PREVENTION OF NEUROLOGICAL COMPLICATIONS IN CORRECTION SURGERY FOR SEVERE SPINAL DEFORMITIES

Objective. To assess the efficacy of neurological complication prevention by multimodal intraoperative monitoring of spinal cord functioning.

Material and Methods. Results of intraoperative spinal cord monitoring in 457 patients during spine correction surgery for grade IV scoliosis with application of the third-generation segmental instrumentation were analyzed. The magnitude of scoliotic curvature exceeded 80 degrees in 353 patients. All patients underwent continuous intraoperative monitoring of lower extremity skin temperature. Out of them, in 45 patients somatosensory evoked potentials were recorded, and in 41 patients intraoperative Stagnara wake-up test was performed.

Results. Neurological complications were registered in 4 patients as lower atonic paraplegia which accompanied with rapid rise in lower extremity skin temperature more than by 1 °C during spinal deformity correction. In two of them SSEP recording showed a sharp decrease in the amplitude of potential waves up to their complete disappearance. Skin temperature monitoring of lower extremities did not revealed significant changes in patients without neurological complications.

Conclusion. Multimodal intraoperative monitoring of the spinal cord function should be performed in patients with high risk of neurological complications after surgical correction of spinal deformity.

1. Евграфов О.Г., Макушкин В.В., Гумеров А.А. Оптимизация анестезиологического обеспечения при хирургической коррекции сколиоза у детей // Сиб. консилиум. 2007. № 2 (57). С. 30–31.

2. Заявка № 2009131538 Российская Федерация. Способ интраоперационной диагностики неврологических осложнений при операциях на позвоночнике / Новиков В.В., Васюра А.С., Лебедева М.Н. и др.; приоритет 19.08.2009.

3. Кралин А.Б., Ветрилэ С.Т., Аржакова Н.И. и др.Анестезиологическое обеспечение операций у больных сколиозом с одновременным вмешательством на вентральных и дорсальных отделах позвоночника // Вестн. травматол. и ортопед. им. Н.Н. Приорова. 1999. № 3. С. 45–49.

4. Михайловский М.В., Садовой М.А. Оперативное лечение сколиотической болезни: Результаты, исходы. Новосибирск, 1993.

5. Михайловский М.В., Фомичев Н.Г. Хирургия деформаций позвоночника. Новосибирск, 2002.

6. Ульрих Г.Э. Анестезиологическое обеспечение операций на позвоночнике у детей: Автореф. дис. … д-ра мед. наук. СПб., 2005.

7. Ульрих Э.В., Мушкин А.Ю. Хирургическое лечение пороков развития позвоночника у детей. СПб., 2007.

8. Фищенко В.Я. Сколиоз. Макеевка, 2005.

9. Цветовский С.Б., Ступак В.В., Калиновский А.В. Интраоперационный мониторинг состояния ствола головного мозга при удалении менингиом основания черепа с использованием Nd-YAG-лазера // Поленовские чтения: Тез. докл. Всерос. науч.-практ. конф. СПб., 2010. С. 291–292.

10. Bardosi L, Illes T. Neurological complication due to epidural hematoma after СD operations. Case report. In: Neurological Complications of Spinal Surgery. Proceedings of the 11th International GICD Congress, Arcachon, France, 1994:60–62.

11. Blussй van Oud-Alblas HJ, Peters JW, de Leeuw TG, et al. A comparison in adolescents of composite auditory evoked potential index and bispectral index during propofol-remifentanil anesthesia for scoliosis surgery with intraoperative wake-up test. Anesth Analg. 2008;107:1683–1688.

12. Bridwell KH, Lenke LG, Baldus C, et al. Major intraoperative neurologic deficits in pediatric and adult spinal deformity patients. Incidence and etiology at one institution. Spine. 1998;23:324–331.

13. Calancie B, Harris W, Broton JG, et al. «Threshold-level» multipulse transcranial electrical stimulation of motor cortex for intraoperative monitoring of spinal motor tracts: description of method and comparison to somatosensory evoked potential monitoring. J Neurosurg. 1998;88:457–470.

14. Cheng JC, Guo X, Sher AH. Posterior tibial nerve somatosensory cortical evoked potentials in adolescent idiopathic scoliosis. Spine. 1998;23:332–337.

15. Delecrin J, Bernard JM, Pereon Y, et al. Various mechanisms of spinal cord injury during scoliosis surgery. In: Neurological Complications of Spinal Surgery. Proceedings of the 11th International GICD Congress, Arcachon, France, 1994:13–14.

16. Deletis V. Intraoperative monitoring of the functional integrity of the motor pathways. In: Advances in Neurology: Electrical and Magnetic Stimulation of the Brain and Spinal Cord, ed. by O Devinsky, A Beric, M Dogali. New York, 1993:201–214.

