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La chirurgie neuro-oncologique, une discipline riche et passionante - Algerie360
Il est très important de ne pas endommager les tissus nerveux délicats pouvant occasionner surtout des paralysies motrices, lors de la chirurgie du cerveau et de la moelle épinière qui comporte des risques tant pour le chirurgien que pour le patient. C’est donc là qu’intervient la méthode la plus populaire de ces dernières années : le Neuromonitoring Intra-opératoire Multimodal…
Les chirurgiens essayent de réaliser l’intervention chirurgicale de manière à éviter des complications avec leurs savoirs, compétences et expériences en faisant attention à toutes les caractéristiques anatomiques et pathologiques lors de la chirurgie. Malgré toutes ces précautions, il est très difficile en particulier de distinguer les tissus nerveux normaux des tumeurs de la moelle épinière et de la colonne vertébrale. Par conséquent, le risque d’hémiplégie augmente.
Au cours des 10 dernières années, le Neuromonitoring Intra-opératoire Multimodal permet justement de diminuer ce risque ; cette méthode a gagné en popularité et a commencé à être utilisée en Turquie et dans le reste du monde en même temps. Par exemple, en sécurisant les voies nerveuses innervant les membres supérieurs et inférieurs, cette technique assure une prévention précoce de paralysie.
En fait, brièvement, pour éviter les complications de perte de mobilité, le chirurgien est informé à temps avec les enregistrements continus des capacités de mobilité du patient. Nous pouvons dire que c’est la méthode la plus fiable aujourd’hui pour identifier le tissu en tant que tissu nerveux à l’œil nu ou sous microscope lors de l’intervention chirurgicale. Cependant, il ne faut pas oublier que cette méthode n’est pas encore utilisée sur certains patients comme ceux qui ont subi une chirurgie cérébrale lourde et des patients qui sont porteurs de stimulateur cardiaque. Le Directeur du Département de Neurochirurgie du centre médical ANADOLU, le Prof. Dr. Serdar Kahraman explique les détails sur ce sujet…
Comment l’utiliser ? Nous pouvons décrire le neuromonitoring brièvement comme un procédé qui enregistre et mesure les influx nerveux entrants et sortants lors de la chirurgie en commençant par le cerveau puis la moelle épinière et enfin ceux des nerfs des membres supérieurs et inférieurs. En fait, c’est un procédé comparable à un enregistrement d’ECG qui contrôle les battements cardiaques et que tout le monde connait. Mais les ondes électriques enregistrées par le neuromonitoring sont les témoins des fonctions motrices et sensitives. Actuellement, c’est une des méthodes de prédilection utilisée fréquemment dans de nombreuses structures de soins pour aider à pratiquer une chirurgie plus sécurisée. Nous pouvons dire qu’elle peut être installée dans toute salle d’opération en tant que simple logiciel de système d’alerte et d’enregistrement portatif. A la fin de l’intervention, les enregistrements sont enregistrés et sauvegardés dans le dossier du patient.
En ce qui concerne l’application : avant l’intervention, lorsque le patient est sous anesthésie générale, on place les électrodes de stimulation musculaire et d’enregistrement sur les parties adéquates du cuir chevelu, des membres supérieurs et inférieurs.
Au début de l’intervention, les réponses électriques sensitives, réflexes et motrices sont enregistrées par l’intermédiaire de dispositifs spécifiques. Le médecin ou le neurophysiologiste réalisant le Neuromonitoring Intra-opératoire informe le chirurgien en observant les réponses lors de la chirurgie, s’il y a ou pas un changement ou bien si les réponses restent stables, donc si les fibres nerveuses sont protégées ou endommagées. Du fait du suivi et de l’enregistrement de toutes ces réponses électriques, on l’appelle le monitoring multimodal, c’est-à dire le suivi et l’enregistrement des fonctions sensitives et motrices.
Si l’intervention chirurgicale provoque une lésion des tissus nerveux et de la moelle épinière, les réponses électriques stimulées obtenues témoignent d’une détérioration. Le spécialiste du Neuromonitoring Intra-opératoire alerte immédiatement le chirurgien et l’anesthésiste réanimateur, il aide ainsi à diminuer le risque de dommages irréversibles.
