頸脊髓損傷患者應用體感誘發電位監測的價值_《華西醫學》

作者：

龍海波 ¹ , 康建平 ¹ ,  馮大雄 ¹ , 葉飛 ¹ , 張戈 ² , 雷飛 ¹ , 周云龍 ¹ , 周慶忠 ¹ , 楊劍 ¹

1瀘州醫學院附屬醫院脊柱外科（四川瀘州，646000）;2瀘州市人民醫院骨科;

關鍵詞：

脊髓損傷誘發電位, 軀體感覺監測, 手術中

DOI：

10.7507/1002-0179.20130115

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目的　探討軀體感覺誘發電位（SEP）在頸脊髓損傷術前、術中監測的意義。方法　納入2010年1月－2012年4月治療的241例頸脊髓損傷患者，術前按美國脊柱脊髓損傷協會（ASIA）評分并分級，確定損傷平面。術前與術中SEP監測，分析不同損傷分級以及不同損傷平面術前的波幅及潛伏期的差異，術中SEP監測以波幅下降＞50%和或潛伏期延長＞10%為預警標準。結果　各損傷分級組術前SEP監測：A級組SEP波消失，呈一直線，而B、C、D、E級組均測出SEP波形，根據是否可測出SEP波形，可將A級與B、C、D、E及組區別。B、C、D級組之間波幅和潛伏期均無統計學意義（P＞0.05）。E級組較B、C、D級組波幅增高、潛伏期縮短，差異有統計學意義（P＜0.05）；不完全性頸脊髓損傷組內不同損傷平面組之間波幅和潛伏期差異均無統計學意義（P＞0.05）。術中SEP對脊髓功能損傷監測的靈敏度83.3%、特異度98.7%。其中術中：SEP陽性8例，真陽性5例，4例術者處理后波幅及潛伏期回復至正常范圍，術后無新的神經功能損傷，另1例術者采取各種處理后波幅及潛伏期無恢復，術后神經功能損傷較術前加重；假陽性3例，1例麻醉師給予升高血壓后波形恢復至正常，另2例經麻醉師調整麻醉深度后波形恢復正常，此3例術后無新的神經功能損傷。SEP陰性233例，真陰性232例，術后無新的神經功能損傷；假陰性1例，患者術中、術后波形未見異常，術后運動功能損傷程度較術前加重。結論　① SEP能準確評估完全性和不完性頸脊髓損傷，但對不完全性頸脊髓損傷的損傷程度不能作出準確評估、也不能區分頸脊髓損傷的損傷平面；② 術中SEP監測能較好地反映頸脊髓功能完整性，對減少頸脊髓損傷術中發生醫源性頸脊髓損傷風險具有重要意義。

引用本文： 龍海波,康建平,馮大雄,葉飛,張戈,雷飛,周云龍,周慶忠,楊劍. 頸脊髓損傷患者應用體感誘發電位監測的價值. 華西醫學, 2013, 28(3): 356-360. doi: 10.7507/1002-0179.20130115 復制

1.	周紅俊, 汪家琮, 劉根林, 等. 脊髓損傷完全與否與體感誘發電位的關系[J]. 中華物理醫學與康復雜志, 2002, 24(3): 160-161.
2.	Li F, Gorji R, Allott G, et al. The usefulness of intraoperative neurophysiological monitoring in cervical spine surgery: a retrospective analysis of 200 consecutive patients[J]. J Neurosurg Anesthesiol, 2012 , 24(3): 185-190.
3.	李建軍, 周紅俊, 孫迎春, 等譯.脊髓損傷神經學分類國際標準（6版, 2006）[J].中國康復理論與實踐, 2007, 13(1): 1-6.
4.	Nuwer MR, Aminoff M, Desmedt J, et al. IFCN recommended standards for short latency somatosensory evoked potentials. Report of an IFCN committee. International Federation of Clinical Neurophysiology[J]. Electroencephalogr Clin Neurophysiol, 1994, 91(1): 6-11.
5.	Nuwer M, Dawson E, C arlson L, et al. Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery : results of a large multicenter survery. Electroencephalogr[J]. Clin Neurophysiol, 1995, 96(1): 6-11.
6.	Szalay E, Carollo J, Roach J, et al. Sensitivity of spinal cord monitoring to intraoperative events[J]. J Pediatr Orthop, 1986, 6(4): 437-441.
7.	Lim PA, Tow AM. Recovery and regeneration after spinal cord injury: a review and summary of recent literature[J]. Ann Acad Med Singapore, 2007, 36(1): 49-57.
8.	沈寧江, 王書成, 盧傳新, 等. 皮層體感誘發電位在評價脊柱脊髓損傷中的意義[J]. 骨與關節損傷雜志, 1996, 11(2): 275-277.
9.	Shields CB, Ping Zhang Y, Shields LB, et al. Objective assessment of cervical spinal cord injury levels by transcranial magnetic motor-evoked potentials[J]. Surg Neurol, 2006, 66(5): 475-483.
10.	金大地, 王健, 瞿東濱. 頸椎前路手術早期并發癥原因分析及對策[J]. 中華骨科雜志, 2005, 25(2): 102-106.
11.	Engler GL, Spielholz NJ, Bernhard WN, et al. Somatosensory evoked potentials during Harrington instrumentation for scoliosis[J]. J Bone Joint Surg Am, 1978, 60(4): 528-532.
12.	周琪琪, 張小峰. 神經監測技術在臨床手術中的應用[M]. 北京：中國社會出版社, 2005: 5-19.
13.	龍厚清, 胡勇, 李廣盛, 等. 皮層體感誘發電位監測輕度醫源性脊髓沖擊損傷的實驗研究[J].中華創傷雜志, 2011, 27(3): 241-244.
14.	Epstein NE, Danto J, Nardi D.Evaluation of intraoperative somatosensory-evoked potential monitoring during 100 cervical operations[J]. Spine, 1993, 18(6): 737-747.
15.	Khan MH, Smith PN, Balzer JR, et al. Intraoperative somatosensory evoked potential monitoring during cervical spine corpectomy surgery: experience with 508 cases[J]. Spine, 2006, 31(4): 105-113.
16.	Ayoub C, Zreik T, Sawaya R, et al. Significance and cost-effectiveness of somatosensory evoked potential monitoring in cervical spine surgery[J]. Neurol India, 2010, 58(3): 424-428.
17.	Taunt CJ Jr, Sidhu KS, Andrew SA. Somatosensory evoked potential monitoring during anterior cervical discectomy and fusion[J]. Spine, 2005, 30(17): 1970-1972.
18.	Jones SJ, Buonamassa S, Crockard HA. Two cases of quadriparesis following anterior cervical discectomy, with normal perioperative somatosensory evoked potentials[J]. J Neurol Neurosurg Psychiatry, 2003, 74(2): 273-276.

