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Lewis MJ. Electrodiagnostic testing in dogs with disorders of the spinal cord or cauda equina. Vet J 2024; 304:106082. [PMID: 38360137 DOI: 10.1016/j.tvjl.2024.106082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 02/17/2024]
Abstract
Electrodiagnostic (EDX) testing is uncommonly utilized in dogs other than for investigation of disorders of the neuromuscular system. In dogs with diseases affecting the spinal cord or cauda equina, EDX testing can provide functional data complementary to imaging information that together can guide therapeutic and management approaches. Additionally, in some clinical scenarios, EDX testing prior to advanced imaging is integral to identifying if there is spinal cord or cauda equina involvement and can aid in determining the appropriate diagnostic path. This review will outline EDX testing methods that have been reported in dogs relating to the diagnosis, monitoring or prognosis of various conditions affecting the spinal cord and cauda equina. The various tests will be briefly outlined regarding how they are performed and what information is provided. The main focus will be on clinical applications including highlighting situations where EDX testing is useful for differentiating between neurologic and non-neurologic presentations. Additional ways these EDX techniques could be incorporated in the management of diseases of the spinal cord and cauda equina in dogs will be presented.
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Affiliation(s)
- M J Lewis
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Dr, Raleigh, NC 27607, USA.
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Deng Y, Chen J, Liu ZX, Yang J, Huang Z, Yang J, Sui W. Descending Neurogenic Evoked Potentials Monitoring Is an Effective Alternative in Spinal Deformity Surgery Under Inhaled Anesthesia. World Neurosurg 2024; 184:e17-e24. [PMID: 38070738 DOI: 10.1016/j.wneu.2023.10.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/21/2023] [Accepted: 10/22/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND To evaluate the reliability of descending neurogenic evoked potentials (DNEP) monitoring in spinal deformity surgery under inhaled anesthesia. METHODS A total of 180 consecutive patients who underwent spinal deformity surgery in our scoliosis center from July 2014 to August 2016 were reviewed. Intraoperative monitoring including somatosensory evoked potentials (SEP), motor evoked potentials (MEP), and DNEP was conducted routinely throughout operation. Patients were divided into 2 groups according to anesthesia methods: group A (n = 72, inhaled anesthesia, SEP/DNEP) and group B (n = 108, total intravenous anesthesia, SEP/MEP/DNEP). Intraoperative monitoring data were collected and analyzed. RESULTS Positive alerts were observed in 26 patients (14.5%), of whom 18 (10%) were confirmed as true-positive events in the study population. No false-negative events were recorded. In group A, the sensitivity and specificity of SEP and DNEP were 100% and 93.8% and 100% and 98.5%, respectively. For group B, the sensitivity and specificity of SEP/MEP and DNEP were 100% and 95.9% and 100% and 98%, respectively. CONCLUSIONS DNEP monitoring seemed to be effective for the detection and prevention of iatrogenic neurologic deficits during spinal deformity surgery. This study indicates that DNEP was an effective alternative in spinal deformity surgery under inhaled anesthesia.
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Affiliation(s)
- Yaolong Deng
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jian Chen
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zi-Xiang Liu
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jingfan Yang
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zifang Huang
- Department of Orthopaedic Surgery, the 1st Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Junlin Yang
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wenyuan Sui
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Chen J, Yang JF, Deng YL, Shao XX, Huang ZF, Yang JL. A Retrospective Study of Surgical Correction for Spinal Deformity with and without Osteotomy to Compare Outcome Using Intraoperative Neurophysiological Monitoring with Evoked Potentials. Med Sci Monit 2020; 26:e925371. [PMID: 32794474 PMCID: PMC7446276 DOI: 10.12659/msm.925371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the effects of different combined evoked potentials monitoring modes for non-osteotomy and osteotomy surgery of spinal deformity, and to select individualized modes for various surgeries. MATERIAL AND METHODS We retrospectively reviewed a total of 188 consecutive cases undergoing spinal deformity correction. All patients were classified into 2 cohorts: non-osteotomy (Group A) and osteotomy (Group B). According to intraoperative evoked potential monitoring mode, Group A was divided into 2 sub-groups: A1 [spinal somatosensory evoked potential (SSEP)/motor evoked potential (MEP), n=67)] and A2 [SSEP/MEP/descending neurogenic evoked potential (DNEP), n=52]. Group B was classified as B1 (SSEP/MEP, n=27) and B2 (SSEP/MEP/DNEP, n=42). The demographics, surgical parameters, and evoked potential events of different combined monitoring modes were analyzed within each group. RESULTS The baselines of SSEP/MEP/DNEP in all cases were elicited successfully. Three cases with evoked potential (EP) events (2 with MEP changes and 1 with SSEP/MEP change) were noted in Group A1 and 1 with SSEP change in Group A2, with no neurological complications. Thirteen cases in Group B1 were positive for MEP intraoperatively, including 16 EP events (13 with MEP change and 3 with both SSEP+MEP changes), with no neural complications. In Group B2, 15 cases had 21 EP events, including 12 with MEP change and 2 with SSEP+MEP changes, with no complications. Postoperative neurological complications were observed in 5 of the 7 cases with SS4EP/DNEP changes. CONCLUSIONS Intraoperative simultaneous SSEP/MEP can effectively reflect neurological function in non-osteotomy spinal surgery patients. Simultaneous SSEP/MEP/DNEP can effectively avoid the unnecessary interference by false-positive results of MEP during osteotomy.
