多模式神经电生理监测技术在儿童腰椎滑脱后路复位融合固定手术中的应用

Application of multi-modal intraoperative monitoring technology during posterior reduction and fusion fixation of lumbar spondylolisthesis in children.

目的探讨多模式神经电生理监测技术在儿童腰椎滑脱后路复位融合固定手术中的应用价值。方法回顾性分析2018年1月至2019年11月首都医科大学附属北京儿童医院收治的腰椎滑脱患者19例,其中男2例,女17例,平均年龄(9.1±2.7)岁,均行后路复位融合固定手术。术中同时进行躯体感觉诱发电位(somatosensory evoked potential,SEP)、运动诱发电位(motion evoked potential,MEP)及自由肌电图(free-run electromyography,EMG)监测。阳性判定标准为:与基线相比,MEP波幅下降≥80%、SEP波幅下降≥50%和(或)潜伏期延长≥10%,或者出现任何形式的肌电反应。结果19例术中均成功获得具有监护价值且重复性较好的SEP及MEP波形,成功率100%。术中在触碰、推挤及牵拉神经根时,相应的自由肌电图监测均出现肌电反应,记录阳性率为100%。本组患者监测过程中SEP与MEP波幅或潜伏期改变均未达到预警标准,其中2例术中出现一侧连续爆发性肌电反应,及时暂停手术操作后,肌电反应明显减少,继续操作后再次出现肌电反应,术中唤醒并调整手术操作。术后出现该侧下肢神经灼性疼痛,肌力正常,症状均在术后3个月内消失。结论在腰椎滑脱复位手术中进行多模式神经电生理监测,有助于同时了解脊髓完整性及神经根功能状态,降低术中损伤脊髓、神经根的风险,提高手术的安全性。

Objective To explore the application value of multi-modal intraoperative neuromonitoring during reduction and fusion of lumbar spondylolisthesis in children.Methods Retrospective analysis was performed for 19 hospitalized cases of lumbar spondylolisthesis from January 2018 to November 2019.There were 2 boys and 17 girls with an average age of(9.1±2.7)years.During posterior reduction,fusion and fixation,somatosensory evoked potential(SEP),motion evoked potential(MEP)and free-run electromyography(EMG)were monitored simultaneously.Declines of MEP wave amplitude>80%and SEP amplitude>50%or latent period extending by 10%were diagnosed as positive changes.And myoelectric response indicated that nerve root was provoked as a positive change.Results The SEP/MEP amplitudes with excellent monitoring value and repeatability were successfully obtained intraoperatively in all 19 cases with a success rate of 100%.The corresponding intraoperative EMG monitoring showed electromyographic response upon touching,pushing and pulling nerve root and the positive rate was 100%.The amplitude or latency of SEP/MEP failed to reach the warning threshold.In 2 cases(10.5%),there was a continuous explosive myoelectric reaction during operation.Also a continuous unilateral explosive EMG reaction was detected.Then operation was suspended in time and EMG reaction significantly declined.EMG reaction occurred again during operation.After operation,nerve burn pain of unilateral lower limb occurred and muscle strength remained normal.The symptoms disappeared within 3 months.Conclusion The method of multi-mode intraoperative neuromonitoring during lumbar spondylolisthesis can both record the integrity of spinal cord and the functional status of nerve root in real time.And it may lower the intraoperative risks of injury of spinal cord and nerve root and improve operative safety.