神经肌电图的临床应用课件1.ppt

1、神经肌电图的临床应用ExcretionGastricCirculatoryBreathSympathetic Nervous SystemParasympathetic Nervous SystemAdrenalineNoradrenalineAcetylcholine(Ach)Receptors脊髓前角运动细胞脊髓前角运动细胞终板终板Peripheral NerveRootVentral RootCells MotorPosterior HornDorsal RootGanglion Cells SensorySPINAL CORDStriated MuscleSensory Recepto

2、rsAfferentEfferentAnterior HornMOTOR UNITMotor Neuron25m5 mmSpecial Needle 4-5 insertions in the same muscle Moderate contraction Minimum 20 potentials Analyze on 2-3 musclesABCABCNormalReinnervation100 ms12MCD MSDBiceps:15.6 5.9Tibialis ant.:32.1 15.0121 msJitter1 2TriggerF波:潜伏期延长或传导速度减慢，部分病人还可有F波的

3、出现率下降，如同时伴有远端MCV正常，对诊断更有意义。如C6、C7神经根病变合并CTS等。2波幅由针尖附近的少数肌纤维决定的，受肌纤维大小和密度的影响。2血清肌酶谱升高特别是CK。I Distal spiral ganglia and auditory nerve意义(1)先天性肌强直；Intra Operating Monitoring干扰相大力收缩时足够的MU募集在一起难以分辨出基线的MUP相互重叠。如有明显的肌肉萎缩动作电位的波幅可降低。Somatic System SimplifiedIII Ventral cochlear nucleus in ponsPhysiologic pot

4、entials and responsesInching Ulnaris NerveMotor ResponseIV Inferior lateral lemiscus in ponsStimulation:Supra Maximal+25%Single Fiber EMGMacro EMG2 EMG ChannelSingle FiberNeedleConcentricNeedleTriggeringAveraging4 FibersAveraging 200 Potentials/each recordRecording 10 times in different position of

5、SFNRecording Time:20 secondsWalking StudiesSynchronization betweenAgonist&AntagonistMusclesConcentric NeedleorMonopolar NeedleStriated MuscleMotor Unit 12100 ms20 ms 5 ms1 2 Recruitment EMGMotor Unit Potentials(1)and(2)AmplitudePhase DurationRising TimeSatelliteTurnsBaseline CrossingSegment Single P

6、otential,Phases 3Group of Muscle Fibersgenerates MUPs.Different Innervationdifferent MUPs.Manual SelectionSingle-Triggering Moderate Contraction Simple/Polyphasic Potentials Ratio Amplitude DurationMUP Algorithm recognitionMulti-MUP-AveragingSTOPNormalNeuropathyMyopathyMyastheniaCNEMG Same Effort,Sa

7、me Muscle,Different PathologiesGroundSTOP（TOSthoracic outlet syndrome）CV=34 m/s（1）时限增宽（20%）。Fiber Contractions(depolarization).Striated Muscle3异常肌电图神经源性损害Sensory Pathways4-5 insertions inMonopolar Needle102血清肌酶谱升高特别是CK。Biceps:15.Correct place of electrodes（5）多发性性骨髓瘤（2）括约肌功能障碍；Somatosensory E.Sensory

8、 Median and Ulnar Nerves典型的皮肌炎 皮疹包括紫色皮疹、Gottrons症和Gottrons丘疹。Latency P40I 1.CTS术后传导速度明显改善CTS是最常见的正中N嵌压性周围神经病。Increased LatencyVI Medial geniculate nucleus(upper mid-brain)（一）各型的临床表现1锁骨下静脉型TOS部分病人尺神经刺激小指展肌记录的F波潜伏期可延长。（1）妊娠18%31%有主观症状，7%10%有客观体征和神经电生理改变(2)萎缩性肌强直；意义(1)先天性肌强直；Scoliosis Operation Electro

9、desII Proximal auditory nerve(cochlea nucleus)4-5 insertions in（三）运动单位电位（MUAP）1时限反映一个MUAP所有的肌纤维同步放电的程度。Fiber Contractions(depolarization).40 0.（三）神经传导速度测定 1SCV 异常是排除诊断的指标。Minimum F Latency is normally measuredStriated MuscleV Lateral lemiscus in lower mid brain正中SCV、波幅；Muscle FibersNeuroMuscularJunc

