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Abstract：
OBJECTIVE: Spinal schwannomas (SS) and spinal meningiomas (SM) account for most intradural extramedullary (IDEM) tumors. These tumors are usually benign lesions, which generally respond favorably to surgical excision. Few studies up to now tried to determine the long-term outcome after minimally invasive surgery (MIS) with multimodal intraoperative neurophysiological monitoring (IONM) for IDEM tumors. The aim of this study was to present one of the largest case series with special regard to IONM findings and long-term outcome after MIS-keyhole surgery with a tubular retractor system.
METHODS: Between January 2013 and August 2018, 87 patients with IDEM tumors who underwent tumor removal surgery via MIS-keyhole approach under multimodal IONM were retrospectively reviewed. The neurological status was assessed using a modified McCormick grading scale pre- and postoperatively. Multimodal IONM consisted of motor evoked potentials (MEP), somatosensory evoked potentials (SEP), and electromyography (EMG). Both short-term and long-term clinical evaluations as well as patients\' medical files were retrospectively analyzed.
RESULTS: Surgeries were performed for resection of SS in 49 patients and SM in 38 patients. Tumor locations were cervical in 16.1%, thoracic in 48.3%, thoracolumbar in 4.6%, lumbar 31%. Critical IONM changes were detected in 9 operations (10.3%) in which there were 2 SEPs, 5 MEPs, and 2 EMG events. Three IONM changes (2 MEPs, 1 EMG) were turned out to be transient change in nature since they were resolved in a short time when immediate corrective actions were initiated. Six patients with permanent IONM changes (2SEPs, 3MEPs, 1EMG event), all deficits had resolved during hospitalization or on short -term follow-up evaluation. Sensitivity, specificity, and positive and negative predicted values of IONM were 100, 96, 67, and 100%, respectively. Gross total resection rate was 100%, and a stable or improved McCormick grade exhibited in all patients. No tumor recurrence and no spinal instability were found in the long-term follow-up evaluation (mean 5.2 ± 2.9 years postoperatively). Overall, 94% of patients were either satisfied or very satisfied with their operation, and 93% patients reported excellent or good general clinical outcome according to Odom\'s criteria.
CONCLUSIONS: MIS-keyhole surgery with multimodal IONM for IDEM tumors enables a high level of satisfaction and a satisfying long-term clinical and surgical outcome.
METHODS: Between January 2013 and August 2018, 87 patients with IDEM tumors who underwent tumor removal surgery via MIS-keyhole approach under multimodal IONM were retrospectively reviewed. The neurological status was assessed using a modified McCormick grading scale pre- and postoperatively. Multimodal IONM consisted of motor evoked potentials (MEP), somatosensory evoked potentials (SEP), and electromyography (EMG). Both short-term and long-term clinical evaluations as well as patients\' medical files were retrospectively analyzed.
RESULTS: Surgeries were performed for resection of SS in 49 patients and SM in 38 patients. Tumor locations were cervical in 16.1%, thoracic in 48.3%, thoracolumbar in 4.6%, lumbar 31%. Critical IONM changes were detected in 9 operations (10.3%) in which there were 2 SEPs, 5 MEPs, and 2 EMG events. Three IONM changes (2 MEPs, 1 EMG) were turned out to be transient change in nature since they were resolved in a short time when immediate corrective actions were initiated. Six patients with permanent IONM changes (2SEPs, 3MEPs, 1EMG event), all deficits had resolved during hospitalization or on short -term follow-up evaluation. Sensitivity, specificity, and positive and negative predicted values of IONM were 100, 96, 67, and 100%, respectively. Gross total resection rate was 100%, and a stable or improved McCormick grade exhibited in all patients. No tumor recurrence and no spinal instability were found in the long-term follow-up evaluation (mean 5.2 ± 2.9 years postoperatively). Overall, 94% of patients were either satisfied or very satisfied with their operation, and 93% patients reported excellent or good general clinical outcome according to Odom\'s criteria.
