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DOI: 10.1055/s-2005-836604
© Georg Thieme Verlag Stuttgart · New York
Motor Nerve Root Monitoring During Percutaneous Transforaminal Endoscopic Sequestrectomy Under General Anesthesia for Intra- and Extraforaminal Lumbar Disc Herniation
Elektrophysiologische Überwachung motorischer Nervenwurzelaktivität während der perkutanen transforaminalen Sequestrektomie bei intra- und extraforaminalen Bandscheibenvorfällen unter VollnarkosePublication History
Publication Date:
29 November 2005 (online)
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Abstract
Introduction: Percutaneous transforaminal endoscopic sequestrectomy (PTFES) for intra- and extraforaminal lumbar disc herniation (IHLD and EHLD) is usually performed under local anesthesia because the patient's full cooperation is necessary during surgery in order to reduce morbidity. This puts intraoperative stress on both the patient and the surgeon. The present study was performed to assess the safety and efficacy of performing PTFES under general anesthesia using a new protocol with continuous intraoperative neurophysiological monitoring (IOM). Patients and Methods: Twenty-five patients with IHLD and/or EHLD were treated by PTFES under general anesthesia without neuromuscular blocking agents. Free-run electromyography (EMG) recordings from characteristic muscles were monitored for the nerve root exiting through the intervertebral foramen at the level of surgery as well as those immediately above and below this level. The recorded potentials were visualized and analyzed on the monitoring screen. Additionally, the EMG activity was played to the surgeon via loudspeakers. Results: EMG-assisted endoscopic sequestrectomy was successfully completed in all 25 cases. Three patients showed complex repetitive discharge patterns already before the actual procedure, but these normalized upon removal of the sequester. Abnormal EMG changes in the form of intraoperative isolated spikes, phasic bursts, or tonic trains were recorded in 17 of the 25 cases. These occurred during placement of the endoscopic working channel in the area of the neuroforamen in 12 cases and during removal of the sequester in 6 cases. Spikes and bursts were evoked by direct contact with the nerve root or indirectly through traction or compression. Tonic discharge patterns, on the other hand, correlated with more severe mechanical stress caused for instance by compression or traction when the nerve root was fixed in the neuroforamen by the sequester. Conclusions: PTFES under general anesthesia is a safe and easy-to-perform technique for surgical management of intra- and/or extraforaminal lumbar disc herniation if combined with intraoperative neurophysiological monitoring. General anesthesia reduces intraoperative stress to a minimum, so that a larger number of patients may benefit from this minimally invasive procedure in future.
Zusammenfassung
Einleitung: Als minimalinvasive Operationstechnik für intra- und extraforaminale lumbale Bandscheibenvorfälle (IHLD und EHLD) steht die perkutane transforaminale endoskopische Sequestrektomie (PTFES) zur Verfügung. Diese Operationstechnik wird jedoch zumeist in Lokalanästhesie durchgeführt, da zur Reduzierung der intraoperativen Morbidität die Kooperation des wachen Patienten erforderlich ist. Das Ziel dieser Studie war es, ein neues Protokoll zu evaluieren, welches durch den Einsatz intraoperativer neurophysiologischer Untersuchungsmethoden die PTFES auch unter Vollnarkose erlaubt. Material und Methodik: Fünfundzwanzig Patienten wurden unter Vollnarkose (TIVA) ohne intraoperative Anwendung von Muskelrelaxantien endoskopisch an einem IHLD und/oder EHLD operiert. Für die intraoperative neurophysiologische Überwachung motorischer Nervenwurzelaktivität wurde ein freilaufendes Elektromyogramm (EMG) aus spezifischen Kennmuskeln, jeweils für das operierte Segment, sowie für das darüber und darunter liegende Segment abgeleitet. Die Potenziale wurden fortlaufend visualisiert, ausgewertet und die elektrophysiologischen Entladungsmuster per Lautsprecher für den Operateur hörbar gemacht. Ergebnisse: In allen 25 Fällen konnte die EMG-assistierte endoskopische Sequestrektomie erfolgreich durchgeführt werden. In 3 Fällen war bereits vor Beginn der eigentlichen Operation EMG-Aktivität in Form eines komplexen repetitiven Entladungsmusters zu registrieren. Diese normalisierten sich nach Sequesterentfernung. Pathologische EMG-Veränderungen in Form von intraoperativ aufgetretener singulärer „spike”, phasischer „burst” oder tonischer „train” Aktivität wurden in 17 der 25 Fälle registriert. Diese traten in 12 Fällen während der Platzierung des Endoskoparbeitsschaftes im Bereich des Neuroforamens und in 6 Fällen bei Entfernung des Sequesters auf. Spikes und bursts wurden dabei durch Berührung der Nervenwurzel bzw. durch indirekten Zug oder Druck ausgelöst. Das Auftreten von tonischen Entladungsmustern korrelierte hingegen mit einer stärkeren mechanischen Affektion der Nervenwurzel, z. B. durch Kompression oder Traktion der durch den Sequester im Neuroforamen fixierten Nervenwurzel. Schlussfolgerungen: Die Ergebnisse dieser Untersuchung zeigen, dass die PTFES auch unter Vollnarkose sicher und suffizient durchführbar ist, wenn die motorische Nervenwurzelaktivität mit Hilfe intraoperativer neurophysiologischer Untersuchungstechniken kontinuierlich kontrolliert wird. Hierdurch lässt sich die Lage der Nervenwurzel identifizieren und das Operationsrisiko minimieren. Durch Anwendung der Vollnarkose lässt sich ferner die intraoperative Belastung für den Patienten reduzieren, so dass diese Operationstechnik für eine größere Patientengruppe attraktiv und tolerabel wird.
Key words
transforaminal endoscopic sequestrectomy - general anesthesia - intraoperative electromyography - neurophysiological monitoring
Schlüsselwörter
transforaminale endoskopische Sequestrektomie - Vollnarkose - intraoperative Elektromyographie - neurophysiologisches Monitoring
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Dr. med. O. Süss
Neurochirurgische Klinik · Charité - Universitätsmedizin Berlin · Campus Benjamin Franklin (CBF)
Hindenburgdamm 30
12200 Berlin
Germany
Phone: +49/30/84 45 25 50
Fax: +49/30/84 45 42 56
Email: olaf.suess@charite.de