Les changements et les détériorations des réponses électriques alertent le chirurgien de manière certaine à 90 % environ au cours de l’intervention chirurgicale. Néanmoins, parfois, même si paraît correct, il peut y avoir des détériorations de réponses électriques que le moniteur n’a pas pu enregistrer et des déficits neurologiques peuvent se produire chez le patient en post-opératoire. L’inverse aussi peut se produire, c’est-à dire même s’il apparait que les réponses électriques sont perturbées, le patient peut n’avoir aucun problème après son réveil.
Ces probabilités sont très minimes, le neuromonitoring permet de sécuriser au maximum l’intervention chirurgicale et offre un grand confort au chirurgien lors de l’intervention chirurgicale.
Dans quelles autres interventions chirurgicale cette technique est-elle utilisee ? Nous pouvons constater que l’utilisation du neuromonitoring augmente la réussite des interventions chirurgicales de certaines maladies congénitales de la colonne vertébrale et de la moelle épinière. Par exemple, lors de l’intervention chirurgicale du syndrome de la moelle attachée (Tethered Cord Syndrome) chez les enfants, les structures anatomiques détériorées entrainant l’accolement de la moelle en bas de la colonne et son étirement, sont stimulées électriquement avec l’aide des électrodes et on peut constater si les racines nerveuses assurent ou pas leurs fonctions motrices. Grâce à cette méthode, le chirurgien peut distinguer quels sont les tissus détériorés qui étirent la moelle épinière ; il sectionne ainsi en toute sécurité la partie qui ne fonctionne pas et libère la moelle épinière. Lors des interventions chirurgicales du syndrome de la moelle attachée (Tethered Cord Syndrome), les nerfs spécifiques tels que le nerf pudendal jouent un rôle important dans les fonctions urinaires, sexuelles et digestives ; ils sont suivis électriquement afin de s’assurer que ces fonctions sont bien protégées.
Nous pouvons aussi dire que les résultats positifs précis importants obtenus par la méthode de Neuromonitoring Intra-opératoire Multimodal dans les interventions chirurgicales de la colonne vertébrale et de la moelle épinière augmenteront régulièrement dans les années à venir. Bien entendu, ces résultats semblent progresser parallèlement au développement des autres technologies de chirurgie comme le microscope et les techniques d’imagerie per-opératoire.
Quels sont les nerfs suivis ? Il y a deux voies principales de structures nerveuses suivies lors de la surveillance monitorée au cours des interventions chirurgicales. La première est le suivi des PEM (Potentiels Evoqués Moteurs), la deuxième est le PES (Potentiels Evoqués Sensitifs). En dehors de ces contrôles, il est possible de mesurer les potentiels électriques des racines nerveuses, technique de l’EMG.
Il est ainsi possible d’obtenir desm informations concernant les racines nerveuses de la partie opérée. Les Potentiels Evoqués Moteurs sont obtenus par la visualisation des voies assurant la motricité et allant du cerveau aux muscles des membres supérieurs et inférieurs. La détérioration de ces voies sur la partie opérée peut provoquer une paralysie chez le patient à son réveil.
Par conséquent, il est très important de prévenir le chirurgien en cas de détérioration des réponses électriques et de suivre le patient de près tout au long de la chirurgie. Les Potentiels Evoqués Sensitifs permettent de suivre les voies de la sensibilité profonde. Lors de chutes de tension artérielle l’hypotension ou de pertes sanguines, les PES – y étant très sensibles – commencent à être perturbés ; on alerte alors l’anesthésiste réanimateur et le chirurgien.
Par ailleurs, lors d’interventions chirurgicales rachidiennes, on contrôle par l’EMG les racines des nerfs spinaux moteurs innervant les muscles. Il est possible de visualiser sur l’EMG la perturbation des racines nerveuses pouvant survenir lors de l’intervention chirurgicale.
Ainsi, le chirurgien est alerté immédiatement par le spécialiste du neuromonitoring qu’un problème survient aux racines nerveuses motrices et la chirurgie est arrêtée sans causer de déficit moteur irréversible ou bien la stratégie opératoire est modifiée.
« Nous pouvons aussi dire que les résultats positifs précis importants obtenus par la méthode de Neuromonitoring Intra-opératoire Multimodal dans les interventions chirurgicales de la colonne vertébrale et de la moelle épinière augmenteront régulièrement dans les années à venir », a déclaré Prof. Dr. Serdar KAHRAMAN.
Pour de plus amples informations sur la chirurgie oncologique, veuillez-vous rendre sur le site internet du Centre médical ANADOLU : Chirurgie oncologique