多模式神经电生理监测在脊柱骨折行椎弓根螺钉内固定术患者中的应用

Application value of multimodal neurophysiological monitoring in patients undergoing pedicle screw fixation for spinal fractures

目的探讨多模式神经电生理监测在脊柱骨折行椎弓根螺钉内固定术(PSF)中的应用价值。方法选择2020年5月至2023年5月开封市中心医院骨科收治的因外伤致脊柱骨折的58例患者,均行PSF治疗,术中实施体感诱发电位(SEP)、运动诱发电位(MEP)及肌电图(EMG)多模式神经电生理监测,比较患者手术前后胫后神经的神经电生理指标、伤椎后凸Cobb角、疼痛视觉模拟评分(VAS)及日本骨科协会(JOA)腰椎评分。患者术后行CT复查评估螺钉发生破壁情况,以Gertzbein分级≥1级为标准,分析多模式神经电生理监测报警的准确性。结果58例患者均成功进行手术,手术时间为(143.72±14.38)min、出血量为(175.92±24.62)mL、术后首次下床时间为(5.68±1.15)d、住院时间为(9.35±1.48)d;术后患者胫后神经SEP潜伏期缩短,波幅及运动神经、感觉神经传导速度均升高(P<0.05);术后患者后凸Cobb角及VAS评分低于术前,JOA评分高于术前(P<0.05);58例患者共置入螺钉384枚,46枚(11.98%)螺钉置入时神经电生理监测报警。术后CT复查Gertzbein分级0级337枚(87.76%)、≥1级47枚(12.24%),SEP、MEP和EMG监测的敏感性分别为91.49%、87.23%和59.57%,特异性分别为94.66%、92.58%和89.32%;多模式监测的敏感性为97.87%,特异性为96.74%。结论多模式神经电生理监测可准确发现PSF术中置入螺钉时患者发生神经损伤的情况,提醒术者修正手术操作,使患者术后脊柱神经功能获得较大改善。

Objective To explore the application value of multimodal neuroelectrophysiological monitoring in pedicle screw fixation(PSF)for spinal fractures.Method A total of 58 patients with spinal fractures caused by trauma admitted to the Department of Orthopedics at Kaifeng Central Hospital from May 2020 to May 2023 were selected and treated with PSF.During the surgery,multimodal neuroelectrophysiological monitoring was performed using somatosensory evoked potentials(SEP),motor evoked potentials(MEP)and electromyography(EMG).The patients were compared with neuroelectrophysiological indicators of the posterior tibial nerves,Cobb angle of the injured vertebra,visual analog scale(VAS)of pain and lumbar spine scored with Japanese Orthopaedic Association(JOA)between before and after surgery.CT re-examination was performed on the patients after surgery to evaluate the occurrence of screw wall rupture,with Gertzbein grading≥1 as a standard.The accuracy of multimodal neurophysiological monitoring alarms was analyzed.Result All 58 patients had successful surgery,with surgical time of(143.72±14.38)min,bleeding volume of(175.92±24.62)ml,the first postoperative time of getting out of bed(5.68±1.15)d and hospital stay of(9.35±1.48)d.After surgery,SEP latency of the posterior tibial nerves in patients were shortened,and the amplitude and conduction velocity of the motor and sensory nerves were elevated(P<0.05).The postoperative Cobb angle and VAS score were lower than those before surgery,while JOA score was higher than that before surgery(P<0.05).A total of 384 screws were implanted in 58 patients.There were 46 screws(11.98%)with neuroelectrophysiological alarms when they were implanted.Postoperative CT re-examination showed 337 screws with Gertzbein grade 0(87.76%)and 47 screws with grade≥1(12.24%).The sensitivities of SEP,MEP and EMG monitoring were 91.49%,87.23%and 59.57%,respectively,and the specificities of SEP,MEP and EMG monitoring were 94.66%,92.58%and 89.32%,respectively.The sensitivity of multimodal monitoring was 97.87%,and the specificity was 96.74%.Conclusion Multimodal neuroelectrophysiological monitoring can accurately detect nerve damage in patients during screw implant in PSF surgery and remind the surgeons to correct surgical procedures,thus significantly improving postoperative spinal nerve function of the patients.