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Affiliation(s)
- Jian Chen
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Jing-Fan Yang
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Yao-Long Deng
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Xie-Xiang Shao
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Zi-Fang Huang
- Department of Orthopaedic Surgery, The 1st Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Jun-Lin Yang
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
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Diwan SM, Yamak Altinpulluk E, Khurjekar K, Nair A, Dongre H, Turan A. Bilateral erector spinae plane block for scoliosis surgery: Case series. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2020; 67:153-158. [PMID: 32057483 DOI: 10.1016/j.redar.2019.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/20/2019] [Accepted: 11/26/2019] [Indexed: 06/10/2023]
Abstract
Spinal correction surgery is a very invasive surgical procedure and results in severe postoperative pain. We report six cases in which Bilateral Erector Spinae Plane Block was performed for scoliosis surgery. Our aim was to provide an effective perioperative pain management and to achieve intraoperative hemodynamic stability with no interference on neuromonitoring. The technical challenges are also highlighted. An ultrasound guided scout scan is necessarry to identify the bony prominences and determine the possible multiple injection points. Erector Spinae Plane Block in scoliosis surgery is an easier and safer technique compared to epidural anesthesia and can use instrumented complex spinal surgery. This block seems to have a role in perioperative pain pathway complementing the multimodal analgesic regimen and not have interference with evocated potentials in adults. However the diffusion mechanism of the this block is not well known hence it should be awake regarding local anesthetic toxicity.
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Affiliation(s)
| | - E Yamak Altinpulluk
- Outcomes Research Department, Anesthesiology Institute, Cleveland Clinic, Ohio, EE. UU.; Department of Anesthesiology and Reanimation, Istanbul University-Cerrahpaşa, Cerrahpasa Medical Faculty, Estambul, Turquía
| | | | - A Nair
- Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | | | - A Turan
- Outcomes Research Department, Anesthesiology Institute, Cleveland Clinic, Ohio, EE. UU
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Jones CF, Clarke EC. Engineering approaches to understanding mechanisms of spinal column injury leading to spinal cord injury. Clin Biomech (Bristol, Avon) 2019; 64:69-81. [PMID: 29625748 DOI: 10.1016/j.clinbiomech.2018.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 02/16/2018] [Accepted: 03/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The mechanical interactions occurring between the spinal column and spinal cord during an injury event are complex and variable, and likely have implications for the clinical presentation and prognosis of the individual. METHODS The engineering approaches that have been developed to better understand spinal column and cord interactions during an injury event are discussed. These include injury models utilising human and animal cadaveric specimens, in vivo anaesthetised animals, finite element models, inanimate physical systems and combinations thereof. FINDINGS The paper describes the development of these modelling approaches, discusses the advantages and disadvantages of the various models, and the major outcomes that have had implications for spinal cord injury research and clinical practice. INTERPRETATION The contribution of these four engineering approaches to understanding the interaction between the biomechanics and biology of spinal cord injury is substantial; they have improved our understanding of the factors contributing to the spinal column disruption, the degree of spinal cord deformation or motion, and the resultant neurological deficit and imaging features. Models of the injury event are challenging to produce, but technological advances are likely to improve these models and, consequently, our understanding of the mechanical context in which the biological injury occurs.
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Affiliation(s)
- Claire F Jones
- Spinal Research Group, Centre for Orthopaedics and Trauma Research, Adelaide Medical School, The University of Adelaide, Australia; School of Mechanical Engineering, The University of Adelaide, Australia
| | - Elizabeth C Clarke
- Institute for Bone and Joint Research, Kolling Institute, Sydney Medical School, University of Sydney, Australia.
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Somatosensory and transcranial motor evoked potential monitoring in a porcine model for experimental procedures. PLoS One 2018; 13:e0205410. [PMID: 30296297 PMCID: PMC6175523 DOI: 10.1371/journal.pone.0205410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 09/25/2018] [Indexed: 11/19/2022] Open
Abstract
Evoked potential monitoring has evolved as an essential tool not only for elaborate neurological diagnostics, but also for general clinical practice. Moreover, it is increasingly used to guide surgical procedures and prognosticate neurological outcome in the critical care unit, e.g. after cardiac arrest. Experimental animal models aim to simulate a human-like scenario to deduct relevant clinical information for patient treatment and to test novel therapeutic opportunities. Porcine models are particularly ideal due to a comparable cardiovascular system and size. However, certain anatomic disparities have to be taken into consideration when evoked potential monitoring is used in animal models. We describe a non-invasive and reproducible set-up useful for different modalities in porcine models. We further illustrate hints to overcome multi-faceted problems commonly occurring while using this sophisticated technique. Our descriptions can be used to answer a plethora of experimental questions, and help to further facilitate experimental therapeutic innovation.
