体感诱发电位在脊柱手术监护中的应用

目前,绝大多数的脊柱手术都是在全身麻醉的情况下完成的,术中了解神经功能的状况是非常重要的。随着诱发电位技术的发展,术中神经监护越来越受到重视。在发达国家脊柱手术的术中监护具有法律效应,否则病人被认为是暴露在危险之中。常见的监护手段有体感诱发电位（SEP）,运动诱发电位（MEP）。其中SEP是应用较早,运用最广泛,     

脊柱侧凸矫形术中皮层体感诱发电位的监护

目的：分析不同类型脊柱侧凸矫形术中皮层体感诱发电位（CSEP）髓护波形，了解其变化规律，制定合理报警标准，降低髓护过程中脊髓损伤预报的假阳性事件，提高准确率。方法：回顾性分析58例不同类型的脊柱侧凸矫形术中脊髓监护，将监护期分为预测试期、调整期、重点监护期和报警期，对应分别为Ⅰ、Ⅱ、Ⅲ和Ⅳ期基准，分析各期基准的特点，由此制定报警标准。58例患者按有无神经功能缺陷分为A、B2组，对比脊髓监护时2组的假阳性率。结果：4期基准报警率间差异有显著性意义，Ⅳ期基准的报警符合率最高。2组间假阳性率比较，A组高于B组。结论：有神经缺陷的脊柱侧凸患者术中CSEP假阳性率高，应尽量采用联合监护；报警基准要因时而异、综合分析。不可教条化。     

体感诱发电位在脊柱手术监护中的应用

目前,绝大多数的脊柱手术都是在全身麻醉的情况下完成的,术中了解神经功能的状况是非常重要的.随着诱发电位技术的发展,术中神经监护越来越受到重视.在发达国家脊柱手术的术中监护具有法律效应,否则病人被认为是暴露在危险之中[1,2].     

体感诱发电位在脊柱侧凸手术中的应用

目的探讨脊柱侧凸矫形术中体感诱发电位的监测意义。方法用体感诱发电位仪对2002-07／2005-03吉林大学第一医院骨科收治的脊柱侧凸患者51例行体感诱发电位监测。观察手术、麻醉事件对体感诱发电位潜伏期及波幅的影响。结果51例患者均进入结果分析。51例中,43例术中体感诱发电位出现波形改变,其中33例潜伏期延长小于10％,波幅下降小于60％;9 例潜伏期延长大于10％,波幅下降大于60％。主要是因麻醉、手术操作等引起。术后均无运动障碍。结论体感诱发电位术中监测具有简便、灵敏度高和及时监测等特点,有助于防止发生术后神经系统并发症。     

体感诱发电位在脊柱侧凸手术中的应用

目的探讨脊柱侧凸矫形术中体感诱发电位的监测意义.方法用体感诱发电位仪对2002-07/2005-03吉林大学第一医院骨科收治的脊柱侧凸患者51例行体感诱发电位监测.观察手术、麻醉事件对体感诱发电位潜伏期及波幅的影响.结果51例患者均进入结果分析.51例中,43例术中体感诱发电位出现波形改变,其中33例潜伏期延长小于10%,波幅下降小于60%;9例潜伏期延长大于10%,波幅下降大于60%.主要是因麻醉、手术操作等引起.术后均无运动障碍.结论体感诱发电位术中监测具有简便、灵敏度高和及时监测等特点,有助于防止发生术后神经系统并发症.     

