CAJ | 학술논문

背景:脊柱外科手术中已广泛应用术中肌电图监测,但肌电图监测标准仍有待深入研究,而术中肌电图监测在国内的应用报道十分有限.目的:分析电诱发肌电图监测在椎弓根螺钉置入内固定过程中的敏感程度以及可靠性.设计、时间、地点:回顾性病例分析,于2008-0712009-05在北京中医药大学东直门医院骨科完成.对象:选择北京中医药大学东直门医院骨科收治的腰椎间盘突出症及腰椎管狭窄症患者74例,男31例,女43例;年龄22-83岁,均58岁. 方法:于椎弓根螺钉内固定和椎管内手术操作中全程使用电诱发肌电图监测,刺激电流为2 Hz、时程0.2 ms的方波脉冲电刺激,打入椎弓根螺钉时刺激强度限制为0-80mA,刺激强度为逐级递增.腰椎板切除减压、髓核摘除、神经根探查松解等椎管内手术操作时刺激强度限制为2-4 mA.于双侧长收肌、股直肌、股二头肌、胫骨前肌和腓肠肌内侧头的肌腹中部及肛门括约肌记录分析肌电反应.主要观察指标:实时监测和记录自由肌电反应及触发肌电反应中动作电位出现的时间频率、振幅、肌群,以及术后神经根功能损伤及恢复情况.结果:74例患者在术中肌电图监测和3-D脊柱导航系统帮助下共置入378只椎弓根螺钉内固定,仅有3只椎弓根螺钉(L_42只,L_51只)置入过程中,当电流强度小于10mA时即出现肌电反应,及时提醒术者,经术中C臂X射线透视证实椎弓根骨皮质穿透,而予以重新置入,置入准确率达99.2%.电诱发肌电图监测下进行椎管内手术操作,仅2例患者术中进行L_5,S_1节段减压、松解时反复出现下肢明显肌电反应,术后出现下肢神经症状较术前加重,经2～4周保守治疗后恢复,神经根误损伤率为2.7%.所有患者术后未出现不可逆的相关神经根损伤症状.结论:椎弓根螺钉置入腰椎椎管内手术过程中电诱发肌电监测可最大限度地保证安全操作、预防神经根损伤.与术中脊柱导航系统的联合应用可增加监测的敏感性,在复杂腰箭推术中是目前最为有效的监测方法. 揹景:脊柱外科手術中已廣汎應用術中肌電圖鑑測,但肌電圖鑑測標準仍有待深入研究,而術中肌電圖鑑測在國內的應用報道十分有限.目的:分析電誘髮肌電圖鑑測在椎弓根螺釘置入內固定過程中的敏感程度以及可靠性.設計、時間、地點:迴顧性病例分析,于2008-0712009-05在北京中醫藥大學東直門醫院骨科完成.對象:選擇北京中醫藥大學東直門醫院骨科收治的腰椎間盤突齣癥及腰椎管狹窄癥患者74例,男31例,女43例;年齡22-83歲,均58歲. 方法:于椎弓根螺釘內固定和椎管內手術操作中全程使用電誘髮肌電圖鑑測,刺激電流為2 Hz、時程0.2 ms的方波脈遲電刺激,打入椎弓根螺釘時刺激彊度限製為0-80mA,刺激彊度為逐級遞增.腰椎闆切除減壓、髓覈摘除、神經根探查鬆解等椎管內手術操作時刺激彊度限製為2-4 mA.于雙側長收肌、股直肌、股二頭肌、脛骨前肌和腓腸肌內側頭的肌腹中部及肛門括約肌記錄分析肌電反應.主要觀察指標:實時鑑測和記錄自由肌電反應及觸髮肌電反應中動作電位齣現的時間頻率、振幅、肌群,以及術後神經根功能損傷及恢複情況.結果:74例患者在術中肌電圖鑑測和3-D脊柱導航繫統幫助下共置入378隻椎弓根螺釘內固定,僅有3隻椎弓根螺釘(L_42隻,L_51隻)置入過程中,噹電流彊度小于10mA時即齣現肌電反應,及時提醒術者,經術中C臂X射線透視證實椎弓根骨皮質穿透,而予以重新置入,置入準確率達99.2%.電誘髮肌電圖鑑測下進行椎管內手術操作,僅2例患者術中進行L_5,S_1節段減壓、鬆解時反複齣現下肢明顯肌電反應,術後齣現下肢神經癥狀較術前加重,經2～4週保守治療後恢複,神經根誤損傷率為2.7%.所有患者術後未齣現不可逆的相關神經根損傷癥狀.結論:椎弓根螺釘置入腰椎椎管內手術過程中電誘髮肌電鑑測可最大限度地保證安全操作、預防神經根損傷.與術中脊柱導航繫統的聯閤應用可增加鑑測的敏感性,在複雜腰箭推術中是目前最為有效的鑑測方法.
