体感诱发电位监测在腰椎管狭窄症-斜外侧椎间融合术中的应用

杨树龙1，潘  宗2，陈  振3，刘晓印3，马  荣3，梁思敏3，张建群3，马宗军3，丁小力3，戈朝晖3

（1 宁夏医科大学 750004 银川市；2 宁夏医科大学总医院电生理科 750004 银川市；3 宁夏医科大学总医院骨科 750004 银川市）

基金项目：2020宁夏重点研发计划项目（项目编号：2020BEG03034）

第一作者简介：男（1982-），在读博士研究生，

研究方向：脊柱外科

电话：（0951）6746129  

E-mail：yangshulong2008@163.com

并列第一作者：潘宗  

E-mail：popstop1983@126.com

通讯作者：戈朝晖  

E-mail：myovid@126.com

【摘要】 目的：探讨术中体感诱发电位（SEP）监测在退行性腰椎管狭窄症斜外侧椎间融合（OLIF）术中的应用价值。方法：选择2017年7月～2019年2月在宁夏医科大学总医院采用OLIF联合Wiltse入路单侧椎弓根螺钉固定术治疗的92例单节段退行性腰椎管狭窄症患者进行回顾性研究，手术全程给予SEP监测。随访时间15.6±1.8个月（12～23个月）。根据Lee等的腰椎管狭窄MRI分级将患者分为1级组（31例）、2级组（33例）和3级组（28例）。记录分析各组椎间隙处理前及融合器置入后的SEP波幅值；测量手术前、末次随访时责任间隙硬膜囊面积、椎间隙高度及椎间孔高度；临床疗效评价采用腰腿痛VAS评分和腰椎JOA评分。影像学结果及临床疗效改善率与SEP波幅改善率的相关性采用Pearson相关性分析。结果：3组椎间隙处理前与融合器置入后SEP平均波幅值的差异有统计学意义（P<0.05）；1级组、2级组和3级组SEP波幅平均改善率分别为（48.32±7.37）%、（112.34±18.67）%和（28.05±6.78）%，其中3级组有3例患者SEP波幅无任何变化。3组术后末次随访时的椎间隙高度、椎间孔高度、硬膜囊面积及腰腿痛VAS评分和腰椎JOA评分均较术前明显改善，差异有统计学意义（P<0.05）；2级组末次随访时椎间隙高度、椎间孔高度、硬膜囊面积改变值大于1级组和3级组，差异有统计学意义（P<0.05）；3组之间末次随访时腰腿痛VAS评分和腰椎JOA评分改变值差异有统计学意义（P<0.05）。末次随访时，1级组、2级组和3级组腰椎JOA评分改善率分别为（87.0±36.2）%、（85.8±35.3）%和（46.1±26.2）%，优良率分别为93.5%（29/31）、84.8%（28/33）和50%（14/28）。1级组和2级组SEP波幅改善率与末次随访时硬膜囊面积、椎间隙高度、椎间孔高度、腰腿痛VAS评分和腰椎JOA评分的改善率呈正相关；3级组SEP波幅改善率与末次随访时硬膜囊面积、腿痛VAS评分和腰椎JOA评分的改善率呈弱相关。1级组优良病例SEP改善率均大于25.6%，2级组优良病例SEP波幅改善率均大于85.3%。结论：OLIF治疗1、2级腰椎管狭窄症术中SEP波幅改善率可以作为判断间接减压是否有效的参考指标，对于手术中判断腰椎管狭窄间接减压的程度具有一定的参考意义。

【关键词】 退行性腰椎管狭窄症；斜外侧椎间融合；体感诱发电位

doi：10.3969/j.issn.1004-406X.2020.10.08

中图分类号：R681.5，R741.044    

文献标识码：A   

文章编号：1004-406X（2020）-10-0921-10

Value of somatosensory evoked potential inthe treatment of lumbar spinal stenosis with oblique lumbar interbodyfusion/YANG Shulong, PAN Zong, CHEN Zhen, et al//Chinese Journal of Spine andSpinal Cord, 2020, 30(10): 921-930

