多模式神经电生理监测在严重脊柱畸形全脊椎截骨术中神经损伤的预警作用
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摘要
目的研究多模式神经电生理监测(intra operative neurophysiological monitoring,IONM)在严重脊柱畸形全脊椎截骨术(vertebral colamn resection,VCR)中的预警作用。方法纳入2014-06-2017-06我院行全脊椎截骨术的12例严重脊柱畸形患者,观察手术过程中IONM严重不良事件类型与发生时间,相应的手术操作以及干预措施,以及采取干预措施后神经监测的改善情况;比较手术前后、末次随访神经功能异常情况。结果 IONM监测发生严重不良事件的手术步骤为置钉、截骨、置棒,比例分为1例(8.33%)、6例(50.00%)、5例(41.67%);监测显示,术中置棒矫形、截骨是出现IONM监测严重不良事件的危险时期。归转情况:4例干预后IONM监测显著改善,术后即刻无神经并发症,6个月后神经功能正常;5例干预后IONM监测有一定改善,术后即刻无神经并发症或较轻,6个月后神经功能恢复正常;3例干预治疗后IONM监测无明显改善,术后即刻发生中重度神经并发症,1个月后神经功能部分恢复正常。结论 IONM监测能够早期发现严重脊柱畸形全脊椎截骨术中神经损伤,经积极干预治疗能改善预后,术中置棒矫形、截骨是出现IONM监测严重不良事件的危险时期。
Objective To investigate the predictive value of severe intraoperative neurophysiological monitoring(IONM) in patients with severe spinal deformity undergoing vertebral column resection(VCR), and to investigate the high risk factors and postoperative outcomes of severe IONM events. Methods In this study, 12 VCR patients with severe IONM events in our hospital from June 2014 to June 2017 were enrolled. The following parameters were evaluated: the timing and type of severe IONM events, operative performance at severe IONM events, intraoperative treatment for severe IONM events, intraoperative change in severe IONM monitoring after treatment, and neurologic status at pre-operation, post-operation, and the last follow-up. Results Severe IONM events occurred at the stages of pedicle screw implanting in 1 patient(8.33%), osteotomy in 6 patients(50.00%) and rod fixation in 5 patients(41.67%),respectively. The stages of rod fixation and osteotomy were high risk phase for severe IONM events. Of the 12 patients, IONM monitoring significantly recovered after treatment in 4 patients without neural complications immediately after operation, and neurologic function recovered at post-operation 6 months; The IONM monitoring slightly improved after treatment in 5 patients with no or mild neural complications, of whom the post-operative neurologic impairment recovered at post-operation 6 months; The IONM monitoring did not improved after treatment in 3 patients with severe neural complications, of whom the post-operative neurologic impairment only partly recovered at post-operation 1 months. Conclusion The multi-mode intraoperative IONM can help to early detect the neurologic impairment and improve the prognosis for patients undergoing VCR. Intraoperative osteotomy and rods contouring are the high risk phase for severe IONM events.
Objective To investigate the predictive value of severe intraoperative neurophysiological monitoring(IONM) in patients with severe spinal deformity undergoing vertebral column resection(VCR), and to investigate the high risk factors and postoperative outcomes of severe IONM events. Methods In this study, 12 VCR patients with severe IONM events in our hospital from June 2014 to June 2017 were enrolled. The following parameters were evaluated: the timing and type of severe IONM events, operative performance at severe IONM events, intraoperative treatment for severe IONM events, intraoperative change in severe IONM monitoring after treatment, and neurologic status at pre-operation, post-operation, and the last follow-up. Results Severe IONM events occurred at the stages of pedicle screw implanting in 1 patient(8.33%), osteotomy in 6 patients(50.00%) and rod fixation in 5 patients(41.67%),respectively. The stages of rod fixation and osteotomy were high risk phase for severe IONM events. Of the 12 patients, IONM monitoring significantly recovered after treatment in 4 patients without neural complications immediately after operation, and neurologic function recovered at post-operation 6 months; The IONM monitoring slightly improved after treatment in 5 patients with no or mild neural complications, of whom the post-operative neurologic impairment recovered at post-operation 6 months; The IONM monitoring did not improved after treatment in 3 patients with severe neural complications, of whom the post-operative neurologic impairment only partly recovered at post-operation 1 months. Conclusion The multi-mode intraoperative IONM can help to early detect the neurologic impairment and improve the prognosis for patients undergoing VCR. Intraoperative osteotomy and rods contouring are the high risk phase for severe IONM events.
引文
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[9] Mcdevitt W, Bill P, Rodrigues D, et al. TM1-1:The utility of intra-operative neuromonitoring(IONM)during complex spinal surgery[J].British Journal of Neurosurgery, 2016, 30(5):485.
[10] Montes-Pe a V, Tramontano V, Sala F, et al. P285 Postoperative clinical motor findings correlations with IONM MEP results during intramedullary spinal cord tumor removal. Presentation of 2 cases[J].Clinical Neurophysiology, 2017, 128(9):e269.
[2]黄紫房,郎传东,邓耀龙,等.重度胸椎畸形全椎体截骨术中神经电生理监测事件的危险因素分析[J].中华骨科杂志, 2016, 36(24):1551-1559.
[3] Nemec M, Praksova P, Repko M, et al. 46. Intraoperative neuro-physiological monitoring in scoliosis surgery at University Hospital Brno[J]. Clinical Neurophysiology, 2014, 125(5):e40-e40.
[4]吴继功,马华松,邵水霖,等.成人重度僵硬性脊柱侧后凸合并脊髓畸形的截骨手术治疗[J].颈腰痛杂志, 2015, 36(6):453-458.
[5] Mahaffy P R, Benna M, King T, et al. The Neutral Gas and Ion Mass Spectrometer on the Mars Atmosphere and Volatile Evolution Mission[J]. Space Science Reviews, 2015, 195(1-4):49-73.
[6]邱勇.全脊椎截骨术治疗脊柱侧后凸畸形的并发症及预防[J].中华解剖与临床杂志, 2014, 19(4):265-267.
[7] Karakas E, Müller H H, Schlosshauer T, et al. Reoperations for primary hyperparathyroidism—improvement of outcome over two decades[J]. Langenbecks Archives of Surgery, 2013, 398(1):99-106.
[8]晏龙强,何向辉,张艳丽,等.应用IONM探测喉返神经信号减弱的影响因素分析[J].重庆医学, 2016, 45(12):1690-1692.
[9] Mcdevitt W, Bill P, Rodrigues D, et al. TM1-1:The utility of intra-operative neuromonitoring(IONM)during complex spinal surgery[J].British Journal of Neurosurgery, 2016, 30(5):485.
[10] Montes-Pe a V, Tramontano V, Sala F, et al. P285 Postoperative clinical motor findings correlations with IONM MEP results during intramedullary spinal cord tumor removal. Presentation of 2 cases[J].Clinical Neurophysiology, 2017, 128(9):e269.