Ishida Wataru, Casaos Joshua, Chandra Arun, D'Sa Adam, Ramhmdani Seba, Perdomo-Pantoja Alexander, Theodore Nicholas, Jallo George, Gokaslan Ziya L, Wolinsky Jean-Paul, Sciubba Daniel M, Bydon Ali, Witham Timothy F, Lo Sheng-Fu L
1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
4Department of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.
J Neurosurg Spine. 2019 Mar 1;30(6):839-849. doi: 10.3171/2018.11.SPINE181095. Print 2019 Jun 1.
With the advent of intraoperative electrophysiological neuromonitoring (IONM), surgical outcomes of various neurosurgical pathologies, such as brain tumors and spinal deformities, have improved. However, its diagnostic and therapeutic value in resecting intradural extramedullary (ID-EM) spinal tumors has not been well documented in the literature. The objective of this study was to summarize the clinical results of IONM in patients with ID-EM spinal tumors.
A retrospective patient database review identified 103 patients with ID-EM spinal tumors who underwent tumor resection with IONM (motor evoked potentials, somatosensory evoked potentials, and free-running electromyography) from January 2010 to December 2015. Patients were classified as those without any new neurological deficits at the 6-month follow-up (group A; n = 86) and those with new deficits (group B; n = 17). Baseline characteristics, clinical outcomes, and IONM findings were collected and statistically analyzed. In addition, a meta-analysis in compliance with the PRISMA guidelines was performed to estimate the overall pooled diagnostic accuracy of IONM in ID-EM spinal tumor resection.
No intergroup differences were discovered between the groups regarding baseline characteristics and operative data. In multivariate analysis, significant IONM changes (p < 0.001) and tumor location (thoracic vs others, p = 0.018) were associated with new neurological deficits at the 6-month follow-up. In predicting these changes, IONM yielded a sensitivity of 82.4% (14/17), specificity of 90.7% (78/86), positive predictive value (PPV) of 63.6% (14/22), negative predictive value (NPV) of 96.3% (78/81), and area under the curve (AUC) of 0.893. The diagnostic value slightly decreased in patients with schwannomas (AUC = 0.875) and thoracic tumors (AUC = 0.842). Among 81 patients who did not demonstrate significant IONM changes at the end of surgery, 19 patients (23.5%) exhibited temporary intraoperative exacerbation of IONM signals, which were recovered by interruption of surgical maneuvers; none of these patients developed new neurological deficits postoperatively. Including the present study, 5 articles encompassing 323 patients were eligible for this meta-analysis, and the overall pooled diagnostic value of IONM was a sensitivity of 77.9%, a specificity of 91.1%, PPV of 56.7%, and NPV of 95.7%.
IONM for the resection of ID-EM spinal tumors is a reasonable modality to predict new postoperative neurological deficits at the 6-month follow-up. Future prospective studies are warranted to further elucidate its diagnostic and therapeutic utility.
随着术中电生理神经监测（IONM）的出现，各种神经外科疾病（如脑肿瘤和脊柱畸形）的手术效果得到了改善。然而，其在切除硬脊膜内髓外（ID-EM）脊柱肿瘤方面的诊断和治疗价值在文献中尚未得到充分记载。本研究的目的是总结IONM在ID-EM脊柱肿瘤患者中的临床结果。
通过回顾性患者数据库，确定了2010年1月至2015年12月期间103例接受IONM（运动诱发电位、体感诱发电位和自由运行肌电图）肿瘤切除术的ID-EM脊柱肿瘤患者。患者被分为6个月随访时无任何新神经功能缺损的患者（A组；n = 86）和有新缺损的患者（B组；n = 17）。收集基线特征、临床结果和IONM结果并进行统计分析。此外，按照PRISMA指南进行荟萃分析，以估计IONM在ID-EM脊柱肿瘤切除术中的总体合并诊断准确性。
两组在基线特征和手术数据方面未发现组间差异。在多变量分析中，IONM的显著变化（p < 0.001）和肿瘤位置（胸段与其他部位，p = 0.018）与6个月随访时的新神经功能缺损相关。在预测这些变化时，IONM的敏感性为82.4%（14/17），特异性为90.7%（78/86），阳性预测值（PPV）为63.6%（14/22），阴性预测值（NPV）为96.3%（78/81），曲线下面积（AUC）为0.893。在神经鞘瘤患者（AUC = 0.875）和胸段肿瘤患者（AUC = 0.842）中，诊断价值略有下降。在81例手术结束时未显示IONM显著变化的患者中，19例（23.5%）出现术中IONM信号暂时加重，通过中断手术操作恢复；这些患者术后均未出现新的神经功能缺损。包括本研究在内，5篇文章共323例患者符合该荟萃分析的条件，IONM的总体合并诊断价值为敏感性77.9%，特异性91.1%，PPV 56.7%，NPV 95.7%。
IONM用于ID-EM脊柱肿瘤的切除是预测6个月随访时新的术后神经功能缺损的合理方法。未来有必要进行前瞻性研究，以进一步阐明其诊断和治疗效用。
