神经电生理监测在经皮内窥镜下腰椎间盘切除术中的应用

The application of neurophysiological monitoring in percutaneous endoscope lumbar discectomy

目的：探讨神经电生理监测在经皮内窥镜下腰椎间盘切除术中的应用。方法：回顾性分析2014年4月-2014年7月收治的37例单节段腰椎间盘突出症患者的临床资料,男16例,女21例;平均年龄48.4±17.5岁。其中单纯腰椎间盘突出症35例,腰椎间盘突出合并椎管狭窄症2例。所有患者均在局部麻醉下行微创经侧路经皮内窥镜下腰椎间盘摘除术（percutaneous endoscope lumbar discectomy,PELD）。术中运用自发性肌电图（spontaneous electromyography,SEMG）监测神经根功能,同时纪录患者的主观感受（疼痛）,分析两者之间的关系。结果：在手术通道放置过程中,所有患者在出现腰部疼痛时,神经电生理无明显改变。2例患者无明显腿痛,电生理却出现明显的成串、波幅较大的肌电反应,调整通道后电生理改变趋于正常。35例患者有明显腿痛且神经电生理出现明显的成串、波幅较大的肌电反应,立即提醒术者,查找原因,调整手术通道后,患者腿痛消失,且电生理发生明显改变,异常肌电反应减轻,趋于正常。所有患者在腰椎间盘髓核摘除时,无明显疼痛且神经电生理无明显变化。在剥离、解压粘连神经根时,均出现明显连串的电位波形改变和明显的腿痛,停止手术操作后,腿痛消失,神经电生理恢复正常。在直视下刺激神经根时,患者出现明显的腿痛,同时神经电生理出现连串的电位。所有患者健侧的监测结果均无明显电生理改变。术后所有患者均无神经并发症。以神经电生理监测作为安全指标,其真阳性率为100%,而以疼痛作为安全指标,其真阳性率为94.6%;假阴性率为5.4%。结论：术中应用自发性肌电图监测可提供更为客观的安全指标,从而提高手术安全性。

Objectives：To investigate the application of neurophysiological monitoring in percutaneous endo-scope lumbar discectomy（PELD）.Methods：A retrospective review was performed on 37 patients（16 males and21 females） with lumbar disc herniation between April 2014 and July 2014.The mean age was 44.8 ±17.5years old.Among these,there were 35 patients with simple lumbar disc herniation and 2 patients combined with spinal stenosis.After local anesthesia,all patients underwent PELD.Spontaneous electromyography（SEMG）was used to monitor nerve root function,and the patient′s subjective feeling（pain） was recorded.The correlation between the SEMG and the patient′s subjective feeling was analyzed.Results：In the process of operation channel placed,all patients showed the low back pain,but SEMG had no obvious change.2 cases showed no significant leg pain but significantly electrophysiological changes,the electrophysiological changes tended to be normal after adjusting the channel.Leg pain and electrophysiological changes were very obvious in 35 cases.By reminding operator,finding out the reasons and adjusting channel,the leg pain and the changes of neurophysiological monitoring disappeared.In the process of discectomy,all patients had no obvious pain or changes in the electrophysiological monitoring.When decompressing the nerve root,there were a series of significantly potential wave amplitude changes and obvious leg pain.Leg pain disappeared and neu-rophysiological monitoring returned normal when stopping surgery.When stimulating the nerve root,the pa-tients showed significant EMG response and leg pain.The monitoring results of contralateral body had no significant electrophysiological changes.All patients had no postoperative neurological complications.The truepositive rate of SEMG was 100%,while the true-positive rate of pain was 94.6%,the false-negative rate of pain was 5.4%.Conclusions：Intraoperative SEMG monitoring provides a more objective safety indicator and further improves surgical safety.