Značaj primene neuromonitoringa u toku operacija intraduralnih tumora kičmenog kanala

Abstract

Neuromonitoring je veoma važan element koji je omogućio intraoperativno praćenje akcionih potencijala nerava i mišića i time smanjio mogućnost lezije kičmene moždine i neurološkog deficita. Uvođenje u praksu intraoperativnog neuromonitoringa tokom operacija tumora kičmenog kanala, naročito intramedularnih tumora, omogućilo je direktan uvid u trenutnu funkciju kičmene moždine i time mogućnost da se izbegnu jatrogena oštećenja koja bi dovela do teških neuroloških ispada. On konkretno zamenjuje neurološki pregled pacijenta u opštoj anesteziji u toku operacije. Oštećenje tkiva kičmene moždine tokom operacije može nastupiti direktnom ili indirektnom traumom, kompresijom, ishemijom, istezanjem nervnih elemenata, hipotenzijom, elektrolitnim poremećajima, kompresijom ili krvarenjem. Primena neuromonitoringa može prikazati svaku promenu koja nastaje navedenim mehanizmima, i to u ranoj reverzibilnoj fazi, kada je moguće reagovati (hirurg i anesteziolog) i sprečiti dalje oštećenje. Rezultati hirurškog lečenja intraduralnih tumora kičmenog kanala su u poslednjih dvadesetak godina izuzetno unapređeni, zahvaljujući pre svega uvođenju u standardnu upotrebu u sve većem broju centara operacionog mikroskopa, ultrazvučnog aspiratora i neuromonitoringa. U ovoj disertaciji je prezentovana uloga neuromonitoringa, ali i ispitani prediktori ishoda pacijenata sa intraduralnim tumorima, kao i preživljavanje ovih pacijenata. CILJEVI ISTRAŽIVANJA: Ciljevi ovog istraživanja su: utvrđivanje razlike u neurološkom ishodu pacijenata sa intraduralnim ekstramedularnim i intramedularnim tumorima (pri otpustu, godinu i tri godine nakon operacije) bez i sa upotrebom neuromonitoringa. Potom, otkrivanje uticaja pojedinih nezavisnih preoperativnih i kliničkih faktora na neurološki status pacijenata, kao i otkrivanje uticaja intraoperativnih parametara i faktora na neurološki status pacijenata i krajnji ishod lečenja. Kao cilj je postavljeno i određivanje preživljavanje ovih grupa pacijenata, kao i njihov period bolesti bez recidiva, i kvalitet života. METODOLOGIJA: Istraživanje je obuhvatilo grupu od ukupno 240 pacijenata hirurški lečenih zbog postojanja intraduralnih tumora u Klinici za neurohirurgiju KCS u Beogradu u periodu od 6 godina, od januara 2008. do decembra 2013. godine.

Neuromonitoring is a very important element that enabled tracking of the action potentials of neurons and muscles and thus reduce the the possibility of spinal cord lesions and neurological deficits. Introduction to the practice of intraoperative neuromonitoring during the operation of spinal canal tumors, especially intramedularnih tumors, allow a direct insight into the current function of the spinal cord and thus the ability to avoid iatrogenic damage that would have resulted in severe neurological deficit. It specifically overrides the neurological examination the patient in general anesthesia during surgery. Damage to the tissues of the spinal cord during surgery may perform from direct or indirect trauma, compression, ischemia, neural elements stretching, hypotension, electrolyte disorders, compression or bleeding. Application of neuromonitoring may show each change that occurs with the above mechanisms, and that in the early stages are reversible, when it is possible to react (surgeon and anaesthesiologist) and prevent further damage. The results of the surgical treatment of intradural tumors of the spinal canal in the last two decades are extremely improved, thanks first of all to the introduction and the standard use, in a growing number of centers, surgery microscopes, ultrasonic extraction unit and neuromonitoring. In this thesis the role of neuromonitoring is presented, but also predictors of outcome of patients with intradural tumours was investigated, as well as the survival of these patients. OBJECTIVES: The objectives of this study were: to determine the differences in neurological outcome of patients with intradural extramedullar and intramedullar tumors (at discharge, one year and three years after surgery) without and with the use of neuromonitoring. Then, to uncover the impact of individual independent preoperative and clinical factors in neurological status of patients, and detection of the influence of intraoperative parameters and factors in neurological status of patients and the outcome of treatment. As the target was also set to determine the survival of these groups of patients, and also their progression free period (PFS), and quality of life (QoL). METHODOLOGY: The survey covered a group of 240 patients operated due to the existence of intradural tumor in Clinic for neurosurgery CCS in Belgrade for a period of 6 years, as of January 2008. by December 2013...