重度脊柱畸形翻修截骨术中神经监测变化的危险因素

Risk factors for neurological monitoring changes in spinal osteotomy of revision surgery for severe spinal deformity

[目的]评估联合体感诱发电位(somatosensory evoked potential,SSEP)和经颅运动诱发电位(transcranial motor evoked potential,TcMEP)监测在重度脊柱畸形翻修截骨矫形手术中的应用价值,探讨术中出现神经监测变化的危险因素。[方法]回顾性分析2015年1月~2017年1月于本科全麻下进行重度脊柱畸形翻修截骨矫形手术54例患者,男19例,女35例。术中均应用SSEP和TcMEP联合监测。统计比较单模式SSEP、单模式TcMEP及双模式联合监测的阳性预测值和阴性预测值、敏感性及特异性。分析术中出现真阳性电生理监测变化的原因和危险因素,并提出相应的管理措施。[结果]联合SSEP及TcMEP监测成功率、阳性预测值、阴性预测值、敏感性及特异性均为最高。54例患者中共有14例(25.93%)出现阳性电生理监测变化。经术中干预后,随访时最终2例(3.70%)未恢复至术前神经功能状态。术前合并胸椎管狭窄、主弯Cobb角>130°为出现真阳性电生理变化的危险因素。[结论]在重度脊柱畸形翻修截骨矫形手术中,联合SSEP及TcMEP监测能有效地检测早期脊髓损伤,有更好地进行预警的价值。积极进行干预能扭转电生理变化并可以避免严重脊髓损伤并发症发生。翻修术中截骨矫形过程出现电生理变化概率较高。术前合并胸椎管狭窄以及主弯Cobb角>130°的患者更易导致真阳性监测变化发生。

[Objective] To evaluate the clinical value of somatosensory evoked potentials （SSEP） and transcranial motor evoked potentials （TcMEP） in intraoperative monitoring for osteotomy of revision surgery for severe spinal deformity, and explore the risk factors for neurological monitoring changes. [Methods] A retrospective analysis was performed on 54 patients who received surgical correction under the general anesthesia for severe spinal deformity from January 2015 to January 2017. There were 35 females and 19 males in this series of cases. Intraoperative neurophysiological monitoring data including SSEP and TcMEP were collected. The true or false positive rate, true or false negative rate, positive or negative predictive value, as well as sensitivity and specificity of SSEP, TcMEP and that combined SSEP with TcMEP were calculated respectively. The risk factors of neurological monitoring changes were analyzed, and the corresponding recommendations were provided according to our clinical practice and literature review. [Results] The monitoring combined SSEP with TcMEP proved the highest successful rate, sensitivity, specificity, as well as positive and negative predictive value. Of the 54 patients, 14 （25.93%） had significantly positive alerts during operation. After intraoperative intervention, 2 patients （3.70%） got permanent neurological deficit at the latest follow up. The accompanied thoracic spinal stenosis before operation, curve Cobb angle more than 130 degrees were positively correlated with the monitoring changes （P〈0.05）. [Conclusion] Combined SSEP with TcMEP monitoring can effectively detect the early spinal cord injury in spinal osteotomy of revision surgery for severe spinal deformity and has an improved warning value. Rapid intervention does reverse monitoring changes and avoid potentially serious neurologic complications. The risk factors for neurological monitoring changes during spinal osteotomy are accompanied thoracic spinal stenosis before operation and curve Cobb angle more than 130 degrees.