Signalveränderungen des kontinuierlichen intraoperativen Neuromonitorings bei Schilddrüseneingriffen mit postoperativen Rekurrensparesen

 

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Zusammenfassung

Einleitung: Das kontinuierliche intraoperative Neuromonitoring (kontIONM) soll dem Chirurgen Informationen zu Zeitpunkt, Ursache und Prognose eines Nervenschadens geben. Methodik: In den Jahren 2009–2011 wurde bei 667 Patienten das kontIONM bei Operationen an der Schilddrüse eingesetzt (Tubuselektrode, Vagussonde V3, ISIS; Fa. Inomed, Emmendingen). Die Laryngoskopie erfolgte standardisiert am 2. postoperativen Tag, bei 34 Patienten wurden Paresen diagnostiziert. Die Signale wurden während des gesamten Operationsverlaufs gespeichert. Der Ausfall des Signals, definiert als Signalamplitude A1<100 µV, und Veränderungen des Delays wurden dem aktuellen Operationsschritt zugeordnet. Ergebnisse: 17,6 % (6/34) der Signalausfälle traten bereits zum Zeitpunkt der Luxation des Schilddrüsenlappens auf, bevor die Grenzlamelle zur Identifikation des N. laryngeus recurrens (NLR) eröffnet wurde. 67,6 % (23/34) der Signalausfälle wurden während der Präparation des NLR in unmittelbarer Nähe des Berry-Ligaments registriert. Insgesamt wurden 85,3 % der postoperativen Paresen bereits intraoperativ bestätigt. In 4 Fällen traten ausschließlich Veränderungen des Delays verschiedener Signalabschnitte auf, die intraoperativ nicht erkannt wurden. Eine Parese war nicht mit Veränderungen des kontIONM-Signals kombiniert. Schlussfolgerungen: Die Parameter Signalausfall und Amplitudenreduktion < 100 µV sind intraoperativ in der Mehrzahl der Fälle zuverlässiger Hinweis auf eine Stimmbandparese. Zug- und Dehnungsschäden scheinen die wesentlichen Ursachen zu sein. Die Möglichkeit zur unmittelbaren Revision des letzten Präparationsschritts ist der wesentliche Vorteil der Methode. Ein Teil der postoperativen Stimmbandparesen ist allerdings nur durch eine Verlängerung des Delays verschiedener Signalabschnitte charakterisiert.

Abstract

Introduction: Continuous intraoperative neuro-monitoring (kontIONM) and the provision of relevant information such as moment, origin and prognosis of nerve function impairment during thyroid resection have been tested. Methods: Between 2009 and 2011, 667 patients were operated for thyroid pathology by applying kontIONM (tube electrode, vagal probe V3, ISIS; Fa. Inomed, Emmendingen, Germany). Vocal cord function was examined laryngoscopically on the 2nd postoperative day. Palsies were diagnosed in 34 patients. Complete kontIONM signals were filed during the operation. Loss of signal (LOS), defined as amplitude reduction < 100 µV, and signal delay > 10 % were attributed to thyroid dissection. Results: A LOS of 17.6 % (6/34) developed already at the moment of thyroid lobe luxation, that is, prior to a dissection for recurrent laryngeal nerve (NLR) identification. An LOS of 67.6 % (23/34) appeared during NLR preparation in the vicinity of the Berry ligament. Thus, 85.3 % of all vocal cord palsies were recognised intraoperatively. For four patients signal delay > 10 % could be observed in the analysis of the postoperative signal but not during the operation. One case was not associated with any of these signal changes. Conclusion: In the majority of cases, signal loss and reduction of amplitude < 100 µV are reliable parameters of post-operative vocal cord palsy. Traction and distension of the nerve seems to be the most important cause of nerve damage. An immediate revision of the last step of the surgical procedure, if required, is the essential advantage of this method to avoid irreversible nerve damage. For a minor part of the cases, vocal cord palsies are characterised intraoperatively by an extended delay of the signal.

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