Comparison of outcomes between patients using SSEP/TcMEP monitoring during PVCR procedure and no monitoring in a single center:

Transcription

1 Comparison of outcomes between patients using SSEP/TcMEP monitoring during PVCR procedure and no monitoring in a single center: --Dose monitoring truly detect all spinal cord abnormalities and improve radiographic correction? Yingsong Wang, Jingming Xie, Tao Li, Ying Zhang, Ni Bi, Zhi Zhao, Leijie Chen, Zhou Liu, Zhiyue Shi The Medical University, Kunming, Yunnan Province, P.R.China Corresponding: xiejingming@vip.163.com 1

2 Disclosures Authors: Yingsong Wang Jingming Xie Tao Li Ying Zhang Ni Bi Zhi Zhao Leijie Chen Zhou Liu Zhiyue Shi 2

3 Background Posterior Vertebral Column Resection Severe/Rigid/Angular deformities Powerful technique: gain remarkable correction Potentially higher risk Neurological Safety Life Safety Intraoperative monitoring for spine surgery Stagnara wake-up test Somatosensory evoked potential (SSEP) Motor evoked potentials (MEP) 3

4 Background More than 100 cases during 10 years IOM absence & Wake-up IOM achieved & Wake-up Can IOM detected all spinal cord abnormalities? Dose IOM result in improved outcomes? The key role of neurological safety for PVCR is

5 Methods Demographic data Radio. features 5 IOM absence IOM achieve Number / /37.1 Age (Year) Gender (n/ %) Male 47 29/ /17.1 Female 58 37/ /20.0 Etiology (n/ %) Idiopathic 37 27/ /9.5 Non-idiopathic 68 39/ /27.6 Main curve (n/%) kyphosis 15 12/11.4 3/2.9 kyphoscoliosis 90 54/ /34.3 Flexibility (%) Apex (n/ %) Upper T6 10 4/3.8 6/5.7 Comparison between IOM absen. & achie. Neuro. status Clinical outcome Radiologic outcome Neurologic outcome T7-L / /30.5 Lower than L / /17.1 Intra-canal anomaly 31 21/ / 9.5 Neural abnormal pre-op 16 11/10.5 5/4.8

6 Methods PVCR Compression: Spinal shortening Correction: In-situ rod bending Evaluation: Closely observation and palpation Adjustment: Spinal cord tension Monitoring IOM absence IOM achieved Positive repeatedly alert: wake-up SSEP Rule out anesthetic agent MEP Compress for spinal shortening Wake-up Adjust excessive opposite displacement Add an adjacent segmental resection appropriate remedial interventions 6 Jingming Xie, et al. J Neurosurg Spine, 2012.

7 Results Absence IOM Achieve IOM P value Clinical outcome OP time (min) 596± ±69 <0.05 EBL (ml) 4861± ±609 <0.05 Radiological outcome Coronal Cobb ( ) 104± ±27.5 >0.05 Sagittal Cobb ( ) 86± ±31.4 >0.05 Coronal correct (%) >0.05 Sagital correct (%) >0.05 Coronal balance correct (%) >0.05 Sagittal balance correct (%) >0.05 7

8 Neurologic outcome Results IOM absen. 4(6.1%) Improved 4(6.1%) Root inj. 1(1.5%) transient cord IOM achie. 4(10.3%) Improved 1(2.6%) transient cord 57(86.4%) Unchange 34(87.2%) Unchange 8 There was no permanent neurologic deficit

9 Results IOM absence 0pt Wake-up alert 1pt Late onset ischemia reperfusion injury IOM achieved 8pts IOM alert 1pt Resect. step 7pts Correc. step 2pts Wake-up alert 1pt post-op N 1pt transient Interventions Returned 9

10 Discussion Reduced EBL & prolonged operation time Improved technique and TXA using Unhurried for shoulder balance, thoracic symmetrical Radiological outcome Keeping of the balance between dynamic and static Dynamic: for the purpose of deformity correction, the spinal columns need controllable move and migration for rearrangement Static: for the neurological safety, the spinal cord around the resected area must reduce overmuch displacement or tension changes The tension of the spinal cord was continuously and closely monitored, by inspection and palpation

11 Reaction strategies for the alerts Discussion Checking and rule out anesthetic factors Verifying of no residual bony or anulus structures around the resected area (corrective space) --eradicate Performing appropriate compression on the concave side or reversed in-situ rod bending Observing and adjustment of the excessive opposite displacement between two aspects of resected area-- translation technique, segmental derotation Adjacent segmental resection--vertebral column resection 11

12 Conclusions 1. For experienced group, IOM did not improve the radiooutcomes of PVCR 2. Surgeons might not depend on combined SSEP and TcMEP monitoring only 3. The key points for archiving spinal cord safety: keep the spinal cord free of any stretching, oppression, or excessive distraction during the entire procedure. Keep of the balance between dynamic and static 12

13 References Xie JM, Zhang Y, Wang YS, Bi N, Zhao Z, Li T, Yang H (2014) The risk factors of neurologic deficits of one-stage posterior vertebral column resection for patients with severe and rigid spinal deformities. Eur Spine J 23: Xie JM, Wang YS, Zhao Z, Zhang Y, Si YY, Li T, Yang ZD, Liu LP (2012) Posterior vertebral column resection for correction of rigid spinal deformity curves more than 100 degrees. J Neurosurgery Spine 17: Lenke LG, Newton PO, Sucato DJ, Shufflebarger HL, Emans JB, Sponseller PD, Shah SA, Sides BA (2013) Complications after 147 consecutive vertebral column resections for severe pediatric spinal deformity: A multicenter analysis. Spine (Phila Pa 1976) 38: Kim SS, Cho BC, Kim JH, Lim DJ, Park JY, Lee BJ, Suk SI (2012) Complications of posterior vertebral resection for spinal deformity. Asian Spine J 6: Cheh G, Lenke LG, Padberg AM, Kim YJ, Daubs MD, Kuhns C, Stobbs G, Hensley M (2008) Loss of spinal cord monitoring signals in children during thoracic kyphosis correction with spinal osteotomy. Why does it occur and what should you do? Spine (Phila Pa 1976) 33: Modi HN, Suh SW, Yang JH, Yoon JY (2009) False-negative transcranial motor-evoked potentials during scoliosis surgery causing paralysis: A case report with literature review. Spine (Phila Pa 1976) 34:E896 E900 Fehlings MG, Brodke DS, Norvell DC, Dettori JR (2010) The evidence for intraoperative neurophysiological monitoring in spine surgery: Does it make a difference? Spine (Phila Pa 1976) 35:S37-S46 Ji L, Dang XQ, Lan BS, Wang KZ, Huang YJ, Wen B, Duan HH, Ren F. (2013) Study on the safe range of shortening of the spinal cord in canine models. Spinal Cord 51: