گزارش سه مورد مانيتورينگ چند جانبه حسي و حركتي در جراحي اصلاحي ستون مهره اي در مبتلايان به كيفواسكوليوز ايديوپاتيك

Multimodal Intraoperative Neurophysiological Monitoring in Corrective Spine Surgery for Idiopathic Kyphoscoliosis, Our Early Methodological Expriences in 3 Cases

ﺟﺮﺍﺣﻲ ﺍﺻﻼﺣﻲ ﮐﻴﻔﻮﺍﺳﮑﻮﻟﻴﻮﺯ ﻣﻤﮑﻦ ﺍﺳﺖ ﺑﻪ ﺻﺪﻣﺎﺕ ﻧﺨﺎﻋﻲ ﻭ ﺿﺎﻳﻌﺎﺕ ﻋﺼﺒﻲ ﻣﻨﺠﺮ ﺷﻮﺩ. ﺑﺎ ﺭﻭﺵ ﻣﺎﻧﻴﺘﻮﺭﻳﻨﮓ ﭼﻨﺪ ﺟﺎﻧﺒﻪ ﻧﻮﺭﻭﻓﻴﺰﻳﻮﻟﻮﮊﻳﮏ ﺣﻴﻦ ﺟﺮﺍﺣﻲ )(MIOM ﻣﻲ ﺗﻮﺍﻥ ﺿﺎﻳﻌﺎﺕ ﺍﺣﺘﻤﺎﻟﻲ ﺭﻳﺸﻪ ﻫﺎﻱ ﻋﺼﺒﻲ ﻭ ﻧﺨﺎﻉ ﺭﺍ ﻫﻨﮕﺎﻡ ﻋﻤﻞ ﻣﺸﺨﺺ ﻭ ﺍﺯ ﭘﻴﺪﺍﻳﺶ ﺁﻥ ﺟﻠﻮﮔﻴﺮﻱ ﮐﺮﺩ. ﺳﻪ ﻣﻮﺭﺩ ﺟﺮﺍﺣﻲ ﺍﺻﻼﺡ ﮐﻴﻔﻮﺍﺳﮑﻮﻟﻴﻮﺯ، ﺑﺮﺍﻱ ﺍﻭﻟﻴﻦ ﺑﺎﺭ ﺩﺭ ﮐﺸﻮﺭ ﺍﻧﺠﺎﻡ ﺷﺪ. ﺩﺭ ﺍﻳﻦ ﺑﻴﻤﺎﺭﺍﻥ ﭘﺘﺎﻧﺴﻴﻞ ﻫﺎﻱ ﺑﺮﺍﻧﮕﻴﺨﺘﻪ ﺣﺴﻲ ﭘﻴﮑﺮﻱ (SSEPs)، ﺗﺤﺮﻳﮏ ﺍﻟﮑﺘﺮﻳﮑﻲ ﻗﺸﺮﺣﺮﮐﺘﻲ ﺍﺯ ﺭﻭﻱ ﺟﻤﺠﻤﻪ (tceMEPs)،ﭘﺘﺎﻧﺴﻴﻞ ﻫﺎﻱ ﺑﺮﺍﻧﮕﻴﺨﺘﻪ ﻗﺸﺮﻱ ﻧﺨﺎﻋﻲ (csEPs)، ﺍﻣﻮﺍﺝ ﺣﺮﮐﺘﻲ D ﺍﺯ ﻧﺨﺎﻉ D motor waves)(، ﺍﻟﮑﺘﺮﻭﻣﻴﻮﮔﺮﺍﻓﻲ )EMG( ﺩﺍﺋﻤﻲ ﻳﺎ ﭘﺲ ﺍﺯ ﺗﺤﺮﻳﮏ، ﺩﺭ ﻣﺮﺍﺣﻞ ﻣﺨﺘﻠﻒ ﺟﺮﺍﺣﻲ ﻭ ﺣﺴﺐ ﻟﺰﻭﻡ ﺍﻧﺠﺎﻡ ﻣﻲ ﺷﺪ. ﭘﺲ ﺍﺯ ﻋﻤﻞ، ﻫﻴﭻ ﻳﮏ ﺍﺯ ﺳﻪ ﺑﻴﻤﺎﺭ ﺗﻐﻴﻴﺮ ﻣﻌﻨﻲ ﺩﺍﺭﻱ ﺩﺭ ﭘﺎﺳﺦ ﻫﺎﻱ SSEP ﻳﺎ ﺭﺍﺩﻳﮑﻮﻟﻮﭘﺎﺗﻲ ﻫﺎﻳﻲ ﺟﺪﺍ ﺍﺯ ﺁﻧﭽﻪ ﻗﺒـﻞ ﺍﺯ ﻋﻤﻞ ﻣﺸﺨﺺ ﺷﺪﻩ ﺑﻮﺩ، ﻧﺪﺍﺷﺘﻨﺪ. ﺩﺭ ﺍﻳﻦ ﺳﻪ ﺟﺮﺍﺣﻲ، ﺩﺭ 78/3 ﺍﺯ ﺗﺤﺮﻳﮑﺎﺕ tceMEPs ﭘﺎﺳﺦ ﻋﻀﻼﻧﻲ ﭘﺎﻳﺪﺍﺭ ﺛﺒﺖ ﺷﺪ. ﺍﺯ ﻧﻈﺮ ﺑﻴﻬﻮﺷﻲ، ﭘﺮﻭﭘﻮﻓﻮﻝ ﻳـ ﺎ ﺗﺮﮐﻴـ ﺐ ﭘﺮﻭﭘﻮﻓﻮﻝ، ﮐﺘﺎﻣﻴﻦ ﻭ ﻧﺎﺭﮐﻮﺗﻴﮏ ﺑﺮﺍﻱ ﺩﺍﺷﺘﻦ ﭘﺎﺳﺦ ﻫﺎﻱ ﺣﺮﮐﺘﻲ ﭘﺎﻳﺪﺍﺭ ﺍﺯ ﻋﻀﻼﺕ ﻣﻨﺎﺳﺐ ﻫﺴﺘﻨﺪ. ﭘﻴﺸﻨﻬﺎﺩ ﻣﻲ ﺷﻮﺩ ﺍﺯ ﺭﻭﺵ MIOM ﺑﺮﺍﻱ ﺟﺮﺍﺣﻲ ﻫﺎﻱ ﺍﺻﻼﺣﻲ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ ﺍﺳﮑﻮﻟﻴﻮﺯ ﺍﺳﺘﻔﺎﺩﻩ ﺷﻮﺩ. ﺍﻳﻦ ﺭﻭﺵ ﻫﺎ ﻋﻤﻼﹰ ﺍﺣﺘﻤﺎﻝ ﭘﻴﺪﺍﻳﺶ ﺁﺳﻴﺐ ﻫﺎﻱ ﻧﻮﺭﻭﻟﻮﮊﻳﮏ ﺭﺍ ﮐﻢ ﻣﻲ ﮐﻨﺪ.

Surgical correction of kyphoscoliosis may result in spinal cord injury and neurologic deficits. Multimodal intraoperative monitoring (MIOM) may allow for early detection and reversal of spinal cord and nerve roots potential injuries. In three consecutive kyphoscoliosis corrections, MIOM were performed. In all cases Somatosensory evoked potentials (SSEPs), transcranial electrical motor evoked potentials, corticospinal evoked potentials, spinal descending D motor waves, free run and/or stimulated electromyography were performed when required. None of the 3 patients had significant SSEPs changes or postoperative radiculopathies distinct from their preoperative presentations. In our cases, tceMEPs were obtained in 78.3% of the applied transcranial stimulations. Propofol or Propofol/Ketamine mixture plus narcotic is suitable to obtain stable reproducible tceMEPs. MIOM is recommended to be used in patients with scoliosis who undergo surgery for spinal deformity. Monitoring can practically reduce possibilities of neurologic deficit