Volume 95  ·  Issue 21  ·  2015

Neuroelectrophysiological monitoring (NM) involves electroencephalography (EEG), electromyography (EMG) and evoked potential (EP) techniques. These techniques not only play an important role in monitoring the depth of anesthesia during operation and ensuring the safety of operation, but also complement the clinical physical examination together with neuroimaging examination, and also play an important role in the diagnosis, differential diagnosis and prognosis prediction of patients in intensive care unit (ICU). Since NM was applied in neurosurgery and prognosis assessment of ICU patients in the 20th century, this technology has been widely used in many clinical disciplines. In recent years, NM has been initially developed in China. In order to promote the development of this work in China's health science, this issue of Chinese Medical Journal published key articles on clinical research and research progress of NM^{[1,2,3,4,5,6,7,8,9,10]}。 Compared with developed countries such as Europe and America, there are still many problems in the application scope of this technology and the standardized training of professionals in China. The history, current situation, existing problems and future development direction of NM are reviewed below.

Cerebrovascular diseases pose a great threat to people's health because of their sudden onset, serious consequences and difficult treatment. At present, microsurgery is still an important method for the treatment of cerebrovascular diseases. In recent years, with the continuous increase of people's health awareness and the gradual improvement of examination and diagnosis level, more and more subclinical symptoms of cerebrovascular diseases have been discovered and diagnosed. This inevitably puts forward higher requirements for clinicians, that is, protecting the patient's neurological function to the greatest extent in the treatment process is more important to some extent than treating the disease. For this reason, it is important to adequately assess the surgical risks before surgery and to fully protect the neurological function during surgery.

In orthopedic spinal surgery, the structural and functional integrity of the nervous system is at risk of being impaired. Neuroelectrophysiological monitoring technology can evaluate the integrity of nervous system structure and function objectively and effectively according to the real-time change trend of nervous system electrophysiological signals. Therefore, intraoperative neuroelectrophysiological monitoring (IOM) technique has become the most commonly used method to monitor neurological functional status in spinal surgery and orthopedics. At present, IOM has become an indispensable part of evaluating the structural and functional integrity of nervous system in clinical spine surgery, and detecting and reducing intraoperative nerve damage in time. Commonly used IOMs in spinal surgery include: (1) somatosensory evoked potentials (SEPs): monitoring ascending sensory nerve conduction pathways; (2) Motor evoked potential (MEP): monitoring the descending motor nerve conduction pathway; (3) Electromyography (EMG): Monitor the functional status of spinal nerve roots and peripheral nerves that govern the activity of corresponding muscles. Any surgery involving the spinal nervous system and the peripheral nervous system can apply the above techniques. Because various monitoring methods have advantages and disadvantages, different combination modes are carried out for different surgery and monitoring purposes, so as to achieve maximum effectiveness and safety.

Critical care medicine was born in the late 1950s. As a clinical specialty for nearly a year, with the increase of population and aging, there are more and more problems in judging and supporting various organ functions. For more than half a century, the monitoring of basic vital signs in clinical critical care medicine has gradually developed into bedside cardiac function and circulatory hemodynamic monitoring represented by various minimally invasive catheters (thermal dilution) and non-invasive ultrasound, monitoring of various respiratory mechanical parameters and lung compliance during mechanical ventilation, bedside bioelectric impedance tomography (EIT) imaging, determination of various markers of acute kidney injury and creatinine clearance, detection of various inflammatory factors and other markers, especially a large number of bedside micro whole blood sample monitoring (POCT) such as arterial blood gas analysis, blood glucose, myocardial injury markers, coagulation and fibrinolysis markers, etc. As critical care medicine gradually matures: from early rescue after multiple organ failure (MOF) to early assessment and monitoring before multiple organ failure (MODS) failure, the success rate of clinical treatment in critical care medicine has been significantly improved. However, the evaluation and monitoring of nervous system function, especially brain function, is still at a relatively backward level compared with other human organs. For this reason, it will be the field with the most potential and space for development in the future.

