腰椎斜外侧融合联合后路椎弓根螺钉内固定术中神经电生理监护模式的探讨及应用  

The study and application of intraoperative neurophysiological monitoring in oblique lateral interbody fusion combined with posterior transpedicle internal fixation

作　　者：王燕燕[1] 刘军辉[1] 范顺武[1] 赵凤东[1] 方向前[1] 张建锋[1] 

机构地区：[1]浙江大学医学院附属邵逸夫医院骨科,杭州310016

出　　处：《中华骨科杂志》2016年第24期1568-1573,共6页Chinese Journal of Orthopaedics

基　　金：浙江省教育厅项目（Y201017108）;浙江省医药卫生一般项目（2015KYA133）

摘　　要：目的探索腰椎斜外侧融合（obliquelateralinterbodyfusion，OLIF）联合后路椎弓根螺钉内固定术中的神经电生理监护模式。方法分析2014年11月至2016年7月问行腰椎OLIF联合后路椎弓根螺钉内固定术并术中应用神经电生理监护的34例患者资料，术中应用躯体感觉诱发电位（somatosensoryevokedpotential，SEP）、经颅电刺激运动诱发电位（transcranialelectricalstimulationmotorevokedpotentials，MEP）和自发肌电图（spontaneouselectromyography，sEMG），并加行皮节体感诱发电位（dermatomalsomatosensoryevokedpotential，DSEP）及诱发肌电图（triggeredelectromyography，tEMG）钉道探测技术。总结术中各种监护方法的波形检出率，以及各种监护指标的报警原因及处理措施。结果SEP监护成功率100％（34／34），术中SEP波幅未见明显下降，潜伏期未见明显延长。DSEP监护成功率为58．8％（20／34），有稳定DSEP波形的患者术中DSEP波幅未见明显下降，潜伏期未见明显延长。MEP监护成功率100％，3例患者术中出现MEP消失，分析原因为术中追加肌松药物所致，行四联刺激肌肉收缩试验（trainoffourtwitchtest，TOF），TOF值〉0．7后MEP恢复；其余患者术中MEP波形未见明显变化。MEP、SEP和DSEP术中均未出现报警，其敏感度为0％，阳性预测值为O％。在OLIF手术通道建立过程中有5例监护到异常肌电反应，其中3例及时提醒术者并暂停手术后仍有异常波形，适当调整扩张通道的角度及方向后3例肌电图波形恢复正常；另2例出现异常波形后暂停手术，未予调整通道而波形自行恢复，继续手术操作未出现异常波形。术中出现异常波形的5例患者中术后1例出现大腿前侧麻木，1例出现大腿前侧疼痛；其余29例术中无异常肌电波形的患者中1例术后出现大腿前侧疼痛。sEMG真阳性2例，假阳性3例，真阴性28例，假阴性1例；其敏感度为66．7％（2／Objective To investigate a reliable and practicable model of intraoperative neurophysiological monitoring （IONM） in oblique lateral interbody fusion （OLIF） combined with posterior transpedicle internal fixation. Methods A total of 34 consecutive patients who underwent OLIF combined with posterior transpedicle internal fixation with IONM at the SRRSH from November 2014 to July 2016 were collected and follow-up at least for 3 months postoperative. The intraoperative somatosensory evoked potentials （SEP）, motor evoked potentials （MEP）, dermatomal somatosensory evoked potential （DSEP） and spontaneous electromyography （sEMG） were used and evaluated, besides, triggered electromyography （tEMG） was used to monitor the implanta- tion of pedicle screws, the possible reasons and treating procedures of monitoring alerts were summarized. Results A total of 34 cases of patients were effectively monitored during OLIF combined with posterior transpedicle internal fixation. SEP monitoring was successful in all patients, and no abnormal SEPs were observed in all cases. DSEP monitoring was successful in 20 cases （58.8%）, and no abnormal DSEPs were observed in these patients. MEP was successfully monitored in all cases, eliminating the an-esthesia factor, no abnormal MEPs were observed in all cases. The sensitivity and positive predictive value of SEP, MEP, DSEP were 0%. 3 cases had abnormal sEMG reactions during the channel establishment which disappeared after adjustment of channel, and 2 cases which appeared abnormal wave recovered after brief observation. Among the 5 patients with abnormal wave, one case got numbness, one patient felt pain in front of the thigh postoperative. Among the other 29 patients without abnormal wave during channel establishment, one case appeared numbness. These 3 patients with neurologic symptoms recovered in 3 months after con- servative treatment. The sensitivity and specificity of sEMG was 66.7% and 90.3% respectively, negative predictive value and pos- itive predicti

关 键 词：腰椎 脊柱融合术 诱发电位 躯体感觉 诱发电位 运动 肌电描记术 

分 类 号：R687.3[医药卫生—骨科学]