严重脊柱畸形全脊椎截骨术中神经电生理监测严重不良事件的危险因素及转归

The high risk factors and prognosis of severe intraoperative neurophysiological monitoring events in patients with se- vere spinal deformity undergoing vertebral column resection

目的分析严重脊柱畸形患者全脊椎截骨（vertebralcolumnresection，VCR）矫形术中神经电生理监测（intraoperativeneurophysiologicalmonitoring，IONM）的严重不良事件，并探讨其对术中神经损害的预警作用、危险因素及术后转归。方法回顾性分析2009年1月至2015年6月10例发生IONM严重不良事件的VCR手术患者，平均年龄（19．9±17．1）岁。分析术中IONM严重不良事件的发生时间和类型，对应的手术操作及随后的处理措施，对症处理后患者神经监测的改善情况等，并对比患者术前、术后即刻及末次随访时的神经功能异常情况。结果IONM监测严重不良事件的发生时间分别为置钉1例（10％）、截骨5例（50％）、置棒4例（40％），术中截骨和置棒矫形是发生IONM监测严重不良事件的高危时期。10例患者中3例患者术中经处理后IONM监测明显恢复，术后无明显神经损害，末次随访时神经功能正常；4例患者术中经积极处理后IONM监测有较大改善，术后神经并发症较轻，末次随访时神经功能完全恢复；3例患者术中经积极处理后IONM监测改善明显较差，术后神经并发症较重，末次随访时神经功能仅部分改善。结论术中多模式IONM监测可早期发现神经损伤、改善预后。术中截骨过程和置棒矫形是发生IONM监测严重不良事件的危险因素，术中经积极对症处理后IONM监测改善明显的患者在术后随访中神经功能预后较好。

Objective To evaluate the severe intraoperative neurophysiological monitoring （IONM） event and its predic- tive value for the intraoperative neurologic impairment in patients with severe spinal deformity undergoing vertebral column resec- tion （VCR）, and to investigate the high risk factors and post-operative outcomes of severe IONM events. Methods Ten patients from January 2009 to June 2015 were retrospectively reviewed, of whom the average age was （19.9±17.1） years. The following pa- rameters were evaluated for each patient： neurologic status at pre-operation, post-operation, and the last follow-up, the timing and type of severe IONM events, operative performance at severe IONM events, intraoperative treatment for severe IONM events and intraoperative change in severe IONM monitoring after treatment. Results Severe IONM events occurred at the stages of pedicle screw implanting in 1 （10%） patient, osteotomy in 5 （50%） patients and rod fixation in 4 （40%） patierits, respectively. The stages of osteotomy and rod fixation were high risk phase for severe IONM events. Of the 10 patients, IONM monitoring significantly recov- ered after treatment in 3 patients, and they had no neurologic impairment at post-operation and at the last follow-up. The IONM monitoring significantly improved after treatment in 4 patients, of whom the post-operative neurologic impairment recovered at the last follow-up. The IONM monitoring did not improved after treatment in 3 patients, of whom the post-operative neurologic impair- ment only partly recovered at the last follow-up. Conclusion The multi-mode intraoperative IONM could help to early detect the neurologic impairment and improve the prognosis for patients undergoing VCR. Intraoperative osteotomy and rods contouring are high risk phase for severe IONM events. Patients with significantly improved IONM monitoring after intraoperative treatment could expect better recovery of neurologic function during follow-up.