脊柱手术中TES-MEP和CSEP联合监测脊髓功能的作用评价

目的 探讨脊柱手术中经颅电刺激运动诱发电位(TES-MEP)和皮层体感诱发电位(CSEP)联合监测脊髓功能的临床应用价值.方法 分析2006年7月至2009年4月脊柱手术中同时记录双侧胫前肌、足足母短屈肌(颈椎病变增加鱼际肌)TES-MEP和双侧胫后神经(颈椎病变增加尺神经)CSEP共293例患者的临床资料.术中全静脉麻醉维持,部分患者辅助使用小剂量七氟烷吸入或小剂量肌肉松弛药.将TES-MEP、CSEP、联合监测的结果与术后脊髓运动和感觉功能进行比较及相关分析.结果 术中TES-MEP、CSEP、联合监测的成功检出率分别为90.8%、96.9%和100%.术中TES-MEP、CSEP判断脊髓运动功能的灵敏度分别为100%和89.3%,特异度分别为98.4%和96.9%,约登指数分别为0.984和0.862;而判断脊髓感觉功能的灵敏度分别为76.7%和93.3%,特异度分别为98.7%和98.0%,约登指数分别为0.754和0.913;联合监测的灵敏度为100%,特异度96.9%,约登指数0.969.结论 TES-MEP监测脊髓运动功能的准确性高于CSEP,而CSEP监测脊髓感觉功能的准确性高于TES-MEP;联合监测对脊髓功能监测的灵敏度和准确性又高于单一的TES-MEP或CSEP监测,它是目前脊柱脊髓手术中较为理想的监测方法.

Evaluation of the role of combined TES-MEP and CSEP monitoring during the spinal surgery

Objective To evaluate of the role of transcranial electrical stimulation motor evoked potential (TES-MEP) in combination with cortical somatosensory evoked potential (CSEP) monitoring during the spinal surgery. Methods TES-MEP on bilateral anterior tibial muscle and flexor hallucal brevis and CSEP on bilateral posterior tibia]nerve were observed simultaneously on 293 patients during spinal surgery from July 2006 to April 2009. Intravenous anesthesia was employed in all the patients, a part of which were added low dose of sevoflurane or muscle relaxant. The results of TES-MEP, CSEP and combined monitoring were analyzed statistically. Pre-operative and post-operative motor and sensory functions of spinal cord were compared. Results Success rate of TES-MEP, CSEP and combined monitoring was 90.8%, 96. 9% and 100% respectively. For the judgment of motor function of spinal cord, the sensitivity of TESMEP and CSEP was 100% and 89. 3% respectively and the specificity of 98.4% and 96. 9%. The Youden index of the two methods was 0.984 and O. 862. For sensory function, the sensitivity of them was 76.7% and 93.3% respectively and the specificity of 98.7% and 98.0%. The Youden index was 0.754 and 0.913. The sensitivity of combined monitoring was 100%, with the specificity of 96. 9%. The Youden index was 0.969. Conclusions The precision of monitoring motor function of spinal cord with TES-MEP is higher than that with CSEP, however, for sensory function, CSEP is more precise. The sensitivity and precision of combined monitoring for spinal cord function were apparently better than that of unitary TES-MEP or CSEP.The combined TES-MEP and CSEP monitoring is a relatively ideal method.