诱发电位量化监护在下腰椎滑脱复位内固定术中的应用

背景临床大量病例证实,下腰椎滑脱复位内固定术中满意的复位、融合及内固定,与患者术后症状体征及功能恢复程度并非一致.目的研究体感诱发电位(SEP)在下腰椎滑脱复位内固定术中监护的应用,对改善患者术后症状及提高脊柱功能的作用.设计随机对照研究.单位一所大学医院的脊柱外科病房.对象2000-06/2003-12暨南大学医学院第二附属医院(深圳市人民医院)脊柱外科收治的下腰椎滑脱症患者52例,男23例,女29例,年龄18～68岁.随机分为对照组20例和监测组32例.方法对照组利用节段性皮神经刺激体感诱发电位(SEP)技术对下腰椎滑脱复位内固定术前,术中监测和术后远期随访,对术后功能改善优良患者的术中电位变化情况进行回顾性研究,确定术中有效的监护指标,从而为监测组手术监护提供参考.主要观察指标①术后脊柱功能评定结果.②体感诱发电位潜伏期及波幅检测结果.结果以患者术前麻醉后SEP指标值为基础,术中监测电位指标变化表现形式①滑脱复位后,若潜伏期缩短10%～15%或波幅增加＞40%,提示愈后良好.②监测电位指标平稳,或潜伏期缩短＜10%,或波幅增加＜30%,可继续完成复位,术后可有部分神经根功能恢复和症状改善.③复位过程中,监测电位指标出现暂时性波动,可在15～20 min内恢复到基础电位,应在电位出现波动时停止复位.术后仍可有部分神经根功能恢复和症状改善.④术中监测电位若潜伏期延长＞5%,或波幅降低＞10%,或部分成分消失或波形离散,提示术后出现疼痛和运动障碍加重,术中应做必要调整.该方法术中监护指标改善与术后脊柱功能恢复状态符合率达93.75%.结论节段性皮神经刺激SEP是下腰椎滑脱复位内固定术中监护指导减压、复位、固定的客观而有效的方法.对改善神经根功能,恢复脊柱功能有重要价值.     

3D打印导航模板在脊柱侧凸矫形术中的初步应用

目的评估3D打印导航模板在脊柱侧凸矫形术中置钉的准确性及安全性。方法选择我院收治的应用3D打印导航模板辅助脊柱侧凸行选择性椎弓根螺钉固定矫形术12例,术前均行全脊柱薄层CT扫描,将原始图像数据以Dicom格式保存,导入mimics17.0软件中进行全脊柱三维模型重建,最终生成导航模板。术中应用导航模板判断置钉的位置,记录置钉数量、置钉准确率、并发症发生情况、术前及术后脊柱主弯Cobb角变化。结果本组共置入螺钉168枚,其中Ⅰ级螺钉136枚(80.95%),Ⅱ级螺钉25枚(14.88%),Ⅲ级螺钉7枚(4.17%),置钉准确率为95.83%。术中无置钉相关的神经、血管损伤等并发症发生。脊柱主弯Cobb角术前、术后分别为(55.8±20.4)、(20.6±13.9)度,差异有统计学意义(P0.05)。结论3D打印导航模板辅助脊柱侧凸矫形术选择性椎弓根螺钉置入的准确率高,矫正效果显著,安全性好。     

诱发电位量化监护在下腰椎滑脱复位内固定术中的应用

背景：临床大量病例证实，下腰椎滑脱复位内固定术中满意的复位、融合及内固定，与患者术后症状体征及功能恢复程度并非一致。目的：研究体感诱发电位(SEP)在下腰椎滑脱复位内固定术中监护的应用，对改善患者术后症状及提高脊柱功能的作用。设计：随机对照研究。单位：一所大学医院的脊柱外科病房。对象：2000—06／2003—12暨南大学医学院第二附属医院(深圳市人民医院)脊柱外科收治的下腰椎滑脱症患者52例，男23例，女29例，年龄18—68岁。随机分为对照组20例和监测组32例。方法：对照组利用节段性皮神经刺激体感诱发电位(SEP)技术对下腰椎滑脱复位内固定术前，术中监测和术后远期随访，对术后功能改善优良患者的术中电位变化情况进行回顾性研究，确定术中有效的监护指标，从而为监测组手术监护提供参考。主要观察指标：①术后脊柱功能评定结果。②体感诱发电位潜伏期及波幅检测结果。结果：以患者术前麻醉后SEP指标值为基础，术中监测电位指标变化表现形式：①滑脱复位后，若潜伏期缩短10％～15％或波幅增加&;gt;40％．提示愈后良好。②监测电位指标平稳，或潜伏期缩短&;lt;10％，或波幅增加&;lt;30％，可继续完成复位，术后可有部分神经根功能恢复和症状改善。③复位过程中，监测电位指标出现暂时性波动，可在15～20min内恢复到基础电位，应在电位出现波动时停止复位。术后仍可有部分神经根功能恢复和症状改善。④术中监测电位若潜伏期延长&;gt;5％，或波幅降低&;gt;10％，或部分成分消失或波形离散，提示术后出现疼痛和运动障碍加重，术中应做必要调整。该方法术中监护指标改善与术后脊柱功能恢复状态符合率达93．75％。结论：节段性皮神经刺激SEP是下腰椎滑脱复位内固定术中监护指导减压、复位、固定的客观而有效的方法。对改善神经根功能，恢复脊柱功能有重要价值。     

