Intraoperative Neurophysiology Unit, Rabin Medical Center, Beilinson Hospital, 39 Jabotinski St, 49100, Petach Tikva, Israel.
Orthopaedics, Meir Medical Center, Kfar-Saba, Israel.
Arch Orthop Trauma Surg. 2022 Nov;142(11):3017-3025. doi: 10.1007/s00402-021-03885-1. Epub 2021 Apr 20.
A reliable, real-time method for the detection of pedicle wall breaching during funnelling in spine deformity surgery could be accessible to any surgeon assisted with neuromonitoring.
Fifty-six consecutive patients (1066 pedicles), who were submitted to spinal deformity surgery from December 2013 to July 2015 were included in the study group. A control group of 13 consecutive patients (226 pedicles) with spinal deformity surgery were operated on from January to December 2013 and were excluded from finder stimulation. In the study cohort, continuous stimulation during funnelling was delivered via a finder and subsequently a compound muscle action potential (CMAP) threshold was determined. Following funnelling, manual inspection of the pedicular internal walls was performed. The CMAP thresholds were compared with the results of palpation to determine the sensitivity and specificity of the technique for detecting pedicular breaching. To cover common ranges of damage, the medial and lateral breaches were compared and the concave-apical breaches compared to the non-apical or convex-apical breaches. In addition, a pedicle screw test was estimated for all patients.
ROC analysis showed 9 mA cut-off to have a sensitivity of 88.0% and a specificity of 89.5% for predicting pedicular breaching, with an area under the curve of 0.92 (95% confidence interval 0.90-0.94; P < 0.001). Using 9 mA threshold as an alert criterion, funnelling at the concave-apical pedicles showed significantly more true and false positive alerts and fewer true negative alerts when compared with the non-apical and convex-apical pedicles (P < 0.001). Medial breaches had significantly lower stimulation thresholds than lateral breaches (P < 0.001). Thresholds of screw-testing were significantly higher for study than for control-patients (P = 0.002).
Finder stimulation has a considerably higher sensitivity and specificity for prediction of pedicular breaching, most prominent for medial breaches. Screw-testing displayed significantly better results in patients undergoing the finder stimulation technique, as compared with the control group. The main advantages of our method are its high safety level and low cost, which may be critical in less affluent countries.
III.
在脊柱畸形手术中，一种可靠的、实时的椎弓根壁破裂检测方法可以让任何接受神经监测辅助的外科医生都能使用。
本研究纳入了 2013 年 12 月至 2015 年 7 月期间接受脊柱畸形手术的 56 例连续患者（1066 个椎弓根）。对照组为 13 例连续患者（226 个椎弓根），这些患者在 2013 年 1 月至 12 月期间接受脊柱畸形手术，未进行探子刺激。在研究组中，在探子引导下进行连续刺激，然后确定复合肌肉动作电位（CMAP）阈值。探子引导完成后，对椎弓根内壁进行手动检查。比较 CMAP 阈值和触诊结果，以确定该技术检测椎弓根破裂的灵敏度和特异性。为了涵盖常见的损伤范围，比较了内侧和外侧破裂，并将凹侧-顶侧破裂与非顶侧或凸侧-顶侧破裂进行了比较。此外，对所有患者进行了椎弓根螺钉测试。
ROC 分析显示，9 mA 截断值预测椎弓根破裂的灵敏度为 88.0%，特异性为 89.5%，曲线下面积为 0.92（95%置信区间 0.90-0.94；P<0.001）。使用 9 mA 阈值作为警报标准，与非顶侧和凸侧椎弓根相比，凹侧-顶侧椎弓根的真阳性和假阳性警报明显更多，真阴性警报明显更少（P<0.001）。内侧破裂的刺激阈值明显低于外侧破裂（P<0.001）。与对照组相比，接受探子刺激技术的患者的螺钉测试阈值明显更高（P=0.002）。
探子刺激对预测椎弓根破裂具有较高的灵敏度和特异性，对于内侧破裂更为明显。与对照组相比，接受探子刺激技术的患者的螺钉测试结果明显更好。该方法的主要优点是安全性高且成本低，这在欠发达国家可能非常重要。
III 级。
