真阳性神经监护警报发生时操作与术后步行能力的相关性

Relationship between intraoperative neurophysiological monitoring alert and postoperative walking ability

背景:神经监护广泛应用脊柱外科手术,但严重的医源性脊髓损伤仍未能避免。是否能够通过真阳性警报发生时的手术操作预测术后神经功能?以期提高脊柱外科手术操作的安全性。目的:评价发生真阳性神经监护时的手术操作与术后步行能力之间的相关性。方法:回顾性分析香港大学玛丽医院脊柱外科行术中神经监护的2249例患者。收集患者的一般资料、诊断、手术方式及术中监护数据,其中发生真阳性神经监护警报患者10例(男4例,女6例,年龄14-88岁),平均随访时间9.8年。按发生神经监护警报时手术操作是否对脊髓形成干扰分为2组,予以分析总结。研究方案的实施符合香港大学玛丽医院医院的相关伦理要求,参与的患病个体及其监护人均签署了“知情同意书”。结果与结论:①术中神经监护警报发生于减压3例,前路椎间盘松解1例;寻找T3椎弓根进钉点1例;螺钉置入1例;骨折复位2例;钢丝置入1例;骨水泥植入1例;②其中脊髓干扰组5例均出现步行困难;而非脊髓干扰组5例中4例可步行,两组间差异有显著性意义(P<0.05);③神经监护警报发生后继续原方案手术者4例,扩大减压3例,放弃手术3例;④结果提示,对脊髓进行干扰性操作发生真阳性神经监护警报时,术后极有可能引起步行困难。上述情况一旦发生,需立即停止手术,马上采取手术减压、给予激素冲击等补救措施。

BACKGROUND:Intraoperative neurophysiological monitoring is popular in spinal surgery.However,a severe iatrogenic spinal cord injury cannot be completely eliminated.Is there a relationship between true positive intraoperative neurophysiological monitoring alert during particular surgical steps and postoperative neurological recovery?This topic is to improve the safety of spinal invasive procedur OBJECTIVE:To determine the relationship between true positive intraoperative neurophysiological monitoring alert during particular surgical steps and postoperative walking ability.METHODS:A retrospective study of 2249 patients undergoing intraoperative neurophysiological monitoring in Li Ka Shing Faculty of Medicine,the University of Hong Kong was conducted.Standard patient demographics,diagnosis and operative features and intraoperative neurophysiological monitoring data were collected.There were 10 cases of true positive intraoperative neurophysiological monitoring alert(4 males,6 females,14-88 years old),and the average follow-up time was 9.8 years.The patients were divided into two groups based on whether surgical steps triggering intraoperative neurophysiological monitoring alert impact the spinal cord or not.The study was performed in accordance with the ethical requirements of Li Ka Shing Faculty of Medicine,the University of Hong Kong,and the patients and their guardians signed the informed consents.RESULTS AND CONCLUSION:These alerts occurred during decompression(n=3),anterior disc release(n=1),finding the entering point of T3 pedicle(n=1),screw insertion(n=1),reduction of fracture(n=2),insertion of wire(n=1),and cement injection(n=1).Among these patients,100%of spinal cord invasive procedure patients developed incompetence of walking,while 80%(4/5)of spine cord non-invasive patients were capable of walking(P<0.05).After the alert was triggered,four patients continued with primary program,three patients underwent expanding decompression and three patients gave up surgery.If true positive intraoperative neurophysiological monitoring alert is reported during spinal invasive procedures,there should be a very high chance of postoperative walking disability.If any conditions occur,the surgery needs to be stopped,and instead,remedial measures such as surgery suspension,steroids injection,and additional decompression should be performed immediately.