| 多模式神经电生理监测技术在外科治疗胸椎结核的术中应用 |
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Received:November 21, 2020
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| 作者 | Author | 单位 | Unit | E-Mail |
| 张晨威 |
ZHANG Chen-wei |
浙江大学医学院附属杭州市胸科医院, 浙江 杭州 310003 |
Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang, China |
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| 费骏 |
FEI Jun |
浙江大学医学院附属杭州市胸科医院, 浙江 杭州 310003 |
Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang, China |
jamfee@163.com |
| 石仕元 |
SHI Shi-yuan |
浙江大学医学院附属杭州市胸科医院, 浙江 杭州 310003 |
Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang, China |
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| 陶晓 |
TAO Xiao |
浙江大学医学院附属杭州市胸科医院, 浙江 杭州 310003 |
Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang, China |
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| 祖罡 |
ZU Gang |
浙江大学医学院附属杭州市胸科医院, 浙江 杭州 310003 |
Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang, China |
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| 胡金平 |
HU Jin-ping |
浙江大学医学院附属杭州市胸科医院, 浙江 杭州 310003 |
Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang, China |
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| 曹天一 |
CAO Tian-yi |
浙江大学医学院附属杭州市胸科医院, 浙江 杭州 310003 |
Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang, China |
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| 期刊信息：《中国骨伤》2021年34卷，第11期，第1065-1071页 |
| DOI：10.12200/j.issn.1003-0034.2021.11.015 |
| 基金项目:杭州市农业与社会发展科研主动设计项目（编号：20180417A04） |
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目的：探究多模式神经电生理检测（multimodal intraoperative monitoring，MIOM）技术在经肋横突入路病灶清除植骨及后路椎弓根螺钉内固定治疗胸椎结核术中评判脊髓及神经根功能的价值。
方法：回顾性分析2018年12月至2019年9月确诊为胸椎结核并行经肋横突入路病灶清除植骨及后路椎弓根内固定术治疗的25例患者临床资料。25例患者中男14例，女11例；年龄20~83（63.45±9.65）岁；单个椎体破坏3例，2个椎体破坏13例，3个及3个以上椎体破坏9例。所有手术患者术中行体感诱发电位（somatosensory evoked potential，SEP），经头颅电刺激运动诱发电位（transcranial electric stimulation-motor evoked potential，TES-MEP）检查，并采用自发肌电图（electromyography，EMG）监测椎弓根螺钉置入及病灶清除。检测血沉（erythrocyte sedimentation rate，ESR）评价患者炎性指标下降情况，采用视觉模拟评分（visual analogue scale，VAS）评价患者胸椎疼痛情况，通过Cobb角及Oswestry功能障碍指数（Oswestry Disability Index，ODI）评价功能改善情况。
结果：25例患者均成功监测。5例患者在术中出现SEP波形异常，其中3例为术中清除病灶及冲洗时脊髓受压导致，及时更换器械及操作手势、调整冲洗水流速后波形恢正常；1例因收缩压下降引起，及时予以升压处理后，波形恢复正常；1例SEP波形出现异常后，暂停手术操作10 min后自行恢复，并至手术结束前未再次出现波形异常。7例患者TES-MEP波形异常，其中5例在椎弓根螺钉置钉时出现，术中及时调整钉道，重新置钉后波形恢复；1例因术中手术床倾斜引起，及时调整手术床后，波形逐渐恢复；1例在椎弓根钉棒系统矫形时出现，术中对侧钉棒矫形完成后波形逐渐恢复正常。5例患者在出现TES-MEP波形异常患同时检测到EMG爆发电位，调整后，EMG爆发电位消失。未出现TES-MEP与SEP波形同时异常的患者。患者术后VAS、ESR、Cobb角、ODI较术前均有改善（P<0.05）。
结论：胸椎结核患者在采用Ⅰ期经肋横突入路病灶清除植骨及后路椎弓根内固定术中联合应用SEP、TES-MEP和EMG监测能及时反映脊髓及神经根功能，在取得良好固定及病灶清除的同时避免术中损伤。 |
| [关键词]:结核,脊柱 外科手术 监测,手术中 电生理学 |
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| Application of multimodal neuroelectrophysiological monitoring technology in surgical treatment of thoracic tuberculosis |
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Abstract:
Objective: To explore the value of multimodal neuroelectrophysiological monitoring technology in the evaluation of spinal cord and nerve root function for the treatment of thoracic tuberculosis with debridement and bone grafting and posterior internal fixation by transcostal transverse process approach.