经颅电刺激运动诱发电位和皮层体感诱发电位在脊柱侧凸手术中联合监护的观察及护理

目的 探讨应用经颅电刺激运动诱发电位(transcranial electrical stimulation motor evoked potential,TES-MEP)和皮层体感诱发电位(cortical som atosensory evoked potential,CSEP)联合监护脊柱侧凸手术中脊髓功能的观察及护理要点.方法 对13例脊柱侧凸手术同时监测双侧胫前肌、足(足母)短屈肌TES-MEP以及双侧胫后肌CSEP,观察手术进程中引起诱发电位阳性变化的相关因素及监护的并发症.结果 12例手术成功检出TES-MEP,11例成功监测CSEP.术中诱发电位阳性12次,2次与低血压有关,l0次与手术操作不当相关,及时采取纠正措施后9次恢复正常,3次明显恢复.患者无发生皮肤烧灼伤、舌咬伤等监护并发症.结论 低血压、不当的手术操作可引起诱发电位阳性.手术室护士应在这些环节上重点观察诱发电位波形情况,及时发现异常,尽早报告手术医生采取干预措施,减少或避免因手术操作失误引起的脊髓神经损伤发生.     

脊柱侧凸矫形术的麻醉处理（附9例报告）

脊柱侧凸矫形术的麻醉处理（附９例报告）黄孟华，翁迪贵，王金华，詹如富脊柱侧凸严重影响青少年的身心健康，矫形术是一有效的治疗途径，而术中需行唤醒试验，其麻醉处理具有一定的特殊性。我院施行脊柱侧凸矫形术９例，取得较好效果，现将有关麻醉处理总结如下。１临床...     

Intraoperative Monitoring Using Somatosensory Evoked Potentials

Objective: To provide an educational service to the intraoperative neurophysiologist community by publishing a position statement by the American Society of Neurophysiological Monitoring on the recommended appropriate and correct use of somatosensory evoked potentials as an intraoperative neurophysiological monitoring tool to protect patient well-being during surgery. This position statement presents the somatosensory evoked potential utilization basis, relevant anatomy, patient preparation, important systemic factors, anesthesia considerations, safety and technical considerations, documentation requirements, neurophysiologist credentials and staffing practice patterns, and monitoring applications for protecting brain, spinal nerve root, peripheral nerve, plexus and spinal cord function. In conclusion, a summary of major recommendations regarding the use of somatosensory evoked potentials in intraoperative neurophysiological monitoring is presented.     

Intraoperative neurophysiological monitoring in spinal surgery

Recently, many surgeons have been using intraoperative neurophysiological monitoring(IOM) in spinal surgery to reduce the incidence of postoperative neurological complications, including level of the spinal cord, cauda equina and nerve root. Several established technologies are available and combined motor and somatosensory evoked potentials are considered mandatory for practical and successful IOM. Spinal cord evoked potentials are elicited compound potentials recorded over the spinal cord. Electrical stimulation is provoked on the dorsal spinal cord from an epidural electrode. Somatosensory evoked potentials assess the functional integrity of sensory pathways from the peripheral nerve through the dorsal column and to the sensory cortex. For identification of the physiological midline, the dorsal column mapping technique can be used. It is helpful for reducing the postoperative morbidity associated with dorsal column dysfunction when distortion of the normal spinal cord anatomy caused by an intramedullary cord lesion results in confusion in localizing the midline for the myelotomy. Motor evoked potentials(MEPs) consist of spinal, neurogenic and muscle MEPs. MEPs allow selective and specific assessment of the functional integrity of descending motor pathways, from the motor cortex to peripheral muscles. Spinal surgeons should understand the concept of the monitoring techniques and interpret monitoring records adequately to use IOM for the decision making during the surgery for safe surgery and a favorable surgical outcome.     

