Gomes C, Kuchenbuch M, Lucas G, Sauleau P, Violas P
Service de neurophysiologie, CHU de Rennes, 35033 Rennes, France.
Service de neurophysiologie, CHU de Rennes, 35033 Rennes, France; Université Rennes 1, 35043 Rennes, France.
Orthop Traumatol Surg Res. 2015 Jun;101(4 Suppl):S193-7. doi: 10.1016/j.otsr.2015.03.002. Epub 2015 Apr 15.
Intraoperative monitoring (IOM) has been proven to decrease the risk of neurological injury during scoliosis surgery. The vertical expandable prosthetic titanium rib (VEPTR) is a device that allows spinal growth. However, injuries to the spinal cord and brachial plexus have been reported after VEPTR implantation in 2 and 5% of patients, respectively. Simultaneous monitoring of these two structures requires the use of multiple time-consuming and complex methods that are ill-suited to the requirements of paediatric surgery, particularly when repeated VEPTR lengthening procedures are needed. We developed a monopolar stimulation method derived from Owen's monitoring technique. This method is easy to implement, requires only widely available equipment, and allows concomitant monitoring of the spinal cord and brachial plexus. The primary objective of this study was to assess the reliability of our technique for brachial plexus monitoring by comparing the stability of neurogenic mixed evoked potentials (NMEPs) at the upper and lower limbs.
We hypothesised that the coefficients of variation (CVs) of NMEPs were the same at the upper and lower limbs.
Twelve VEPTR procedures performed in 6 patients between 1st January 2012 and 1st September 2014 were monitored using a monopolar stimulating probe. NMEPs were recorded simultaneously at the upper and lower limbs, at intervals of 150 s. The recording sites were the elbow over the ulnar nerve and the popliteal fossa near the sciatic nerve. Wilcoxon's test for paired data was used to compare CVs of the upper and lower limb NMEPs on the same side.
Mean CV of NMEP amplitude at the lower limbs was 16.34% on the right and 16.67% on the left; corresponding values for the upper limbs were 18.30 and 19.75%, respectively. Mean CVs of NMEP latencies at the lower limbs were 1.31% on the right and 1.19% on the left; corresponding values for the upper limbs were 1.96 and 1.73%. The risk of type I error for a significant difference between the upper and lower limbs was 0.5843 on the right and 0.7312 on the left for NMEP amplitudes and 0.7618 on the right and 0.4987 on the left for NMEP latencies.
Using an epidural active electrode and a sternal return electrode allows simultaneous stimulation of the cervical spinal cord and brachial plexus roots. The NMEPs thus obtained are as stable (reliable) at the upper limbs as at the lower limbs. This easy-to-implement method allows simultaneous monitoring of the upper and lower limbs. It seems well suited to VEPTR procedures.
IV, retrospective single-centre non-randomised study.
术中监测（IOM）已被证明可降低脊柱侧弯手术期间神经损伤的风险。垂直可扩展人工钛肋骨（VEPTR）是一种可促进脊柱生长的装置。然而，分别有2%和5%的患者在植入VEPTR后报告了脊髓和臂丛神经损伤。同时监测这两个结构需要使用多种耗时且复杂的方法，这些方法不符合小儿外科手术的要求，特别是在需要重复进行VEPTR延长手术时。我们开发了一种源自欧文监测技术的单极刺激方法。该方法易于实施，仅需使用广泛可得的设备，并可同时监测脊髓和臂丛神经。本研究的主要目的是通过比较上肢和下肢神经源性混合诱发电位（NMEP）的稳定性来评估我们的臂丛神经监测技术的可靠性。
我们假设NMEP的变异系数（CV）在上肢和下肢相同。
在2012年1月1日至2014年9月1日期间，对6例患者进行的12例VEPTR手术使用单极刺激探头进行监测。上肢和下肢同时记录NMEP，间隔150秒。记录部位为尺神经上方的肘部和坐骨神经附近的腘窝。使用配对数据的威尔科克森检验比较同一侧上肢和下肢NMEP的CV。
下肢NMEP波幅的平均CV在右侧为16.34%，在左侧为16.67%；上肢相应值分别为18.30%和19.75%。下肢NMEP潜伏期的平均CV在右侧为1.31%，在左侧为1.19%；上肢相应值分别为1.96%和1.73%。NMEP波幅上肢和下肢之间存在显著差异的I类错误风险在右侧为0.5843，在左侧为0.7312；NMEP潜伏期在右侧为0.7618，在左侧为0.4987。
使用硬膜外有源电极和胸骨返回电极可同时刺激颈脊髓和臂丛神经根。由此获得的NMEP在上肢和下肢一样稳定（可靠）。这种易于实施的方法可同时监测上肢和下肢。它似乎非常适合VEPTR手术。
IV级，回顾性单中心非随机研究。
