Ghadirpour Reza, Nasi Davide, Iaccarino Corrado, Giraldi David, Sabadini Rossella, Motti Luisa, Sala Francesco, Servadei Franco
Neurosurgery-Neurotraumatology Unit, Emergency Department, University Hospital of Parma, Parma, Italy; Neurosurgery Unit, Neuromotor Department, IRCCS "Arcispedale Santa Maria Nuova" of Reggio Emilia, Reggio Emilia, Italy.
Clinic of Neurosurgery, Department of Neurological Sciences, Polytechnic University of Marche, Umberto I General Hospital, Ancona, Italy.
Clin Neurol Neurosurg. 2015 Mar;130:140-9. doi: 10.1016/j.clineuro.2015.01.007. Epub 2015 Jan 12.
While intraoperative neurophysiological monitoring (IOM) for intramedullary tumors has become a standard in neurosurgical practice, IOM for intradural extramedullary tumors (IDEMs) is still under debate. The aim of this study is to evaluate the role of IOM during surgery for IDEMs.
From March 2008 to March 2013, 68 patients had microsurgery with IOM for IDEMs (31 schwannomas, 25 meningiomas, 6 ependymomas of the cauda/filum terminalis, 4 dermoid cysts and 2 other lesions). The IOM included somatosensory evoked potentials (SEPs), motor evoked potentials (MEPs), and--in selected cases--D-waves. Also preoperative and postoperative neurophysiological assessment was performed with SEPs and MEPs. All patients were evaluated at admission and at follow up (minimum 6 months) with the Modified McCormick Scale (mMCs).
Three different IOM patterns were observed during surgery: no change in evoked potentials (63 cases), transitory evoked potentials change (3 cases) and loss of evoked potentials (2 cases). In the first setting surgery was never stopped and a radical tumor removal was achieved (no stop surgery group). In 3 cases of transitory evoked potentials change, surgery was temporarily halted but the tumors were at the end completely removed (stop and go surgery group). In 2 more patients the loss of evoked potentials led to an incomplete resection (stop surgery group). No patients presented a worsening of the pre-operative clinical conditions (at admission 47 patients presented mMCs 1-2 and 21 patients mMCs 3-5, while at follow up 62 patients are mMCS 1-2 and 6 patients mMCs 3-5).
In our series significant IOM changes occurred in 5 out of 68 patients with IDEMs (7.35%), and it is conceivable that the modification of the surgical strategy - induced by IOM - prevented or mitigated neurological injury in these cases. Vice versa, in 63 patients (92.65%) IOM invariably predicted a good neurological outcome. Furthermore this technique allowed a safer tumor removal in IDEMs placed in difficult locations as cranio-vertebral junction or in antero/antero-lateral position (where rotation of spinal cord can be monitored) and even in case of tumor adherent to the spinal cord without a clear cleavage plane.
虽然髓内肿瘤的术中神经生理监测（IOM）已成为神经外科手术的标准操作，但硬膜内髓外肿瘤（IDEMs）的IOM仍存在争议。本研究的目的是评估IOM在IDEMs手术中的作用。
2008年3月至2013年3月，68例患者接受了IDEMs的显微手术并进行了IOM监测（31例神经鞘瘤、25例脑膜瘤、6例马尾/终丝室管膜瘤、4例皮样囊肿和2例其他病变）。IOM包括体感诱发电位（SEPs）、运动诱发电位（MEPs），并在部分病例中监测D波。术前和术后也用SEPs和MEPs进行神经生理评估。所有患者入院时及随访（至少6个月）时均采用改良麦考密克量表（mMCs）进行评估。
手术过程中观察到三种不同的IOM模式：诱发电位无变化（63例）、诱发电位短暂变化（3例）和诱发电位消失（2例）。在第一种情况下，手术从未停止，肿瘤被彻底切除（不停手术组）。在3例诱发电位短暂变化的病例中，手术暂时停止，但肿瘤最终被完全切除（停走手术组）。另外2例患者诱发电位消失导致肿瘤切除不完全（停手术组）。没有患者术前临床状况恶化（入院时47例患者mMCs为1 - 2级，21例患者mMCs为3 - 5级，而随访时62例患者为mMCS 1 - 2级，6例患者为mMCs 3 - 5级）。
在我们的系列研究中，68例IDEMs患者中有5例（7.35%）出现了显著的IOM变化，可以想象，在这些病例中，由IOM引起的手术策略改变预防或减轻了神经损伤。反之，在63例患者（92.65%）中，IOM始终预示着良好的神经功能结局。此外，该技术使位于颅颈交界或前/前外侧等困难位置的IDEMs（可监测脊髓旋转），甚至在肿瘤与脊髓粘连且无清晰分离平面的情况下，更安全地切除肿瘤。
