2015年 · 第95卷第21期

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.

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.