CONCLUSIONS: MIS-keyhole surgery with multimodal IONM for IDEM tumors enables a high level of satisfaction and a satisfying long-term clinical and surgical outcome.
摘要：
目的：脊髓神经鞘瘤（SS）和脊髓脑膜瘤（SM）占大多数硬膜内髓外（IDEM）肿瘤。这些肿瘤通常是良性病变，通常对手术切除反应良好。到目前为止，很少有研究试图确定IDEM肿瘤的微创手术（MIS）和多模式术中神经生理监测（IONM）后的长期结果。这项研究的目的是介绍最大的病例系列之一，特别是使用管状牵开器系统进行MIS锁孔手术后的IONM发现和长期结果。
方法：回顾性分析了2013年1月至2018年8月在多模式IONM下，经MIS-锁孔入路行肿瘤切除手术的87例IDEM肿瘤患者。术前和术后使用改良的McCormick分级量表评估神经状态。多模态IONM由运动诱发电位（MEP）组成，体感诱发电位（SEP），和肌电图（EMG）。回顾性分析了短期和长期临床评估以及患者的医疗档案。
结果：手术切除SS49例，SM38例。肿瘤部位为宫颈16.1%,胸廓占48.3%，胸腰椎占4.6%，腰椎31%。在有2个SEP的9个手术（10.3％）中检测到严重的IONM变化，5个欧洲议会议员，和2个EMG事件。三个IONM更改（2个MEP，1EMG）被证明是自然界中的瞬时变化，因为它们在立即采取纠正措施的短时间内得到解决。6例永久性IONM改变的患者（2SEPs，3MEPs,1EMG事件)，所有缺陷均在住院期间或短期随访评估中得到解决.灵敏度,特异性，IONM的正预测值和负预测值分别为100％、96％、67％和100％，分别。总切除率为100%,所有患者均表现出稳定或改善的麦考密克等级。在长期随访评估中（平均术后5.2±2.9年），未发现肿瘤复发和脊柱不稳定。总的来说,94%的患者对他们的手术满意或非常满意，根据Odom的标准，93%的患者报告了优异或良好的一般临床结果。
结论：MIS-锁孔手术联合多模式IONM治疗IDEM肿瘤可获得较高的满意度和令人满意的长期临床和手术结果。
方法：回顾性分析了2013年1月至2018年8月在多模式IONM下，经MIS-锁孔入路行肿瘤切除手术的87例IDEM肿瘤患者。术前和术后使用改良的McCormick分级量表评估神经状态。多模态IONM由运动诱发电位（MEP）组成，体感诱发电位（SEP），和肌电图（EMG）。回顾性分析了短期和长期临床评估以及患者的医疗档案。
结果：手术切除SS49例，SM38例。肿瘤部位为宫颈16.1%,胸廓占48.3%，胸腰椎占4.6%，腰椎31%。在有2个SEP的9个手术（10.3％）中检测到严重的IONM变化，5个欧洲议会议员，和2个EMG事件。三个IONM更改（2个MEP，1EMG）被证明是自然界中的瞬时变化，因为它们在立即采取纠正措施的短时间内得到解决。6例永久性IONM改变的患者（2SEPs，3MEPs,1EMG事件)，所有缺陷均在住院期间或短期随访评估中得到解决.灵敏度,特异性，IONM的正预测值和负预测值分别为100％、96％、67％和100％，分别。总切除率为100%,所有患者均表现出稳定或改善的麦考密克等级。在长期随访评估中（平均术后5.2±2.9年），未发现肿瘤复发和脊柱不稳定。总的来说,94%的患者对他们的手术满意或非常满意，根据Odom的标准，93%的患者报告了优异或良好的一般临床结果。
结论：MIS-锁孔手术联合多模式IONM治疗IDEM肿瘤可获得较高的满意度和令人满意的长期临床和手术结果。
