電凝機(jī)、術(shù)中透視、無影燈、自體血回收處理機(jī)、CT、核磁等[27]。而不同機(jī)器對(duì)干擾的敏感度同樣存在差異。所以理想的狀態(tài)是關(guān)閉除手術(shù)必需以外的設(shè)備、同一手術(shù)室手術(shù)、同一機(jī)器監(jiān)測(cè)。

4 國外相關(guān)研究

Stone等[28]首次在髖關(guān)節(jié)置換術(shù)中運(yùn)用體感誘發(fā)電位監(jiān)測(cè)，證明神經(jīng)監(jiān)測(cè)可能在髖關(guān)節(jié)翻修術(shù)中有實(shí)際意義。Ohannes等[18]在髖關(guān)節(jié)翻修術(shù)臨床對(duì)照研究中運(yùn)用體感誘發(fā)電位，發(fā)現(xiàn)術(shù)中體感誘發(fā)電位神經(jīng)監(jiān)測(cè)可降低神經(jīng)損傷的風(fēng)險(xiǎn)。Pereles等[29]在52例髖關(guān)節(jié)置換術(shù)中運(yùn)用體感誘發(fā)電位監(jiān)測(cè)，8例共11次出現(xiàn)監(jiān)測(cè)陽性，其中，9次發(fā)生在向前外側(cè)牽拉股骨近端時(shí)，終止操作后恢復(fù)正常，與患者年齡、性別、肢體延長長度、術(shù)前關(guān)節(jié)活動(dòng)度無關(guān)。Satcher等[30]在27例髖關(guān)節(jié)翻修術(shù)中運(yùn)用運(yùn)動(dòng)誘發(fā)電位及自發(fā)肌電圖神經(jīng)監(jiān)測(cè)發(fā)現(xiàn)，重建髖臼時(shí)最易損傷坐骨神經(jīng)，因此，后側(cè)入路處理髖臼時(shí)應(yīng)避免過度屈曲髖關(guān)節(jié)，以免坐骨神經(jīng)接觸前方髖臼組件；15例出現(xiàn)爆發(fā)電位，其中運(yùn)動(dòng)誘發(fā)電位10例，自發(fā)肌電圖5例，及時(shí)終止操作，術(shù)后未發(fā)現(xiàn)神經(jīng)損傷癥狀，1例術(shù)后由于硬膜外血腫導(dǎo)致雙側(cè)下肢一過性癱瘓，術(shù)中神經(jīng)監(jiān)測(cè)未見異常。Sutherland等[31]在44例復(fù)雜人工髖關(guān)節(jié)置換術(shù)和髖關(guān)節(jié)翻修術(shù)中應(yīng)用自發(fā)肌電圖神經(jīng)監(jiān)測(cè)發(fā)現(xiàn)，5例術(shù)中爆發(fā)連續(xù)性神經(jīng)損傷反應(yīng)，中止操作后均恢復(fù)正常，術(shù)后無神經(jīng)癥狀，1例術(shù)后坐骨神經(jīng)支配區(qū)感覺麻木，無運(yùn)動(dòng)障礙，術(shù)中未監(jiān)測(cè)到陽性反應(yīng)。Brown等[32]報(bào)道，由于體感誘發(fā)電位易受干擾，在63例髖關(guān)節(jié)翻修術(shù)中選用自發(fā)肌電圖聯(lián)合神經(jīng)旁刺激電位神經(jīng)監(jiān)測(cè)，共監(jiān)測(cè)到25次爆發(fā)電位，解除誘因后均恢復(fù)正常，術(shù)后無坐骨神經(jīng)損傷癥狀，因此認(rèn)為術(shù)中神經(jīng)監(jiān)測(cè)可為神經(jīng)損傷提供實(shí)時(shí)有效的證據(jù)，明顯縮短手術(shù)時(shí)間，但神經(jīng)監(jiān)測(cè)技術(shù)需要一定的學(xué)習(xí)曲線。Sutter等[33]報(bào)道69例復(fù)雜髖關(guān)節(jié)手術(shù)采用多模式神經(jīng)電生理監(jiān)測(cè)，記錄到24例術(shù)中監(jiān)測(cè)陽性，僅1例術(shù)后發(fā)現(xiàn)神經(jīng)損傷癥狀，無假陽性與假陰性。而Rasmussen等[34]發(fā)現(xiàn)，在一項(xiàng)775例應(yīng)用體感誘發(fā)電位神經(jīng)監(jiān)測(cè)的髖關(guān)節(jié)置換術(shù)臨床對(duì)照研究中，實(shí)驗(yàn)組神經(jīng)損傷發(fā)生率為2.8%，與對(duì)照組的2.7%比較，差異無統(tǒng)計(jì)學(xué)意義，認(rèn)為神經(jīng)監(jiān)測(cè)并不能預(yù)計(jì)或預(yù)防坐骨神經(jīng)損傷的發(fā)生。Shiramizu等[35]報(bào)道，對(duì)23例髖關(guān)節(jié)置換者應(yīng)用運(yùn)動(dòng)誘發(fā)電位術(shù)中監(jiān)測(cè)，發(fā)現(xiàn)髖關(guān)節(jié)屈曲60°，內(nèi)旋60°，膝關(guān)節(jié)屈曲到最大角度時(shí)神經(jīng)壓力最小。由于人工髖關(guān)節(jié)置換術(shù)中，神經(jīng)損傷發(fā)生率相對(duì)較低，所以現(xiàn)有文獻(xiàn)并不支持普通人工關(guān)節(jié)置換術(shù)中常規(guī)神經(jīng)電生理監(jiān)測(cè)，但在髖關(guān)節(jié)翻修或髖關(guān)節(jié)發(fā)育不良的關(guān)節(jié)置換術(shù)中，其對(duì)預(yù)防神經(jīng)損傷有幫助。

