运动诱发电位和肌电图联合监测在微创经椎间孔腰椎椎间融合术中的有效性及安全性
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摘要
目的评估运动诱发电位(MEP)和肌电图(EMG)联合监测在微创经椎间孔腰椎椎间融合术(MIS-TLIF)中的有效性及安全性。方法回顾性分析2016年1月—2016年6月行MIS-TLIF治疗的64例腰椎椎管狭窄症患者的临床资料,于术中采用MEP和EMG联合监测,并使用监测安全预警,保证MIS-TLIF的安全性。结果本组患者中44例术中MEP和EMG均未发生显著性改变,术后恢复良好,未出现神经功能障碍。20例术中发生MEP和/或EMG显著性改变,其中2例由非手术因素造成信号变化,术后未出现神经功能障碍,列入真阴性;18例确认信号改变与高危手术操作相关。后者有3例术后出现神经功能障碍,其中1例右侧小腿麻木加重;1例右侧足背伸肌肌力减弱,末次随访时肌力恢复至5级;1例术后腰痛及双下肢麻木、疼痛改善不明显,术后1年随访时双下肢麻木、疼痛同术前,考虑为神经功能障碍。MEP和EMG联合监测的敏感性为100.0%,特异性为75.4%,阳性预计值为16.7%,假阳性率为24.6%,阴性预计值为100.0%,假阴性率为0,与单独应用MEP或EMG监测相比提高了敏感性。结论 MEP和EMG联合监测比单一形式的监测更为敏感,术者可获得连续的反馈信息,使多数假阳性信号在术中得到注意或纠正,避免转变为真阳性,提高了脊柱微创手术的有效性和安全性。
Objective To evaluate the efficacy and safety of motion evoked potentials(MEP) combined with electromyography(EMG) in minimally invasive transforaminal lumbar intervertebral fusion(MIS-TLIF). Methods The clinical data of 64 patients undergoing MIS-TLIF for spinal stenosis from January 2016 to June 2016 were retrospectively analyzed. All the patients received MEP and EMG intraoperative neurological monitoring,and monitoring safety warning was used to guarantee the safety of operation. Results Among 66 patients,44 cases had no significant intraoperative changes,and all of them had a sighificant clinical effect and no neurological deficits postoperatively. In other 20 cases,significant changes in MEP and/or EMG occurred,2 caused by non operative factors and without neurological dysfunction after operation defined as true negative;and signal changes in 18 cases were associated with high-risk operation. Among 18 cases,3 had neurological deficits after operation :right leg numbness increased in 1;right dorsal extensor muscle strength weakened,the muscle strength recovered to level 5 at the final follow-up in 1;and the third had postoperative low back pain and lower limbs pain without obvious improvement,and the numbness in both lower extremities was the same as pre-operation after 1 year follow-up,which was considered as a neurological deficit. The sensitivity and specificity of MEP combined with EMG were 100.0% and 75.4% respectively. The positive predictive value was 16.7%,and the false positive rate was 24.6%. The negative predictive value was 100.0%,and the false negative rate was 0. Compared with MEP or EMG monitoring alone,the sensitivity was improved. Conclusion MEP combined with EMG monitoring is more sensitive than single form monitoring. The operators can obtain continuous feedback of information,and notice or correct most of the false-positive signals during the operation,thus avoiding the transformation into true positive,and improving the effectiveness and safety of the minimally invasive operation.
Objective To evaluate the efficacy and safety of motion evoked potentials(MEP) combined with electromyography(EMG) in minimally invasive transforaminal lumbar intervertebral fusion(MIS-TLIF). Methods The clinical data of 64 patients undergoing MIS-TLIF for spinal stenosis from January 2016 to June 2016 were retrospectively analyzed. All the patients received MEP and EMG intraoperative neurological monitoring,and monitoring safety warning was used to guarantee the safety of operation. Results Among 66 patients,44 cases had no significant intraoperative changes,and all of them had a sighificant clinical effect and no neurological deficits postoperatively. In other 20 cases,significant changes in MEP and/or EMG occurred,2 caused by non operative factors and without neurological dysfunction after operation defined as true negative;and signal changes in 18 cases were associated with high-risk operation. Among 18 cases,3 had neurological deficits after operation :right leg numbness increased in 1;right dorsal extensor muscle strength weakened,the muscle strength recovered to level 5 at the final follow-up in 1;and the third had postoperative low back pain and lower limbs pain without obvious improvement,and the numbness in both lower extremities was the same as pre-operation after 1 year follow-up,which was considered as a neurological deficit. The sensitivity and specificity of MEP combined with EMG were 100.0% and 75.4% respectively. The positive predictive value was 16.7%,and the false positive rate was 24.6%. The negative predictive value was 100.0%,and the false negative rate was 0. Compared with MEP or EMG monitoring alone,the sensitivity was improved. Conclusion MEP combined with EMG monitoring is more sensitive than single form monitoring. The operators can obtain continuous feedback of information,and notice or correct most of the false-positive signals during the operation,thus avoiding the transformation into true positive,and improving the effectiveness and safety of the minimally invasive operation.
引文
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[2]肖波,毛克亚,王岩,等.微创经椎间孔腰椎椎体间融合术与传统后路腰椎椎体间融合术并发症的比较分析[J].脊柱外科杂志,2013,11(1):23-27.
[3]杨晓清,杨全中,张少甫,等.术前脊髓监测异常患者脊柱截骨术中脊髓监测参数改变与预后关系[J].脊柱外科杂志,2017,15(1):34-38.
[4]Klem GH,Lüders HO,Jasper HH,et al.The ten-twenty electrode system of the International Federation.The International Federation of Clinical Neurophysiology[J].Electroencephalogr Clin Neurophysiol Suppl,1999,52:3-6.
[5]Joseph JR,Smith BW,La Marca F,et al.Comparison of complication rates of minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion:a systematic review of the literature[J].Neurosurg Focus,2015,39(4):E4.
[6]Langeloo DD,Lelivelt A,Louis Joumée H,et al.Transcranial electrical motor-evoked potential monitoring during surgery for spinal deformity:a study of 145 patients[J].Spine(Phila Pa 1976),2003,28(10):1043-1050.
[7]Gunnarsson T,Krassioukov AV,Sarjeant R,et al.Real-time continuous intraoperative electromyographic and somatosensory evoked potential recordings in spinal surgery:correlation of clinical and electrophysiologic findings in a prospective,consecutive series of 213 cases[J].Spine(Phila Pa 1976),2004,29(6):677-684.
[8]Sutter M,Deletis V,Dvorak J,et al.Current opinions and recommendations on multimodal intraoperative monitoring during spine surgeries[J].Eur Spine J,2007,16(Suppl 2):S232-237.
[9]Liu X,Konno S,Miyamoto M,et al.Clinical value of motor evoked potentials with transcranial magnetic stimulation in the assessment of lumbar spinal stenosis[J].Int Orthop,2009,33(4):1069-1074.