多模式监测在脊柱侧弯矫形术中应用的研究

发布时间：2018-03-06 04:10

本文选题：脊柱侧弯　切入点：矫形术　出处：《宁夏医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的评估多模式术中监测(Mutimodal intraoperative monitoring,MIOM)在脊柱侧弯矫形术中监测神经功能的有效性,探讨术中监测数据出现异常的影响因素。方法回顾性分析2009年1月至2017年2月在银川国龙医院接受矫形手术治疗的70例脊柱侧弯患者的病历资料,术中采用体感诱发电位(Somatosensory evoked potential,SEP)+经颅电刺激运动诱发电位(Transcranial electric stimulation motor evoked potential,TES-MEP)+自发性肌电图(Free-run Electromyography,Free-run EMG)联合的多模式监测,所有患者术前均无神经功能障碍。测量患者术前、术后冠状面主弯Cobb角及矢状面胸椎后凸角大小并计算矫正率,记录一般资料、手术时间、术中失血量、术中神经电生理监测结果、报警因素及改善措施、术后神经功能损害及转归等。根据神经电生理监测结果分析术中监测数据出现异常的影响因素。结果70例患者术中均成功进行SEP+TES-MEP+Free-run EMG联合监测。侧凸和后凸分别从术前平均56.7°±18.5°和52.9°±31.0°矫正至术后平均16.4°±6.8°和26.5°±17.6°,矫正率分别为70.4%±8.4%和50.9%±13.0%;手术时间2.5~6.5h,平均为(4.13±1.22)h;术中失血量150~3500ml,平均为(952.56±785.96)ml。术中神经电生理监测无假阴性发生。SEP+TES-MEP+Free-run EMG联合监测共有16例患者出现监测报警,9例患者为真阳性((截骨)矫形过程7例,置钉过程2例),其余7例与非手术因素有关,灵敏度为100%(9/9),特异度为88.5%(54/61),假阳性率为11.5%(7/61),假阴性率为0.0%(0/9)。12例患者术中SEP监测异常,8例为真阳性,灵敏度为88.9%(8/9),特异度为93.4%(57/61),假阳性率为6.6%(4/61),假阴性率为11.1%(1/9)。10例患者术中TES-MEP监测异常,7例为真阳性,灵敏度为77.8%(7/9),特异度为95.1%(58/61),假阳性率为4.9%(3/61),假阴性率为22.2%(2/9)。11例患者术中Free-run EMG监测异常,8例为真阳性,灵敏度为88.9%(8/9),特异度为95.1%(58/61),假阳性率为4.9%(3/61),假阴性率为11.1%(1/9)。1例术前合并胸椎重度后凸畸形的神经纤维瘤病患者,在矫形过程中SEP、TES-MEP和Free-run EMG均监测报警,术后出现短暂性神经功能障碍,表现为右下肢小腿前侧麻木,给予药物营养神经、理疗等治疗后恢复正常。结论1.MIOM应用于脊柱侧弯矫形术中可全面监测脊髓及神经根功能。2.MIOM灵敏度高,能及时发现潜在的神经功能损伤,优于单一监测模式。3.脊柱侧弯矫形手术MIOM监测数据出现异常的影响因素较多,截骨矫形、置钉、胸椎后凸畸形为MIOM发生严重不良事件的危险因素。
[Abstract]:Objective to evaluate the effectiveness of monitoring neurologic function in scoliosis orthopedic surgery with multiple mode intraoperative monitoring of Mutimodal intraoperative monitoring. Methods from January 2009 to February 2017, 70 patients with scoliosis underwent orthopedic surgery in Guolong Hospital of Yinchuan were retrospectively analyzed. The spontaneous electromyography (Free-run electromyography) and Free-run electromyography (Free-run EMG) were monitored by transcranial electric stimulation motor evoked potentialTES-MEP by somatosensory evoked potentialSEP during the operation. There were no neurological dysfunction in all patients before operation. The Cobb angle of the main coronal curvature and the size of the sagittal thoracic kyphoid angle were calculated, the correction rate was calculated, the general data, the operation time, the blood loss during the operation, the monitoring results of intraoperative nerve electrophysiology, the alarm factors and the improvement measures were recorded. According to the results of electrophysiologic monitoring, the influencing factors of abnormal intraoperative monitoring data were analyzed. Results SEP TES-MEP Free-run EMG combined monitoring was performed successfully in 70 patients during operation. The scores of scoliosis and kyphosis were obtained. The average preoperative correction was 56.7 掳卤18.5 掳and 52.9 掳卤31.0 掳to the postoperative mean 16.4 掳卤6.8 掳and 26.5 掳卤17.6 掳, the correction rates were 70.4% 卤8.4% and 50.9% 卤13.0, respectively; the operation time was 2.5 to 6.5 hours, with an average of 4.13 卤1.22h. the blood loss during operation was 1503500ml, with an average of 952.56 卤785.96ml. A total of 16 patients were detected and alerted. 9 cases were true positive orthopedic procedure, 7 cases were orthopedic. The other 7 cases were related to non-operative factors, the sensitivity was 100 / 9 / 9, the specificity was 88.5 / 64 / 61, the false positive rate was 11.5g / 7 / 61g, the false negative rate was 0.00 / 9 / 12, the abnormal SEP monitoring was true positive in 8 cases. The sensitivity was 88. 9%, the specificity was 93. 4% / 67%, the false positive rate was 6. 6% / 61%, the false negative rate was 11. 1% and 9 / 9%, 7 cases were true positive. The sensitivity was 77.8 / 9, the specificity was 95.1a / 58 / 61, the false positive rate was 4.9C / 61g, the false negative rate was 22.2 / 9.11 cases, the abnormal Free-run EMG monitoring was true positive in 8 cases. The sensitivity was 88. 9%, the specificity was 95. 1% / 58 / 61, the false positive rate was 4. 9% / 61%, the false negative rate was 11. 1% / 9. 1 cases of neurofibromatosis with severe thoracic kyphosis before operation. SEPTES-MEP and Free-run EMG were monitored and alerted during the orthopedic procedure. The function of spinal cord and nerve root can be completely monitored by MIOM in scoliosis orthopedics. 2. The sensitivity of MIOM in spinal cord and nerve root is high. Potential neurological function injury can be detected in time, which is superior to single monitoring mode .3.There are many factors influencing abnormal MIOM monitoring data in scoliosis orthopedic surgery, osteotomy, orthopedics and nail placement. Thoracic kyphosis is a risk factor for severe adverse events in MIOM.
【学位授予单位】：宁夏医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3

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