方法:根据建议分级制定临床实践指南,评估,开发和评估(等级)过程。
目的:本研究的目的是制定指南,概述术中神经监测(IONM)在脊柱手术患者中检测术中脊髓损伤(ISCI)的实用性。定义接受脊柱手术的患者中ISCI风险较高的一部分,并制定预防方案,诊断,并管理ISCI。
方法:所有系统评价均根据PRISMA标准进行,并在PROSPERO上注册。多学科,国际指南发展小组(GDG)使用GRADE协议审查和讨论了证据。共识是由GDG成员之间80%的共识定义的。进行了系统评价和诊断测试准确性(DTA)荟萃分析,以综合关于IONM在脊柱手术患者中检测ISCI的诊断准确性的汇总证据。评估的IONM模态包括体感诱发电位(SSEP),运动诱发电位(MEPs),肌电图(EMG),和多模式神经监测。利用这些知识和他们的临床经验,多学科GDG为在脊柱手术患者中使用IONM识别ISCI提出了建议.总结了与管理ISCI的现有护理途径相关的证据,并在此基础上创建了一种新型的AOSpine-PRAXIS护理途径。
结果:我们的建议如下:(1)我们建议对接受脊柱手术的高危患者采用术中神经生理监测,和(2)我们建议患者在脊柱手术期间的“高风险”ISCI被主动识别,在确定了这些病人之后,进行多学科团队讨论以管理患者,以及实施包括使用IONM在内的术中方案。预防的护理途径,诊断,ISCI的管理是由GDG开发的。
结论:我们预计这些指南将促进使用IONM来检测和管理ISCI,并促进外科医生和其他团队成员对接受脊柱手术的高危患者使用术前和术中检查表。我们欢迎团队实施和评估由我们的GDG创建的护理途径。
METHODS: Development of a clinical practice
guideline following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process.
OBJECTIVE: The objectives of this study were to develop
guidelines that outline the utility of intraoperative neuromonitoring (IONM) to detect intraoperative spinal cord injury (ISCI) among patients undergoing spine surgery, to define a subset of patients undergoing spine surgery at higher risk for ISCI and to develop protocols to prevent, diagnose, and manage ISCI.
METHODS: All systematic reviews were performed according to PRISMA standards and registered on PROSPERO. A multidisciplinary, international
Guidelines Development Group (GDG) reviewed and discussed the evidence using GRADE protocols.
Consensus was defined by 80% agreement among GDG members. A systematic review and diagnostic test accuracy (DTA) meta-analysis was performed to synthesize pooled evidence on the diagnostic accuracy of IONM to detect ISCI among patients undergoing spinal surgery. The IONM modalities evaluated included somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), electromyography (EMG), and
multimodal neuromonitoring. Utilizing this knowledge and their clinical experience, the multidisciplinary GDG created recommendations for the use of IONM to identify ISCI in patients undergoing spine surgery. The evidence related to existing care pathways to manage ISCI was summarized and based on this a novel AO Spine-PRAXIS care pathway was created.
RESULTS: Our recommendations are as follows: (1) We recommend that intraoperative neurophysiological monitoring be employed for high risk patients undergoing spine surgery, and (2) We suggest that patients at \"high risk\" for ISCI during spine surgery be proactively identified, that after identification of such patients, multi-disciplinary team discussions be undertaken to manage patients, and that an intraoperative protocol including the use of IONM be implemented. A care pathway for the prevention, diagnosis, and management of ISCI has been developed by the GDG.
CONCLUSIONS: We anticipate that these guidelines will promote the use of IONM to detect and manage ISCI, and promote the use of preoperative and intraoperative checklists by surgeons and other team members for high risk patients undergoing spine surgery. We welcome teams to implement and evaluate the care pathway created by our GDG.