Patel Akash J, Agadi Satish, Thomas Jonathan G, Schmidt Robert J, Hwang Steven W, Fulkerson Daniel H, Glover Chris D, Jea Andrew
Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA.
Childs Nerv Syst. 2013 Feb;29(2):281-7. doi: 10.1007/s00381-012-1918-2. Epub 2012 Oct 23.
Neurophysiological monitoring during complex spine procedures may reduce risk of injury by providing feedback to the operating surgeon. This tool is a well-established and important surgical adjunct in adults, but clinical data in children are not well described. Moreover, to the best of our knowledge, neurophysiologic intraoperative monitoring data have not been reported in children with neurodevelopmental disorders, such as Down syndrome, who commonly present with craniocervical instability requiring internal fixation. The purpose of this study is to determine the reliability and safety of neurophysiologic intraoperative monitoring in a group of children with Down syndrome undergoing neurosurgical spine procedures.
A total of six consecutive spinal procedures in six children with Down syndrome (three boys and three girls; mean age 10 years, range 4-16 years) were analyzed between January 1, 2008 and June 31, 2011. Somatosensory evoked potentials were stimulated at the ulnar nerve and tibial nerve for upper and lower extremities, respectively, and recorded at Erb's point and the scalp. Motor evoked potentials were elicited by transcranial electrical stimulation and recorded at the extensor carpi ulnaris muscle and tibialis anterior muscle for upper and lower extremities, respectively. A standardized anesthesia protocol for monitoring consisted of a titrated propofol drip combined with bolus dosing of fentanyl or sufentanil.
Somatosensory and motor evoked potentials were documented at the beginning and end of the procedure in all six patients. Changes during the surgery were recorded. Five patients maintained somatosensory potentials throughout surgery. One patient demonstrated a >10% increase in latency or >50% decrease in amplitude suggesting spinal cord dysfunction. A mean baseline stimulation threshold for motor evoked potentials of 485 + 85 V (range 387-600 V) was used. Four patients maintained motor evoked potentials throughout surgery. One patient had loss of left lower somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) after rod placement; upon removal of the rod, SSEPs returned but not MEPs. Another patient did not have consistent MEPs on one side and had absent MEPs on the contralateral side throughout the case. Loss of MEPs in these two patients did not correlate with postoperative neurological status. There were no complications directly related to neurophysiologic intraoperative monitoring technique.
Neurophysiologic intraoperative monitoring during neurosurgical procedures in children with Down syndrome may be reliably and safely implemented. Changes in neurophysiologic parameters during surgery must be carefully interpreted, and discussed with the neurosurgeon, neurophysiologist, and neuroanesthesiologist, and may not correlate with postoperative clinical changes. These changes may be related to abnormal physiology rather than an insult at the time of surgery. Nonetheless, the authors advocate routine neurophysiologic intraoperative monitoring in this special group of children undergoing neurosurgical spine procedures.
在复杂脊柱手术中进行神经生理监测，可为手术医生提供反馈，从而降低损伤风险。该工具在成人手术中是一种成熟且重要的辅助手段，但儿童的临床数据描述尚不充分。此外，据我们所知，对于患有神经发育障碍（如唐氏综合征）的儿童，术中神经生理监测数据尚未见报道，而这类儿童常伴有颅颈不稳，需要进行内固定。本研究的目的是确定在一组接受神经外科脊柱手术的唐氏综合征儿童中，术中神经生理监测的可靠性和安全性。
对2008年1月1日至2011年6月31日期间连续6例患有唐氏综合征的儿童（3名男孩和3名女孩；平均年龄10岁，范围4 - 16岁）进行的6例脊柱手术进行分析。分别在尺神经和胫神经刺激上肢和下肢的体感诱发电位，并在Erb点和头皮记录。通过经颅电刺激引出运动诱发电位，分别在上肢的尺侧腕伸肌和下肢的胫前肌记录。用于监测的标准化麻醉方案包括滴定丙泊酚滴注联合芬太尼或舒芬太尼推注给药。
所有6例患者在手术开始和结束时均记录到体感和运动诱发电位。记录了手术过程中的变化。5例患者在整个手术过程中保持体感电位。1例患者潜伏期增加>10%或波幅降低>50%，提示脊髓功能障碍。运动诱发电位的平均基线刺激阈值为485 + 85 V（范围387 - 600 V）。4例患者在整个手术过程中保持运动诱发电位。1例患者在置入棒后左下肢体感诱发电位（SSEP）和运动诱发电位（MEP）消失；取出棒后，SSEP恢复，但MEP未恢复。另1例患者一侧MEP不一致，且在整个病例中对侧MEP缺失。这2例患者MEP的消失与术后神经状态无关。没有与术中神经生理监测技术直接相关的并发症。
在唐氏综合征儿童的神经外科手术中，术中神经生理监测可以可靠且安全地实施。手术过程中神经生理参数的变化必须仔细解读，并与神经外科医生、神经生理学家和神经麻醉医生进行讨论，这些变化可能与术后临床变化无关。这些变化可能与异常生理状态有关，而非手术时的损伤。尽管如此，作者主张在这组接受神经外科脊柱手术的特殊儿童中常规进行术中神经生理监测。
