术中经颅电刺激运动诱发电位监测在术前脊髓损伤患者中的应用

背景:经颅电刺激运动诱发电位(TceMEP)监测已经广泛应用于脊柱外科手术中,但是到目前为止,针对术前脊髓损伤(POSD)患者的神经监测有效性还存有争议。目的:探讨POSD患者术中TceMEP监测的可行性,并且分析Tce MEP信号快速消失的临床意义。方法:共收集2014年1月至2018年1月349例POSD患者的术中神经监测数据,其中332例患者获得了有效的术中TceMEP基线,17例神经功能障碍较为严重者(11例瘫痪和6例不完全截瘫)未获得。332例中,27例术中TceMEP信号显著消失,收集其临床特征,并严格随访术后3个月的神经功能变化。结果:在POSD患者中,TceMEP基线获得成功率为95.1%(332/349);27例患者出现了明显的TceMEP信号消失,其中23例为真阳性,4例为假阳性。其中21例患者术后出现新发脊髓损伤(13例为暂时性脊髓损伤,8例为永久性脊髓损伤)。预测脊髓损伤的术中TceMEP监测敏感度为100%,特异度为98.7%,阳性预测值为85.2%,阴性预测值为100%。与颈椎管狭窄症相比,先天性脊柱后凸、结核性脊柱后凸和胸椎管狭窄是TceMEP信号消失的高危诊断。结论:术中TceMEP监测对大多数POSD来说是可行的。在高危诊断和复杂的外科手术过程中,快速的TceMEP信号消失可能预示着新的脊髓损伤。

Intraoperative monitoring of transcranial electrical stimulation motor evoked potentials in patients with preoperative spinal deficits

Background:Transcranial motor evoked potential(TceMEP)monitoring has been widely adopted in spine surgery,but the validity of neuromonitoring for the patients with preoperative spinal deficits(POSD)remains controversial.Objective:To discuss the feasibility of TceMEP monitoring in POSD and the significance of rapid TceMEP loss.Methods:The neuromonitoring data of 349 POSD patients treated from January 2014 to January 2018 were collected.Effective TceMEP baselines were obtained from 332 patients,and not available from the other 17 patients(paraplegia in 11 and severe incomplete paraplegia in 6).Clinical features of 27 patients with obvious monitoring signal loss were analyzed,and the neurological function was strictly followed up 3 months after operation.Results:The successful rate of feasible TceMEP baseline was 95.1%(332/349).In the 27 patients with significant TceMEP loss,23 was true positive,and 4 was false positive.There were 21 new spinal deficits(13 transient spinal cord injuries and 8 permanent spinal cord injuries).The sensitivity of intraoperative TceMEP monitoring was 100%,the specificity was 98.7%,the positive predictive value was 85.2%,and the negative predictive value was 100%.The congenital kyphoscoliosis,tuberculous kyphoscoliosis and thoracic spinal stenosis were thought of high-risk diagnoses compared to cervical spondylosis.Conclusions:Intraoperative TceMEP monitoring is feasible for the most POSD.The rapid Tce MEP loss during high-risk diagnoses and complicated surgical procedures may indicate new spinal deficits.