Paradiso Guillermo, Lee Gabriel Y F, Sarjeant Roger, Hoang Ly, Massicotte Eric M, Fehlings Michael G
Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Spine (Phila Pa 1976). 2006 Aug 15;31(18):2095-102. doi: 10.1097/01.brs.0000231687.02271.b6.
Prospective analysis of a consecutive series in which multimodality intraoperative neurophysiologic monitoring was used as an adjunct to microneurosurgery for adult tethered cord syndrome. The results of multimodality intraoperative neurophysiologic monitoring were compared with the "gold standard" (neurologic outcomes).
To assess the sensitivity, specificity, and positive and negative predictive values of multimodality intraoperative neurophysiologic monitoring in surgery for adult tethered cord syndrome.
Although intraoperative electrophysiologic techniques may help to minimize neural injury during spinal microneurosurgery, to our knowledge, no study has quantitatively evaluated the value of multimodality intraoperative neurophysiologic monitoring in the management of adult tethered cord syndrome.
Multimodality intraoperative neurophysiologic monitoring included posterior tibial nerve somatosensory evoked potentials (SSEPs), continuous electromyographic (EMG) monitoring of the L2 to S4 myotomes, and evoked EMG. Follow-up neurologic evaluations were performed for at least 1 year.
A total of 44 consecutive patients, including 19 males and 25 females (aged 43 +/- 15 years), who underwent microsurgery for adult tethered cord syndrome were evaluated. After surgery, new neurologic deficits, including 1 transient and 1 permanent, developed in 2 patients. There was 1 patient who had persistent posterior tibial nerve SSEP amplitude reduction following microsurgical manipulation. In 1 patient, a transient posterior tibial nerve SSEP amplitude reduction prompted a change in microneurosurgical strategy. This patient awoke with no new postoperative neurologic deficits. For SSEPs, the sensitivity was 50% and specificity 100%. EMG bursts were recorded in 36 patients (82%). The 2 patients with postoperative neurologic worsening had EMG activity in the myotomes, where their new deficits presented. Continuous EMG had a sensitivity of 100% and a specificity of 19%.
To our knowledge, this is the largest series to date reporting the use of multimodality intraoperative neurophysiologic monitoring in the surgical management of adult tethered cord syndrome. Posterior tibial nerve SSEPs have high specificity, but low sensitivity, for predicting new neurologic deficits. In contrast, continuous EMG showed high sensitivity and low specificity. Evoked EMG accurately identified functional neural tissue. The combined recording of SSEPs in concert with continuous and evoked EMGs may provide a useful adjunct to complex microsurgery for adult tethered cord syndrome.
对一系列连续病例进行前瞻性分析，其中多模式术中神经生理监测被用作成人脊髓拴系综合征显微神经外科手术的辅助手段。将多模式术中神经生理监测结果与“金标准”（神经学结果）进行比较。
评估多模式术中神经生理监测在成人脊髓拴系综合征手术中的敏感性、特异性以及阳性和阴性预测值。
尽管术中电生理技术可能有助于在脊柱显微神经外科手术中减少神经损伤，但据我们所知，尚无研究定量评估多模式术中神经生理监测在成人脊髓拴系综合征治疗中的价值。
多模式术中神经生理监测包括胫后神经体感诱发电位（SSEP）、对L2至S4肌节的连续肌电图（EMG）监测以及诱发肌电图。进行至少1年的随访神经学评估。
总共评估了44例连续接受成人脊髓拴系综合征显微手术的患者，其中男性19例，女性25例（年龄43±15岁）。术后，2例患者出现了新的神经功能缺损，包括1例短暂性和1例永久性缺损。有1例患者在显微手术操作后胫后神经SSEP波幅持续降低。在1例患者中，胫后神经SSEP波幅短暂降低促使显微神经外科手术策略发生改变。该患者术后醒来无新的神经功能缺损。对于SSEP，敏感性为50%，特异性为100%。36例患者（82%）记录到肌电图爆发。2例术后神经功能恶化的患者在出现新缺损的肌节中有肌电图活动。连续肌电图的敏感性为100%，特异性为19%。
据我们所知，这是迄今为止报道多模式术中神经生理监测用于成人脊髓拴系综合征外科治疗的最大系列病例。胫后神经SSEP对预测新的神经功能缺损具有具有高特异性高，但敏感性低。相比之下，连续肌电图显示出高敏感性和低特异性。诱发肌电图能准确识别功能性神经组织。将SSEP与连续和诱发肌电图联合记录可能为成人脊髓拴系综合征的复杂显微手术提供有用的辅助手段。