Intraoperative neuroelectrophysiological monitoring (IOM) refers to the application of various neuroelectrophysiological techniques to comprehensively monitor the nervous system function of patients under general anesthesia. By monitoring the changes of electrophysiological signals transmitted, the cerebral cortex function and the integrity of multiple nerve conduction pathways under different anesthesia conditions and different surgical operations can be continuously monitored and evaluated in real time^[1], considered the gold standard for intraoperative brain functional area localization techniques. Basic techniques include^[2](1) Monitoring of evoked potentials: common somatosensory evoked potentials (mainly reflecting deep sensory conduction functions such as brainstem and thalamus), motor evoked potentials (mainly reflecting motor cortex and pyramidal tract functions), brainstem auditory evoked potentials (mainly evaluating brainstem function) and visual evoked potentials (occipital visual center function); (2) spontaneous or induced electromyographic response; (3) EEG monitoring. At present, IOM is mainly used in the surgical fields of nerve, spine, cardiovascular and otolaryngology, which is convenient to guide and suggest the neuroprotective effect of surgery and achieve the purpose of improving the prognosis of surgery. On the whole, IOM is widely used in surgical fields at present, and its evaluation significance is positive. However, due to many interference factors, expensive monitoring equipment, complicated operation and other reasons, it has not been carried out on a large scale so far, and is only widely used in developed countries and some large specialized hospitals in China. There are many literatures on this area, but most of them are limited to clinical trials with simple and single monitoring methods, lacking authoritative verification of multicenter, large sample, and multimodal neuroelectrophysiological monitoring, and lacking unified standards. Eccher^[3]It is considered that the "false positive" rate and "false negative rate" of clinical IOM are too high at present.

To Preliminary study of facial nerve F wave evaluation hypoglossal-facial nerve reconstruction with pre-degenerated nerve graft for peripheral facial palsy.

The clinical data were retrospectively reviewed for 30 patients with peripheral facial palsy after cerebellontine angle underwent nerve anastomosis were analyzed between November 2011 and February 2014. F wave and M wave detection were used to evaluate the pre-, post-opertive and status.The hypoglossal-facial nerve by "side- to-side" anastomisis was performed.

All patients were followed-up.The mean time of follow-up was 8 months(ranged from 3 to 20 months). 12 patients were found a higher recovery of facial nerve function after the nerve anastomosis.16 patients who F wave of post-opertive were found a higher recovery compared to F wave of pre-opertive(P<0.05).

The hypoglossal-facial nerve by "side" -to-side anastomisis with pre-degenerated auto-nerve graft was effective for the treatment of peripheral facial palsy after CPA tumor resection, F wave can be used as one of the objective index for the effect of the operation.

To explore the alarming effect of intraoperative neuroelectrophysiological monitoring in microvascular decompression (MVD) for primary trigeminal neuralgia.

In 2014, a total of 44 patients with an initial diagnosis of primary trigeminal neuralgia were consecutively recruited for surgery. And 41 of them with an intraoperative confirmation of primary trigeminal neuralgia underwent MVD. Intraoperative neuroelectrophysiological monitoring was employed for brainstem auditory evoked potentials (BAEPs), spontaneous electromyogram for obicularis oculi, obicularisoris and masseter muscles. The real-time alarming report was offered to the operator who adjusted operations accordingly.

There were abnormal changes in 23 cases (56.10%) with a total of 77 instances (BAEPs 27, trigeminal nerve 32, facial nerve18). The outcomes were no facial pain (n=26), pain relief (n=15) and facial numbness (n=6, two with concurrent hearing disturbance). And the rates of facial pain disappearance and sequela occurrence were much better than those in controls without monitoring.

Intraoperative neuroelectrophysiological monitoring helps enhance the MVD effect and decrease operative squela through alarming reporting.

To explore the choice of timing for baseline and alert levels of somatosensory evoked potential (SEP) monitoring during scoliosis surgery.

From March 2011 to December 2014, a total of 113 patients with kyphoscoliosis deformity were monitored intraoperatively by SEP. There were 52 males and 61 females with a mean age of (20±15) years. All the patients were recorded preoperativeandintraoperative SEPs on double lower limbs. Latency and amplitude of SEPs were recorded after anesthesia and vertebral laminae exposure respectively and compared with each other. Intraoperative SEPs were compared to baseline as SEP after exposure and divided into 4 groups of A (<40%), B(40%-50%), C (50%-60%) and D (>60%) according to the reduced amplitude. Nerve functions were recorded during follow-ups.