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Biomechanical Simulation of Stresses and Strains Exerted on the Spinal Cord and Nerves During Scoliosis Correction Maneuvers. Spine Deform 2018; 6:12-19. [PMID: 29287811 DOI: 10.1016/j.jspd.2017.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 02/02/2017] [Accepted: 04/15/2017] [Indexed: 11/23/2022]
Abstract
STUDY DESIGN Biomechanical analysis of the spinal cord and nerves during scoliosis correction maneuvers through numerical simulations. OBJECTIVE To assess the biomechanical effects of scoliosis correction maneuvers and stresses generated on the spinal nervous structures. BACKGROUND DATA Important forces are applied during scoliosis correction surgery, which could potentially lead to neurologic complications due to stresses exerted on the nervous structures. The biomechanical impact of the different types of stresses applied on the nervous structures during correction maneuvers is not well understood. METHODS Three correction techniques were simulated using a hybrid computer modeling approach, personalized to a right thoracic adolescent idiopathic scoliotic case (Cobb angle: 63°): (1) Harrington-type distraction; (2) segmental translation technique; and a (3) segmental rotation-based procedure. A multibody model was used to simulate the kinematics of the instrumentation maneuvers; a second comprehensive finite element model was used to analyze the local stresses and strains on the spinal cord and nerves. Average values of the internal medullar pressure (IMP), shear stresses, nerve compression, and strain were computed over three regions and compared between techniques. RESULTS Harrington distraction maneuver generated high stresses and strains over the thoracolumbar region. In the main thoracic region, the segmental translation maneuver technique induced 15% more shear stress, 25% more strain, and 62% lower nerve compression than Harrington distraction maneuver. The segmental rotation-based procedure induced 25% lower shear stresses and 18% more strain, respectively, at the apical level, as well as 72%, 57%, and 7% lower IMP, nerve compression, and strain in the upper thoracic region, compared with Harrington distraction maneuver. CONCLUSION This study quantified the relative stress induced on the spinal cord and spinal nerves for different correction maneuvers using a novel hybrid patient-specific model. Of the three maneuvers studied, the Harrington distraction maneuver induced the most important stresses over the thoracolumbar region.
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Abstract
STUDY DESIGN Clinical case series. OBJECTIVE To investigate the efficacy of intraoperative neuromonitoring in pediatric cervical spine surgery. SUMMARY OF BACKGROUND DATA Intraoperative neuromonitoring (IONM) consisting of somatosensory-evoked potentials (SSEP) and transcranial motor-evoked potentials (tcMEP) has been shown to effectively prevent permaneny neurologic injury in deformity surgery. The role of IONM during pediatric cervical spine surgery is not well documented. Advances in cervical spine instrumentation have expanded the surgical options in pediatric populations. The goal of this study is to report the ability of IONM to detect neurologic injury during pediatric cervical spine instrumentation. METHODS A single institution database was queried for pediatric-aged patients who underwent cervical spine instrumentation and fusion between 2011 and 2014. Age, diagnosis, surgical indication, number of instrumented levels, and a complete IONM were extracted. Sensitivity and specificity for the detection of neurologic deficits were calculated with exact 95% confidence intervals. Positive and negative predictive values were calculated with estimated 95% confidence intervals. RESULTS Sixty-seven patients who underwent cervical spine instrumentation were identified with a mean age of 11.6 years (range 1-18). Diagnoses included instability (27), congenital (11), kyphosis (8), fracture (7), tumor (7), arthritis (4), and basilar invagination (3). Mean number of vertebral levels fused was 4 (range 2-7). All patients underwent cervical instrumentation with SSEP and tcMEP monitoring. A significant change in tcMEP monitoring was observed in 7 subjects (10%). There were no corresponding SSEP changes in these patients. The sensitivity of combined IONM was 75% [95% CI = 24.9, 98.7] and the specificity was 98.5% [92.7, 99.9]. CONCLUSION tcMEP is a more sensitive indicator to spinal cord injury than SSEP, which is consistent with previous studies. IONM changes in 10% of a patient population are significant enough to warrant intraoperative determination if true SCI has occurred or is underway and intervene accordingly. LEVEL OF EVIDENCE 4.
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Campos Mello Inglez de Souza MC, Ferreira RJR, Patricio GCF, Matera JM. Neurophysiological assessment of spinal cord injuries in dogs using somatosensory and motor evoked potentials. Acta Vet Scand 2017; 59:37. [PMID: 28606109 PMCID: PMC5469055 DOI: 10.1186/s13028-017-0305-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 05/30/2017] [Indexed: 11/16/2022] Open
Abstract
Somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) are non-invasive neurophysiological tests that reflect the functional integrity of sensory and motor pathways. Despite their extensive use and description in human medicine, reports in veterinary medicine are scarce. SSEPs are obtained via peripheral stimulation of sensory or mixed nerves; stimulation induces spinal and cortical responses, which are recorded when sensory pathways integrity is preserved. MEPs can be obtained via transcranial electrical or magnetic stimulation; in this case, thoracic and pelvic limb muscle responses are captured if motor pathways are preserved. This review describes principles, methodology and clinical applicability of SSEPs and MEPs in companion animal medicine. Potential interferences of anesthesia with SSEP and MEP recording are also discussed.
