不同压迫类型的责任血管在面神经显微血管减压术中的临床疗效观察

doi:10.3877/cma.j.issn.2095-123X.2020.05.002

目的

探讨持续多模态电生理监测责任血管对面神经出脑干区（REZ）不同程度的压迫在面神经显微血管减压（MVD）术中的临床意义。

方法

回顾性分析西安交通大学附属红会医院功能神经外科自2017年3月至2019年3月收治的行乙状窦后入路行面神经MVD的648例面肌痉挛患者的临床资料，术中监测侧方扩散反应（LSR）、脑干听觉诱发电位（BAEP）。根据术中观察到的面神经根部受压程度将压迫类型分为接触压迫（血管与REZ显微镜下仅见有接触）、压迹压迫（血管在REZ形成压迹）、合并穿支血管压迫（有血管分支穿过面听神经之间）、椎动脉复合体压迫，统计其病例数。观察术中受压程度与LSR消失的关系和术中BAEP变化。

结果

本组患者术前、术中均可监测到LSR，术中635例患者LSR消失，其中分离血管后LRS消失者199例，垫离血管后LRS消失者436例；LSR持续存在13例，发生术中BAEP报警者79例，其中术后发生听力障碍者41例。

结论

多模态电生理监测能够帮助术者更好的判断责任血管，血管对面神经根部的不同压迫类型与减压后LSR消失与否关系密切，LSR消失时机影响预后，并且增加BAEP报警的几率。

关键词: 面肌痉挛, 显微血管减压术, 压迫程度, 侧方扩散反应

Objective

To explore the clinical significance of continuous multi-modal electrophysiological monitoring of the different degrees of compression of the facial roots entry/exit zone (REZ) of brainstem by the responsible blood vessels in the facial nerve microvascular decompression (MVD) operation.

Methods

The clinical data of 648 patients with hemifacial spasm underwent facial nerve MVD through retrosigmoid sinus approach from March 2017 to March 2019 in Functional Neurosurgery Department of Honghui Hospital Affiliated to Xi’an Jiaotong University were analyzed retrospectively. Lateral spread response (LSR) and brainstem auditory evoked potentials (BAEP) were monitored during the operation. According to the degree of facial nerve root compression observed during the operation, the types of compression are divided into contact compression (blood vessels are only in contact with the REZ microscope), pressure compression (blood vessels form pressure marks in REZ), combined compression of perforator blood vessels (blood vessel branches passing between the facial and auditory nerves), compression of the vertebral artery complex; the number of cases was counted. The relationship between the degree of intraoperative compression and the disappearance of LSR and the change of intraoperative BAEP were observed.

Results

LSR can be monitored before and during the operation. During the operation, 635 cases of LSR disappeared and 13 cases persisted. Among them, 199 cases disappeared after the blood vessel was separated, and 436 cases disappeared after the blood vessel was removed. LSR persisted in 13 cases. A total of 79 cases of BAEP alarm occurred during the operation, including 41 cases of hearing impairment after the operation.

Conclusion

Multimodal electrophysiological monitoring can help the surgeon better judge the responsible blood vessel. Different types of pressure on the facial nerve root by blood vessels are closely related to whether LSR disappears after decompression. The timing of LSR disappearance affects the prognosis and increases the probability of BAEP alarm.

Key words: Hemifacial spasm, Microvascular decompression, Types of compression, Lateral spread response

图1 责任血管压迫REZ的分型资料

表1 术后LSR消失与否与一般临床资料的关系

病例特征		LSR消失（n=635）	LSR持续存在（n=13）	χ²值	P值
性别				0.164	0.685
	男	280	5
	女	355	8
患病侧				0.001	0.920
	左	333	7
	右	302	6
压迫模式				17.240	0.001
	接触压迫	186	1
	压迹压迫	293	3
	穿支压迫	90	7
	椎动脉复合体	66	2
术后1年预后				61.500	0.001
	症状存在	2	6
	症状消失	633	7

表1 术后LSR消失与否与一般临床资料的关系

病例特征		LSR消失（n=635）	LSR持续存在（n=13）	χ²值	P值
性别				0.164	0.685
	男	280	5
	女	355	8
患病侧				0.001	0.920
	左	333	7
	右	302	6
压迫模式				17.240	0.001
	接触压迫	186	1
	压迹压迫	293	3
	穿支压迫	90	7
	椎动脉复合体	66	2
术后1年预后				61.500	0.001
	症状存在	2	6
	症状消失	633	7

表2 血管压迫模式与LSR消失时机的关系

模式	垫离血管前（n=199）	垫离血管后（n=436）
接触压迫	85	101
压迹压迫	84^a	209^a
穿支压迫	13^ab	77^ab
椎动脉复合体	17^ab	49^ab
χ²值	31.689
P值	0.000

表2 血管压迫模式与LSR消失时机的关系

模式	垫离血管前（n=199）	垫离血管后（n=436）
接触压迫	85	101
压迹压迫	84^a	209^a
穿支压迫	13^ab	77^ab
椎动脉复合体	17^ab	49^ab
χ²值	31.689
P值	0.000

表3 随访1年后LSR消失与否与术后治愈的关系

LSR消失与否	治愈（n=640）	未愈（n=8）
消失	633	2
未消失	7	6
χ²值	0.000
P值	0.000

表3 随访1年后LSR消失与否与术后治愈的关系

LSR消失与否	治愈（n=640）	未愈（n=8）
消失	633	2
未消失	7	6
χ²值	0.000
P值	0.000

表4 BAEP报警与术后发生听力下降的关系

报警类型	有听力下降（n=41）	无听力下降（n=38）	χ²值	P值
潜伏期延迟	5	21
波幅下降	19	10	11.942	<0.001^a
两者均有	17	7	13.487	<0.001^a

表4 BAEP报警与术后发生听力下降的关系

报警类型	有听力下降（n=41）	无听力下降（n=38）	χ²值	P值
潜伏期延迟	5	21
波幅下降	19	10	11.942	<0.001^a
两者均有	17	7	13.487	<0.001^a

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Observation on the clinical effect of different compression types of responsible blood vessels in facial nerve microvascular decompression

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Observation on the clinical effect of different compression types of responsible blood vessels in facial nerve microvascular decompression