多模式神经电生理监测在体位摆放及颈椎手术过程中的作用

Effectiveness of Multimodal Intraoperative Monitoring during Positioning and Cervical Spine Surgery

背景尽管多模式神经电生理监测(MIOM)技术已广泛应用于颈椎手术中,但国内外鲜有其在体位摆放及颈椎手术过程中对机械性损伤的监测作用的相关报道。目的评估MIOM在体位摆放及颈椎手术过程中监测脊髓及神经功能变化的作用,为手术的安全保驾护航。方法回顾性收集2016年9月—2017年9月在北大医疗鲁中医院脊柱外科接受颈椎手术的61例患者的资料。患者均行术前及术中MIOM,数据由体感诱发电位(SEP)、运动诱发电位(MEP)及肌电图(EMG)组成,从术前颈部体位摆放直至手术结束。记录患者MIOM结果及临床疗效〔采用日本骨科协会评估治疗(JOA)评分评估患者术前、术后7 d脊髓及神经功能,并计算JOA评分改善率〕。计算SEP、MEP的灵敏度、特异度、阳性预测值和阴性预测值。结果 61例患者中,6例患者在体位摆放或手术过程中出现MEP警报(MEP突然部分或完全消失),然而SEP未见明显变化。6例患者均在体位摆放过程中出现MEP警报,其中5例重新摆放体位后MEP恢复至基线水平且手术操作中均未出现诱发电位警报,1例植骨融合后MEP恢复至基线水平;6例患者术后MEP较基线电位明显升高,术后未出现新的神经功能障碍或原有神经功能障碍加重。然而,只有1例患者(行枕骨寰椎融合术)在体位摆放及颈椎手术过程中出现MEP警报,MEP部分消失,SEP正常,术后未出现新的神经功能障碍或原有神经功能障碍加重。61例患者监测过程中无假阴性或假阳性记录,均未出现EMG异常。MEP的灵敏度、特异度、阳性预测值、阴性预测值均为100.0%;SEP的灵敏度为0,特异度为100.0%,阳性预测值为0,阴性预测值为90.2%。患者术后JOA评分高于术前(P<0.05)。患者JOA评分改善率为12.5%～75.0%,平均(42.9±17.6)%。结论 MIOM技术是预防体位摆放及颈椎手术过程中脊髓、神经根损伤的有效工具。其中MEP监测脊髓及神经根损伤的灵敏度最高;SEP、MEP和EMG联合监测具有互补作用,可降低手术风险,共同提高手术安全性,并为手术疗效评估以及术后神经功能的恢复提供客观依据。

Background Although multimodal intraoperative monitoring(MIOM)has been widely used in cervical spine surgery,there are few reports about its monitoring effect on mechanical injury during cervical spine surgery and positioning procedures at home and abroad.Objective To evaluate the role of the MIOM in monitoring changes of spinal cord and the neurological function during positioning and the cervical procedure,ensuring the safety of the operation.Methods The date of 61 patients undergoing cervical surgery in the Department of Spine Surgery,PKUCare Luzhong Hospital during September 2016 to September 2017 was retrospectively collected.All patients underwent MIOM before and during operation.MIOM data of 61 patients were composed of somatosensory evoked potential(SEP),motor evoked potential(MEP)and electromyography(EMG)from the onset of positioning to the end of the surgical procedure.Results of MIOM and clinical efficacy〔the spinal cord and neurological function of the patients were evaluated by the Japanese Orthopaedic Association(JOA)score before and 7 days after operation,and the improvement rate of JOA score was calculated〕was calculated.The sensitivity,specificity,positive predictive value and negative predictive value of SEP and MEP were calculated.Results Six of 61 patients showed MEP alarms during positioning or surgery(MEP suddenly disappeared partially or completely),while SEP did not change significantly.All six patients showed MEP alarm during positioning,five of whose MEP was restored to the baseline level after repositioning and no evoked potential alarm was observed during surgical operation later,and one of whose MEP was restored to the baseline level after grafting fusion.MEP was significantly higher compared with the baseline potential in six patients after operation,and no new neurological dysfunction or aggravation of the original neurological dysfunction occurred after operation.However,only one patient(occipital atlanto-atlas fusion)showed MEP alarm during positioning and cervical spine surgery,with partial disappearance of MEP and normal SEP,and no new neurological dysfunction or aggravation of existing neurological dysfunction after surgery.No EMG abnormality was observed in 61 patients with no false negative or false positive records during the monitoring.The sensitivity and specificity of MEP were both 100.0%,while the positive and negative predictive value were 100.0%.The sensitivity,specificity,positive predictive value and negative predictive value of SEP were 0,100.0%,0 and 90.2%,respectively.Postoperative JOA score of the patients was higher than that before surgery(P<0.05).The improvement rate of JOA score was 12.5%-75.0%,with an average of(42.9±17.6)%.Conclusion MIOM is a useful tool to prevent cervical spinal cord and nerve root injury in cervical spine surgical procedures and during positioning of patient.MEP showed the highest sensitivity in detecting injuries in cervical spine related to surgery and positioning.The combined application of SEP,MEP and EMG intraoperative monitoring have complementary effects and can help to reduce the risk of neurological deficit and improve the safety of cervical surgery and it can also provide an objective basis for the evaluation of surgical efficacy and the recovery of postoperative neurological improvement.