[논문]대동맥수술에서의 수술 중 신경계감시의 적용

장민환; 채지원; 임성혁

doi:10.15324/kjcls.2022.54.1.61

대동맥수술에서의 수술 중 신경계감시의 적용
Application of Intraoperative Neurophysiological Monitoring in Aortic Surgery 원문보기

Korean journal of clinical laboratory science : KJCLS = 대한임상검사과학회지, v.54 no.1, 2022년, pp.61 - 67

장민환 (삼성서울병원 뇌신경센터 신경과) , 채지원 (가톨릭대학교 인천성모병원 심장내과) , 임성혁 (삼성서울병원 뇌신경센터 신경과)

초록
AI-Helper

INM은 수술의 안정성을 더해주고 고위험군의 수술을 안전하게 진행할 수 있게 도움을 주고 있다. INM검사가 적용이 되는 모든 수술에서의 수술 과정과 신경학적 결손이 발생할 수 있는 과정에서 집중적으로 검사를 진행해 보다 신속하게 수술자에게 알리지 않으면 손상이 되었을 때 그에 대한 대처가 늦어서 환자에게 돌이킬 수 없는 심각한 후유증을 가져다 줄 수 있다. 대동맥류 및 대동맥 박리로 발생되는 대동맥 치환술은 개흉 및 개복술이 진행되며 심장의 혈류를 차단하는 매우 위험한 수술이다. 대동맥에서 분지되어 척수에 혈류를 공급하는 혈관들을 교체할 때 척수로 가는 혈류가 감소해 척수 허혈이 올 수 있다. 대동맥 수술에서의 INM은 겸자시에 유발전위를 이용하여 빠르게 척수 허혈이 시작되는 시점을 찾아내고 수술자에게 보고해 척수 허혈을 방지하며 심각한 합병증을 막는 중요한 역할을 수행한다. 이에 수술의 과정과 TceMEP, SSEPs의 검사 방법 및 검사 시점, 검사 기준에 대하여 작성을 하여 INM을 시행하는 검사자들에게 도움이 되고자 본문을 작성하였다. 본문으로 인해 대동맥수술에서 INM의 필요성, 대동맥 수술에서의 흐름을 파악하고 정확하고 신속한 검사를 통한 보고로 원활한 검사가 진행되길 바라는 바이다.

Abstract ▼ AI-Helper

Intraoperative neurophysiological monitoring (INM) ensures the stability and safety of specific surgeries in high-risk groups. As part of INM, intensive tests are conducted during the surgical process. When INM tests are applied during surgery, a delay in notifying the operating surgeon in cases of neurological defects can cause serious irreversible sequelae to the patient. Aortic replacement, which is necessitated due to aortic aneurysms and aortic dissection, is a complicated procedure that blocks the blood flow to the heart. When arteries that branch out from the aorta and supply blood to the spinal cord are replaced, blood flow to the spinal cord decreases, resulting in spinal ischemia. In aortic surgery, INM plays an important role in preventing spinal ischemia and serious complications by quickly detecting the early signs of spinal ischemia during cross-clamping and reporting it to the surgeon. Therefore, this paper was prepared to help examiners who conduct INM by detailing the process, method, time, and warning criteria for INM. This paper identifies the need for INM in aortic surgery and the process flow for a smooth test, accurate and rapid examination, and subsequent reporting.

주제어

표/그림 (7)

그림 Figure 1. Aortic aneurysm observed by echocardiography. (A) Normal in parasternal long axis view. (B) Aorta aneurysm in parasternal long axis view.
그림 Figure 2. Crawford classification of thoracoabdominal aneurysms. Type I: aneurysm involves the descending part of thoracic aorta from the left subclavian artery and the abdominal aorta proximal to renal arteries. Type II: aneurysm involves the entire thoracic aorta distal to the left subclavian artery and abdominal aorta to the aortic bifurcation. Type III: aneurysm involves the aorta segment of the thoracic aorta and the abdominal aorta to the aortic bifurcation. Type IV: aneurysm involves the aorta from the level of the diaphragm an extends to the aortic bifurcation. Type V: aneurysm involves the distal part of the thoracic aorta and the part of the abdominal aorta proximal to the renal arteries.
그림 Figure 3. Before and after aortic replacement. (A) Thoracic-abdominal aortic aneurysm before aortic replacement. (B) Thoracic-abdominal aortic aneurysm after aortic replacement.
그림 Figure 4. Insertion of stimulation electrodes for transcranial electric motor evoked potential and recording electrode for somatosensory evoked potential in brain surgery.
그림 Figure 5. Electrode insertion method. (A) Transcranial electric motor evoked potential recording abductor pollicis brevis muscle, abductor digit quinti muscle and stimulation of somatosensory evoked potentials nerves in the upper extremity. (B) Transcranial electric motor evoked potential recording abductor hallucis muscle and stimulation of somatosensory evoked potentials nerve in the lower extremity. (C) Transcranial electric motor evoked potential recording tibialis anterior muscle.
그림 Figure 6. Changes in transcranial electric motor evoked potential due to spinal cord ischemia after aortic cross clamping. (A) Decreased in lower transcranial electric motor evoked potential. (B) Decreased and recovery of transcranial electric motor evoked potential after cross-clamping.
그림 Figure 7. Changes in somatosensory evoked potentials with temperature. (A) Latency of somatosensory evoked potentials at 34.7°C. (B) Latency of somatosensory evoked potentials at 31.2°C.

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