Significant statistical difference existed between SEPs post-anesthesia and SEPs after vertebral laminae exposure (P<0.01). Compared with SEP post-anesthesia, the latency of SEP after exposure was prolonged with (3.28±1.72) ms (left lower limb) and (3.30±2.09) ms (right lower limb) and amplitude decreased with 0.17(0.39) μV (left lower limb) and 0.19(0.40) μV (right lower limb). There was a positive relationship of impaired nerve function between groups C and D (P<0.05).

Adopting SEP waveform after exposure as a baseline can improve the accuracy of SEP monitoring during scoliosis surgery. Intraoperative alarm with a reduced amplitude over 50% as the standard may be too sensitive. Alert with a reduced amplitude of over 60% reduces the false positive rate of alarm.

To retrospectively explore the multimodal intraoperative monitoring (IOM) technique during untethering cord procedures in 37 patients between 1 month and 16 years of age with tethered cord syndrome during 2014.

All patients were diagnosed as tethered cord syndrome by clinical manifestations and verified by magnetic resonance imaging (MRI). Free and trigger electromyogram (EMG) and transcranial motor-evoked potentials (tcMEP) of extremity muscles and anal sphincters were used to map the nerves and monitor the functional motor integrity continuously.

The monitorability rate was 100 % for nervous mapping, 86.5% (32/37) for extremity muscle tcMEP. In all patients, tcMEP remained stable during surgery, 43.8% (14/32) patients showed a significant postoperative increase of amplitude of tcMEP, none of them patients presented a significant and yet transient neurological worsening.

The combined technique of monitoring and mapping may boost the procedural safety, minimize the long-term morbidity and improve the clinical outcomes.

To evaluate the application value of continuous video-electroencephalographic (cVEEG) monitoring in patients with consciousness disorders in intensive care unit (ICU).

Retrospective analyses were conducted for applying cVEEG in the clinical diagnosis and outcome evaluation of 54 patients with consciousness disorders in intensive care unit (ICU) at our hospital from January 2008 to April 2014.

The most common cause was cerebrovascular disease (46.3%) followed by ischemic-hypoxic encephalopathy after cadio-pulmonary resuscitation (18.5%). And 49 cases (90.7%) showed an abnormal background on initial cVEEG, 19 cases (35.2%) had epileptic discharge and 8 cases (14.8%) were diagnosed with nonconvulsive status epilepticus (NCSE). Among 6 cases of convulsive patients, only 1 had epileptic discharge patterns of isoelectric, invariable low amplitude. Burst-suppression, persistent θ rhythm-like background activity, persistent diffuse epileptic discharge and periodic waves had high mortality rate.

Stroke is a major cause of consciousness disorders. And continuous VEEG monitoring is beneficial for clinical diagnosis, differential diagnosis and outcome evaluation.

To explore the mutations of VAPB (vesicle associated membrane protein/synaptobrevin associated membrane protein B) in Chinese patients with familial amyotrophic lateral sclerosis (FALS).

The clinical data were collected from 40 FALS families from 2008 to 2011 and the mutations of VAPB gene screened in probands using polymerase chain reaction (PCR) and direct sequencing.

All 40 ALS families were of autosomal dominant inheritance. The male-to-female ratio of probands was 1∶0.7 and the average onset age (49±12) years. Upper limb onset accounted for 52.5%, lower limb onset 42.5% and bulbar onset 5.0%. No mutations were detected in VAPB gene.

VAPB mutations are not a common cause and ALS8 is rare in Chinese FALS.

To explore the effects of clinical indicators, particularly thymectomy on the development of juvenile myasthenia gravis (JMG) through the developmental status of bone age (BA) and height.

A cross-sectional study of 80 JMG patients was recruited to examine whether JMG patients had the abnormalities of height and bone development according to the distribution of height standard deviation score (Ht SDS) and BA.

