誘發電位及肌電圖在嚴重脊椎側彎融合手術的應用：病例報告

一般而言，經過背架治療仍進展至50度以上的嚴重脊柱側彎建議接受手術治療，治療目的除了改善側彎角度、心肺功能，對於病人美觀上及生活品質都有幫助。在不傷害到脊髓及神經的狀態下做最大角度的修正，恢復病人脊柱的平衡及功能，是手術最理想的目標。除了X光影像透視定位及導航儀（navigation）增加手術的準確度之外，術中監測同時利用體感覺誘發電位（somatosensory-evoked potentials）、運動誘發電位（motor-evoked potential）及電刺激椎弓根螺釘（pedicle screw stimulation）監測誘發之肌電圖更可以及時顯示病人神經功能上的變化。此位26歲女性罹患嚴重脊柱側彎，S型之脊柱主要側彎角度（cobb's angle）約111度。她先接受由後路進行截骨術手術（ponte osteotomy）及椎弓根置入螺釘（pedicle screw insertion），接著體外脊椎牽引（halo-femoral traction）兩星期後，第二次接受內固定置入及骨融合手術（posterior instrument and fusion）。第一階段手術中置入椎弓根螺釘並進行電刺激時，使用4.5mA電量刺激左側第7胸椎椎弓根螺釘時，記錄到疑似因裂痕（medial breach）造成的電位變化，此電位變化於修正調整螺釘方向後消失。手術結束時感覺與動作誘發電位與術前均無顯著差異，個案臨床上也無任何不適。第二階段術後側彎角度由111度下降至62度，手術結束時感覺與動作誘發電位與術前也均無顯著差異，然患者術後第三天開始抱怨右側鼠蹊部至大腿上約三分之一處有麻痛感。根據臨床症狀及神經電學檢查結果推測有胸椎第12節及腰椎第1節神經根的損傷。神經根損傷造成的麻痛經過服用維生素B12及鎮頑癲（Gabapentin）膠囊後有大幅改善。個案對於外觀、步態及心態上的改善感到滿意，生活品質較術前有明顯改善。（台灣復健醫誌2012；40(2)：117 - 123）

關鍵字

脊椎側彎；術中監測；體感覺誘發電位；動作誘發電位；電刺激椎弓根螺釘

並列摘要

Surgical intervention is frequently suggested for scoliosis patients who have a Cobb's angle of more than 50 degrees and who are not responding to conservative treatment such as bracing. In addition, surgical intervention prevents further deterioration of spinal curvature, preserves cardiopulmonary function, provides cosmetic benefits, and improves quality of life for patients. Although the goal of surgical intervention is to improve the balance and function of the spine, iatrogenic spinal cord and nerve injury remains a major concern. Certain instruments are useful in preventing this type of iatrogenic injury. A combination of somatosensory-evoked potentials, motor-evoked potentials, and pedicle screw stimulation allow immediate detection of neurological changes during surgery and reduce the risk of permanent neurological deficits.The 26-year-old woman who is the focus of this case study was diagnosed with severe scoliosis with a primary Cobb's angle of 111 degrees. She underwent the first stage of surgical intervention, which included Ponte osteotomy and pedicle screw insertion. Neurophysiologic intraoperative monitoring of somatosensory-evoked potentials, motor-evoked potentials, and pedicle screw stimulation was conducted during surgery. However, an action potential that may have been caused by medial breach was detected during pedicle screw stimulation of 4.5 mA after the screw was inserted into the left T7 pedicle. This potential disappeared after redirection of the pedicle screw. No significant changes of somatosensory-evoked potentials and motor-evoked potentials had occurred by the end of the surgery. The patient returned to consciousness without any neurological damage. Posterior instrumentation with fusion was performed after the patient received halo-femoral traction for two weeks. The post-operative Cobb's angle was 62 degrees. However, although no significant change of somatosensory-evoked potentials and motor-evoked potentials was detected during surgery, numbness over the right inguinal area and the upper third of the anterior thigh developed 3 days after the second intervention. Neurological examination showed hypoesthesia over the right T12 and L1 dermatome, and a nerve conduction study and electromyography suggested right T12/L1 radiculopathy. The patient's numbness improved after a vitamin B12 supplement and gabapentin was prescribed. At the 3rd month of follow-up, the patient was content with her appearance and reported improved speed of gait and quality of life. (Tw J Phys Med Rehabil 2012; 40(2): 117 - 123)

並列關鍵字

scoliosis ； intra-operative monitor ； somatosensory-evoked potential ； motor-evoked potential ； pedicle screw stimulation

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誘發電位及肌電圖在嚴重脊椎側彎融合手術的應用：病例報告

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