Artikel
The prognosis of L5 radiculopathy after reduction and instrumented fusion of adult isthmic high-grade lumbosacral spondylolisthesis and the role of multimodal intraoperative neuromonitoring (MIOM)
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Autoren
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Ralph T. Schär
- Wirbelsäulenzentrum,; Universitätsklinik für Neurochirurgie, Inselspital, Bern, Schweiz
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Martin Sutter
- Klinik für Neurologie
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Anne F. Mansion
- Abteilung für Forschung und Entwicklung, Schulthess Klinik, Zürich, Schweiz
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Andreas Eggspühler
- Abteilung für Forschung und Entwicklung, Schulthess Klinik, Zürich, Schweiz
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Dezsö Jeszenszky
- Wirbelsäulenzentrum
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Tamas Fekete
- Wirbelsäulenzentrum
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Frank Kleinstück
- Wirbelsäulenzentrum
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Daniel Haschtmann
- Wirbelsäulenzentrum
| Veröffentlicht: | 2. Juni 2015 |
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Gliederung
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Objective: Iatrogenic L5 nerve root injury is a common complication of reduction of isthmic high-grade spondylolisthesis (HGS). However, the clinical presentation and prognosis as well as its impact on patient-rated outcome have never been analysed systematically and the role of multimodal intraoperative neuromonitoring (MIOM) is largely unknown.
Method: Clinical and radiographic data from consecutive patients who underwent reduction and instrumented fusion of HGS between 2005-2013 in a single center were analysed. The multidimensional Core Outcome Measures Index (COMI) was completed before and 1 year after surgery. MIOM with transcranial motor evoked potentials (MEP) and continuous electromyography (EMG) of index muscles was carried out.
Results: The data from 17 patients (13f, 4m; mean (± SD) age 26.5 (± 9.2) years) with a mean radiographic follow-up of 19 (range 3 to 48) months were included. Mean L5-S1 slip was 72% (± 21%), which was reduced to 19% (± 13%). After 1 year, COMI improved from 6.7 ± 1.7 to 3.7 ± 3.1, leg pain from 5.2 ± 3.1 to 2.3 ± 3 and back pain from 6.2 ± 1.9 to 3.4 ± 2.6. In 5 patients (29%), an incomplete L5 motor deficit occurred: 2 suffered a moderate, and 3 a mild paresis. 4 patients fully recovered after 3 months, and 1 patient was lost to follow-up. 25 intraoperative MIOM alerts were recorded in 15 of the 17 procedures (88%). Based on intraoperative signal recovery, MIOM predicted a new neurological deficit in just 1 out of 17 patients. In respect of new L5 motor deficits postperatively, MIOM had a sensitivity of 20% and a specificity of 100%. Related to final outcome with all followed up patients (N=16) recovering by 3 months, MIOM specificity remained at 100%.
Conclusions: Reduction and instrumented fusion of HGS showed a satisfactory outcome. The rate of transient L5 palsy was relatively high. However, the prognosis of this deficit was favorable and full recovery was achieved after 3 months in all followed up cases. MIOM alerts occurred in 88% of the procedures and thereby possibly prevented permanent neurological deficits. Intraoperative recovery of deteriorating MIOM signals cannot predict transient neurological deficits.
