Prevention of spinal cord injury during thoracic spine surgery

胸椎手术中脊髓损伤的预防

• 批准号: 8105036
• 负责人: Blair Calancie
• 金额: $ 26.93万
• 依托单位: UPSTATE MEDICAL UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2008
• 资助国家: 美国
• 起止时间: 2008-08-01 至 2013-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8105036
• 关键词: Back; Bone Screws; Chest; Deformity; Feedback; Frequencies; Gender; Goals; Health; Human; Image; Implant; Incidence; Injury; Intervention; Lead; Left; Location; Lower Extremity; Medial; Metals; Methods; Monitor; Muscle; Neurostimulation procedures of spinal cord tissue; Operative Surgical Procedures; Outcome Measure; Patients; Pattern; Physiologic pulse; Positioning Attribute; Postoperative Period; Prevention; Property; Protocols documentation; Randomized; Relative (related person); Risk; Site; Spinal; Spinal Canal; Spinal Cord; Spinal cord injury; Spinal nerve root structure; Staging; Stimulus; Study Subject; Surgeon; Symptoms; Testing; Time; Tissues; Training; Trauma; Vertebral column; X-Ray Computed Tomography; arm; base; bone; cohort; high risk; implantation; improved; information gathering; innovation; instrumentation; novel; operation; prevent; prospective; relating to nervous system; response; retinal rods; spine bone structure

DESCRIPTION (provided by applicant): Surgery involving the thoracic spine sometimes requires the implantation of metal rods to stabilize and fuse the vertebrae. One increasingly-popular method of anchoring these rods is to place large bone screws through the pedicles that connect the `back' part of each vertebra (i.e. the lamina) with its `front' part (i.e. the body), and then connecting the rods to these implanted screws. Typically a narrow `awl' (or pedicle finder) is forced through the pedicle (creating the pedicle track), and then a screw is placed along this track. Ideally the screw should be fully- contained within bone, but if it `misses' towards the midline (i.e. medially) at any level within the thoracic spine, it may hit and injure the spinal cord. The goal of this study is to develop a new intra-operative monitoring (IOM) test of spinal cord conduction to prevent medial malplacement of thoracic pedicle screws, thereby preventing spinal cord injury. In the first of 2 Specific Aims, we will establish the relationship between the amount of energy needed to electrically stimulate spinal cord and nerve roots through the pedicle track (i.e. prior to screw implantation) and the position of that screw relative to the pedicle, once the screw is placed. We anticipate that pedicle tracks which have broken through the bone of the medial pedicle wall will lead to spinal cord stimulation with weak current intensities. We will retrospectively develop rules to tell us when it is safe to put a screw in a particular pedicle track. In Specific Aim #2, we will apply these rules in a prospective manner to actively prevent screw malplacement during surgery in new subjects. Moreover, we will randomize these subjects into two cohorts. In one group we will actively stimulate through a modified pedicle finder while the surgeon is making a pedicle track, to provide immediate feedback to the surgeon if the orientation of the pedicle track needs to change. We anticipate that there will be fewer cases of medially-malplaced thoracic pedicle screws in subjects studied in Specific Aim #2 compared to those tested with the protocol from Specific Aim #1. Moreover we expect that those subjects who receive active stimulation through the pedicle finder will have the lowest incidence of medial screw malplacement of all subjects tested. By the end of this study period, we will have developed and validated a novel form of intra- operative monitoring for thoracic pedicle screw placement. Not only will this test lower the risk of spinal cord injury, but it will also lower the numbers of subjects who require additional surgery to revise screw placements that " while not causing spinal cord injury per se" are still encroaching upon the canal space enough that they would eventually lead to symptoms if left in place. PUBLIC HEALTH RELEVANCE: Surgery to the thoracic spine to treat deformity or trauma places the spinal cord at relatively high risk for injury, particularly when screws are implanted into the pedicles of the spine. This project will develop a novel method to prevent accidental screw placement into the spinal cord, thereby preventing spinal cord injury.

描述(申请人提供)：涉及胸椎的手术有时需要植入金属棒来稳定和融合椎骨。一种越来越流行的锚定这些棒的方法是将大的骨钉穿过连接每个椎体的“后部”部分(即椎板)和“前面”部分(即身体)的椎弓根，然后将棒连接到这些植入的螺钉上。通常，一个狭窄的‘锥子’(或椎弓根搜索器)被强行穿过椎弓根(形成椎弓根轨迹)，然后沿着该轨迹放置一枚螺钉。理想情况下，螺钉应该完全包含在骨骼内，但如果它在胸椎内的任何一个水平向中线(即内侧)“偏离”，它可能会击中并损伤脊髓。本研究的目的是开发一种新的术中脊髓传导监测(IOM)测试，以防止胸椎椎弓根螺钉内侧错位，从而防止脊髓损伤。在两个具体目标的第一个目标中，我们将建立通过椎弓根轨迹电刺激脊髓和神经根所需的能量(即在螺钉植入之前)与螺钉放置后该螺钉相对于椎弓根的位置之间的关系。我们预计椎弓根内侧壁骨断裂的椎弓根轨迹将导致弱电流强度的脊髓刺激。我们将追溯制定规则，告诉我们何时在特定的椎弓根轨道上放置螺钉是安全的。在具体目标2中，我们将以前瞻性的方式应用这些规则，以积极防止新受试者在手术中螺钉错位。此外，我们将把这些受试者随机分成两组。在一组中，我们将在外科医生制作椎弓根轨迹时通过改进的椎弓根寻踪器进行积极刺激，以便在椎弓根轨迹的方向需要改变时立即向外科医生提供反馈。我们预计，在特定目标2的研究对象中，与使用特定目标1中的方案测试的受试者相比，胸椎椎弓根螺钉中段错位的病例会更少。此外，我们预计那些通过椎弓根探索器接受主动刺激的受试者，在所有受试者中，胸椎椎弓根螺钉中段错位的发生率最低。到本研究结束时，我们将开发并验证一种新的胸椎椎弓根螺钉放置的术中监测形式。这项测试不仅将降低脊髓损伤的风险，还将减少需要额外手术以修改螺钉放置方式的受试者数量，这些螺钉放置方式“在本身不会造成脊髓损伤的情况下”仍在侵蚀椎管空间，如果留在适当的位置，它们最终会导致症状。公共卫生相关性：对胸椎进行手术以治疗畸形或创伤会使脊髓处于相对较高的损伤风险，特别是当螺钉植入脊柱椎弓根时。该项目将开发一种新的方法来防止意外将螺钉放置到脊髓中，从而防止脊髓损伤。

项目成果

Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 1. Methods and alarm criteria.

使用脉冲序列刺激进行胸椎椎弓根螺钉植入的神经监测：一项盲法随机临床研究。

• DOI: 10.3171/2014.2.spine13648
• 发表时间: 2014
• 期刊: Journal of neurosurgery. Spine
• 作者: Calancie,Blair;Donohue,MiriamL;Harris,ColinB;Canute,GregoryW;Singla,Amit;Wilcoxen,KaitlinG;Moquin,RossR
• 通讯作者: Moquin,RossR

Is in vivo manual palpation for thoracic pedicle screw instrumentation reliable?

• DOI: 10.3171/2014.1.spine13197
• 发表时间: 2014-05-01
• 期刊: JOURNAL OF NEUROSURGERY-SPINE
• 影响因子: 2.8
• 作者: Donohue, Miriam L.;Moquin, Ross R.;Calancie, Blair
• 通讯作者: Calancie, Blair