Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
Spine J. 2021 Apr;21(4):555-570. doi: 10.1016/j.spinee.2021.01.010. Epub 2021 Jan 16.
Cervical decompression and fusion surgery remains a mainstay of treatment for a variety of cervical pathologies. Potential intraoperative injury to the spinal cord and nerve roots poses nontrivial risk for consequent postoperative neurologic deficits. Although neuromonitoring with intraoperative somatosensory evoked potentials (SSEPs) is often used in cervical spine surgery, its therapeutic value remains controversial.
The purpose of the present study was to evaluate whether significant SSEP changes can predict postoperative neurologic complications in cervical spine surgery. A subgroup analysis was performed to compare the predictive power of SSEP changes in both anterior and posterior approaches.
The present study was a meta-analysis of the literature from PubMed, Web of Science, and Embase to identify prospective/retrospective studies with outcomes of patients who underwent cervical spine surgeries with intraoperative SSEP monitoring.
The total cohort consisted of 7,747 patients who underwent cervical spine surgery with intraoperative SSEP monitoring.
Inclusion criteria for study selection were as follows: (1) prospective or retrospective cohort studies, (2) studies conducted in patients undergoing elective cervical spine surgery not due to aneurysm, tumor, or trauma with intraoperative SSEP monitoring, (3) studies that reported postoperative neurologic outcomes, (4) studies conducted with a sample size ≥20 patients, (5) studies with only adult patients ≥18 years of age, (6) studies published in English, (7) studies inclusive of an abstract.
The sensitivity, specificity, diagnostic odds ratio (DOR), and likelihood ratios of overall SSEP changes, reversible SSEP changes, irreversible SSEP changes, and SSEP loss for predicting postoperative neurological deficit were calculated.
The total rate of postoperative neurological deficits was 2.50% (194/7,747) and the total rate of SSEP changes was 7.36% (570/7,747). The incidence of postoperative neurological deficit in patients with intraoperative SSEP changes was 16.49% (94/570) while only 1.39% (100/7,177) in patients without. All significant intraoperative SSEP changes had a sensitivity of 46.0% and specificity of 96.7% with a DOR of 27.32. Reversible and irreversible SSEP changes had sensitivities of 17.7% and 37.1% and specificities of 97.5% and 99.5%, respectively. The DORs for reversible and irreversible SSEP changes were 9.01 and 167.90, respectively. SSEP loss had a DOR of 51.39, sensitivity of 17.3% and specificity 99.6%. In anterior procedures, SSEP changes had a DOR of 9.60, sensitivity of 34.2%, and specificity of 94.7%. In posterior procedures, SSEP changes had a DOR of 13.27, sensitivity of 42.6%, and specificity of 94.0%.
SSEP monitoring is highly specific but weakly sensitive for postoperative neurological deficit following cervical spine surgery. The analysis found that patients with new postoperative neurological deficits were nearly 27 times more likely to have had significant intraoperative SSEP change. Loss of SSEP signals and irreversible SSEP changes seem to indicate a much higher risk of injury than reversible SSEP changes.
颈椎减压融合术仍然是治疗多种颈椎疾病的主要方法。术中对脊髓和神经根的潜在损伤会导致术后神经功能缺损，风险不容忽视。虽然术中体感诱发电位（SSEP）神经监测常用于颈椎手术，但它的治疗价值仍存在争议。
本研究旨在评估术中 SSEP 变化是否能预测颈椎手术的术后神经并发症。进行了亚组分析，比较了前路和后路手术中 SSEP 变化的预测能力。
本研究是对 PubMed、Web of Science 和 Embase 文献的荟萃分析，以确定有术中 SSEP 监测的颈椎手术患者的前瞻性/回顾性研究。
共有 7747 例接受颈椎手术并进行术中 SSEP 监测的患者纳入了总体队列。
研究选择的纳入标准如下：（1）前瞻性或回顾性队列研究；（2）在因动脉瘤、肿瘤或创伤以外的原因接受择期颈椎手术且术中进行 SSEP 监测的患者中进行的研究；（3）报告术后神经结局的研究；（4）样本量≥20 例的研究；（5）仅纳入≥18 岁成人患者的研究；（6）发表于英文文献的研究；（7）包含摘要的研究。
计算了总体 SSEP 变化、可逆 SSEP 变化、不可逆 SSEP 变化和 SSEP 丢失对预测术后神经功能缺损的敏感性、特异性、诊断比值比（DOR）和似然比。
术后神经功能缺损总发生率为 2.50%（194/7747），术中 SSEP 变化总发生率为 7.36%（570/7747）。术中 SSEP 变化患者的术后神经功能缺损发生率为 16.49%（94/570），而无术中 SSEP 变化患者的发生率为 1.39%（100/7177）。所有显著的术中 SSEP 变化的敏感性为 46.0%，特异性为 96.7%，DOR 为 27.32。可逆和不可逆 SSEP 变化的敏感性分别为 17.7%和 37.1%，特异性分别为 97.5%和 99.5%。可逆和不可逆 SSEP 变化的 DOR 分别为 9.01 和 167.90。SSEP 丢失的 DOR 为 51.39，敏感性为 17.3%，特异性为 99.6%。在前路手术中，SSEP 变化的 DOR 为 9.60，敏感性为 34.2%，特异性为 94.7%。在后路手术中，SSEP 变化的 DOR 为 13.27，敏感性为 42.6%，特异性为 94.0%。
SSEP 监测对颈椎手术后的神经功能缺损具有高度特异性，但敏感性较低。分析发现，新出现术后神经功能缺损的患者发生显著术中 SSEP 变化的可能性接近 27 倍。SSEP 信号丢失和不可逆 SSEP 变化似乎比可逆 SSEP 变化预示着更高的损伤风险。