【Abstract】 Objectives: To explore the value of intraoperative somatosensoryevoked potential (SEP) monitoring in the treatment of degenerative lumbarspinal stenosis with oblique lateral interbody fusion(OLIF). Methods: The dataof 92 patients who underwent combined OLIF and unilateral pedicle screwfixation for degenerative lumbar spinal stenosis with SEP monitoring theoperation in General Hospital of Ningxia Medical University from July 2017 toFebruary 2019 were retrospectively reviewed. According to Lee′s grading system of lumbar central canalstenosis, all patients were divided into grade 1 group (n=31), grade 2 group(n=33) and grade 3 group(n=28). Our follow-up study lasted 12-23 months,averaged 15.6±1.8 months． The amplitude of SEP was recorded and analyzed before disk excisionand 5 minutes after implantation of fusion cage in each group. Thecross-sectional area in the dura(CAD) was measured on T2WI axial MRI. The diskheight(DH) and intervertebral foramen height(IFH) were measured on the lateralX-ray. Visual analog scale(VAS) score and JOA score of lumbar spine were usedto evaluate the clinical effect. Pearson correlation analysis was used toanalyze the correlation between the improvement rate of SEP amplitude and theimprovement rate of the radiographic and clinical results. Results: There weresignificant changes in the average amplitude of SEP in the three groups beforedisk excision and after implantation of fusion cage under generalanaesthesia(P<0.05). The average improvement rate of SEP amplitude in grade1, grade 2 and grade 3 groups were (48.32±7.37)%, (112.34±18.67)% and(28.05±6.78)% respectively, while 3 patients in grade 3 group showed no changesin SEP amplitude. At the last follow-up, the DH, IFH, CAD, lumbocrural pain VASscore and JOA score of the three groups were significantly improved comparedwith those at pre-operation(P<0.05). The change values of DH, IFH and CAD ingrade 2 group were larger than those in grade 1 group and grade 3group(P<0.05); There were significant difference in the change values oflumbocrural pain VAS score and JOA score among the three groups(P<0.05). Bythe evaluation standard of JOA score, at the last follow-up, the averageimprovement rate of JOA score in grade 1, grade 2, and grade 3 groups were(87.0±36.2)%, (85.8±35.3)% and (46.1±26.2)% respectively, and the excellent andgood rate were 93.5%(29/31), 84.8% (28/33) and 50%(14/28) respectively. Theimprovement rate of SEP amplitude in grade 1 and grade 2 groups were positivelycorrelated with the improvement rate of DH, IFH, CAD, lumbocrural pain VASscore and JOA score. The improvement rate of SEP amplitude was weaklycorrelated with the improvement rate of CAD, leg pain VAS score and JOA scorein the grade 3 group. The improvement rate of SEP amplitude in eligible casesin grade 1 group was more than 25.6%, and that in grade 2 group was more than85.3%. Conclusions: The improvement rate of SEP amplitude during the OLIFprocedure in the treatment of grade 1 and grade 2 lumbar spinal stenosis can beused as an important reference index to judge whether the indirectdecompression is effective or not, and it has some reference value forevaluating the degree of indirect decompression in the operation.

【Key words】 Degenerative lumbar spinal stenosis; Oblique lumbar interbodyfusion; Somatosensory evoked potential

【Author′s address】 Ningxia Medical University, Yinchuan, 750004, China

图1  患者男，68岁 a、b 术前正侧位X线片示腰椎退变，L4/5椎间隙变窄，L4椎体Ⅰ度滑脱 c 术前MRI示L4/5平面1级椎管狭窄 d 术前左下肢疼痛明显，左下肢SEP波幅改善率为65.2%；术后14个月随访，临床疗效优 e~g 术后14个月，正侧位X线片示融合器及椎弓根螺钉位置良好，椎间隙高度和椎间孔高度较术前增加，MRI 示L4/5平面硬膜囊面积较术前明显增大

Figure 1 The patient was a 68 year old male a, b Pre-operative X-ray showedlumbar vertebra was degenerated, L4/5 intervertebral space narrowed and L4vertebral body slipped(Ⅰ°) c Preoperative MRI showed grade 1 lumbar spinal stenosis in L4/5level d The improvement rate of SEP′s amplitude of left lower extremity was 65.2%. At 14 months′ follow-up, the clinical effect wasexcellent e, f 14 months postoperatively, X-ray showed that the fusion cage andpedicle screw were in good position. The height of intervertebral space andintervertebral foramen increased compared with that before operation gPost-operation MRI showed that the cross-sectional area of L4/5 level dural sacincreased significantly

图2  患者男，66岁 a、b 术前正侧位X线片示L4椎体Ⅰ度滑脱 c 术前MRI示L4/5平面2级椎管狭窄 d 左下肢SEP波幅改善率为150%；术后13个月随访，临床疗效优 e~g 术后13个月腰椎X线正侧位片及MRI显示椎间高度、椎间孔高度和硬膜囊面积较术前增加

Figure 2 Male, 66 years old a, b Preoperative X-ray showed L4 degenerativespondylolisthesis grade Ⅰ, L4/5 intervertebral space narrowed c Preoperative MRI showed grade2 lumbar spinal stenosis in L4/5 level d The improvement rate of SEP′s amplitude of left lower extremity was150%. At 13 months′ follow-up, the clinical effect was excellent e-g At 13 months afterthe operation, X-ray and MRI showed that the disk height, intervertebralforamen height, and cross-sectional area in the dura were increased comparedwith those before operation

图3  患者女，69岁 a、b 术前正侧位X线片示腰椎退变明显，L4/5 椎间隙变窄 c 术前MRI示L4/5平面3级椎管狭窄，黄韧带肥厚 d 左下肢SEP波幅改善率为40%；术后16个月随访，临床疗效良e~g 术后16个月腰椎X线片及MRI显示椎间高度、椎间孔高度和硬膜囊面积较术前增加

Figure 3 Female, 69 years old a, b Preoperative X-ray showed that the lumbarvertebra was obviously degenerated, L4/5 intervertebral space narrowed cPreoperative MRI showed grade 3 lumbar spinal stenosis in L4/5 level d Theimprovement rate of SEP′s amplitude of right lower extremity was 40%. At 16 months′ follow-up, the clinical effect was goode-g At 16 months after the operation, X-ray and MRI showed that the diskheight, intervertebral foramen height, and cross-sectional area in the durawere increased compared with those before operation