The mean BA was delayed by (0.15±1.32) years compared with patient chronological age (CA). The mean Ht SDS (Ht_CASDS -1.25±1.03) was also lower than healthy controls. In multivariate analysis, the age at onset was negatively associated with delayed BA (P=0.007) whereas the cumulative intake of prednisone was negatively associated with Ht_CASDS (P=0.043). No significant correlation existed between thymectomy and delayed BA or Ht_CASDS. Delayed BA and slow growth existed in JMG patients. The age at onset of JMG was a correlative factor for delayed BA. And the intake of cumulative prednisone might be a determinant of height retardation. Thymectomy had no impact on the development of bone and height.

We should pay more attention to monitoring BA and height in JMG patients to take appropriate therapeutic interventions.

To explore abnormal brain activation of spatial working memory in primary insomnia and its potential neuromechanism.

we recruited 30 cases primary insomnia (PI) patients and 30 cases age, gender matched healthy control (HC) subjects from July 2013 to December 2013, the diagnosis of primary insomnia matched the diagnosis criterion of DSM-Ⅳ and Classification and diagnostic criteria of mental disorders in China third edition (CCMD-3). All the subjects attended the tests of PSQI, HAMA, HAMD and index of spatial working memory. And then, we collected the data of routine MRI and spatial working memory task fMRI on 3.0 T MRI scanner. After that, we used SPM8 and REST1.8 to analyze the fMRI data, compared difference of PSQI, HAMA, HAMD, index of spatial working memory and brain activation of spatial working memory between PI group and HC group.

There were significant difference between PI group and HC group in PSQI, HAMA, HAMD and index of spatial working memory (P<0.05). In the spatial working memory related activate brain region, compared with HC group, left temporal lobe, occipital lobe and right frontal lobe activation increased and bilateral parahippocampalis, temporal cortex, frontal cortex and superior parietal lobule activation reduced in PI group.

Spatial working memory task fMRI revealed the pathological mechanisms of cognitive dysfunction of clinical spatial working memory and emotional disorder in primary insomnia patients.

To explore the pathological features of muscles and peripheral nerves of Kennedy′s disease (KD).

A total of 12 male patients were selected at our department from January 2006 to October 2014. Their definite diagnoses of KD were made by genetic testing of androgen receptor. Their average age was (52±10) years old. All onset sites were lower limbs. Serum creatine kinase levels were elevated in varying degrees of 209-3 600 U/L. Electrophysiological examination revealed generalized neurogenic damage and impaired peripheral motor and sensory nerves. Biopsies were performed on biceps brachii (n=8), gastrocnemius (n=3), quadriceps femoris (n=1) and sural nerve (n=4).

The major muscular pathological features were neurogenic pathological changes. Some patients had myopathic changes, showing necrotic fibers, regenerating fibers, fiber splitting, vortex-like fibers, central nuclei and reduced oxidase activities. Sural nerve pathology of 4 patients showed a loss of myelinated nerve fibers, as well as axonal degeneration, regeneration clusters and thin myelinated fibers. Electron microscopy examination showed axonal degeneration, regeneration clusters, thin myelinated fibers and onion bulbs-like pathological changes.

KD has myopathic changes with an impairment of chronic axonal and demyelinating sensory nerves.

To investigate whether H₂O₂ treatment negatively regulates PPARγ in primary cortical neurons by increasing PPARγ phosphorylation.

Primary cultured cortical neurons were treated with H₂O₂ (250, 500, and 750 μmol/L) for 2 h. 30 min before the H ₂O₂ (500 μmol/L), the specific inhibitor of ERK1/2 activation, U0126, was added to the culture. Morphological observation, MTT assay and the trypan blue exclusion method were used to detect cell damage. Western blot was carried out to evaluate the expressions of p-PPARγ (phospho-PPARγ) and total PPARγ, as well as to investigate the nuclear translocation of PPARγ (PPARγ activity).