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DIAS ANDERSONALVES, LANNA RACHELALVARENGABOY, FERREIRA JUNIOR MARCOSANTÔNIO, DUARTE MARCELOGONÇALVESPEREIRA, FALCON ROBERTOSAKAMOTO, PORTO FILHO MANUELDEARAÚJO, OLIVEIRA DANIELDEABREU, LOPES SOBRINHO ALVARODEASSIS, ROSA MÁRCIOGUILHERME, AGUIAR LEONARDOFERNADES, MENEZES CRISTIANOMAGALHÃES. ELECTROMYOGRAPHY AND INSTRUMENTATION IN PATIENTS WITH IDIOPATHIC SCOLIOSIS. COLUNA/COLUMNA 2017. [DOI: 10.1590/s1808-185120171601147822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: The objective of this study is to relate the use of intraoperative electromyography with surgical time, proper placement of screws, type of curve and time spent per screw in idiopathic scoliosis correction surgery in a group of surgeons from Belo Horizonte. This study used the database of protocol evaluation of patients operated in the service, and separately analyzed the results of motor and somatosensory potentials. Methods: Retrospective study of 80 patients undergoing surgery for correction of idiopathic scoliosis between December 2008 and January 2015. A single group of Belo Horizonte spine surgeons performed the intraoperative electromyographic (EMG) monitoring. EMG was performed with stimulation of pedicle screws in patients undergoing instrumentation with pedicle screws as fixation elements. Results: The sample consisted of 85% females (mean age 17 years) and 37.5% of cases had classification type 1AN of Lenke. Of the total surgical cases, 60% had EMG changes. Of the total cases analyzed, 66.3% were true positives for the result. Conclusion: Intraoperative monitoring with EMG is a very important tool for the surgical treatment of patients with scoliosis undergoing instrumentation with pedicle screws. It enables to check if the screw is located on the correct path, helping to decrease the error rate and providing corrections to the surgical approach through a change of strategies. Moreover, it contributes to decrease the time to screw positioning and the total surgical time.
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Legatt AD, Emerson RG, Epstein CM, MacDonald DB, Deletis V, Bravo RJ, López JR. ACNS Guideline: Transcranial Electrical Stimulation Motor Evoked Potential Monitoring. J Clin Neurophysiol 2016; 33:42-50. [PMID: 26756258 DOI: 10.1097/wnp.0000000000000253] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Alan D Legatt
- *Departments of Neurology, Neuroscience, and Internal Medicine (Critical Care Medicine), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York, U.S.A.; †Department of Neurology, Hospital for Special Surgery, New York, New York, U.S.A.; ‡Department of Neurology, Emory University School of Medicine and the Emory Brain Health Center, Atlanta, Georgia, U.S.A.; §Section of Clinical Neurophysiology, Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; ‖Laboratory for Human Experimental Neurophysiology, School of Medicine, University of Split, Split, Croatia; ¶Neurophysiology Services, Palomar Medical Center, South Gate, California, U.S.A.; and #Departments of Neurology & Neurological Sciences and Neurosurgery, Stanford University School of Medicine, Stanford, California, U.S.A
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Gomes C, Kuchenbuch M, Lucas G, Argaud S, Violas P, Sauleau P. Validity and utility of monopolar spinal cord stimulation in pediatric scoliosis surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3201-3207. [PMID: 26957100 DOI: 10.1007/s00586-016-4504-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 02/26/2016] [Accepted: 02/26/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the validity and utility of monopolar stimulation (between a peridural needle and a large adhesive anode placed in the sternal area) for intraoperative monitoring in scoliosis surgery. METHODS This procedure was assessed during 41 operations involving either arthrodesis with posterior instrumentation or a Vertical Expandable Prosthetic Titanium Rib (VEPTR). Responses evoked by monopolar stimulation were compared with those evoked by bipolar stimulation between two epidural needle electrodes. Potentials evoked by monopolar stimulation in the upper limbs were compared with those evoked in the lower limbs during the same stimulation procedure. RESULTS Monopolar stimulation yielded equivalent and, if anything, more stable responses in the lower limbs. Recording in the upper limbs was satisfactory and allowed a decrease in responses to be detected in two patients. Acceptable thresholds for changes in amplitude relative to baseline were 40 % for upper limbs and 30 % for lower limbs. CONCLUSIONS Monopolar stimulation can be used to monitor the spinal cord during surgery for scoliosis correction. This procedure is more convenient for the surgeon and allows for the combined recording of responses in all four limbs, which can be useful in the case of surgical techniques such as those involving a VEPTR.
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Affiliation(s)
- Constantin Gomes
- Department of Neurophysiology, Rennes University Hospital, 35033, Rennes, France
| | - Mathieu Kuchenbuch
- Department of Neurophysiology, Rennes University Hospital, 35033, Rennes, France
| | - Grégory Lucas
- Department of Pediatric Orthopedic Surgery, Rennes University Hospital, 35033, Rennes, France
| | - Soizic Argaud
- "Behavior and Basal Ganglia" Research Unit (EA 4712), EA 4712 "Comportement et Noyaux Gris Centraux", Faculté de Médecine, Université de Rennes 1, Avenue Léon Bernard, 35043, Rennes, France
| | - Philippe Violas
- Department of Pediatric Orthopedic Surgery, Rennes University Hospital, 35033, Rennes, France
| | - Paul Sauleau
- Department of Neurophysiology, Rennes University Hospital, 35033, Rennes, France.
- "Behavior and Basal Ganglia" Research Unit (EA 4712), EA 4712 "Comportement et Noyaux Gris Centraux", Faculté de Médecine, Université de Rennes 1, Avenue Léon Bernard, 35043, Rennes, France.
