Abstract:Objective To explore the values of intraoperative neurophysiological monitoring(IONM) in the placement of thoracic pedicle screws in thoracic fracture surgery. Methods From February 2015 to December 2016,a total of 18 patients suffering from thoracic fracture underwent posterior instrumentation and fusion in our hospital.They were 16 males and 2 females,with an average age of(32.6±12.3) years.Preoperative spinal cord function was graded by Frankel criteria.There were 1 case of grade A,2 cases of grade B,6 cases of grade C,8 cases of grade D and 1 case of grade E.Somatosensory evoked potentials(SEP) were tested before and 1 week after surgery.Pedicle screws were inserted under the monitoring of SEP and motor evoked potentials(MEP).The accuracy of pedicle screw placement was assessed according to postoperative CT scans.Results The average operation time was(167±36) min and intraoperative blood loss(EBL) was(423±141)mL.The Cobb angle of segmental kyphosis was corrected from(31.2±5.7)° to(10.6±4.9)° after surgery.A total of 144 screws were inserted in the 18 patients.No significant changes of SEP and MEP were observed in the placement of 86 screws(59.7%).Changes were detected but did not reach the alarm level in 40 screws(27.8%).Changes of 18 screws(12.5%) reached the alarm level.According to CT evaluation,the satisfactory rate of pedicle screw placement was 93.1%,while the perforation rate was 6.9%.The results of SEP evaluation were improved significantly 1 week after surgery.No neurologic?deterioration was found during and after surgery.Conclusion SEP and MEP monitoring can early detect the possible neurologic injury during the placement of thoracic pedicle screws.Neurologic defect could be reduced,if the operation is stopped when the monitoring reaches the alarm level.
戴小青,荣国强 *. 神经电生理监测技术在胸椎骨折椎弓根螺钉置入中的应用[J]. 实用骨科杂志, 2018, 24(4): 324-384.
Dai Xiaoqing,Rong Guoqiang. Application of Intraoperative Neurophysiological Monitoring in the Placement of Pedicle Screws in Thoracic Fracture Surgery. sygkzz, 2018, 24(4): 324-384.
[1]Gaines RW Jr.The use of pediclescrew internal fixation for the operative treatment of spinal disorder[J].J Bone Joint Surg(Am),2000,82(10):1458-1476.
[2]张国富,刘波,顾岳山,等.椎弓根钉椎板钩系统结合植骨治疗青少年腰椎峡部裂[J].实用骨科杂志,2017,23(8):733-735.
[3]邱勇.青少年特发性脊柱侧凸上胸椎与邻近结构解剖关系的特殊性:重视上胸椎椎弓根螺钉置钉安全性[J].中华解剖与临床杂志,2016,21(6):506-509.
[4]李明,许明,刘洋,等.徒手胸椎椎弓根螺钉置入技术治疗青少年特发性脊柱侧凸的安全性评价[J].脊柱外科杂志,2005,3(4):193-198.
[5]Vougioukas VI,Weber J,Scheufler KM.Clinical and radiological results after parapedicular screw fixation of the thoracic spine[J].J Neurosurg Spine,2005,3(4):283-287.
[6]张乐乐,马华松,吴继功,等.术中电生理监测在脊柱侧凸翻修截骨手术中的应用[J].实用骨科杂志,2017,23(8):684-689.
[7]史本龙,邱俊荫,毛赛虎,等.严重脊柱畸形全脊椎截骨术中神经电生理监测严重不良事件的危险因素及转归[J].中华骨科杂志,2016,36(24):1545-1550.
[8]马薇薇,邱勇,王斌,等.胸椎管狭窄症术中SEPs改变模式与术后神经功能状态的不一致性[J].中国矫形外科杂志,2007,15(5):337-339.
[9]黄紫房,郎传东,邓耀龙,等.重度胸椎畸形全椎体截骨术中神经电生理监测事件的危险因素分析[J].中华骨科杂志,2016,36(24):1551-1559.
[10]Polly DW Jr,Rice K,Tamkus A.What is the frequency of intraoperative alerts during pediatric spinal deformity surgery using current neuromonitoring methodology?A retrospective study of 218 surgical procedures[J].Neurodiagn J,2016,56(1):17-31.
[11]陈裕光,李佛保,杨军林,等.经颅电刺激运动诱发电位和皮层体感诱发电位在脊柱侧凸手术中联合监护的观察研究[J].中华骨科杂志,2009,29(1):27-31.
[12]Devlin VJ,Anderson PA,Schwartz DM,et al.Intraoperative neurophysiologic monitoring:focus on cervical myelopathy and related issues[J].Spine J,2006,6(6 Suppl):212-224.
[13]Langeloo DD,Lelivelt A,Louis Journee H,et al.Transcranial electrical motor-evoked potential monitoring during surgery for spinal deformity:a study of 145 patients[J].Spine(Phila Pa 1976),2003,28(10):1043-1050.
[14]Gertzbein SD,Robbins SE.Accuracy of pedicular screw placement in vivo[J].Spine(Phila Pa 1976),1990,15(1):11-14.
[15]Schwartz DM,Auerbach JD,Dormans JP,et al.Neurophysiological detection of impending spinal cord injury during scoliosis surgery[J].J Bone Joint Surg(Am),2007,89(11):2440-2449.
[16]金掌,张立岩,叶亚云,等.神经电生理监测技术在胸腰椎骨折微创椎弓根螺钉置入术中的应用[J].脊柱外科杂志,2015,13(3):158-160.
[17]Kelleher MO,Tan G,Sarjeant R,et al.Predictive value of intraoperative neurophysiological monitoring during cervical spine surgery:a prospective analysis of 1055 consecutive patients[J].J Neuro Surg Spine,2008,8(8):215-221.
[18]王燕燕,刘军辉,范顺武,等.腰椎斜外侧融合联合后路椎弓根螺钉内固定术中神经电生理监护模式的探讨及应用[J].中华骨科杂志,2016,36(24):1568-1573.
[19]周栋,徐南伟,农鲁明,等.CT三维导航系统辅助胸椎椎弓根钉治疗胸椎骨折[J].中华医学杂志,2010,90(23):1612-1614.
[20]Allam Y,Silbermann J,Riese F,et al.Computer tomography assessment of pedicle screw placement in thoracic spine:comparison between free hand and a generic 3D-based navigation techniques[J].Eur Spine J,2013,22(3):648-653.