The method of identification of the facial nerve when removing large extracerebral tumors mostomozzhechkovogo angle
The invention relates to medicine, namely neurosurgery. The essence of the method lies in the fact that after vnutrikoronarnogo removal of the tumor mass produce transcapillary stimulation of isolated bipolar electrode in oral-caudal direction along several parallel lines. Measure the amplitude of the received M-responses and produce a mapping of a tumor capsule. Identify accurate projection of the passage of the facial nerve on the basis of tumor capsule, in which the stimulation received the maximum amplitude of the muscle response. Then the facial nerve is separated from the capsule of the tumor. The method improves the accuracy of determination. 7 Il.
The invention relates to medicine, namely, neurosurgery, and can be used in operations to remove large tumors mostomozzhechkovogo angle.
The known method of identification of the facial nerve during removal of neuromas VIII nerve (A. C. of the USSR №1113097, 1982), in order to determine the localization of the facial nerve, exercise, electrical stimulation via the inner surface of the capsule of the tumor, after vnutrikoronarnogo removal of the tumor mass. Identify the course of the nerve and before separating the key muscle responses to stimulation of the facial nerve using visual observation of the face of the patient, that is not possible to accurately trace the course of the facial nerve in the capsule or stroma of the tumor, since visual inspection is subjective and often difficult to fix different in amplitude of muscle contraction. In addition, you can get a false positive muscle responses during stimulation away from the facial nerve when the bypass current through the liquid medium in the wound. If the facial nerve is pushed back by a tumor in the oral direction, false-positive responses can also be obtained with the motor portion of the trigeminal nerve.
The closest to the technical nature of the claimed method is the identification of the facial nerve during removal of tumors mostomozzhechkovogo angle (Coaxial bipolar insulated electrode to identify the neural tissue. Secuties, A., Schmid U. D. Questions of neurosurgery, 1996, No. 3, S. 41-44) adopted for the prototype. For identification of the facial nerve using electromyography and alternate stimulation bipolar and monopolar electrodes. After the implementation of the access produce vnutricapsulino removal of the tumor. Then, to approximate locations of the tumor-free nerve, producing monopolar trims the lead bipolar stimulation coaxial, insulated to the tip electrode through the inner surface of the capsule. Identify the projection of the facial nerve, and then remove the remaining part of the tumor with preservation of the facial nerve. The disadvantage of the prototype is the lack of accurate data about the projection of the facial nerve. Enough high-amplitude muscle responses can be obtained and at a distance from the nerve. It is also hard to differentiate false-positive results caused by the shunting of current through the liquid medium in the wound or stimulation in the projection of the trigeminal nerve. Muscular responses from facial muscles can be obtained by stimulation away from the facial nerve, even in strict compliance with all technical requirements and the exclusion of false-positive responses from the trigeminal nerve. This complicates the identification of the facial nerve and increases the risk of damage.
The invention is directed to a method of identification of the facial nerve when removing large extracerebral tumors mostomozzhechkovogo angle, providing the ability to accurately determine the projection of the passage of the facial nerve in the capsule of the tumor.
The essence of the proposed method lies in the fact that after vnutrikoronarnogo remove the actual direction along several parallel lines. Measure the amplitude of the received M-responses and produce a mapping of a tumor capsule. Identify accurate projection of the passage of the facial nerve on the basis of tumor capsule, in which the stimulation received the maximum amplitude of the muscle response. Then the facial nerve is separated from the capsule of the tumor.
The inventive method differs from the prototype in that register and compare the amplitude of the muscle response, produce a mapping of a tumor capsule, exercising 3-5 lines of electrical stimulation in the oral-caudal direction from the medial departments of the capsule and to the rear face of the pyramid of the temporal bone, and identify the course of the nerve on the capsule of the tumor.