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Henao J, Aubin CÉ, Labelle H, Arnoux PJ. Patient-specific finite element model of the spine and spinal cord to assess the neurological impact of scoliosis correction: preliminary application on two cases with and without intraoperative neurological complications. Comput Methods Biomech Biomed Engin 2015; 19:901-10. [DOI: 10.1080/10255842.2015.1075010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gomes C, Kuchenbuch M, Lucas G, Sauleau P, Violas P. Monopolar-probe monitoring during spinal surgery with expandable prosthetic ribs. Orthop Traumatol Surg Res 2015; 101:S193-7. [PMID: 25890812 DOI: 10.1016/j.otsr.2015.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Intraoperative monitoring (IOM) has been proven to decrease the risk of neurological injury during scoliosis surgery. The vertical expandable prosthetic titanium rib (VEPTR) is a device that allows spinal growth. However, injuries to the spinal cord and brachial plexus have been reported after VEPTR implantation in 2 and 5% of patients, respectively. Simultaneous monitoring of these two structures requires the use of multiple time-consuming and complex methods that are ill-suited to the requirements of paediatric surgery, particularly when repeated VEPTR lengthening procedures are needed. We developed a monopolar stimulation method derived from Owen's monitoring technique. This method is easy to implement, requires only widely available equipment, and allows concomitant monitoring of the spinal cord and brachial plexus. The primary objective of this study was to assess the reliability of our technique for brachial plexus monitoring by comparing the stability of neurogenic mixed evoked potentials (NMEPs) at the upper and lower limbs. HYPOTHESIS We hypothesised that the coefficients of variation (CVs) of NMEPs were the same at the upper and lower limbs. MATERIAL AND METHODS Twelve VEPTR procedures performed in 6 patients between 1st January 2012 and 1st September 2014 were monitored using a monopolar stimulating probe. NMEPs were recorded simultaneously at the upper and lower limbs, at intervals of 150 s. The recording sites were the elbow over the ulnar nerve and the popliteal fossa near the sciatic nerve. Wilcoxon's test for paired data was used to compare CVs of the upper and lower limb NMEPs on the same side. RESULTS Mean CV of NMEP amplitude at the lower limbs was 16.34% on the right and 16.67% on the left; corresponding values for the upper limbs were 18.30 and 19.75%, respectively. Mean CVs of NMEP latencies at the lower limbs were 1.31% on the right and 1.19% on the left; corresponding values for the upper limbs were 1.96 and 1.73%. The risk of type I error for a significant difference between the upper and lower limbs was 0.5843 on the right and 0.7312 on the left for NMEP amplitudes and 0.7618 on the right and 0.4987 on the left for NMEP latencies. CONCLUSION Using an epidural active electrode and a sternal return electrode allows simultaneous stimulation of the cervical spinal cord and brachial plexus roots. The NMEPs thus obtained are as stable (reliable) at the upper limbs as at the lower limbs. This easy-to-implement method allows simultaneous monitoring of the upper and lower limbs. It seems well suited to VEPTR procedures. LEVEL OF EVIDENCE IV, retrospective single-centre non-randomised study.
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Affiliation(s)
- C Gomes
- Service de neurophysiologie, CHU de Rennes, 35033 Rennes, France.
| | - M Kuchenbuch
- Service de neurophysiologie, CHU de Rennes, 35033 Rennes, France; Université Rennes 1, 35043 Rennes, France
| | - G Lucas
- Service de chirurgie orthopédique pédiatrique, CHU de Rennes, 35033 Rennes, France; Université Rennes 1, 35043 Rennes, France
| | - P Sauleau
- Service de neurophysiologie, CHU de Rennes, 35033 Rennes, France; Inserm, EA 4712, 35043 Rennes, France
| | - P Violas
- Service de chirurgie orthopédique pédiatrique, CHU de Rennes, 35033 Rennes, France; Université Rennes 1, 35043 Rennes, France
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Affiliation(s)
- Alan D. Legatt
- Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York
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Osburn LL. A Guide to the Performance of Transcranial Electrical Motor Evoked Potentials. Part 1. Basic Concepts, Recording Parameters, Special Considerations, and Application. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/1086508x.2006.11079565] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Leisha L. Osburn
- Neurophysiology Lab Clarian Health Partners Methodist Hospital Indianapolis, Indiana
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Affiliation(s)
- Michael R. Isley
- Intraoperative Neuromonitoring Department and Neurosciences Institute Orlando Regional Medical Center Orlando, Florida
| | - Jeffrey R. Balzer
- Department of Neurosurgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Ronald C. Pearlman
- School of Communication Howard University Washington, District of Columbia
| | - Xiao-Feng Zhang
- Intraoperative Neuromonitoring Department and Neurosciences Institute Orlando Regional Medical Center Orlando, Florida
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Rare true-positive isolated SSEP loss with preservation of MEPs response during scoliosis correction. Spine (Phila Pa 1976) 2014; 39:E60-3. [PMID: 24153165 DOI: 10.1097/brs.0000000000000076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVE To report a case of a true-positive isolated somatosensory evoked potential (SSEP) loss with preservation of motor evoked potential (MEP) response during scoliosis correction. SUMMARY OF BACKGROUND DATA Combined intraoperative monitoring uses SSEPs and MEPs to decrease the probability of observing false-negative events. In combination, SSEPs and MEPs have become a standard of care for spinal deformity surgery. However, literature review reveals several cases of false-negative response with combined SSEPs and MEPs, raising the contention that intraoperative monitoring does not reliably identify all isolated selective spinal cord dysfunction. METHODS A 15-year-old female patient with a 65° right thoracic adolescent idiopathic scoliosis underwent correction and posterior spinal fusion with segmental pedicle screw instrumentation. After capture and derotation of the left concave rod, left-sided irreversible SSEP loss occurred whereas MEPs remained unchanged. After excluding systemic factors, anesthetic causes, or technical fault, deformity correction was released and instrumentation removed. No cortical breach was reported during pedicle screw removal. RESULTS Postoperatively, no clinical sensory or motor deficit was present; computed tomography demonstrated a burst left pedicle at T10 with the medial pedicle wall fragment in direct contact with the dorsal spinal cord. Magnetic resonance imaging excluded cord edema or other evidence of injury. Three days after surgery, intraoperative monitoring showed delayed latencies and amplitudes of the left SSEP. An uneventful reinsertion of instrumentation and correction excluding the left T10 pedicle screw was performed 7 days after the initial surgery. CONCLUSION This case report provides evidence of selective posterior spinal cord dysfunction with sparing of the anterior columns immediately after a correction maneuver and emphasizes the importance of simultaneous SSEP and MEP monitoring. To the authors' knowledge, there is no previous report of a true-positive isolated SSEP loss with preservation of MEP response during scoliosis correction. LEVEL OF EVIDENCE N/A.
