Korn A, Halevi D, Lidar Z, Biron T, Ekstein P, Constantini S
Department of Neurosurgery, Tel Aviv Medical Center and Tel Aviv University, Tel Aviv, Israel.
Acta Neurochir (Wien). 2015 May;157(5):819-30. doi: 10.1007/s00701-014-2307-2. Epub 2014 Dec 18.
Intradural-extramedullary spinal cord tumor surgery is common. Unlike intramedullary spinal cord tumor surgery, where intraoperative neurophysiological monitoring (IONM) has been described extensively, the application of IONM has not been described in this context, and its relevance has not been investigated.
From 2001 to 2012, 100 patients underwent intradural-extramedullary spinal cord tumor resection with IONM. Preoperative and postoperative clinical evaluations were completed retrospectively, using a modified McCormick grading scale and correlated with IONM monitorability and dynamics. IONM consisted of transcranial motor evoked potentials (tcMEP), spinal (D wave) and muscle generators, somatosensory evoked potentials (SSEP), and electromyography (EMG). Both short-term and long-term clinical evaluations were performed. Patient demographics, tumor type, span, location, and morphologic complexity were analyzed.
Surgeries were performed for resection of schwannomas (33 %), meningiomas (22 %), ependymomas (12 %), and other pathologies (20 %); pathology was unknown in 13 % of patients. Tumor locations were cervical in 21 %, thoracic in 46 %, thoracolumbar in 7 %, lumbar 20 %, and not specified in 6 %. Tumors spanned an average of 2.2 spinal levels. Monitorability was 97 and 67 % with tcMEP and SSEP modalities respectively. D waves were monitorable in 73 % of attempts. Intraoperative tcMEP changes were reported in 29 cases with 14 resolved intraoperatively, There were one false-negative outcome and five true-positive outcomes. For SSEP, 13 changes were noted and three resolved; there were three false-negative results and one true-positive result. For D wave monitoring there were two intraoperative changes with none resolved leading to one false negative and one true positive result. With a multimodality approach incorporating any change in evoked potential, IONM demonstrated sensitivity of 0.82, specificity of 0.95, positive predictive value of 0.82, and a negative predictive value of 0.95.
IONM is feasible and useful in the context of intradural-extramedullary spinal cord surgery for identifying iatrogenic injury to the spinal cord.
硬脊膜内髓外脊髓肿瘤手术较为常见。与髓内脊髓肿瘤手术不同，后者术中神经生理监测（IONM）已有广泛描述，而IONM在硬脊膜内髓外脊髓肿瘤手术中的应用尚未见报道，其相关性也未得到研究。
2001年至2012年，100例患者接受了硬脊膜内髓外脊髓肿瘤切除并采用IONM监测。回顾性地完成术前和术后临床评估，使用改良的 McCormick 分级量表，并与IONM的可监测性和动态变化相关联。IONM包括经颅运动诱发电位（tcMEP）、脊髓（D波）和肌肉发生器、体感诱发电位（SSEP）以及肌电图（EMG）。进行了短期和长期临床评估。分析了患者的人口统计学特征、肿瘤类型、范围、位置和形态复杂性。
手术用于切除神经鞘瘤（33%）、脑膜瘤（22%）、室管膜瘤（12%）和其他病变（20%）；13%的患者病理情况不明。肿瘤位置在颈椎的占21%，胸椎的占46%，胸腰段的占7%，腰椎的占20%，未明确的占6%。肿瘤平均跨越2.2个脊髓节段。tcMEP和SSEP模式的可监测率分别为97%和67%。73%的尝试中D波可监测。术中报告tcMEP变化29例，其中14例术中得到解决，有1例假阴性结果和5例真阳性结果。对于SSEP，记录到13次变化，3次得到解决；有3例假阴性结果和1例真阳性结果。对于D波监测，术中出现2次变化，均未得到解决，导致1例假阴性和1例真阳性结果。采用结合诱发电位任何变化的多模式方法，IONM显示敏感性为0.82，特异性为0.95，阳性预测值为0.82，阴性预测值为0.95。
IONM在硬脊膜内髓外脊髓手术中对于识别脊髓医源性损伤是可行且有用的。