17. Devinsky O. Electrical and magnetic stimulation of central nervous system. Historical overview. In: Advances in Neurology: Electrical and Magnetic Stimulation of the Brain and Spinal Cord, еd. by O Devinsky, A Beric, M Dogali. New York, 1993:1–16.

18. Edmonds HLJr, Paloheimo MP, Backman MH, et al. Transcranial magnetic motor evoked potentials (tcMMEP) for functional monitoring of motor pathways during scoliosis surgery. Spine. 1989;14:683–686.

19. Ewen A, Cox RG, Davies SA, et al. The ankle clonus test is not a clinically useful measure of spinal cord integrity in children. Can J Anaesth. 2005;52:524–529.

20. Heine J, Hopf C, Arai Y. The examination of the complications and problems in Cotrel – Dubousset Instrumentation (CDI). Proceedings of the 7th International Congress on CDI Neurological Complications of Spinal Surgery, 1990;169–172.

21. Kai Y, Owen JH, Lenke LG, et al. Use of sciatic neurogenic motor evoked potentials versus spinal potentials to predict early-onset neurologic deficits when intervention is still possible during overdistraction. Spine. 1993;18:1134–1139.

22. Komanetsky RM, Padberg AM, Lenke LG, et al. Neurogenic motor evoked potentials: a prospective comparison of stimulation methods in spinal deformity surgery. J Spinal Disord. 1998;11:21–28.

23. Lieberman JA, Lyon R, Feiner J, et al. The effect of age on motor evoked potentials in children under propofol/isoflurane anesthesia. Anesth Analg. 2006;103:316–321.

24. McCulloch PR, Milne B. Neurological phenomena during emergence from enflurane or isoflurane anaesthesia. Can J Anaesth. 1990;37:739–742.

25. Mechin JF. Neurological complications with CDI. In: Neurological Complications of Spinal Surgery. Proceedings of the 11th International GICD Congress, Arcachon, France, 1994:9–11.

26. Nash CLJr, Brown RN. Spinal cord monitoring. J Bone Joint Surg Am. 1989;71:627–630.

27. Owen JH. The application of intraoperative monitoring during surgery for spinal deformity. Spine. 1999;24:2649–2662.

28. Padberg AM, Bridwell KH. Spinal cord monitoring: current state of the art. Orthop Clin North Am. 1999;30:407–433.

29. Padberg AM, Wilson-Holden TJ, Lenke LG, et al. Somatosensory and motor evoked potential monitoring without a wake-up test during idiopathic scoliosis surgery. An accepted standard of care. Spine. 1998;23:1392–1400.

30. Pajewski TN, Arlet V, Phillips LH. Current approach on spinal cord monitoring: the point of view of the neurologist, the anesthesiologist and the spine surgeon. Eur Spine J. 2007;16(2):S115–S129.

31. Rodola F, D’Avolio S, Chierichini A, et al. Wake-up test during major spinal surgery under remifentanil balanced anaesthesia. Eur Rev Med Pharmacol Sci. 2000;4:67–70.

32. Schwartz DM, Auerbach JD, Dormans JP, et al. Neurophysiological detection of impending spinal cord injury during scoliosis surgery. J Bone Joint Surg Am. 2007;89:2440–2449.

33. Sessler DI, Rubinstein EH, Moayeri A. Physiologic responses to mild perianesthetic hypothermia in humans. Anesthesiology. 1991;75:594–610.

34. Seyal M, Mull B. Mechanisms of signal change during intraoperative somatosensory evoked potential monitoring of the spinal cord. J Clin Neurophysiol. 2002;19:409–415.

35. Shufflebarger HL, Grimm JO, Bui V, et al. Anterior and posterior spinal fusion. Staged versus same-day surgery. Spine. 1991;16:930–933.

36. Tamaki T, Noguchi T, Takano H, et al. Spinal cord monitoring as a clinical utilization of the spinal evoked potential. Clin Orthop Relat Res. 1984;(184):58–64.

37. Vauzelle C, Stagnara P, Jouvinroux P. Functional monitoring of spinal cord activity during spinal surgery. Clin Orthop Relat Res. 1973;93:173–178.

38. Wilson-Holden TJ, Padberg AM, Lenke LG, et al. Efficacy of intraoperative monitoring for pediatric patients with spinal cord pathology undergoing spinal deformity surgery. Spine. 1999;24:1685–1692.

39. Yao WL, Wang XR, Li BL, et al. Application of A-line autoregressive model with exogenous input index during the wake-up test in spinal surgery under propofol-remifentanil anaesthesia. Chin Med J (Engl.). 2007;120:1013–1016.

40. Yilmazlar A, Aydinli U, Korfali G, et al. Intraoperative awakening during spine surgery with propofol and alfentanil. In: Neurological Complications of Spinal Surgery. Proceedings of the 11th GICD Congress, Arcachon, France, 1994:122–124.