10、tionand are main playersto transfer MOTOR UNIT+-+-+-+-+-+-+-+-+-+-+-:2-5 V/Dthe same muscleF波的出现率低于75%为异常。Somatosensory E.Czfixed securely-No way back（1）家族性淀粉样变性EMG检查顺序和报告的书写主要用于侧枝芽生的定量分析和估计运动单位的数量等研究。（二）自发电位 肌肉安静下的电活动 1终板噪音 2终板电位 发放R2 nl 30 ms下肢较上肢重。Above 120 dB（1）时限增宽（20%）。Latency S1-Latency S2Neu

11、roMuscular JunctionMotor Unit PotentialsSomatic System as an Electrical Circuit!（2）恢复期 MUAP时限增宽、大小不等、多相波百分比增高IV 5.UlnarAbove Elbow UlnarBelow Elbow MedianElbowRadialUlnarWristMedianWristMedian-UlnarPalmerPlexusAxillaryCruralPeronealPeronealSciaticTibialPopliteal fossaPosteriorTibialSuralErb PointTho

12、ra-codorsalisLongThoracicCruralErb PointPhrenicSpinal XIAuricularPosteriorTrunkMediumLowerHigherBLACK TO BLACKStimulation Polarity :NEGATIVETo reduce Stimulation Artifact as possible,Ground must be placed between Stim.&Rec.NerveAnode CathodeActive ReferenceSTIMULATIONRECORDINGGROUNDDiff.:4.7 ms Dist

13、.:240 mm C.V.:51 m/s 3.5 ms8.2 msDistanceStim.1Stim.2Rec.WristElbow LatencyRecording:Surface ElectrodesStimulation:Handgrip or BipolarDistance 2Stim.2Stim.1Stim.3Stim.4Stim.5D1D3Distance 4Diff.:3.5 ms Distance 2:190 mm C.V.:54.3 m/s 3.1 ms6.6 msPalmWristElbow B.Elbow A.Plexus(Axillary)Latency1.8 ms7

14、.1 ms10.5 msVolontarycontralateralmotor actionto facilitate FStim.Rec.MFblockF Latence 30 to 50 msMFMinimum F Latency is normally measured（一）临床特点 颈和肩部疼痛和麻木并可向上肢和手部放射；发生在颈外侧多种解剖结构异常（颈肋、第七颈椎横突过长、前及中斜角肌等）压迫臂丛、锁骨下动脉和静脉或腋动脉引起前臂和手部小肌肉萎缩、无力、疼痛等表现的一组综合征。儿童DM（或PM）伴血管炎5.Node of Ranvier Schwann Cell辅助判断病情及预后评价

15、（5）先天性腕管狭窄。Motor Conduction Median NerveAveraging:200-300Recording ElectrodesAch:AcetylcholinePrevious TraceAnalyze on 2-3 muscles主要体征为桡动脉搏动减弱甚至消失、手指溃疡、指甲粗糙脆弱，锁骨上窝常常可听到血管杂音。最常见的原因，占所有CTS的47%。最常见的原因，占所有CTS的47%。stimulation.Macro EMG Application:Fiber densityLatence:3.Tibialis ant.意义(1)先天性肌强直；CTS术后传导速度

16、明显改善神经传导速度测定神经传导速度测定SCV:取决于受累的部位，通常正常取决于受累的部位，通常正常MCV:病变早期病变早期MCV正常。如有明显的肌肉萎缩动正常。如有明显的肌肉萎缩动作电位的波幅可降低。作电位的波幅可降低。F波波:潜伏期延长或传导速度减慢，部分病人还可有潜伏期延长或传导速度减慢，部分病人还可有F波的波的出现率下降，如同时伴有远端出现率下降，如同时伴有远端MCV正常，对诊断正常，对诊断更有意义。更有意义。正中神经和尺神经复合肌肉动作电位（正中神经和尺神经复合肌肉动作电位（M波）的波波）的波幅降低。幅降低。F波波:部分病人尺神经刺激小指展肌记录的部分病人尺神经刺激小指展肌记录的F波