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Kroeker SG, Ching RP. Coupling between the spinal cord and cervical vertebral column under tensile loading. J Biomech 2013; 46:773-9. [DOI: 10.1016/j.jbiomech.2012.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 11/03/2012] [Accepted: 11/09/2012] [Indexed: 11/26/2022]
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Netto MB, Risso Neto MI, Ferreira RJR, Zuiani GR, Cavali PTM, Veiga IG, Pasqualini W, Lehoczki MA, Rossato AJ, Silva HJSSD, Landim É. A realidade do uso da monitorização neurofisiológica intraoperatória entre os cirurgiões de coluna brasileiros. COLUNA/COLUMNA 2012. [DOI: 10.1590/s1808-18512012000400012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar o uso da monitorização neurofisiológica intraoperatória (MNIO) por cirurgiões de coluna brasileiros. MÉTODO: A coleta de dados foi realizada através de um questionário aplicado em 307 cirurgiões de coluna brasileiros, durante o 11º Congresso de Cirurgia Espinhal e XIII Congresso da Sociedade Brasileira de Coluna. RESULTADOS: Dos cirurgiões entrevistados, 42% são neurocirurgiões e 58% ortopedistas. A maioria (72,3%) relatou que já fez uso do MNIO, entretanto apenas 29,6% utilizam este procedimento rotineiramente. Destes 39% são ortopedistas. Entre os neurocirurgiões, a maior parte (84%) relatou não utilizar MNIO como rotina. Nos casos de deformidade, 85,7% dos profissionais disseram usar rotineiramente a MNIO. Do total, 68,1% responderam que não tinham fácil acesso à MNIO, sendo que 10% deles atuam na região Centro-oeste do país e 11%, na região Nordeste. Dos que relataram facilidade de acesso ao procedimento, 77% atuam na região Sudeste. A média de idade dos participantes foi 41,9 anos, com mediana de 39,0, desvio padrão de 11,3 e intervalo de confiança de 1,3. Para o tempo de formação médica, a média foi 17,8 anos, com mediana de 14,0 e intervalo de confiança 1,2. Em relação ao tempo de prática em cirurgia de coluna encontrou-se que 56,3% têm até 10 anos de prática. CONCLUSÃO: A maioria dos cirurgiões de coluna já fez uso da MNIO, contudo poucos utilizam-na como rotina. A região Sudeste é onde se encontra maior facilidade de acesso à MNIO, ao contrário das regiões Centro-oeste e Nordeste.
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Gavaret M, Trébuchon A, Aubert S, Jacopin S, Blondel B, Glard Y, Jouve JL, Bollini G. Intraoperative monitoring in pediatric orthopedic spinal surgery: three hundred consecutive monitoring cases of which 10% of patients were younger than 4 years of age. Spine (Phila Pa 1976) 2011; 36:1855-63. [PMID: 21270706 DOI: 10.1097/brs.0b013e3181f806d9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Analysis of a prospective series of 300 consecutive cases undergoing intraoperative monitoring in pediatric orthopedic spinal surgery, of which 10% were children younger than 4 years. OBJECTIVE Determine feasibility and performance of intraoperative monitoring in children younger than 4 years. Analyze distinct physiopathologic mechanisms of relevant alerts. SUMMARY OF BACKGROUND DATA There are few studies in the literature concerning the intraoperative monitoring of children younger than 4 years. During childhood, the development of sensori-motor pathways is dominated by two coexisting phenomena, which have opposite effects: maturation decreasing latencies and height increasing them. METHODS We used intraoperative somatosensory-evoked potentials and neurogenic mixed evoked potentials with a flexible bipolar epidural electrode. Uniform total intravenous anesthesia was used. RESULTS Values of sensitivity and specificity of the monitoring showed slight differences between patients younger than 4 years versus older patients. There was no false-negative outcome. Various tendencies were highlighted. There were more true positive alerts for secondary etiologies than for idiopathic ones, for revision spinal surgeries than for index ones, and for boys than for girls. There were no more true positive alerts for children younger than 4 years than for older patients whereas the proportion of hemivertebrae was obviously greater for the younger group. Relevant monitoring alerts were more frequent in case of kyphoscoliosis. This is highlighted in case reports. CONCLUSION In some cases of kyphoscoliosis, during a posterior-based vertebral column resection, monitoring changes were corrected by positioning a rod that allowed correction of the position of the spine in the sagittal plane. Intraoperative spinal cord monitoring can be performed in children younger than 4 years and allows real-time assessment of spinal functional integrity.
