riirk Noro$iriirji Dergisi 9: 57 - 64, 1999 Zileli: Omuri/ik monitor/ernesi

Ameliyat SlraSlnda Omurilik Monitorlemesi

Intraoperative Spinal Cord Monitoring

MEHMET ZiLELi, ERDAL CO$KUN, BERNA ZiLELi

Ege Universitesi Tip Fakultesi Norolojik Cerrahi Anabilim Dah, izmir (MZ, BZ),Pamukkale Universitesi Tip Fakultesi Norolojik Cerrahi Anabilim Dah, Denizli (EC)

Ozet: Bu l;ah~mada omurilik ve omurga cerrahisislrasmdaevoked potansiyel monitorlemesi uyguladlglmlz32 olguluk bir klinik serinin sonul;lan sunulmaktadlr.Dokuzhastada intrameduller tumor, 5 hastada intraduralekstrameduller tumor, 5 hastada ekstradural tUmor, 6hastadaservikal spondilotik miyelopati, 6 hastada gerginomurilik sendromu, 1 hastada torakal disk hernisimevcuttu. Turn hastalarda tibial ve median sinir uyanmlilekortikal SEP'ler (Somatosensoryel Evoked Potansiyel),29 hastada aynca spinal SEP'ler elde edildi. Dura al;llml~saintradural, al;ilmaml~sa ekstradural kaYltlar yaplldl.yirmibir olguda intraoperatif E' ler (Evoked Potansiyel)degi~medi,9 olguda kotUle~ti.Postoperatif erken donemdeklinik tablo 24 olguda degi~medi, 1 olguda duzelmeg6sterdi, 8 olguda ise kotUle~me gosterdi. iki yanh~negatiflik,3 yanh~ pozitiflik, 6 dogru pozitiflik elde edildi.Kauda-konuspatolojilerinde anal sfinkter uyanmh SEP'lerdaha anlamh sonul;lar verdi. Bir olguda klsa surelik6tiile~meyecerrahm yamt vermesiyle SEP'ler duzeldi.Genel olarak norolojik defisi ti olan hastalannmoit6rlenmesi, skolyoz cerrahisi gibi defisitsiz olgulannmonitorlenmesinden daha zor olmaktadlr. Bu olgulardazatenbozuk olan kortikal SEP'ler ameliyat slrasmda ciddidalgalanmalar gosterebilmektedir. Ancak spinal SEP'lerinkayblya da bozulmasl norolojik defisitin bir gostergesiolup,mutlak uyan kriteri olarak kabul edilmelidir.

Anahtar Kelimeler: Omurilik monitorlenmesi,somatosensoryel evoked potansiyeller, omurilikpotansiyelleri, pudendal SEP

GiRi$

Omurilik ve omurga cerrahisi, kanal it;inde vekanalt;evresinde yer alan kIymetli yapdarm, omurilikvekoklerin zedelenmesine yol at;abilir. Omuriliik ve

Abstract: This study presents a clinical series with 32 casesthat have evoked potentials monitoring during spine andspinal cord surgery. Clinical diagnosis was intramedullarytumors in 9 patients, intradural extramedullary tumors in5 patients, extradural tumors in 5 patients, cervicalspondylotic myelopathy in 6 patients, tethered cordsyndrome in 6 patients, thoracic disc herniation in onepatient. All of the patients were monitored with corticalSEPs (Somatosensory Evoked Potentials) by tibial andmedian nerve stimulation, 29 patients were addititonallymonitored with spinal SEPs. In case the dura was opened,subdural recordings were done, otherwise epiduralrecordings were done. Intraoperative SEPs did not changein 21 patients, and worsened in 9 patients. Postoperativeevaluation showed that clinical deficits did not change in24 cases, progressed in one patient, deteriorated in 8patients. We reported 2 false-negative, 3 false-positive, 6true positive monitoring. SEPs with anal sphincterstimulation were more sensitive for monitoring of lesionsin cauda and conus region. Since the surgeon reactedpromptly to wave loss in one patient, SEPs were recoveredduring operation.In conclusion, monitoring of the patientswith neurological deficits is harder than the patientswithout deficits such as scoliosis surgery. We noted seriousfluctuations in already hampered base line activitiy ofcortical SEPs in these patients. However, worsening or lossof spinal SEPs reflects the function of neurologic deficits,and should be considered as an absolute warning criteria.

Key Words: Spinal cord monitoring, somatosensoryevoked potentials, spinal cord potentials, pudendal SEP

kok hasan, bu yapllara kompresyon, kontiizyon ileveya omurilik kan aklmmmm bozulmasl ile olabilir.Sonut;ta istenmeyen bir norolojik morbiditegeli~ecektir .

Turk Nijro~irurji Dergisi 9: 57 - 64, 1999 Zileli: Omurilik monitorlemesi

kortikal SEP ve omurilik potansiyelleri ileuyguladlglmlz omurilik monitorlemesi deneyimi-mizin sonu

TUrk Noro§iriirji ,Dergisi 9: 57 - 64, 1999

TabloII: Hastalann norolojik tablolan, eerrahilokalizasyonlan ve uygulanan eerrahigiri~imler

Norolojik Tablo I NKuadriparezi 8Paraparezi 13Hemiparezi 4Diparezi 1Brakialji 4Bill ok 2Lokalizas on N

Kranyoservikal bile~ke 3Servikal 14Torakal 8Lomber 7Cerrahi .ri~im N

Anterior giri~im I 9Posterior giri~im 23

alman olgularda aranan ko~ullar Tablo III'tegiirUlmektedir.

Aynea tUrnhastalara ameliyat oneesi ve 9.meliyatsomaSldikkatli norolojik muayene yapIlml~ ve bubulgularelektrofizyolojik verilerle kar~Ila~tmlml~tIr.

Kapt Ko~ullan: Kapt i

Tark Noro~irarji Dergisi 9: 57 - 64, 1999 Zileli: Omurilik monitOrlemesi

SONUC;LAR

diskine kaydedildi, ameliyat somaSl donemdekaglda baslldl, mevcut %10>1.5 illS>%25

SEP Dyan KriterleriAmplitiid azalmaslLatans uzamaSl

veyaSantral iletim zamam uzamaSl

EP modalitesi ~Kortikal SEP 32

(median veya tibial sinir uyanrm ile sa

Turk Noro§irurji Dergisi 9: 57 - 64, 1999 Zileli: Omurilik mOl1itorlemesi

Kahn filum terminal eye bagh gerilmi$ omuriliksendromu nedeniyle opere edilen bir olguda, tibialSEP monitorlemesi slrasmda kortikal potansiyellerdeamplitud dU$mesi ve latans uzamaS1 saptanmasmaragmen, omurilik potansiyellerinde degi$meOlmam1$tIr. Bu nedenle cerrah uyanlmam1$tIr.

Servikal miyelopati i

Turk Noro~irurji Dergisi 9: 57 - 64, 1999

Tablo VII: Omurilik monitorlemesinde kullamlanEP teknikleri

A-Afferent yollannmonitorlenmesi

(SEP)Stimulus yeri

KaYlt yeriI-Periferik sinir

1-0murilikten (SSEP)2-0murilik

a)Ciltb)interspinoz yapllarc)Epidural mesafed) Subdural mesafe2-Sa

Turk Noro~irurji Dergisi 9: 57 - 64, 1999

seyrek goriilmekte ise de, sonUl;lar goz oniinealmdlgmda daha onemlidir.

Bu

Turk Noro§irurji Dergisi 9: 57 - 64, 1999

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