17、潜伏期可延波潜伏期可延长。长。但近年的研究认为是周围神经芽生所致的不稳定电位。Manual Selection2血清肌酶谱升高特别是CK。Recruitment EMGStep CommentsMinimum 20 potentialsI Distal spiral ganglia and auditory nerveRadiculopathies波幅轴索的功能Muscle FiberStriated MuscleMacro EMG Application:Fiber densityFacial Motor Nerve特别是与ALS鉴别更有意义。Cells Motor由于脊柱的退行性变累及骨、

18、椎间盘和周围韧带及纤维组织引起脊髓和神经根受压的一组常见疾病。Previous Trace-Opening PhaseV 5.CTS的严重程度与正中神经的严重程度与正中神经SCV和和ML改变的程度有改变的程度有关，后者是手术的指征，及手术后随诊的参考指关，后者是手术的指征，及手术后随诊的参考指标。标。PolyneuropathiesRadiculopathiesStimulationDur.1 msInt.from 0 mAto M Max.Increment step 0.2 mAH Max Ampl.M Max Ampl.Latencies M:10 ms H:30 ms depend h

19、eightStim.Rec.HMHVolontarycontralateralmotor actionto facilitate FStim.Rec.MFblockF Latence 30 to 50 msMFMinimum F Latency is normally measuredPolyneuropathiesRadiculopathiesStim.Rec.HMHSingleIntensityHDistanceStim.Rec.Negative Stim.Latence:3.1 msPositive Stim.Latence:3.5 msDistance=120 mmCV=39 m/sC

20、V=34 m/sPathologicPalmWristNo Stim.LatencyIncreased LatencyOthers Graphics with Amplitudes and DurationsRec.1 inch dist.betweenStim.SitesStim.DistanceStim.1Stim.2MOTORRec.Stim.Digit 2.3.4.5 DistanceSENSORYRec.UlnarisMedianusSingleIntensityNext TracePrevious TraceWirstElbowDig.4Dig.5Dig.3SummaryDataR

21、un AVGMotorSensoryDistanceStim.1Stim.2MOTORRec.Motor Median NerveWirstElbowSensory Median and Ulnar NervesDigit 2Digit 3Digit 4LatencyStim.Digit 2.3.4 DistanceSENSORYRec.UlnarisMedianus3.5 ms6.2 ms2.2 ms2.4 ms1.9 ms Striated MusclePeripheral NerveMuscle FiberMotor Nerve terminal(Axon)Presynaptic Sit

22、eAch ReceptorsMuscle end-platePostsynaptic SiteAch:AcetylcholineSynapseStim.Rec.Stimulation:Supra Maximal+25%Train 10 Stimuli -Frequency 3 HzLambert-EatonNormalAmplitude Increase 90%-Calcium flux Neuromuscular JunctionReceptorsAcetylcholine ReleasedNormalMyasthenia Gravis1.10Amplitude Decrease 20%-R

23、eceptors numberStim.Rec.1 st Train10”LaterAfter Vol.EffortAmp.0%Amp.-10%Amp.-30%10 Stim.3 HzTrainNoteSingleIntensitySet Train:10 Stim.3 HzSelect first window by clicking on,then TrainObserve curves and resultsAdd note in this first window by clicking NoteSelect next window NextWindowUpPrev.WindowDow

24、nElectrodes:2 x Surfaces 9013S0211 or 2 x Needles9013S0011R1R2Rec.LeftRec.RightStim.Left(Needle Electrodes)Latencies:R1 nl 10 ms R2 nl 30 msAmplitude:0.5 to 1 mVStim.LStim.RCathodeRec.LeftRec.RightFacial Motor NerveTrigeminal NerveUnilateral facial paralysisStriated MuscleMotor UnitStriated MuscleMu

25、scle FibersSignal ReceptorsMotor PathwaysSensory PathwaysStimulationInterpretation Orderfor ActionSensoryMotorMuscleSensory ReceptorsSpinal CordPeripheral Nerve!DescendingAscendingSomatosensory Evoked PotentialPain -+RootMuscleSensoryReceptorSwitchBatteryBrainSpinal Cord MuscleSensoryReceptorRootMot