Concomitant hypertension,bradycardia, and loss of transcranial electric motor evoked potentials during pedicle hook removal: report of a case

Neurophysiologic monitors in the form of transcranial electric motor evoked potentials (tceMEPs) and somatosensory evoked potentials (SSEPs) have become widely used modalities to monitor spinal cord function during major orthopedic spine procedures. In combination with invasive and non-invasive clinical monitoring and an anesthesia information management system (AIMS), we promptly recognized an acute change in hemodynamic and neurophysiologic parameters, managed intraoperative spinal cord contusion, and successfully minimized iatrogenic injury to the spinal cord during corrective spine surgery.     

Safe transcranial electric stimulation motor evoked potential monitoring during posterior spinal fusion in two patients with cochlear implants

Transcranial electric stimulation (TES) motor evoked potentials (MEPs) have become a regular part of intraoperative neurophysiologic monitoring (IONM) for posterior spinal fusion (PSF) surgery. Almost all of the relative contraindications to TES have come and gone. One exception is in the case of patients with a cochlear implant (CI). Herein we illustrate two cases of pediatric patients with CIs who underwent PSF using TES MEPs as part of IONM. In both instances the patients displayed no untoward effects from TES, and post-operatively both CIs were intact and functioning as they were prior to surgery.     

神经电生理监测的影响因素

神经电生理监测因其可以监测术中神经损伤,改善患者预后的优点广泛应用于神经外科、脊柱外科、甲状腺外科手术等。与此同时神经电生理监测受到包括麻醉药物、体温、手术体位等多种因素的影响。众多影响因素制约了神经电生理监测,了解、掌握并规避影响因素,对提高神经电生理监测指导临床操作的可信度至关重要。     

Correlation between preoperative somatosensory evoked potentials and intraoperative neurophysiological monitoring in spinal cord tumors

Intraoperative neurophysiological monitoring (IONM) is widely used in spinal cord tumors (SCTs) removal surgery. This study mainly hypothesized that patients with prolonged latency of preoperative somatosensory evoked potentials (preSEP_Lat) would have more deteriorated intraoperative evoked potentials. Among 506 patients who underwent SCTs removal surgery, 74 underwent both preSEPs and IONM. The correlation between preSEP_Lat and intraoperative SEPs (ioSEPs) was mainly analyzed, and subgroup analysis according to anatomical type was also conducted. Secondly, whether preSEP_Lat related to intraoperative motor evoked potentials (ioMEPs) or postoperative motor deterioration (PMD) was analyzed. In addition, risk factors for PMD were examined among anatomical factors, including operation level, tumor-occupying area ratio, and anatomical type, as well as electrophysiological factors, such as preSEP_Lat, ioSEPs, and ioMEPs. Changes in ioSEP and ioMEP were considered significant even if they were recovered before the end of the monitoring. Patients with prolonged preSEP_Lat were more likely to have significant ioSEP changes for intradural-extramedullary (IDEM) but not for intramedullary or extradural tumors. The anatomical type and tumor-occupying area ratio were prognostic factors for transient PMD, while the ioSEPs were the only prognostic factor for persisted PMD over 4 weeks after surgery. PreSEPs are helpful in predicting the significant changes in ioSEPs during IDEM tumor removal surgery. The tumor-occupying area ratio and anatomical type are contributing factors for the transient PMD, whereas ioSEPs are prognostic factors in predicting the PMD that persists over 4 weeks after SCTs removal surgery. To our knowledge, this is the first study that mainly focused on the correlations of preoperative and intraoperative evoked potentials.