(1) Compared with the control group, cell survival rates were decreased by H₂O₂ at concentrations of 250, 500, and 750 μmol/L (74.8%±5.2%, 53.6%±6.7% and 26.5%±5.8%, respectively, P<0.05), while cell death rate were increased (ctrl group 6.6%±1.0%, H₂O₂-injured groups: 23.1%±2.8%, 48.2%±4.1% and 75.9%±4.4% respectively, P<0.05). (2) Compared with the control group, the expression of total PPARγ failed to show significant change in H₂O₂-injured group, whereas the expression of p-PPARγ increased. Neurons injured by H₂O₂ (500 μmol/L) also showed a reduction of PPARγ nuclear translocation (an increase in cytosol PPARγ and a simultaneous decrease in nuclear PPARγ). (3) Compared with H ₂O₂-injured group, inhibition of ERK1/2 activation decreased p-PPARγ expression, and increased PPARγ nuclear translocation, as well as improved cell survival rate (53.6%±6.7%vs 70.8%±1.3%, P<0.05) and decreased cell death rate (48.2%±4.1%vs 29.8%±3.4%, P<0.05).

Phosphorylation of PPARγ may be involved in cell death induced by hydrogen peroxide in primary cultured cortical neurons.

To prepare rhBMP-2/chitosan microspheres (rhBMP-2 CMs) with vanilline as a cross-linking reagent and study the biocompatibility and drug release characteristic of microspheres in vitro.

Emulsion cross-linking method was utilized to prepare rhBMP-2 CMs, Scanning electron microscope (SEM) was used to observe the microstructure of microspheres.Leaching solution of microspheres and blank culture medium were designated as experimental and control groups respectively.Both groups were cultured with human mesenchymal stem cells (hMSCs) to determine its cytotoxicity and its effect on the proliferation of hMSCs.Dynamic immersion method was used to examine the in vitro release characteristic of rhBMP-2.And the alkaline phosphatase (ALP) activity of hMSCs was determined to reveal the bioactivity of released rhBMP-2.

The rhBMP-2 CMs were spherical under SEM.After treating with leaching solution for 24 and 48 h, there was no inter-group statistical difference in optical density (OD) values at both timepoints (24 h: 0.72±0.07 vs 0.73±0.05, P>0.05; 48 h: 1.19±0.11 vs 1.27±0.06,P>0.05). After culturing with leaching solution for 1, 3 and 7 days, the number of cells increased with time for both groups.And the OD values were not statistically different at each timepoint.Five milligram rhBMP-2 CMs soaked for 19 days with a gradual release of rhBMP-2.The concentration of rhBMP-2 was 216.1±20.0 ng/ml at Day 19. At Days 3 and 7, the ALP activities of hMSCs were (0.50±0.07) and (0.68±0.06) μmol pNPP·min^-1·mg^-1 protein respectively and both were higher than that of blank culture medium group (0.14±0.01) (P<0.05).

With an excellent biocompatibility, rhBMP-2 CMs may be an ideal carrier for control-released rhBMP-2 and encapsulated rhBMP-2 remains bioactive.

To explore the optimal condition of crosslinking modification of ultra high molecular weight polyethylene (UHMWPE) by gamma ray irradiation.

The hip and knee joint samples of UHMWPE were tested with regards to friction and wear performance at different doses of ⁶⁰Co radiation and heat treatment. And the optimal condition of crosslinking was determined by wear performance and physicochemical properties.

Under the condition of 75 kGy irradiation and 150 ℃ heat treatment, crosslinked UHMWPE showed the best performance. Acetabular sample wear rate decreased 63.24% and knee sample wear rate decreased 59.95% compared with conventional UHMWPE. The modified material had excellent mechanical properties of impact strength 83 kJ/m^2, tensile strength 50.32 MPa, yield strength 21.83 MPa and elongation at break 312%. Also the material showed excellent antifatigue and reliable chemical properties.

The optimal condition of crosslinking modification of UHMWPE is 75 kGy irradiation after 150 ℃ heat treatment.

