术中电生理监测在脊柱侧凸翻修截骨手术中的应用

Application of Intraoperative Neurophysiological Monitoring in Kyphoscoliosis Osteotomy Revision Surgery

目的探讨经颅电刺激运动诱发电位(transcranial electric motor evoked potentials,TCeMEP)和体感诱发电位(somatosensory evoked potentials,SSEP)监测在脊柱侧凸翻修截骨手术中的应用价值。方法回顾性分析2011年3月至2016年3月于我科全麻下行脊柱侧凸翻修截骨术的患者176例,均行SSEP监测,其中134例同时应用TCeMEP监测。分别统计单独SSEP、单独TCeMEP及TCeMEP联合SSEP监测的真阳性率、假阳性率、真阴性率、假阴性率、阳性预测值、阴性预测值、敏感性及特异性。结果单独SSEP成功监测162例(92.0%),TCeMEP成功监测109例(81.3%)。134例应用TCeMEP联合SSEP监测患者,有124例(92.5%)采用任意一种监测方式成功监测。162例成功监测的患者中共有14例报警,报警率为8.6%(14/162)。最终残留神经损伤患者3例,占1.9%(3/162)。统计单独SSEP监测组的敏感性和特异性分别为72.7%和98.7%,单独TcMEP组为90.9%和98.0%,而联合TcMEP及SSEP监测组的敏感性为最高100%,特异性为98.2%。联合TcMEP及SSEP监测组阳性及阴性预测值为85.7%和100%,高于单独SSEP组(80.0%和98.0%)及单独TcMEP组(83.3%和99.0%)。结论脊柱侧凸翻修截骨术手术操作复杂,联合TcMEP及SSEP监测较单一监测能更早地发现神经损害,降低手术风险。我们建议对于脊柱侧凸翻修截骨患者应常规应用TcMEP及SSEP进行联合监测。

Objective To evaluate the clinical value of transcranial electric motor evoked potentials（TCeMEP）and somatosensory evoked potentials（SSEP）monitoring in spinal kyphoscoliosis osteotomy revision surgery.Methods A retrospective study was performed in 176 Kyphoscoliosis patients who were takenosteotomyrevision surgery under total anesthesia from March 2011 to March 2016.Intraoperative neurophysiological monitoring data including SSEP and TCeMEP were collected.SSEP was attempted in 176 patients,meanwhile TCeMEPwas attempted in 134 patients.The monitoring results are identified andanalyzed.The true and false positive rate,true and false negative rate,positive predictive value,negative predictive value,sensitivity and specifi-city of SSEP and TCeMEP and combined use of SSEP and TCeMEP were calculated,respectively.Results SSEP was successful attempted in 162 patients（92.0%）,and TCeMEP was successful attempted in 109patients（81.3%）.By combined using SSEP and TCeMEP,the successful rate increased to 92.5%（124/134）.The overall incidence of significant alerts was 8.6%（14/162）and overall permanent neurological deficit was 1.9%（3/162）.The sensitivity and specificity were 72.7% and 98.7% for SSEP,90.9% and 98.0% for TCeMEP,respectively.The sensitivity and specificity were 100% and 98.2% by combined using.The positive and negative predictive values of SSEPTCeMEP were 85.7% and 100%,higher than SSEP alone（80.0% 98.0%）and TceMEP alone（83.3% 99.0%）.Conclusion Kyphoscoliosis revision surgery is complex,but it can greatly decrease the risk of operation by usingSSEP and TCeMEP.We suggest intraoperative neurophysiological monitoring is the current gold standard for kyphoscoliosis osteotomy revision surgery.