1. 　周紅俊, 汪家琮, 劉根林, 等. 脊髓損傷完全與否與體感誘發電位的關系[J]. 中華物理醫學與康復雜志, 2002, 24(3): 160-161.
2. 　Li F, Gorji R, Allott G, et al. The usefulness of intraoperative neurophysiological monitoring in cervical spine surgery: a retrospective analysis of 200 consecutive patients[J]. J Neurosurg Anesthesiol, 2012 , 24(3): 185-190.
3. 　李建軍, 周紅俊, 孫迎春, 等譯.脊髓損傷神經學分類國際標準（6版, 2006）[J].中國康復理論與實踐, 2007, 13(1): 1-6.
4. 　Nuwer MR, Aminoff M, Desmedt J, et al. IFCN recommended standards for short latency somatosensory evoked potentials. Report of an IFCN committee. International Federation of Clinical Neurophysiology[J]. Electroencephalogr Clin Neurophysiol, 1994, 91(1): 6-11.
5. 　Nuwer M, Dawson E, C arlson L, et al. Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery : results of a large multicenter survery. Electroencephalogr[J]. Clin Neurophysiol, 1995, 96(1): 6-11.
6. 　Szalay E, Carollo J, Roach J, et al. Sensitivity of spinal cord monitoring to intraoperative events[J]. J Pediatr Orthop, 1986, 6(4): 437-441.
7. 　Lim PA, Tow AM. Recovery and regeneration after spinal cord injury: a review and summary of recent literature[J]. Ann Acad Med Singapore, 2007, 36(1): 49-57.
8. 　沈寧江, 王書成, 盧傳新, 等. 皮層體感誘發電位在評價脊柱脊髓損傷中的意義[J]. 骨與關節損傷雜志, 1996, 11(2): 275-277.
9. 　Shields CB, Ping Zhang Y, Shields LB, et al. Objective assessment of cervical spinal cord injury levels by transcranial magnetic motor-evoked potentials[J]. Surg Neurol, 2006, 66(5): 475-483.
10. 　金大地, 王健, 瞿東濱. 頸椎前路手術早期并發癥原因分析及對策[J]. 中華骨科雜志, 2005, 25(2): 102-106.
11. 　Engler GL, Spielholz NJ, Bernhard WN, et al. Somatosensory evoked potentials during Harrington instrumentation for scoliosis[J]. J Bone Joint Surg Am, 1978, 60(4): 528-532.
12. 　周琪琪, 張小峰. 神經監測技術在臨床手術中的應用[M]. 北京：中國社會出版社, 2005: 5-19.
13. 　龍厚清, 胡勇, 李廣盛, 等. 皮層體感誘發電位監測輕度醫源性脊髓沖擊損傷的實驗研究[J].中華創傷雜志, 2011, 27(3): 241-244.
14. 　Epstein NE, Danto J, Nardi D.Evaluation of intraoperative somatosensory-evoked potential monitoring during 100 cervical operations[J]. Spine, 1993, 18(6): 737-747.
15. 　Khan MH, Smith PN, Balzer JR, et al. Intraoperative somatosensory evoked potential monitoring during cervical spine corpectomy surgery: experience with 508 cases[J]. Spine, 2006, 31(4): 105-113.
16. 　Ayoub C, Zreik T, Sawaya R, et al. Significance and cost-effectiveness of somatosensory evoked potential monitoring in cervical spine surgery[J]. Neurol India, 2010, 58(3): 424-428.
17. 　Taunt CJ Jr, Sidhu KS, Andrew SA. Somatosensory evoked potential monitoring during anterior cervical discectomy and fusion[J]. Spine, 2005, 30(17): 1970-1972.
18. 　Jones SJ, Buonamassa S, Crockard HA. Two cases of quadriparesis following anterior cervical discectomy, with normal perioperative somatosensory evoked potentials[J]. J Neurol Neurosurg Psychiatry, 2003, 74(2): 273-276.

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頸脊髓損傷患者應用體感誘發電位監測的價值

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