5 國內(nèi)相關(guān)研究

目前，國內(nèi)在關(guān)節(jié)置換中的神經(jīng)電生理監(jiān)測(cè)研究較少。蔣青等[36]報(bào)道，對(duì)12例復(fù)雜全髖關(guān)節(jié)置換術(shù)患者，術(shù)前清醒狀態(tài)下行體感誘發(fā)電位檢查，術(shù)中麻醉后行體感誘發(fā)電位監(jiān)測(cè)發(fā)現(xiàn)，體感誘發(fā)電位監(jiān)測(cè)對(duì)預(yù)防全髖關(guān)節(jié)置換術(shù)中坐骨神經(jīng)損傷有幫助，尤其對(duì)下肢短縮或翻修病例更有價(jià)值。陳藝等[37]報(bào)道，10例復(fù)雜全髖關(guān)節(jié)置換術(shù)中，采用經(jīng)顱電刺激運(yùn)動(dòng)誘發(fā)電位和自發(fā)肌電圖聯(lián)合監(jiān)測(cè)預(yù)防下肢周圍神經(jīng)損傷發(fā)現(xiàn)，聯(lián)合運(yùn)用經(jīng)顱電刺激運(yùn)動(dòng)誘發(fā)電位和自發(fā)肌電圖實(shí)時(shí)監(jiān)測(cè)能及時(shí)反映復(fù)雜全髖關(guān)節(jié)置換術(shù)中下肢周圍神經(jīng)受激惹情況和運(yùn)動(dòng)功能狀態(tài)，預(yù)防醫(yī)源性神經(jīng)損傷，尤其對(duì)于需要延長下肢或翻修的患者，更值得在臨床推廣應(yīng)用。

6 小結(jié)

神經(jīng)電生理監(jiān)測(cè)在人工全髖關(guān)節(jié)置換術(shù)中應(yīng)用較少，預(yù)測(cè)的敏感性及精確性仍需進(jìn)一步研究，現(xiàn)有證據(jù)表明，復(fù)雜髖關(guān)節(jié)置換術(shù)中多模式神經(jīng)電生理監(jiān)測(cè)可有效地預(yù)測(cè)及預(yù)防下肢周圍神經(jīng)損傷，但因花費(fèi)較高、需要專門的技術(shù)指導(dǎo)、手術(shù)時(shí)間延長限制了其應(yīng)用。

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Research progress on nerve injury and intraoperative neurophysiologicall monitoring in total hip arthroplasty

KONG Xiangpeng,CHAI Wei,NI Ming,LI Xiang,WANG Yan*

(Department of Orthopedic Surgery,Chinese PLAGeneral Hospital,Beijing 100853,China)

Total hip arthroplasty(THA)is the earliest and most widely-used joint replacement surgery.Nerve injury is one of the rare postoperative complications,affecting the patients'prognosis seriously.The literatures show that multimodal neurophysiological monitoring can effectively forecast and prevent the peripheral nerve injury in complicated hip arthroplasty. In this paper we reviewed the research progress on nerve injury and neurophysiological monitoring in THA from aspects as the incidence of nerve injury,nerve anatomy,prognosis,risk factors,intraoperative neurophysiological monitoring and latest studies worldwide.

Arthroplasty,Replacement,Hip;Nerve Injury;Monitoring,Intraoperative;Evoked Potential;Electrophysiology

2095-9958（2017）06-0 265-04

10.3969/j.issn.2095-9958.2017.03-21

*通信作者：王巖，E-mail：yanwang301@163.com