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DOI: 10.1055/s-2002-22109
Georg Thieme Verlag Stuttgart · New York
Methode, Indikationen und kritische Wertung der intraoperativen Nervenfunktionsdiagnostik[*]
Methods, Indications and Validation of Intraoperative Nerve Conductivity TestingPublication History
Publication Date:
18 March 2002 (online)
Zusammenfassung
Bei Nervenoperationen werden elektrophysiologische Methoden intraoperativ angewandt, um Gehalt, Qualität und Kontinuität von Nervenfasern zu beurteilen mit dem Ziel, chirurgische Maßnahmen der Art der Läsion optimal anzupassen. Histologische Kontrollen und das Operationsresultat werden zur kritischen Bewertung der Funktionsdiagnostik herangezogen.
Methode und Besonderheiten der intraoperativen Ableitung von Nervenaktionspotenzialen (NAP) und somatosensorisch evozierten Potenzialen (SEP), deren Interpretation und deren Einschränkungen werden beschrieben.
Die intraoperative Funktionsdiagnostik hat sich uns bei Läsionen in Kontinuität als zuverlässige Methode zum frühen Nachweis einer erfolgten oder ausgebliebenen spontanen Reinnervation eines Nervs oder von Nervenfaszikeln bewährt. Nach unserer Erfahrung können mit ihrer Hilfe unnötige Resektionen weitgehend vermieden werden. Neben dieser wichtigen Indikation kann die Funktionsdiagnostik mit Vorteil auch bei anderen Nervenoperationen eingesetzt werden, bei denen die Qualität des Nervenparenchyms aus diagnostischer und strategischer Sicht von Interesse ist. Beispielhaft werden die intraoperative Evaluation von Armplexusverletzungen einschließlich der Plexuskontinuität zum Rückenmark, die Beurteilung der proximalen Anschlussstelle bei der Nervenrekonstruktion, das Aufsuchen einer Nervenläsion und die pathophysiologische Beurteilung von Nervenfunktionsstörungen als weitere Indikationen vorgestellt.
Die intraoperative Elektrodiagnostik ist eine nützliche Ergänzung der konventionellen präoperativen klinischen, elektrophysiologischen und bildgebenden Diagnostik und der sorgfältigen intraoperativen morphologischen Beurteilung. Sie ist nur in der Synopsis mit diesen Befunden aufschlussreich.
Abstract
During nerve surgery, electrodiagnostic methods are applied to assess the availability and viability of nerve fibers and to adjust operative measures accordingly. The validity of this procedure is verified by histology and by the outcome of the operation. This paper explains the techniques of intraoperative nerve action potential (NAP) and somatosensory evoked potential (SEP) recording, how to interpret the electrodiagnostic results, and describes both the special features and the limitations of the methods.
We found reliable results of neurography, detecting the presence or absence of spontaneous nerve regeneration across a lesion in continuity months before the reinnervation reached its final target. Based on our results, we suggest that NAP recording of the exposed nerve can widely prevent unnecessary nerve or fascicle resection. Besides this important indication, the nerve function evaluation was successfully used in nerve surgery whenever the quality of the nerve parenchyma was crucial to the operative management. Further indications such as evaluating brachial plexus lesions and the condition of nerve roots, judging the proximal coaptation site in nerve reconstruction, tracing the site of a nerve lesion and identifying the pathophysiology of nerve malfunction are exemplified.
Intraoperative nerve conductivity testing should not be considered as a replacement of but rather as a complement to preoperative clinical, electrophysiological and imaging evaluations and a thorough intraoperative morphological examination.
Schlüsselwörter
Intraoperative Nervenaktionspotenziale - NAP - intraoperative Funktionsdiagnostik - intraoperative evozierte Potenziale - SEP - Nervenchirurgie - Plexuschirurgie
Key words
Intraoperative nerve action potential recording - NAP - intraoperative evoked potential - SEP - nerve reconstruction - brachial plexus surgery
1 Teilweise vorgetragen auf der 22. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße vom 5. bis 7. Oktober 2000 in Zürich
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1 Teilweise vorgetragen auf der 22. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße vom 5. bis 7. Oktober 2000 in Zürich
Dr. med. Doris Burg
Klinik für Wiederherstellungschirurgie, Universitätsspital Zürich
Rämistraße 100
8091 Zürich
Schweiz
Email: doris.burg@chi.usz.ch