The method is as follows. After vnutrikoronarnogo remove the main tumor mass produce transcapillary stimulation of the facial nerve isolated bipolar electrode. This should achieve the same thickness is left of the tumor capsule. Muscle responses are recorded on the electromyograph. The distance between the branches of the stimulator should not exceed one millimeter. Produce stimulation from oral pole of the tumor to the caudal using pulse current with rectangular pulses h of stimulation remains constant and equal depending on the thickness of the capsule 1-4 mA. As you progress through the capsule of the tumor and proximity to the facial nerve on the electromyograph record the contractions of the facial muscles, the amplitude of the maximum projection of the facial nerve. Exercise 3 to 5, depending on the size of the tumor, parallel lines of stimulation in the oral-caudal direction from the medial departments of the capsule and to the rear face of the pyramid of the temporal bone, with a step of about 1 cm. The received amplitude of the muscle response measure and map, identifying a pattern in the form of increasing the amplitude of the muscle response as it approaches the point of projection of the facial nerve. Based on the data, produce a mapping of a tumor capsule. Place the capsule of the tumor with a maximum amplitude of the muscle response of the facial muscles, which are the points of the projection of the facial nerve, mark using small fragments of hemostatic sponge. Combining an imaginary line obtained location of the tumor capsule, receive with great precision projection passing of the facial nerve in the capsule of the tumor. "Safe" fragments capsules excised over a large area that allows you to visualize and microsurgical techniques to separate from the tumor liscie tests in Russian scientific research neurosurgical Institute. Professor A. L. Polenov in the surgical treatment of 8 patients with large and giant neuromas of the auditory nerve. This method allowed us to achieve a satisfactory facial nerve function in the postoperative period in all cases (1-3 score Haus-Brackmann).
Here are clinical example. Patient K., aged 23, I. B. No. 932-2002 entered neurooncological Department of the Polenov research neurosurgical Institute 23.04.2002, the Diagnosis of Neurofibromatosis type II. Giant neuroma right of the VIII nerve. Neuroma left of the VIII nerve. Neurinoma of the left C2 spine, meningioma area in the left occipital lobe. Clinical presentation at admission was presented hypertension-hydrocephalic syndrome with initial stagnation in the fundus, static and dynamic ataxia, complete loss of function of the VIII nerve on the right, light the insufficiency of the VII nerve on the right (1 point on a scale Haus-Brackmann), stem symptoms in the form of multiple nystagmus. Assessment on a scale Karnofsky 70 points. 08.05.2002 the patient had an operation: Subtotal removal of the tumor from the right-hand retrosigmoid access. Was carried out according to standard methods right retrosigmoid access. To reduce the tension of the Dura emptied most of Sato-grey abundantly krovosnabjaemah. Removed parametern and using an ultrasonic aspirator of the cage. After vnutrikoronarnogo remove the left layer of the capsule thickness of about 1.5-2 mm. According to the claimed method was carried out by mapping the left of the tumor capsule four lines of electrical stimulation with marked places of capsules with the maximum amplitude of the muscle response. Identified projection of the nerve, which is pushed by a tumor in the medial-oral direction. Used a constant current of 3 mA. At the beginning of stimulation with oral pole of the tumor along the line in the field of medial divisions of the capsules obtained low-amplitude muscle response (1.7 mV) (Fig.1). As you progress in the caudal direction, the amplitude of the muscle response was increased to 4.8 mV (Fig.2-3) with the maximum amplitude in the area of projection of the facial nerve to 12.6 mV (Fig.4). Upon further stimulation in the caudal direction, the amplitude of the muscle response was decreased (Fig.5-7). Deleted fragments capsules above and below the projection of the passage of the facial nerve. Rendered facial nerve, he intimately span with the capsule of the tumor. Acute way in the medial-lateral direction of the nerve over a large area are exempt from the tumor. Small, intimate spanny cocoonlike answers when recording EMG mode Free-run. Also left fragments of capsules up to 0.5 mm thick, intimately welded with the brain stem. The volume of the removed tumor - 95%. The postoperative course was favorable. Observed regression of hypertensive syndrome, cerebellar and stem symptoms. The function of the facial nerve in the postoperative period - 3 points on a scale Haus-Brackmann. At discharge the function of the facial nerve is 2 points on a scale Haus-Brackmann. The second stage is removed neuroma C2 spine. The patient was discharged in a compensated state. Assessment on a scale Karnofsky 80 points.
Thus, using the proposed method ensures the greatest possible radical tumor removal while maintaining satisfactory facial nerve function by measuring and comparing the amplitudes of muscle responses and mapping of a tumor capsule. This method allows to exclude false-positive results caused by the shunting of current through the liquid medium in the wound, or by stimulation in the projection of the trigeminal nerve, as the mapping capsule appearance in the series of M responses irregular high-amplitude response can relate it to false.
The way identifikationssysteme electrostimulation, electromyography and separation from the capsule under visual control, characterized in that register and compare the amplitude of the muscle response, produce a mapping of a tumor capsule, exercising 3-5 lines of electrical stimulation in the oral-caudal direction from the medial departments of the capsule and to the rear face of the pyramid of the temporal bone, and identify the course of the nerve on the capsule of the tumor.
FIELD: medicine, pulmonology.
