Isley Michael R, Zhang Xiao-Feng, Balzer Jeffrey R, Leppanen Ronald E
Intraoperative Neuromonitoring Department and Neurosciences Institute Orlando Regional Medical Center and Arnold Palmer Hospital for Children Orlando, Florida, USA.
Neurodiagn J. 2012 Jun;52(2):100-75.
Unequivocally, pedicle screw instrumentation has evolved as a primary construct for the treatment of both common and complex spinal disorders. However an inevitable and potentially major complication associated with this type of surgery is misplacement of a pedicle screw(s) which may result in neural and vascular complications, as well as impair the biomechanical stability of the spinal instrumentation resulting in loss of fixation. In light of these potential surgical complications, critical reviews of outcome data for treatment of chronic, low-back pain using pedicle screw instrumentation concluded that "pedicle screw fixation improves radiographically demonstrated fusion rates;" however the expense and complication rates for such constructs are considerable in light of the clinical benefit (Resnick et al. 2005a). Currently, neuromonitoring using free-run and evoked (triggered) electromyography (EMG) is widely used and advocated for safer and more accurate placement of pedicle screws during open instrumentation procedures, and more recently, guiding percutaneous placement (minimally invasive) where the pedicle cannot be easily inspected visually. The latter technique, evoked or triggered EMG when applied to pedicle screw instrumentation surgeries, has been referred to as the pedicle screw stimulation technique. As concluded in the Position Statement by the American Society of Neurophysiological Monitoring (ASNM), multimodality neuromonitoring using free-run EMG and the pedicle screw stimulation technique was considered a practice option and not yet a standard of care (Leppanen 2005). Subsequently, the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Joint Section on Disorders of the Spine and Peripheral Nerves published their "Guidelines for the Performance of Fusion Procedures for Degenerative Disease of the Lumbar Spine" (Heary 2005, Resnick et al. 2005a, Resnick et al. 2005b). It was concluded that the "primary justification" of intraoperative neuromonitoring"... is the perception that the safety and efficacy of pedicle screw fixation are enhanced..." (Resnick et al. 2005b). However in summarizing a massive (over 1000 papers taken from the National Library of Medicine), contemporary, literature review spanning nearly a decade (1996 to 2003), this invited panel (Resnick et al. 2005b) recognized that the evidence-based documents contributing to the parts related to pedicle screw fixation and neuromonitoring were "... full of potential sources of error ..." and lacked appropriate, randomized, prospective studies for formulating rigid standards and guidelines. Nevertheless, current trends support the routine use and clinical utility of these neuromonitoring techniques. In particular free-run and triggered EMG have been well recognized in numerous publications for improving both the accuracy and safety of pedicle screw implantation. Currently, treatment with pedicle screw instrumentation routinely involves all levels of the spine - lumbosacral, thoracic, and cervical. Significant historical events, various neuromonitoring modalities, intraoperative alarm criteria, clinical efficacy, current trends, and caveats related to pedicle screw stimulation along the entire vertebral column will be reviewed.
毋庸置疑，椎弓根螺钉内固定术已发展成为治疗常见和复杂脊柱疾病的主要术式。然而，这类手术不可避免且可能出现的主要并发症是椎弓根螺钉置入位置不当，这可能导致神经和血管并发症，还会损害脊柱内固定装置的生物力学稳定性，进而导致内固定失效。鉴于这些潜在的手术并发症，对使用椎弓根螺钉内固定术治疗慢性下腰痛的疗效数据进行的严格审查得出结论：“椎弓根螺钉固定可提高影像学显示的融合率”；然而，鉴于临床获益，此类内固定装置的费用和并发症发生率相当可观（雷斯尼克等人，2005年a）。目前，在开放手术过程中，使用自由运行和诱发（触发）肌电图（EMG）进行神经监测被广泛应用并提倡，以更安全、准确地置入椎弓根螺钉，最近，还用于指导在无法轻易通过视觉检查椎弓根的情况下进行经皮置入（微创）手术。后一种技术，即诱发或触发EMG应用于椎弓根螺钉内固定手术时，被称为椎弓根螺钉刺激技术。正如美国神经生理监测学会（ASNM）立场声明中所总结的，使用自由运行EMG和椎弓根螺钉刺激技术进行多模式神经监测被视为一种实践选择，而非护理标准（莱帕宁，2005年）。随后，美国神经外科医师协会/神经外科医师大会（AANS/CNS）脊柱与周围神经疾病联合分会发表了他们的《腰椎退行性疾病融合手术操作指南》（赫里，2005年；雷斯尼克等人，2005年a；雷斯尼克等人，2005年b）。得出的结论是，术中神经监测的“主要理由”“……是认为椎弓根螺钉固定的安全性和有效性得到了提高……”（雷斯尼克等人，2005年b）。然而，在总结一项大规模（从美国国立医学图书馆获取的1000多篇论文）、涵盖近十年（1996年至2003年）的当代文献综述时，这个受邀小组（雷斯尼克等人，2005年b）认识到，与椎弓根螺钉固定和神经监测相关部分的循证文献“……充满了潜在的误差来源……”，并且缺乏用于制定严格标准和指南的适当的随机、前瞻性研究。尽管如此，当前的趋势支持这些神经监测技术的常规使用和临床实用性。特别是自由运行和触发EMG在众多出版物中已得到充分认可，可提高椎弓根螺钉植入的准确性和安全性。目前，椎弓根螺钉内固定术的治疗常规涉及脊柱的所有节段——腰骶部、胸部和颈部。本文将回顾与整个脊柱的椎弓根螺钉刺激相关的重大历史事件、各种神经监测方式（模式）、术中警报标准、临床疗效、当前趋势以及注意事项。
