A Neuromonitoring Approach to Facial Nerve Preservation During Image- guided Robotic Cochlear Implantation
A Neuromonitoring Approach to Facial Nerve Preservation During Image- guided Robotic Cochlear Implantation
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DOI：
10.1097/mao.0000000000000914
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发表时间：
2016-01-01
影响因子：
2.1
通讯作者：
Weber, Stefan
中科院分区：
文献类型：
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作者：
Anso, Juan;Duer, Cilgia;Weber, Stefan
假设：在图像引导人工耳蜗植入术中，在钻孔距离不安全的情况下，多电极探针结合优化的刺激方案可以提供足够的灵敏度和特异性，作为保护面神经的有效安全机制。背景：一种微创人工耳蜗植入是通过图像引导和机器人辅助的通道钻到中耳腔。该方法要求钻头在距离面神经1毫米以下的地方通过，因此需要保护这一关键结构的安全机制。神经监测目前用于确定乳突切除术中面神经的接近程度，但缺乏有效区分微创入路中经历的近距离范围所需的敏感性和特异性，这可能是因为钻孔隧道中非绝缘刺激钻孔工具的电流分流以及未优化的刺激参数。为此，我们提出了一种先进的神经监测方法，使用不同水平的刺激参数以及集成的双极和单极刺激探针。材料和方法：进行了一项体内研究（绵羊模型），在特定计划和导航的距离上进行测量，以确定特定的刺激参数集与拟议的神经监测系统相结合是否可以可靠地检测到即将发生的与面神经的碰撞。为了神经监测探头的准确定位，我们使用了专用的图像引导人工耳蜗植入机器人系统，并在术后显微计算机断层图像上校正钻孔精度。结果：分析了5个不同被试的29条轨迹，发现在距离面神经0.5mm以下与面神经碰撞的轨迹（距离95%）的刺激阈值与面神经距离之间存在相关性。然而，当刺激阈值降低到0.3mA或更低时，面神经距离检测范围降低到0.1mm以下（>95%灵敏度）。随后对3例具有代表性的病例进行组织病理学随访，其中神经监测系统能够可靠地检测到与面神经的碰撞（距离）
Hypothesis:A multielectrode probe in combination with an optimized stimulation protocol could provide sufficient sensitivity and specificity to act as an effective safety mechanism for preservation of the facial nerve in case of an unsafe drill distance during image-guided cochlear implantation.Background:A minimally invasive cochlear implantation is enabled by image-guided and robotic-assisted drilling of an access tunnel to the middle ear cavity. The approach requires the drill to pass at distances below 1mm from the facial nerve and thus safety mechanisms for protecting this critical structure are required. Neuromonitoring is currently used to determine facial nerve proximity in mastoidectomy but lacks sensitivity and specificity necessaries to effectively distinguish the close distance ranges experienced in the minimally invasive approach, possibly because of current shunting of uninsulated stimulating drilling tools in the drill tunnel and because of nonoptimized stimulation parameters. To this end, we propose an advanced neuromonitoring approach using varying levels of stimulation parameters together with an integrated bipolar and monopolar stimulating probe.Materials and Methods:An in vivo study (sheep model) was conducted in which measurements at specifically planned and navigated lateral distances from the facial nerve were performed to determine if specific sets of stimulation parameters in combination with the proposed neuromonitoring system could reliably detect an imminent collision with the facial nerve. For the accurate positioning of the neuromonitoring probe, a dedicated robotic system for image-guided cochlear implantation was used and drilling accuracy was corrected on postoperative microcomputed tomographic images.Results:From 29 trajectories analyzed in five different subjects, a correlation between stimulus threshold and drill-to-facial nerve distance was found in trajectories colliding with the facial nerve (distance 95%) at distances to the facial nerve below 0.5mm. However, reduction in stimulus threshold to 0.3mA or lower resulted in a decrease of facial nerve distance detection range below 0.1mm (>95% sensitivity). Subsequent histopathology follow-up of three representative cases where the neuromonitoring system could reliably detect a collision with the facial nerve (distance