多模式神经电生理联合监护技术在腰椎后路开放手术和经皮内镜下椎间盘切除术中的应用

Application of multi-modality intraoperative neurophysiological monitoring in posterior lumbar open surgery and percutaneous endoscopic lumbar discectomy

中文关键词:  神经电生理监护  体感诱发电位  经颅电刺激运动诱发电位  自由肌电图  经皮内镜下腰椎间盘摘除术  后路腰椎开放性手术

英文关键词:Neurophysiological monitoring  Somatosensory evoked potential  Transcranial electrical stimulation motor evoked potential  Free-electromyography  Percutaneous endoscopic lumbar discectomy  Posterior lumbar open surgery

中文摘要:

  【摘要】 目的：探讨在腰椎后路开放手术和经皮内镜下椎间盘切除术（percutaneous endoscopic lumbar discectomy，PELD）中应用多模式神经电生理联合监护技术的必要性和临床价值。方法：2021年4月~2024年5月在我院行腰椎后路开放手术和PELD手术的患者应用多模式神经电生理联合监护技术进行术中监护，70例行腰椎后路开放手术的患者采用皮层体感诱发电位（somatosensory evoked potential，SEP）和经颅电刺激运动诱发电位（transcranial electrical stimulation motor evoked potential，TES-MEP）联合监护，男29例，女41例，年龄8~85岁（33.3±22.4岁），纳入开放组；70例PELD手术的患者采用SEP、TES-MEP和自由肌电图（free-electromyography，Free-EMG）联合监护，男36例，女34例，年龄13~83岁（50.9±15.2岁），纳入PELD组。分析不同监护模式在两种手术方式中对神经损伤预警的有效性。结果：两组患者术中神经电生理监护均能有效实施，未出现神经电生理监护相关的并发症。开放手术组2例患者术中出现电生理信号波幅降低，PELD组6例患者术中出现电生理异常变化，两组术中异常电生理信号变化经预警并采取合理的应对措施，患者术后未出现严重和不可逆神经功能损伤。PLED手术过程中引发的异常神经电生理信号表现为Free-EMG或TES-MEP的异常变化，TES-MEP信号的异常变化与Free-EMG是否异常无直接关系，TES-MEP与Free-EMG具有独立神经监测功能。结论：多模式神经电生理联合监护技术在腰椎后路开放手术和PELD中有一定的有效性和临床价值；在PELD手术中发生预警的概率较高，多模式神经电生理联合监护对其有重要的临床意义。

英文摘要:

  【Abstract】 Objectives: To explore the necessity and clinical value of multi-modality intraoperative neurophysiological monitoring(IONM) in posterior lumbar open surgery and percutaneous endoscopic lumbar discectomy(PELD). Methods: Multi-modality IONM was applied in patients undergoing posterior lumbar open surgery and PELD surgery from April 2021 to May 2024 in our hospital. 70 patients undergoing posterior lumbar open surgery and were monitored with cortical somatosensory evoked potential(SEP) and transcranial electrical stimulation motor evoked potential(TES-MEP) were included in the open group, including 29 males and 41 females, aged 8-85 years(33.3±22.4 years); 70 patients undergoing PELD surgery and were monitored with SEP, TES-MEP and free-electromyography(Free-EMG) were included in PELD group, including 36 males and 34 females, aged 13-83 years(50.9±15.2 years). The effectiveness of different monitoring modes in predicting nerve injury in the two types of operation was analyzed. Results: Intraoperative neurophysiological monitoring was effectively implemented in the two groups with no complications related to neurophysiological monitoring. There were two patients showed decreased amplitude of intraoperative neurophysiological signals in the open group, while there were 6 intraoperative neurophysiological abnormalities in PELD group. After early warning and reasonable counter measures, no serious and irreversible nerve function injury occurred in the patients after surgery. Abnormal neuroelectrophysiological signals caused by PELD surgery were manifested as abnormal changes in Free-EMG or TES-MEP, and the changes of TES-MEP signal were not directly related to Free-EMG, indicating that TES-MEP and Free-EMG had independent nerve monitoring functions. Conclusions: Multi-modality IONM has its effectiveness and clinical value in posterior lumbar open surgery and PELD; There is a high risk of warning during PELD surgery, so multi-modality IONM has important clinical value for PELD surgery.