Proper Responding Strategies to Neuromonitoring Alerts During Correction Step in Posterior Vertebral Column Resection Patients With Severe Rigid Deformities Can Reduce Postoperative Neurologic Deficits
Proper Responding Strategies to Neuromonitoring Alerts During Correction Step in Posterior Vertebral Column Resection Patients With Severe Rigid Deformities Can Reduce Postoperative Neurologic Deficits
复制标题
严重刚性畸形后路椎体切除术患者矫正步骤中对神经监测警报的正确反应策略可以减少术后神经功能缺损
作者：
Wang Yingsong;Xie Jingming;Zhao Zhi;Li Tao;Bi Ni;Zhang Ying;Shi Zhiyue;Xie JM
研究设计。回顾性研究。目的。分析严重刚性畸形患者后路椎体切除术（PVCR）术中神经监测（IOM）的变化，并描述我们的逐步应对策略。背景资料摘要。伴随 PVCR 矫正的明显神经功能缺损风险已被反复强调。方法。回顾了 46 例接受 PVCR 实现 IOM 的患者的记录。 IOM 警报触发响应方案：(1) 将凸形矫正杆更换为凹形稳定杆，(2) 适当压缩脊柱缩短，(3) 扭转原位杆弯曲，(4) 平移技术和单节段去旋转，(5) 相邻节段切除。结果。总体脊柱侧弯矫正率为 65.4%（从 112±28.6 到 39±13.4），节段性后凸矫正率为64.2%（从101±37.3到36±19.2）。在校正步骤中，11名患者（23.9%）检测到体感诱发电位警告（3个）和体感诱发电位/经颅运动诱发电位警告（8个）。可能的原因识别包括排除 IOM 技术因素、残余撞击以及是否存在脊柱不稳定 (1)、脊髓凹侧过度张力 (3) 以及切除区域两个方面之间过度的反向脊柱移位 (7)。在更换杆 (1)、压缩 (2)、弯曲 (3)、去旋转 (3) 和邻近切除 (2) 后，所有 IOM 变化均处于警告标准之下。所有 11 名患者术后神经功能均完好。 IOM 警报与否之间的纠正率没有差异。然而，在成人IOM警觉患者中，极其严重或尖锐的角形弯曲往往更常见。结论。PVCR中脊柱三维分割和重新连接，以及矫正操作仅限于单一维度，不可避免地导致脊髓张力变化和脊柱相对位移。为了及时发现它们，应及时进行干预，甚至扩大切除面积，以减少脊髓突然旋转的倾向。证据水平：5术中神经监测（IOM）已被脊柱外科医生广泛采用，以提供有关脊髓功能状态的实时神经生理信息，并警惕可能的脊髓功能障碍。体感诱发电位 (SSEP) 历来是 IOM 的支柱。 1 然而，报告显示，许多仅通过上行通路监测的患者出现假阳性和假阴性。 2-4 运动诱发电位 (MEP) 已开发用于补充下行运动通路监测。最近，联合 SSEP 和经颅 MEP (TcMEP) 监测仪已被认可并报道，其在进行脊柱畸形手术时早期识别潜在的脊髓功能障碍具有高敏感性和特异性。 5
Study Design.Retrospective study.Objective.To analyze the intraoperative neuromonitoring (IOM) changes in posterior vertebral column resection (PVCR) for severe rigid deformity patients, and describe our stepwise responding strategies.Summary of Background Data.Obvious neurological deficit risk accompanied with PVCR correction has been emphasized repeatedly.Methods.The records of 46 patients who underwent PVCR achieved IOM were reviewed. IOM alerts triggered responding protocols:(1) exchange the convex corrective rod to concave stabilizing rod,(2) appropriate compression for spinal shortening,(3) reversed in situ rod bending,(4) translation technique and unisegmental derotation,(5) adjacent segmental resection.Results.The overall scoliotic correction rate was 65.4%(from 112±28.6 to 39±13.4) and segmental kyphotic correction rate was 64.2%(from 101±37.3 to 36±19.2). During correction step, somatosensory-evoked potential warning (3) and somatosensory-evoked potential/transcranial motor-evoked potential warning (8) were detected in 11 patients (23.9%). Probable cause identification including rule out IOM technical factors, residual impingement, and if there was unstable spinal column (1), spinal cord excessive tension on concave side (3), and the excessive opposite spinal displacement between two aspects of resected area (7). After rod change (1), compression (2), bending (3), derotation (3), and adjacent resection (2), all IOM changes went to under warning criteria. All 11 patients revealed neurologically intact postoperatively. There was no difference of correction rate between IOMs alert or not. However, adult, extremely severe or sharp angular curves tend to be more common in IOM alert patients.Conclusion.As three-dimensional spinal column divided and relinked in PVCR, and the correction maneuvers were restricted on single dimension, inevitably resulted in spinal cord tension changes and spinal column opposite displacement. To timely identify them, prompt interventions should be performed, and even enlarge the resected area to reduce the abrupt turning tendency of the spinal cord.Level of Evidence: 5Intraoperative neuromonitoring (IOM) has been widely adopted by spine surgeons, to provide real-time neurophysiological information on the functional status of the spinal cord and alert possible spinal cord dysfunction. Somatosensory-evoked potential (SSEP) has traditionally been the mainstay of IOM. 1 However, reports revealed a number of patients with false-positive and false-negative monitored by ascending pathway only. 2–4 Motor-evoked potentials (MEPs) have been developed to supplement descending motor pathway monitoring. Recently combined SSEP and transcranial MEP (TcMEP) monitors have been recognized and reported with high sensitivity and specificity on early identification of potential cord dysfunction in performing spinal deformity surgery. 5