SUBSTANCE: in patients with chronic bronchitis one should detect the level of central frequency of diaphragmatic spectrum due to myography at attempt of inhalation in case of overlapping respiratory tract at the level of residual volume (CFRVD) in Hz. Simultaneously, one should detect maximal oral inspiratory pressure (Oip)in kPa. Due to mathematical formula including altered parameters it is necessary to calculate criterial D value to diagnose hyperreactivity of respiratory tract.
EFFECT: higher efficiency of diagnostics.
FIELD: medicine, vertebrology, orthopedics, neurosurgery, traumatology.
SUBSTANCE: one should perform both horizontal and vertical vertebral traction and electrodiagnostics to detect the degree of the impact. Moreover, as electrodiagnostic trial one should apply the technique of electroneuromyography (ENMG) to detect the activity of motoneurons. Traction should be fulfilled due to distractional asymmetric and/or symmetric impact at the level of affected segment of vertebral column and/or spinal cord and its radicles. ENMG testing should be carried out both before and after traction, moreover, the nature, degree and terms of traction should be detected by positive result of motoneurons activity value. Additionally, one should conduct electrostimulation - epidural - of spinal cord at the level of its lesion or percutaneous - in projection of affected areas of spinal cord and/or affected radicles and peripheral nerves. The nature of electrostimulation impact should be determined according to altered activity of motoneurons to be detected during stimulation and after it. The method enables to decrease dystrophic processes in vertebral column and spinal cord and decrease, also, in involved spinal radicles, peripheral nerves and innervated tissues, redistribute the loading in spasmodic muscles and, thus increase stimulation of nervous tissue and activate circulation in affected areas that helps to restore muscular-tonic disorders in vertebral-motor segment and decrease autonomic-vascular disorders, trophic disorders of spinal cord and its radicles.
EFFECT: higher efficiency of therapy.
3 cl, 7 dwg, 3 ex
SUBSTANCE: method involves placing glass carrying biological indicator on skin surface in the area of muscle-under-study projection before and 3 and 7 days after intramuscular or subcutaneous Dysport® preparation introduction. The biological indicator is taken as aqueous solution mixture in 4:1:5 proportion of 0.1% of leucine, glycine, proline, serine, phenylalanine, histidine, oxyproline, arginine, glutamic and aspartic amino acids, 0.5% neuromediator solutions of dopamine and histamine, 12% magnesium sulfate solution taken in equal quantities, respectively. It is hold 2-3 min long and dried at T=+35-40°C and studied in polarized light. Distinctly demarcated polygonal compartments of radial annular orientation being observed, orbicular eye muscle tonus recovery is considered to be the case. Distinctly demarcated polygonal compartments of radial ray cruciform orientation being observed, sternocleidomastoid muscle tonus recovery is considered to be the case.
EFFECT: enhanced effectiveness of treatment.
SUBSTANCE: method involves using relative characteristics of mechanical force. It comprises two stages of provoking action and recording mechanical force. Patient applies pressure to examiner hand and the examiner resists with submaximum force at the first stage. The examiner applies supramaximum force to patient extremity at the second stage. Recording is carried out with mechanical force transducer. The data are saved in computer and relative parameters of SD/M and dMax/M are calculated and their values are compared to threshold values for given parameters. Conclusions on muscle weakness are drawn using offered criteria, that is, a muscle is considered to be weak if general test time is less than 3 s or dMax/M is lower than its threshold value or SD/M is greater than its threshold value.
EFFECT: high reliability of obtained data.
2 cl, 3 dwg, 1 tbl
FIELD: medicine, orthopedics.
SUBSTANCE: the present innovation deals with both quantitative and qualitative evaluation of functional state of paravertebral muscles. In a patient's standing position it is necessary to register electromyogram of paravertebral muscles from the right and from the left against spinous processes Th I-L V, fix a mean amplitude of muscular biopotentials, calculate the value of standardized difference being the ratio of amplitudes difference against the maximal one out of them. For evaluating a hypothetical vertebral deviation it is important to plot a diagram for distribution of standardized differences with an approximating curve - a polynomial degree VI. One should calculate integral values of bioelectrical activity of paravertebral muscles: total deviation (TD) is the summarized modules of standardized differences taken by the module. Normal coordination of paravertebral muscular activity should be characterized by the following ratio: I class (light degree of manifestation) of affected coordination could be illustrated by the following ratio: II class (moderate degree of manifestation) is restricted with the following limits: III class (pronounced manifestation) should be depicted with the following inequality: The innovation suggested is of widened functional capacities, it enables to fulfill differential evaluation of coordination of paravertebral muscular activity and, thus, improve the results of therapy in patients with pathological states, diseases and vertebral lesions.
EFFECT: higher accuracy and efficiency of evaluation.
