Bianchi Francesca, Cursi Marco, Caravati Heike, Butera Calogera, Bosco Luca, Monaco Fabrizio, Baccellieri Domenico, Bertoglio Luca, Kahlberg Andrea, Filippi Massimo, Melissano Germano, Chiesa Roberto, Carro Ubaldo Del
Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
Neurophysiol Clin. 2022 Jun;52(3):232-241. doi: 10.1016/j.neucli.2021.12.006. Epub 2022 Jan 5.
Despite the introduction of several adjuncts to improve spinal perfusion, spinal cord ischemia (SCI) remains a devastating complication of thoracoabdominal aortic aneurysm (TAAA) repair. Our aim was to assess the effects on clinical outcome of interventions triggered by motor evoked potentials (MEP) alerts. Furthermore, we want to assess whether a multimodal intraoperative neurophysiologic monitoring (IONM) protocol is helpful for stratifying patients according to the risk of SCI at the end of the vascular phase of surgery.
We prospectively studied one-hundred consecutive patients who underwent TAAA repair. We applied a multimodal IONM including MEP, somatosensory evoked potentials (SEP) and peripheral nerve monitoring techniques. Signal deteriorations were classified as reversible/irreversible according to whether they recovered or not at the end of monitoring (EOM), set at the end of the vascular phase of surgery. Significant MEP changes drove a series of corrective measures aimed to improve spinal perfusion.
The rate of immediate postoperative motor deficits consistent with SCI was significantly higher with irreversible MEP deteriorations compared to reversible ones. The interpretation of MEP findings at the EOM led to the development of risk categories for SCI, based on the association between MEP results and motor outcome.
Our data seem to justify interventions made to reverse MEP deterioration in order to improve the clinical outcome. A multimodal IONM protocol could improve MEP interpretation at the end of the vascular phase of surgery, supporting the surgeon in their decision-making, before concluding vascular maneuvers.
尽管已引入多种辅助手段来改善脊髓灌注，但脊髓缺血（SCI）仍是胸腹主动脉瘤（TAAA）修复手术中一种极具破坏性的并发症。我们的目的是评估运动诱发电位（MEP）警报触发的干预措施对临床结局的影响。此外，我们想评估多模式术中神经生理监测（IONM）方案是否有助于在手术血管阶段结束时根据SCI风险对患者进行分层。
我们前瞻性地研究了连续100例行TAAA修复手术的患者。我们应用了包括MEP、体感诱发电位（SEP）和周围神经监测技术在内的多模式IONM。根据信号在监测结束时（EOM，设定在手术血管阶段结束时）是否恢复，将信号恶化分为可逆/不可逆。显著的MEP变化促使采取一系列旨在改善脊髓灌注的纠正措施。
与可逆性MEP恶化相比，不可逆性MEP恶化导致术后立即出现与SCI一致的运动功能缺损的发生率显著更高。根据EOM时MEP结果与运动结局之间的关联，对MEP结果的解读形成了SCI的风险类别。
我们的数据似乎证明为逆转MEP恶化而采取的干预措施是合理的，以改善临床结局。多模式IONM方案可以在手术血管阶段结束时改善MEP解读，在结束血管操作之前支持外科医生进行决策。
