ELECTROMYOGRAPHY, NERVE ACTION POTENTIAL, AND COMPOUND MOTOR ACTION POTENTIALS IN OBSTETRIC BRACHIAL PLEXUS LESIONS: VALIDATION IN THE ABSENCE OF A "GOLD STANDARD"
ELECTROMYOGRAPHY, NERVE ACTION POTENTIAL, AND COMPOUND MOTOR ACTION POTENTIALS IN OBSTETRIC BRACHIAL PLEXUS LESIONS: VALIDATION IN THE ABSENCE OF A "GOLD STANDARD"
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DOI：
10.1227/01.neu.0000338429.66249.7d
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发表时间：
2009-10-01
期刊：
影响因子：
4.8
通讯作者：
van Dijk, J. Gert
中科院分区：
文献类型：
--
作者：
Malessy, Martijn J. A.;Pondaag, Willem;van Dijk, J. Gert
目的：产程中牵引臂丛引起的产科臂丛损伤(OBPLs)。通常，在这些病变中，神经通常不会完全破裂，而是形成“连续性神经瘤”。即使在最严重的OBPL病变中，至少有一些轴突将穿过这种连续性神经瘤，到达病变部位远端的管子。这些轴突可能特别容易出现异常的分支和错误的路径，这可能解释了协同收缩的典型特征。另一个可能减少功能再生的因素是可能发生不正确的中央电机编程。手术应仅限于不会发生自发功能恢复的严重病例，即神经衰弱或根性撕脱。一个主要的问题是如何预测自发神经生长或神经重建手术后的功能是最好的。当决定进行早期手术探查时，如何处理连续性神经瘤可能是一个问题。术中评估是困难的，依赖于经验，但即使是有经验的人，也可能做出错误判断。方法：我们进行了一项观察性研究，以评估早期肌电图(1个月大)是否能够预测严重的病变。结果：根据临床表现和二头肌针刺肌电图可在1个月龄时发现重度OBPL。这一结果需要独立的验证，目前正在进行中。神经动作电位和复合运动动作电位的记录在撕脱、神经传导、轴索传导和正常之间有统计学意义的差异。对于个体患者，找不到临床上有用的临界点。术中神经动作电位和复合运动动作电位的记录不会增加手术中的决策。结论：由于缺乏评估OBPL病变严重程度的“金标准”，OBPL复合体的预后研究。讨论了用于获得最佳可能解决方案的当前可用的评估策略。
OBJECTIVE: Obstetric brachial plexus lesions (OBPLs) are caused by traction to the brachial plexus during labor. Typically, in these lesions, the nerves are usually not completely ruptured but form a "neuroma-in-continuity." Even in the most severe OBPL lesions, at least some axons will pass through this neuroma-in-continuity and reach the tubes distal to the lesion site. These axons may be particularly prone to abnormal branching and misrouting, which may explain the typical feature of co-contraction. An additional factor that may reduce functional regeneration is that improper central motor programming may occur. Surgery should be restricted to severe cases in which spontaneous restoration of function will not occur, i.e., in neurotmesis or root avulsions. A major problem is how to predict whether function will be best after spontaneous nerve outgrowth or after nerve reconstructive surgery. When a decision has been made to perform an early surgical exploration, what to do with the neuroma-in-continuity can be a problem. The intraoperative appraisal is difficult and depends on experience, but even in experienced hands, misjudgment can be made.METHODS: We performed an observational study to assess whether early electromyography (at the age of 1 month) is able to predict severe lesions. Additionally, the value of intraoperative nerve action potential and compound motor action potentials was investigated.RESULTS: Severe cases of OBPL can be identified at 1 month of age On the basis of clinical findings and needle electromyography of the biceps. This outcome needs independent validation, which is currently in progress. Nerve action potential and compound motor action potential recordings show statistically significant differences on the group level between avulsion, neurotmesis, axonotmesis, and normal. For the individual patient, a clinically useful cutoff point could not be found. Intraoperative nerve action potential and compound motor action potential recordings do not add to the decision making during surgery.CONCLUSION: The absence of a "gold standard" for the assessment of the severity of the OBPL lesion makes prognostic studies of OBPL complex. The currently available assessment strategies used to obtain the best possible solutions are discussed.