배경:척주외과수술중이엄범응용술중기전도감측,단기전도감측표준잉유대심입연구,이술중기전도감측재국내적응용보도십분유한.목적:분석전유발기전도감측재추궁근라정치입내고정과정중적민감정도이급가고성.설계、시간、지점:회고성병례분석,우2008-0712009-05재북경중의약대학동직문의원골과완성.대상:선택북경중의약대학동직문의원골과수치적요추간반돌출증급요추관협착증환자74례,남31례,녀43례;년령22-83세,균58세. 방법:우추궁근라정내고정화추관내수술조작중전정사용전유발기전도감측,자격전류위2 Hz、시정0.2 ms적방파맥충전자격,타입추궁근라정시자격강도한제위0-80mA,자격강도위축급체증.요추판절제감압、수핵적제、신경근탐사송해등추관내수술조작시자격강도한제위2-4 mA.우쌍측장수기、고직기、고이두기、경골전기화비장기내측두적기복중부급항문괄약기기록분석기전반응.주요관찰지표:실시감측화기록자유기전반응급촉발기전반응중동작전위출현적시간빈솔、진폭、기군,이급술후신경근공능손상급회복정황.결과:74례환자재술중기전도감측화3-D척주도항계통방조하공치입378지추궁근라정내고정,부유3지추궁근라정(L_42지,L_51지)치입과정중,당전류강도소우10mA시즉출현기전반응,급시제성술자,경술중C비X사선투시증실추궁근골피질천투,이여이중신치입,치입준학솔체99.2%.전유발기전도감측하진행추관내수술조작,부2례환자술중진행L_5,S_1절단감압、송해시반복출현하지명현기전반응,술후출현하지신경증상교술전가중,경2～4주보수치료후회복,신경근오손상솔위2.7%.소유환자술후미출현불가역적상관신경근손상증상.결론:추궁근라정치입요추추관내수술과정중전유발기전감측가최대한도지보증안전조작、예방신경근손상.여술중척주도항계통적연합응용가증가감측적민감성,재복잡요전추술중시목전최위유효적감측방법.
MAIN OUTCOME MEASURES: Free running EMG and stimulus triggered EMG, including time, frequency, amplitude, muscle group were observed and recorded simultaneously. Never root functional injury and restoration after surgery were detected.RESULTS: 378 pedicle screws in 74 patients were monitored intraoperatively, and only 3 pedicle screw malposition (2 of L_4, 1 of L_5) was detected and then replaced with the help of C-arm fluoroscopic examination. Myoelectricity appeared when the current intensity was less than 10 mA. The correct rate of implantation was 99.2%. Nerve root impingement was found in two cases during laminectomy for L_5 and S_1 decompression and never root solution, which alerted the surgical team of critical neural structures. Nerve symptoms of the lower limb were aggravated after surgery and restored following 2-4 weeks of conventional treatment. The error injury rate of nerve root was 2.7%. In all reported cases, no irreversible neurological deficit was observed 2-4 weeks after operation.CONCLUSION: Intraoperative EMG monitoring can find improperly placed screws and detect impending nerve root injury promptly. Combined EMG and 3-D imaging modality monitoring is a reliable and practicable method that can be used to protect neural structures during complex lumbosacral surgery.