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Affiliation(s)
- Martine Gavaret
- Hôpital de la Timone, Service de Neurophysiologie Clinique, Marseille, France.
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Abstract
STUDY DESIGN Review of the literature with analysis of pooled data. OBJECTIVE To assess common intraoperative neuromonitoring (IOM) changes that occur during the course of spinal surgery, potential causes of change, and determine appropriate responses. Further, there will be discussion of appropriate application of IOM, and medical legal aspects. The structured literature review will answer the following questions: What are the various IOM methods currently available for spinal surgery? What are the sensitivities and specificities of each modality for neural element injury? How are the changes in each modality best interpreted? What is the appropriate response to indicated changes? Recommendations will be made as to the interpretation and appropriate response to IOM changes. SUMMARY OF BACKGROUND DATA Total number of abstracts identified and reviewed was 187. Full review was performed on 18 articles. METHODS The MEDLINE database was queried using the search terms IOM, spinal surgery, SSEP, wake-up test, MEP, spontaneous and triggered electromyography alone and in various combinations. Abstracts were identified and reviewed. Individual case reports were excluded. Detailed information and data from appropriate articles were assessed and compiled. RESULTS Ability to achieve IOM baseline data varied from 70% to 98% for somatosensory-evoked potentials (SSEP) and 66% to 100% for motor-evoked potentials (MEP) in absence of neural axis abnormality. Multimodality intraoperative neuromonitoring (MIOM) provided false negatives in 0% to 0.79% of cases, whereas isolated SSEP monitoring alone provided false negative in 0.063% to 2.7% of cases. MIOM provided false positive warning in 0.6% to 1.38% of cases. CONCLUSION As spine surgery, and patient comorbidity, becomes increasingly complex, IOM permits more aggressive deformity correction and tumor resection. Combination of SSEP and MEP monitoring provides assessment of entire spinal cord functionality in real time. Spontaneous and triggered electromyography add assessment of nerve roots. The wake-up test can continue to serve as a supplement when needed. MIOM may prove useful in preservation of neurologic function where an alteration of approach is possible. IOM is a valuable tool for optimization of outcome in complex spinal surgery.
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Validity and reliability of intraoperative monitoring in pediatric spinal deformity surgery: a 23-year experience of 3436 surgical cases. Spine (Phila Pa 1976) 2010; 35:1880-6. [PMID: 20802388 DOI: 10.1097/brs.0b013e3181e53434] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This was a 23-year retrospective study of 3436 consecutive pediatric orthopedic spinal surgery patients between 1995 and 2008. OBJECTIVE To demonstrate the effectiveness of multimodality electrophysiologic monitoring in reducing the incidence of iatrogenic neurologic deficit in a pediatric spinal surgery population. SUMMARY OF BACKGROUND DATA The elective nature of many pediatric spinal surgery procedures continues to drive the need for minimizing risk to each individual patient. Electrophysiologic monitoring has been proposed as an effective means of decreasing permanent neurologic injury in this population. METHODS A total of 3436 consecutive monitored pediatric spinal procedures at a single institution between January 1985 and September 2008 were reviewed. Monitoring included somatosensory-evoked potentials, descending neurogenic-evoked potentials, transcranial electric motor-evoked potentials, and various nerve root monitoring techniques. Patients were divided into 10 diagnostic categories. True-positive and false-negative monitoring outcomes were analyzed for each category. Neurologic deficits were classified as transient or permanent. RESULTS Seven of 10 diagnostic groups demonstrated true positive findings resulting in surgical intervention. Seventy-four (2.2%) potential neurologic deficits were identified in 3436 pediatric surgical cases. Seven patients (0.2%) had false-negative monitoring outcomes. These patients awoke with neurologic deficits undetected by neuromonitoring. Intervention reduced permanent neurologic deficits to 6 (0.17%) patients. Monitoring data were able to detect permanent neurologic status in 99.6% of this population. The ratio of intraoperative events to total monitored cases was 1 event every 42 surgical cases and 1 permanent neurologic deficit every 573 cases. CONCLUSION The combined use of somatosensory-evoked potentials, transcranial electric motor-evoked potentials, descending neurogenic-evoked potentials, and electromyography monitoring allowed accurate detection of permanent neurologic status in 99.6% of 3436 patients and reduced the total number of permanent neurologic injuries to 6.