SUBSTANCE: method involves fixing proximal asymmetry stage when mean E-waves amplitude being from 450.0 to 500.0 mcV and M-response amplitude being from 3.5 to 6 mV, asymmetry between the sides being less than 1 mV and pulse conduction speed being from 40 to 60 m/s. Mean F-waves amplitude being from 350 to 450 mcV and tachydispersion equal to 10-15 m/s with M-response amplitude being from 3.5 to 6 mV, asymmetry between the sides being less than 1 mV and pulse conduction speed being from 40 to 60 m/s, radiculopathy stage is diagnosed. Mean F-waves amplitude being from 150 to 350 mcV and tachydispersion equal to 15-20 m/s with M-response amplitude being from 1.5 to 3.5 mV, asymmetry between the sides being greater than 1 mV and pulse conduction speed being from 40 to 60 m/s, radiculopathy-axonopathy stage is diagnosed. Mean F-waves amplitude being from 150 to 350 mcV and tachydispersion equal to 15-20 m/s with M-response amplitude being from 1.5 to 3.5 mV, asymmetry between the sides being greater than 1 mV and pulse conduction speed being from 40 to 60 m/s, radiculopathy-axonopathy stage is diagnosed. Mean F-waves amplitude being from 500 to 1000 mcV and tachydispersion equal to 15-20 m/s with M-response amplitude being from 1.5 to 3.5 mV, asymmetry between the sides being greater than 1 mV and pulse conduction speed being from 40 to 60 m/s, myelopathy-radiculopathy-axonopathy stage is diagnosed.
EFFECT: high objectivity in diagnosing radicular spinal cord injuries.
4 dwg, 1 tbl
SUBSTANCE: method involves determining slow myoelectric stomach activity waves duration Tbas and slow waves duration after endoserous stomach electrostimulation in addition in s as Tstim Then, formula is used Kir = (Tstim - Tbas)/(20-Tbas)*100% for determining imposed rhythm percent Kir, where 20 is slow waves duration in norm. Kir value being greater than 60% during the first 2 days, favorable resolution of postoperative paresis within the nearest 3 days is to be predicted. Kir being less than 60%, prolonged gastroparesis clinical course is to be predicted.
EFFECT: high prognosis accuracy in postoperative period.
2 cl, 1 dwg
FIELD: medicine, diagnostics.
SUBSTANCE: the present innovation deals with predicting fibromyalgia (FM). One should detect myofascial trigger cords (MTC) in one or several areas to study sensitive points (SP) there and record microcurrents from SP and determine their value. SP should be divided into highly active - the value of microcurrent ranges 21-30 mA, active - ranges 11-20 and poorly active - ranges 1-10 mA. One should conclude upon FM diagnosis if it is possible to detect from area - not less than 80% highly active or 90% active points, from two areas and more - not less than 60% highly active or 60% active SP. The innovation suggested enables to objectivize the results of FM diagnostics.
EFFECT: higher accuracy of diagnostics.
17 dwg, 1 ex
SUBSTANCE: method involves investigating opticofacial reflex by applying electric stimulation of supraorbital nerve, infraorbital nerve. Motor response of orbicular muscle of eye is additionally examined under magnetic stimulation of medulla. Isolated latent period length increase being observed in recorded early stage responses of opticofacial reflex and motor responses of the orbicular muscle of eye, objective differentiated estimation and exact localization of I and II trigeminus branches, facial nerve and afferent paths of posterior brain.
EFFECT: high accuracy in diagnosing I and II trigeminus branches, facial nerve and afferent paths of posterior brain injury.
FIELD: medicine, obstetrics, perinatology.
SUBSTANCE: it is necessary to evaluate uterine circulation with rheohysterographic values during 2-3 cardiac cycles, moreover, current electrodes should be located at a costal arch and on a right thigh, and potential electrodes should be fixed at anterior abdominal wall in area of the bottom and inferior segment of uterine body. Then it is necessary to determine diastolic index, rheographic index and volumetric circulation in radial and spiral arteries, calculate the ratio of diastolic index against rheographic index (DI/RI) and the ratio of volumetric circulation of spiral arteries against radial arteries (SA/RA) and at DI/RI values being above 0.6 relative U and SA/RA ones being above 1.0 relative U one should diagnose initial disorders of uterine circulation that illustrate the decrease of circulatory intensity in the arteries of uterine-placental area and inhibited venous outflow from intervillous space. The innovation should be highly useful in the work of women's consultations, perinatal centers and in the Departments of Pathology in pregnant women for earlier diagnostics of affected uterine circulation in the second half of pregnancy.
EFFECT: higher accuracy and specificity of diagnostics.
4 dwg, 2 ex