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.

Claims

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.

 

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