The 82-year-old female was hospitalized in the cardiology department of a foreign hospital on December 25, 2011 due to dizziness for 15 years, aggravated for 1 day. The diagnosis considered III-degree atrioventricular block and pacemaker implantation. The patient underwent VVI pacemaker implantation in 1999 due to III-degree atrioventricular block and pulse generator replacement in 2007 due to battery depletion (ventricular electrodes were not replaced). During this hospitalization, there was twitching of the left upper limb, followed by loss of consciousness, fainting to the ground, refusing to respond to a call, staring upward with both eyes, and involuntary shaking of the corners of the mouth. Each attack lasted for about 10 s, relieved by itself, and the frequency of attacks was uncertain, ranging from 3 to 4 times a day. There was no chest tightness or chest pain after the attack. The above symptoms recurred, and the patient experienced fatigue, nausea, anorexia, and eating less. CT of the head showed multiple lacunar infarctions in bilateral basal ganglia and semi-oval area. Holter EEG on January 6, 2012 (Figure 1) shows that high-amplitude slow wave, sharp slow wave and spiny slow wave length ranges up to 560 μ V are frequently seen in waking and sleeping, and the two sides are not completely symmetrical and synchronous, so epileptiform discharge is considered. After the neurological consultation, he was diagnosed as symptomatic epilepsy. He was given sodium valproate (Debakin) and levetiracetam (Kaipulan) orally, but there were still intermittent seizures. For further treatment, he was transferred to the neurological department of our hospital on January 15, 2012. Deny history of hypertension, diabetes, long-term use of other drugs, and sudden death of family members.

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in China, ranking 2nd in urban areas and 1st in rural areas, with more males than females, and the mortality rate is second only to lung cancer^[1,2]。 In recent years, with the continuous progress of minimally invasive interventional therapy technology guided by HCC imaging and the development of related large-scale clinical randomized trials, the status of minimally invasive interventional therapy has been highlighted. At the same time, the multidisciplinary comprehensive treatment model of HCC has also been widely recognized in clinical practice. This article combines the clinical characteristics and diagnosis and treatment status of hepatocellular carcinoma in China, aims to embody the individualized, rational and scientific constructive model treatment mode of hepatocellular carcinoma, which is more comprehensive, comprehensive and specific.

Unlike simple sacral fractures, traumatic spinal-pelvic dislocation is a more complex type of injury characterized by a transverse accompanied longitudinal (multiplanar) fracture of the sacrum, which affects not only the stability of the pelvic ring but also the stability of the lumbosacral region, resulting in spinal-pelvic instability or even dislocation^[1,2]。 There are no good classification criteria and treatment options for traumatic spinal-pelvic dislocation. This kind of fracture is high energy injury accompanied by high rate of nerve injury and serious combined injury, which brings some difficulty to diagnosis and treatment. In the past, conservative treatment was used, probably because there were no good endoimplants to stabilize complex fractures at that time. In recent years, some scholars have used surgery to stabilize lumbosacral and pelvis, which is beneficial to the recovery of nerve injury, allows early weight bearing, and achieves certain curative effect^[3,4,5]。 The purpose of this study is to explain the epidemiology and injury characteristics, fracture classification, clinical diagnosis and treatment of traumatic spinal-pelvic dislocation.

multiple system atrophy (MSA) is a rare, unexplained, progressive degenerative disease with multiple involvement of functional anatomy of the nervous system. The main clinical manifestations are Parkinson's disease, cerebellar ataxia, pyramidal tract sign with dyskinesia and autonomic nervous system damage. According to whether Parkinson's disease or cerebellar ataxia is the prominent clinical manifestation, MSA can be divided into MSA-P type and MSA-C type, namely Parkinson's disease and cerebellar type. Pathology confirmed that glial intracellular inclusion bodies are the characteristic pathological markers of this disease, and the main component is a highly phosphorylated alpha synuclein. Based on 2008 Gilman et al.^[1]The established diagnostic criteria for MSA, the diagnosis of MSA depends on pathology, and it can be clinically diagnosed as probable MSA and probable MSA. Compared with other neurodegenerative diseases such as Parkinson's disease (PD), MSA lacks effective treatment, and the disease progresses rapidly, and the prognosis is poor. Therefore, which factors affect the progression of MSA and how to delay the development of MSA are one of the research directions of MSA. There are many studies on the prognosis of MSA abroad, but there is still a lack of relevant research in this field in China. This article reviews the research progress of the natural history and prognostic factors of MSA.