26、orSensorySEP-VEP-BAEP-AEP-P300-IOM-MEPLRN I5 cm2 cm7 cmFzC3 C4CPi CPcFpzStim.EpcEpiC5SCPc-CPiCPi-EpcC5S-EpcEpi-EpcMedian NerveEPN20P14N18N1310 20 30 msStim.Freq.:3 HzIntensity:ThresholdAveraging:200-500AVG Sens.:2-5 V/DRN I5 cm2 cm7 cmFz CzCPi CPz CPcLC5SICT12SStim.N34CPi-FpzCPz-FpzFpz-C5ST12S-ICP37

27、P31LPTibial NerveP3720 40 60 msStim.Freq.:3 HzIntensity:ThresholdAveraging:200-500AVG Sens.:2-5 V/DFpzLatency P40typ.39 ms(nl 44 ms)Record on Scalp with Scalp Needle or Surface ElectrodeAveraging:2002 cmCz-2FPzGroundStimulation Penil NerveStimulation Clitoral NerveP40Cz-2-FPzOptic NerveOptic tractLa

28、teral geniculate bodyOccipital lobePattern:Checkers-Bares Goggles Flash O1-CzOz-CzO2-CzCz-A1P100N75N145N100VER Right eye100 200 ms70 cmStim.:CheckerChecker size:Visual angle*Stim.Freq.:Max.2 HzDark roomAveraging:200-300AVG Sens.:5 to 10 V/D*See this term in Technical sectionI Distal spiral ganglia a

29、nd auditory nerve II Proximal auditory nerve(cochlea nucleus)III Ventral cochlear nucleus in ponsIV Inferior lateral lemiscus in ponsV Lateral lemiscus in lower mid brainVI Medial geniculate nucleus(upper mid-brain)VII Primary auditory cortexIIIIIIIVVVIIVIStimulation:threshold+70 dB SPL*Unfiltred Cl

30、ick 50-100 sAbove 120 dB Max.:132 dBIIIIIIIV V V IV II*See this term in Technical sectionBAERs RightA2-CzIIIIIIIV V V INormal Values Latences Amplitudes Peaks ms SD V SD I 1.7 0.15 0.28 0.14 II 2.8 0.17 0.23 0.12 III 3.9 0.19 0.25 0.12 IV 5.1 0.24 0.40 0.13 V 5.7 0.25 0.47 0.16 VI 7.3 0.29 0.43 0.16

31、LeftRight5 10 msStim.:Click 50 sAverag.:2000-4000AVG Sens.:0.1 V/DIntra Operating Monitoringq Monitoring during critical phases of operationq Physiologic potentials and responses are affected by:.Anesthesic Drugs No EP Responses in the Brain.Curare No Motor Responsesq Always perform EP Tests before

32、operation for:.Correct place of electrodes.Latency Reference.Status before operationPatient With Scoliosis-Preparation-Opening PhaseInstallation of Materials-Hooks on vertebra-BaresThe Most Critical PhaseRisk to Pinch Spinal Cord and Roots-Bares Rotation by StepsMonitoring NeededFinal phase-Closing4

33、 to 6 Hours20 to 30 min.Stim.Stim.Rec.ScalpRec.CervicalC3sStimulation on Lower extremities onlyStim.Stim.Stim.Stim.Rec.ScalpRec.CervicalC3sStimulation on Lower and Upper extremitiesUse Only Disposable Scalp ElectrodesFor Recording and Stimulation 9013R0311Stim.Stim.Stim.Stim.Rec.ScalpRec.CervicalC3s

34、Needles and Cables must befixed securely-No way backfor reinstallation after start.Stim.Stim.C3sCpzFpz-Ref.A2GroundOperating FieldStim.Rec.Keypoint IOM08:00:15 SEP Start08:05:15 rotation 1-1008:06:10 rotation 1-2008:07:00 rotation 2-done08:09:00 rotation 3-30SEP -StandardTrendingURULLRLLUpper R/L an

35、d Lower R/L are average recorded alternatively with alternativestimulation.Graphic display Latencies-Amplitudestrends.Step CommentsDuring operationMaglite CompactTriggerMagnetic Stimulation MuscleMotorNerveDescendingRecordKeypointLRN I Cz2 cm backStim.Conduction ms:Brain+Spine L1-L2 LeftRightCortexL4L4CortexStim.SitesL1L2L4Recording ElectrodesStim.CortexStim.Roots