     

脊柱侧弯矫形手术术中采用神经电生理功能监测838例效果分析

目的探讨脊柱侧弯矫形手术术中采用神经电生理功能监测的临床效果。方法使用十通道神经电生理功能监测系统,共对838例手术患者进行了术中神经电生理功能监测,分析838例脊柱侧弯矫形手术中应用体感诱发电位(SEP)监测脊髓和运动诱发电位的效果和体会。结果 838例患者中,19例患者术中神经电生理功能监测出现了SEP异常,波幅值下降50%或潜伏期延长超过10%。19例患者中术中SEP波幅恢复至基线的有8例,波幅好转11例。838例患者中有11个患者术中SEP没有变化,但是术后反而下肢有症状,假阳性率为1.4%。结论脊柱侧弯矫形手术术中联合应用SEP能够通过为术者实时监测脊髓功能,已达到了解神经系统功能状态的目的,最大限度地避免脊髓的损伤风险,为手术的安全性提供了一定的保障,降低了手术的致残率,应成为脊柱侧弯矫形手术的常规监测项目。     

The effects of isoflurane and propofol on intraoperative neurophysiological monitoring during spinal surgery

Objectives. To compare the effects of isoflurane and propofol on intraoperative neurophysiological monitoring (IONM) during spinal surgery. Methods. Thirty-five patients were randomly assigned to receive isoflurane (n = 17) or propofol (n = 18) anesthesia. Somatosensory evoked potentials (SEPs) following posterior tibial nerve stimulation were recorded before induction as baselines. Isoflurane concentrations and propofol infusions were adjusted to obtain four pre-determined BIS ranges: 65–55, 55–45, 45–35 and 35–25. For each range, a stable state was maintained for at least 10 min to perform IONM. The SEP latency P40 and amplitude P40-N50, the onset latency and amplitude of transcranial motor evoked potentials (tcMEPs), and threshold intensity of triggered electromyographic activity (EMG) following pedicle screw stimulation were statistically analyzed. Results. Compared with baseline values, P40 latency increased and P40-N50 amplitude decreased after anesthesia with isoflurane or propofol. Isoflurane caused a dose-dependent depression of SEPs, but propofol did not. TcMEPs were recordable and stable in all patients receiving propofol in each BIS range, but only recordable in 10 (58.8%) receiving isoflurane with BIS > 55, and 3 (17.8%) with BIS < 55. No difference was noted in triggered EMG. Conclusions. Isoflurane inhibited IONM more than propofol. Propofol is recommended for critical spinal surgery, particularly when motor pathway function is monitored. Chen Z, The effects of isoflurane and propofol on intraoperative neurophysiological monitoring during spinal surgery     

Monitoring of cortical evoked potentials during surgical procedures on the cervical spine

We reviewed the results of intraoperative monitoring of short-latency cortical evoked potentials in 81 patients who underwent surgical procedures of the cervical spine. Of these patients, 43 had baseline somatosensory evoked potentials from stimulation of the upper and lower extremities, intraoperative monitoring for at least 3 hours, and absence of an intrinsic lesion of the spinal cord. Major reductions in amplitude of the ulnar and tibial cortical evoked potentials occurred shortly after induction of anesthesia in 12% of patients. Latencies gradually increased during the operation as the concentration of volatile anesthetic agents increased. In patients with preoperative evidence of cervical cord damage, the cortical responses showed more fluctuations and could be lost without major changes in the concentration of the anesthetic agent or surgical manipulation. In one patient, intraoperative monitoring of the cervical cord function prevented a postoperative neurologic deficit. Ulnar and tibial cortical evoked potentials were successfully monitored throughout operation in all patients in whom baseline scalp responses could be obtained, but careful monitoring of anesthetic effect is necessary for proper interpretation.     

Loss of Intraoperative Evoked Responses during Dorsal Column Surgery Associated with Isolated Postoperative Sensory Deficit

Two patients underwent surgery for the removal of dermoid tumors that involved the dorsal aspect of the spinal cord. Both patients were monitored with intraoperative posterior tibial nerve somatosensory evoked potentials (SSEPs). In each case, the surgical procedure was nearly complete when an abrupt and persistent loss of SSEPs occurred. Although minor recovery of waveforms was present by the end of the operation, the SSEP waveforms remained strikingly abnormal. Neither patient had a postoperative motor deficit, although both had evidence of dorsal column dysfunction. These observations suggest that, during dorsal column surgery, even dramatic SSEP loss may not be associated with motor pathway injury, but rather, may correlate better with postoperative dorsal column dysfunction. The possible implications for intraoperative monitoring of SSEPs during dorsal column surgical procedures are discussed.