Neurological Surgery 脳神経外科41巻4号

2013年04月発行

総説

脳神経外科手術に必要な麻酔の知識，最近の動向

著者： 糟谷祐輔¹ 尾崎眞¹

所属機関： ¹東京女子医科大学麻酔科学教室

ページ範囲：P.295 - P.304

Ⅰ．はじめに

　昨今の画像診断技術の進歩に伴って脳神経外科領域の疾患はより正確に，より早期に診断されるようになった．脳腫瘍や脳血管性の疾患のみならず，不随意運動疾患や慢性疼痛，てんかんなどの非腫瘍性，非血管性疾患に対する機能改善を目的とする術式も増えている．今や脳神経外科で扱う手術は非常に多岐にわたり，かつて第一に求められてきた救命のための手術という考え方から，神経学的および全人的な機能予後の維持・改善に重点が置かれるようになってきている．

　術中の脳神経機能モニタリングは守るべき脳神経機能の局在と保全状態を知る手段として極めて重要であり，腫瘍摘出術，脳血管手術，脊髄手術など多くの手術でスタンダードとなっている．

　聴神経腫瘍摘出術では脳神経モニタリングの精度が術後の神経予後に直結するため，精度の高い神経モニタリングを行う必要があり，それには全身麻酔の知識が必須である．なぜならば，全身麻酔薬は体性感覚，運動神経や脳神経などの神経系モニタリングに大きく干渉するからである．患者の不動，無動，無意識という全身麻酔の要素を達成しつつ，脳神経モニタリングの精度を維持するという絶妙な手術フィールドを提供するには，高度な知識と経験に裏打ちされた麻酔管理が必要である．

　また，言語機能モニタリングは全身麻酔下では施行不可能なため，言語野領域近傍の手術では覚醒下で開頭手術を行うawake craniotomyが行われる．開頭操作時には鎮静鎮痛が必要であり，気道管理が重要であるとともに，必要時に十分な覚醒が得られるように鎮静レベルをコントロールするという特殊な麻酔管理が必要である．

　本稿では，一般的な脳神経麻酔についてのポイントをいくつかと神経モニタリングについて詳しく述べ，新しい領域の手術であるawake craniotomyの麻酔とてんかん手術の麻酔法，最後に近年術後合併症として重要視されている肺血栓塞栓症の予防について，最新の知見を交えて解説する．

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