The value of intraoperative motor evoked potential monitoring during surgical intervention for thoracic idiopathic spinal cord herniation Clinical article
The value of intraoperative motor evoked potential monitoring during surgical intervention for thoracic idiopathic spinal cord herniation Clinical article
复制标题
DOI：
10.3171/2011.10.spine11109
复制
发表时间：
2012-02-01
影响因子：
2.8
通讯作者：
Deletis, Vedran
中科院分区：
文献类型：
--
作者：
Novak, Klaus;Widhalm, Georg;Deletis, Vedran
目的。胸段特发性脊髓疝（TISCH）是一种罕见的神经系统疾病，其特征是腹侧硬脑膜缺损处脊髓嵌顿。该疾病与进行性胸部脊髓病的临床症状相关。手术可以保留自然的临床病程，但硬脑膜缺损的手术修复存在术后额外运动缺陷的重大风险，包括永久性截瘫。有关脊髓功能完整性的术中在线信息以及有关运动通路急性功能损伤的警告信号可能有助于降低术后永久性运动缺陷的风险。运动诱发电位 (MEP) 监测可以即时、可靠地检测脊髓运动通路的功能障碍。作者在 TISCH 手术修复的术中神经生理学监测 (IOM) 期间应用了 MEP，并将 IOM 的结果与其对手术过程的影响以及功能性术后结果相关联。方法。作者回顾性分析了 3 家常规使用 IOM（包括体感诱发电位和 MEP）进行脊髓手术的机构中接受 TISCH 手术治疗的 4 例患者的术中神经生理学数据和临床记录。所有 4 名患者均通过后路复位脊髓，并使用硬脑膜移植物修复硬脑膜缺损。结果。运动诱发电位监测对所有患者都是可行的。 2 名患者术中观察到 MEP 发生显着变化。操纵脊髓后几秒钟内就可以检测到这些变化。对 MEP 的监测导致立即修改了一个病例中硬脑膜移植物的位置，并在另一例中暂时停止了嵌顿脊髓的释放。变化在欧洲议会议员中有选择地发生并且是可逆的。在这两名患者中，术中 MEP 的短暂变化与可逆的术后运动缺陷相关。体感诱发电位和 MEP 没有显着变化的患者术后没有表现出额外的神经功能缺损，并且在随访期间显示出运动功能的改善。结论。硬脑膜缺损的手术修复是通过释放和复位脊髓以及在硬脑膜缺损上插入硬脑膜替代物来实现的。在脊髓手术操作过程中仔细监测脊髓长束的功能完整性可以检测手术引起的损伤。作者记录了与可逆性术后运动缺陷相关的 MEP 急性丧失，证实了 IOM 的必要性，包括对 TISCH 手术治疗中的 MEP 进行持续监测。 （DOI：10.3171/2011.10.SPINE11109）
Object. Thoracic idiopathic spinal cord herniation (TISCH) is a rare neurological disorder characterized by an incarceration of the spinal cord at the site of a ventral dural defect. The disorder is associated with clinical signs of progressive thoracic myelopathy. Surgery can withhold the natural clinical course, but surgical repair of the dural defect bears a significant risk of additional postoperative motor deficits, including permanent paraplegia. Intraoperative online information about the functional integrity of the spinal cord and warning signs about acute functional impairment of motor pathways could contribute to a lower risk of permanent postoperative motor deficit. Motor evoked potential (MEP) monitoring can instantly and reliably detect dysfunction of motor pathways in the spinal cord. The authors have applied MEPs during intraoperative neurophysiological monitoring (IOM) for surgical repair of TISCH and have correlated the results of IOM with its influence on the surgical procedure and with the functional postoperative outcome.Methods. The authors retrospectively reviewed the intraoperative neurophysiological data and clinical records of 4 patients who underwent surgical treatment for TISCH in 3 institutions where IOM, including somatosensory evoked potentials and MEPs, is routinely used for spinal cord surgery. In all 4 patients the spinal cord was reduced from a posterior approach and the dural defect was repaired using a dural graft.Results. Motor evoked potential monitoring was feasible in all patients. Significant intraoperative changes of MEPs were observed in 2 patients. The changes were detected within seconds after manipulation of the spinal cord. Monitoring of MEPs led to immediate revision of the placement of the dural graft in one case and to temporary cessation of the release of the incarcerated spinal cord in the other. Changes occurred selectively in MEPs and were reversible. In both patients, transient changes in intraoperative MEPs correlated with a reversible postoperative motor deficit. Patients without significant changes in somatosensory evoked potentials and MEPs demonstrated no additional neurological deficit postoperatively and showed improvement of motor function during follow-up.Conclusions. Surgical repair of the dural defect is effected by release and reduction of the spinal cord and insertion of dural substitute over the dural defect. Careful monitoring of the functional integrity of spinal cord long tracts during surgical manipulation of the cord can detect surgically induced impairment. The authors' documentation of acute loss of MEPs that correlated with reversible postoperative motor deficit substantiates the necessity of IOM including continuous monitoring of MEPs for the surgical treatment of TISCH. (DOI: 10.3171/2011.10.SPINE11109)