Four-limb muscle motor evoked potential and optimized somatosensory evoked potential monitoring with decussation assessment: results in 206 thoracolumbar spine surgeries
Four-limb muscle motor evoked potential and optimized somatosensory evoked potential monitoring with decussation assessment: results in 206 thoracolumbar spine surgeries
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DOI：
10.1007/s00586-007-0426-7
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发表时间：
2007-11-01
影响因子：
2.8
通讯作者：
Al Saddigi, Abdulmoneam
中科院分区：
文献类型：
--
作者：
MacDonald, David B.;Al Zayed, Zayed;Al Saddigi, Abdulmoneam
这项研究的目的是改进腿部躯体感觉诱发电位(SEP)监测，使截瘫风险减半，但可能缓慢、遗漏或错误地暗示运动损伤，并遗漏手臂和十字交叉评估。我们应用四肢经颅肌运动诱发电位(MEP)和优化的外周/皮质SEP监测结合交叉评估，在异丙酚/阿片类药物麻醉下用于206例胸腰段脊柱手术。SEP被优化到确定MEP/SEP集合之间的反馈间隔的最小平均时间。广义的变化定义了系统性的变化。局灶性减退(MEP消失和/或SEP明显减退)定义了神经损害并促使干预。它们是短暂的(很快消失)或延长的(>；40分钟)。上肢和小腿MEP/SEP监测准确率分别为100%和98/97%(神经病理学检查)。十字交叉评估显示，6例(2.9%)脊柱侧弯手术中有感觉运动性非十字交叉需要同侧监测。反馈间隔为1~3min。系统性的变化从来不会产生伤害，无论程度如何。它们是渐进的，通常包括MEP/SEP减弱，有时需要大量的刺激增量来维持MEP或产生50%的SEP减少。病灶的减少是突然的；它们对长期损伤的阳性预测值为100%，而对暂时性损伤的阳性预测值为13%。6例一过性臂损伤预测1例一过性桡神经损伤；5例建议预防上臂神经损伤(2.4%)。有15条腿减少：6条仅有MEP，4条在SEP之前，3条同时发生，2条仅SEP。其中5例为延迟性损伤，预示有4例暂时性脊髓损伤(3例运动性损伤，1例Brown-Sequard损伤)和1例暂时性神经根病。10个是一过性的，预测1个暂时的感觉索损伤；9个建议脊髓损伤预防(4.4%)。两例神经根性疾病和一例暂时性迟发性瘫痪是不可预测的。这些方法是可靠的，提供了技术/系统控制，适应于非交叉，并改善了脊髓和手臂的神经保护。SEP优化可加快反馈速度，MEP应可进一步降低截瘫风险。神经根病和迟发性截瘫可以逃避预测。
The objective of this study was to improve upon leg somatosensory-evoked potential (SEP) monitoring that halves paraplegia risk but can be slow, miss or falsely imply motor injury and omits arm and decussation assessment. We applied four-limb transcranial muscle motor-evoked potential (MEP) and optimized peripheral/ cortical SEP monitoring with decussation assessment in 206 thoracolumbar spine surgeries under propofol/opioid anesthesia. SEPs were optimized to minimal averaging time that determined feedback intervals between MEP/SEP sets. Generalized changes defined systemic alterations. Focal decrements (MEP disappearance and/or clear SEP reduction) defined neural compromise and prompted intervention. They were transient (quickly resolved) or protracted (> 40 min). Arm and leg MEP/SEP monitor-ability was 100% and 98/97% (due to neurological pathology). Decussation assessment disclosed sensorimotor non-decussation requiring ipsilateral monitoring in six scoliosis surgeries (2.9%). Feedback intervals were 1-3 min. Systemic changes never produced injury regardless of degree. They were gradual, commonly included MEP/SEP fade and sometimes required large stimulus increments to maintain MEPs or produced > 50% SEP reductions. Focal decrements were abrupt; their positive predictive value for injury was 100% when protracted and 13% when transient. Six transient arm decrements predicted one temporary radial nerve injury; five suggested arm neural injury prevention (2.4%). There were 15 leg decrements: six MEP-only, four MEP before SEP, three simultaneous and two SEP-only. Five were protracted, predicting four temporary cord injuries (three motor, one Brown-Sequard) and one temporary radiculopathy. Ten were transient, predicting one temporary sensory cord injury; nine suggested cord injury prevention (4.4%). Two radiculopathies and one temporary delayed paraparesis were unpredicted. The methods are reliable, provide technical/systemic control, adapt to non-decussation and improve spinal cord and arm neural protection. SEP optimization speeds feedback and MEPs should further reduce paraplegia risk. Radiculopathy and delayed paraparesis can evade prediction.