Methods: The clinical data of 25 patients with thoracic tuberculosis underwent debridement and bone grafting and posterior vertebral arch internal fixation by transcostal transverse process approach from December 2018 to September 2019 was retrospectively analyzed. Among these 25 patients, including 14 males and 11 females;aged from 20 to 83 years old, with a mean of (63.45±9.65) years;there were 3 cases of single vertebral body destruction, 13 cases of 2 vertebral bodies destruction, and 9 cases of 3 or more vertebral bodies destruction. All surgical patients underwent intraoperative detection of somatosensory evoked potential(SEP) and transcranial electric stimulation-motor evoked potential(TES-MEP);and electromyography (EMG) was used to monitor the pedicle screw placement and lesion removal. The erythrocyte sedimentation rate(ESR) was used to evaluate the decline of inflammatory indexes, the visual analogue scale (VAS) was used to evaluate the thoracic spine pain, and the Cobb angle and Oswestry Disability Index(ODI) were used to evaluate the improvement of function.
Results: All 25 patients were successfully monitored. Five patients had abnormal SEP waveforms during operation, 3 cases were caused by intraoperative clearing of lesions and spinal cord compression during irrigation, timely replacement of instruments and gestures, and adjustment of irrigation water flow rate returned the waveform to normal; one case was caused by a decrease in systolic blood pressure, and the waveform returned to normal after timely treatment of increased blood pressure;after 1 case of SEP waveform abnormality, the operation was suspended for 10 minutes and recovered spontaneously, and the waveform abnormality did not reappear until the end of the operation. Seven patients had abnormal TES-MEP waveforms, 5 cases occurred when the pedicle screw was inserted, the nail path was adjusted in time, and the waveform recovered after nail repositioning;one case was caused by tilting the operation bed during operation, and the waveform gradually recovered after adjusting the tilt angle of operation bed; one case occurred during the correction of the pedicle screw and rod system, and the waveform gradually returned to normal after the contralateral screw and rod correction were completed during operation. In 5 cases, the EMG burst potential was detected at the same time when the TES-MEP waveform was abnormal. After adjustment, the EMG burst potential disappeared. There was no abnormality in the TES-MEP and SEP waveforms at the same time. Postoperative VAS, ESR, Cobb angle, and ODI were improved compared with preoperatively (P<0.05).
Conclusion: In patients with thoracic tuberculosis, the use of debridement and bone grafting and posterior internal fixation by transcostal transverse process approach combined with intraoperative SEP, TES-MEP and EMG monitoring can timely reflect the spinal cord and nerve root function, avoid intraoperative injuries while achieving good fixation and lesion removal. |
| KEYWORDS:Tuberculosis,spinal Surgical procedures,operative Monitoring,intraoperative Electrophysiology |
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| 引用本文，请按以下格式著录参考文献： |
| 中文格式: | 张晨威,费骏,石仕元,陶晓,祖罡,胡金平,曹天一.多模式神经电生理监测技术在外科治疗胸椎结核的术中应用[J].中国骨伤,2021,34(11):1065~1071 |
| 英文格式: | ZHANG Chen-wei,FEI Jun,SHI Shi-yuan,TAO Xiao,ZU Gang,HU Jin-ping,CAO Tian-yi.Application of multimodal neuroelectrophysiological monitoring technology in surgical treatment of thoracic tuberculosis[J].zhongguo gu shang / China J Orthop Trauma ,2021,34(11):1065~1071 |
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