Huang Zi-Fang, Chen Liuyun, Yang Jing-Fan, Deng Yao-Long, Sui Wen-Yuan, Yang Jun-Lin
Department of Orthopaedic Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China.
World Neurosurg. 2019 Jul;127:e416-e426. doi: 10.1016/j.wneu.2019.03.140. Epub 2019 Apr 11.
Multimodal intraoperative neuromonitoring (IONM) has been proposed as an effective way to reduce permanent neurologic injury during spinal deformity surgery. However, few studies have reported evoked potential changes at different surgical stages of thoracic posterior vertebral column resection (PVCR).
A total of 82 cases with severe thoracic deformity (Yang's A type) treated by PVCR in a single institution between January 2010 and March 2015 were reviewed. Multimodal IONM including somatosensory evoked potential, motor evoked potential, and descending neurogenic evoked potential was performed for real-time assessment of spinal cord function during surgery. The risk factors of neuromonitoring events at different surgical stages were documented and analyzed.
Multimodal IONM was successfully performed in all 82 cases. Thirty-nine neuromonitoring events presented in 27 (32.9%) cases. Neurologic monitoring events were more likely to occur in patients with larger scoliosis and kyphosis, longer osteotomy closure distance, more Halo gravity traction, more screw insertion, and higher PVCR segments. The reasons for monitoring changes included 6 events during screw insertion, 20 during osteotomy, 9 during osteotomy gap closure, and 4 during deformity correction. New postoperative neurologic deficits were observed in 11 (13.4%) cases including 1 incomplete paraplegia, 8 transient cord deficits, and 2 nerve root injuries.
Multimodal IONM can effectively identify neurologic deficits throughout surgery. Osteotomy and osteotomy gap closure are the surgical stages with the highest neurologic risks during PVCR procedures. It is imperative to improve dexterity since the majority of neuromonitoring events are caused by surgical techniques.
多模式术中神经监测（IONM）已被提议作为减少脊柱畸形手术中永久性神经损伤的有效方法。然而，很少有研究报道胸椎后路脊柱切除术（PVCR）不同手术阶段的诱发电位变化。
回顾了2010年1月至2015年3月在单一机构接受PVCR治疗的82例严重胸椎畸形（杨式A型）患者。在手术期间进行包括体感诱发电位、运动诱发电位和下行神经源性诱发电位在内的多模式IONM，以实时评估脊髓功能。记录并分析不同手术阶段神经监测事件的危险因素。
82例患者均成功进行了多模式IONM。27例（32.9%）出现39次神经监测事件。神经监测事件更可能发生在脊柱侧凸和后凸较大、截骨闭合距离较长、头颅重力牵引较多、螺钉置入较多以及PVCR节段较高的患者中。监测变化的原因包括螺钉置入期间6次、截骨期间20次、截骨间隙闭合期间9次以及畸形矫正期间4次。11例（13.4%）患者术后出现新的神经功能缺损，包括1例不完全性截瘫、8例短暂性脊髓缺损和2例神经根损伤。
多模式IONM可在整个手术过程中有效识别神经功能缺损。截骨和截骨间隙闭合是PVCR手术中神经风险最高的手术阶段。由于大多数神经监测事件是由手术技术引起的，提高操作技巧势在必行。
