颅面与颅底手术中的神经损伤：共同机制、预防与修复策略

文献信息

中文摘要

背景： 颅面与颅底手术使颅神经面临损伤风险，并影响运动、感觉、听力、吞咽、视觉和生活质量。
方法： 本叙述性综述整合了46篇原始文献，并在修订期间补充了6篇针对性参考文献，涵盖神经外科、耳鼻咽喉科和颌面外科中的损伤机制、预防、术后评估、重建和康复。
结果： 反复出现的机制包括牵拉、压迫、缺血、热损伤、直接创伤和离断。神经监测在配合可重复的基线记录、适当的模式选择、技术故障排除以及预先设定的手术警报反应时，有助于定位、功能监测和预后判断。术前和术后电生理检查可补充但不能替代术中监测。已确认的离断在可行时倾向于立即进行无张力重建；解剖上连续但电反应不利的神经需要结合情境解读，而非自动牺牲。康复结合靶器官保护、选择性运动或感觉再训练、症状控制以及患者报告评估。
结论： 实践中的区别在于潜在可逆的功能障碍与确认的结构性不连续。管理应将监测变化与纠正措施联系起来，保留有活力的神经，并协调及时重建与康复。异质性且主要为观察性的证据不支持通用警报阈值、单一重建截止时间或保证功能恢复。

英文摘要

BACKGROUND: Craniofacial and skull base procedures place cranial nerves at risk of injury, with consequences for movement, sensation, hearing, swallowing, vision, and quality of life.
METHODS: This narrative review integrates 46 original publications with six targeted references added during revision, addressing injury mechanisms, prevention, postoperative assessment, reconstruction, and rehabilitation across neurosurgery, otolaryngology, and maxillofacial surgery.
RESULTS: Recurring mechanisms include traction, compression, ischemia, thermal injury, direct trauma, and transection. Neuromonitoring contributes to localization, functional surveillance, and prognosis when paired with reproducible baseline recordings, appropriate modality selection, technical troubleshooting, and a predefined surgical response to alerts. Preoperative and postoperative electrophysiological testing complements but does not replace intraoperative monitoring. Recognized transection favors immediate tension-free reconstruction when feasible; an anatomically continuous nerve with an unfavorable electrical response requires contextual interpretation rather than automatic sacrifice. Rehabilitation combines target-organ protection, selective motor or sensory retraining, symptom control, and patient-reported assessment.
CONCLUSIONS: The practical distinction is between a potentially reversible functional disturbance and confirmed structural discontinuity. Management should link monitoring changes to corrective action, preserve viable nerves, and coordinate timely reconstruction with rehabilitation. Heterogeneous, predominantly observational evidence does not support universal alert thresholds, a single reconstruction deadline, or guaranteed functional recovery.