关节镜单孔辅助下经椎间孔腰椎间融合术中多模态神经电生理监测预测神经功能损伤的价值

Value of uni-portal arthroscope-assisted multimodal neurophysiological monitoring for predicting neurological injury in transforaminal lumbar interbody fusion

中文关键词:  腰椎管狭窄症  关节镜辅助单孔脊柱技术  经椎间孔腰椎间融合术  术中神经电生理监测  术后感觉障碍  预测价值

英文关键词:Lumbar spinal stenosis  Arthroscope-assisted uni-portal spinal surgery  Transforaminal lumbar interbody fusion  Intraoperative neurophysiological monitoring  Postoperative sensory deficits  Predictive value

中文摘要:

  【摘要】 目的：在行单孔非同轴脊柱内镜手术（uni-portal non-coaxial spinal endoscopic surgery，UNSES）/关节镜辅助单孔脊柱手术（arthroscope-assisted uni-portal spinal surgery，AUSS）-经椎间孔腰椎间融合术（transforaminal lumbar interbody fusion，TLIF）期间，通过体感诱发电位（somatosensory evoked potentials，SSEPs）、经颅电刺激运动诱发电位（transcranial electric motor evoked potentials，TCeMEPs）和肌电图（electromyography，EMG），评估术中神经电生理监测（intraoperative neurophysiological monitoring，IONM）报警事件与术后感觉障碍（postoperative sensory deficits，PSD）的关联。方法：回顾性分析2024年9月～2025年9月行AUSS-TLIF手术的腰椎管狭窄症患者98例，评估患者基线资料、IONM参数及术后转归。采用二元判别分析和Logistic回归模型分析IONM参数对PSD的预测能力，绘制受试者工作特征（receiver operating characteristic，ROC）曲线并计算曲线下面积（area under curve，AUC），确定EMG预测价值及阈值。基于EMG≥5.45s或MEP波幅下降>80%的复合预警标准评估IONM系统的临床效能，包括敏感性、特异性、阳性预测值、阴性预测值及假阴性率。结果：二元判别分析显示模型解释力73.5%，Logistic回归解释力75.5%。最具预测力的变量包括EMG肌电活动持续时间（0.795）、MEP振幅下降百分比（0.725）和手术时间（0.655）。ROC分析确定EMG肌电活动持续时间阈值为5.45s，AUC为0.867（95%CI：0.795～0.939，P＜0.001），≥4.0s时敏感性最高（90.2%），≥6.5s时特异性最高（92.4%）。基于复合预警标准，IONM系统预警敏感性80.0%，特异性84.9%，阳性预测值64.5%，阴性预测值高达92.5%，假阴性率仅5.1%。结论：EMG肌电活动持续时间作为监测指标，可以对术中神经损伤发出预警信息，指导术者及时干预，从而改善患者术后感觉功能转归。

英文摘要:

  【Abstract】 Objectives: To evaluate the association between intraoperative neurophysiological monitoring(IONM) alert events and postoperative sensory deficits(PSD), as detected by somatosensory evoked potentials(SSEPs), transcranial electric motor evoked potentials(TCeMEPs), and electromyography(EMG), during uni-portal non-coaxial spinal endoscopic surgery(UNSES)/arthroscope-assisted uni-portal spinal surgery(AUSS) via transforaminal lumbar interbody fusion(TLIF). Methods: This retrospective study included 98 patients with lumbar spinal stenosis who underwent AUSS-TLIF between September 2024 and September 2025. Baseline characteristics, IONM parameters, and postoperative outcomes were assessed. Binary discriminant analysis and logistic regression models were used to evaluate the predictive ability of IONM parameters for PSD. Receiver operating characteristic(ROC) curves were generated and area under the curve(AUC) was calculated to determine the predictive value and threshold of EMG. Based on a composite warning criterion of EMG activity duration ≥5.45s or MEP amplitude reduction >80%, the clinical performance of the IONM system was evaluated, including sensitivity, specificity, positive predictive value, negative predictive value, and false-negative rate. Results: Binary discriminant analysis showed an explanatory power of 73.5%, and logistic regression showed an explanatory power of 75.5%. The most predictive variables included EMG activity duration(0.795), percentage decrease in MEP amplitude(0.725), and operative time(0.655). ROC analysis identified an EMG activity duration threshold of 5.45s, with the AUC of 0.867(95%CI: 0.795-0.939, P<0.001). The highest sensitivity was observed at a threshold of ≥4.0s(90.2%), and the highest specificity was observed at ≥6.5s(92.4%). Using the composite warning criterion, the IONM system had a sensitivity of 80.0%, a specificity of 84.9%, a positive predictive value of 64.5%, a negative predictive value of 92.5%, and a false-negative rate of only 5.1%. Conclusions: EMG activity duration can serve as a monitoring indicator that provides early warning of intraoperative nerve injury, guiding timely surgical intervention and thereby improving postoperative sensory outcomes.