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Pasqualini W, Tebet MA, Carvalho MOPD, Kanno RM, Castellon AT. Monitoração intraoperatória com teste de estimulação eletromiográfica dos instrumentais de pacientes submetidos à correção cirúrgica de escoliose idiopática. COLUNA/COLUMNA 2010. [DOI: 10.1590/s1808-18512010000300006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJETIVO: apresentar a metodologia empregada na monitoração neurofisiológica de pacientes submetidos a tratamento para correção de escoliose idiopática com instrumentação cirúrgica, utilizando parafusos pediculares torácicos e lombares. MÉTODOS: foram estudados, retrospectivamente, 32 prontuários de pacientes operados no Serviço de Cirurgia da Coluna Vertebral do Instituto da Coluna,Jundiaí, São Paulo, entre os anos de 2004 e 2008. A idade variou de 11 a 18 anos, e a maioria era do sexo feminino (93,75%). RESULTADOS: verificou-se que em seis pacientes houve relação entre a incidência de positividade no teste com estimulação eletromiográfica dos instrumentais e mau posicionamento dos parafusos pediculares, sem evidências de complicações após correção dos mesmos. CONCLUSÃO: os resultados confirmam a eficácia da monitoração intraoperatória.
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Kuluz J, Samdani A, Benglis D, Gonzalez-Brito M, Solano JP, Ramirez MA, Luqman A, De Los Santos R, Hutchinson D, Nares M, Padgett K, He D, Huang T, Levi A, Betz R, Dietrich D. Pediatric spinal cord injury in infant piglets: description of a new large animal model and review of the literature. J Spinal Cord Med 2010; 33:43-57. [PMID: 20397443 PMCID: PMC2853328 DOI: 10.1080/10790268.2010.11689673] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To develop a new, clinically relevant large animal model of pediatric spinal cord injury (SCI) and compare the clinical and experimental features of pediatric SCI. METHODS Infant piglets (3-5 weeks old) underwent contusive SCI by controlled cortical impactor at T7. Severe complete SCI was induced in 6 piglets, defined as SCI with no spontaneous return of sensorimotor function. Eight piglets received incomplete SCI, which was followed by partial recovery. Somatosensory evoked potentials, magnetic resonance imaging, neurobehavioral function, and histopathology were measured during a 28-day survival period. RESULTS Mean SCI volume (defined as volume of necrotic tissue) was larger after complete compared with incomplete SCI (387 +/- 29 vs 77 +/- 38 mm3, respectively, P < 0.001). No functional recovery occurred after complete SCI. After incomplete SCI, piglets initially had an absence of lower extremity sensorimotor function, urinary and stool retention, and little to no rectal tone. Sensory responses recovered first (1-2 days after injury), followed by spontaneous voiding, lower extremity motor responses, regular bowel movements, and repetitive flexion-extension of the lower extremities when crawling. No piglet recovered spontaneous walking, although 4 of 8 animals with incomplete injuries were able to bear weight by 28 days. In vivo magnetic resonance imaging was performed safely, yielded high-resolution images of tissue injury, and correlated closely with injury volume seen on histopathology, which included intramedullary hemorrhage, cellular inflammation, necrosis, and apoptosis. CONCLUSION Piglets performed well as a reproducible model of traumatic pediatric SCI in a large animal with chronic survival and utilizing multiple outcome measures, including evoked potentials, magnetic resonance imaging, functional outcome scores, and histopathology.
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Affiliation(s)
- John Kuluz
- Pediatric Critical Care (R-131), University of Miami School of Medicine, 1611 NW 12th Avenue, Miami, FL 33136, USA.
| | - Amer Samdani
- Shriners Hospitals for Children, Philadelphia, Pennsylvania
| | - David Benglis
- University of Miami School of Medicine, Miami, Florida
| | | | - Juan P Solano
- University of Miami School of Medicine, Miami, Florida
| | | | - Ali Luqman
- University of Miami School of Medicine, Miami, Florida
| | | | | | - Mike Nares
- University of Miami School of Medicine, Miami, Florida
| | - Kyle Padgett
- University of Miami School of Medicine, Miami, Florida
| | - Dansha He
- University of Miami School of Medicine, Miami, Florida
| | | | - Allan Levi
- University of Miami School of Medicine, Miami, Florida
| | - Randal Betz
- Shriners Hospitals for Children, Philadelphia, Pennsylvania
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Kundnani VK, Zhu L, Tak HH, Wong HK. Multimodal intraoperative neuromonitoring in corrective surgery for adolescent idiopathic scoliosis: Evaluation of 354 consecutive cases. Indian J Orthop 2010; 44:64-72. [PMID: 20165679 PMCID: PMC2822422 DOI: 10.4103/0019-5413.58608] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Multimodal intraoperative neuromonitoring is recommended during corrective spinal surgery, and has been widely used in surgery for spinal deformity with successful outcomes. Despite successful outcomes of corrective surgery due to increased safety of the patients with the usage of spinal cord monitoring in many large spine centers, this modality has not yet achieved widespread popularity. We report the analysis of prospectively collected intraoperative neurophysiological monitoring data of 354 consecutive patients undergoing corrective surgery for adolescent idiopathic scoliosis (AIS) to establish the efficacy of multimodal neuromonitoring and to evaluate comparative sensitivity and specificity. MATERIALS AND METHODS The study group consisted of 354 (female = 309; male = 45) patients undergoing spinal deformity corrective surgery between 2004 and 2008. Patients were monitored using electrophysiological methods including somatosensory-evoked potentials and motor-evoked potentials simultaneously. RESULTS Mean age of patients was 13.6 years (+/-2.3 years). The operative procedures involved were instrumented fusion of the thoracic/lumbar/both curves, Baseline somatosensory-evoked potentials (SSEP) and neurogenic motor-evoked potentials (NMEP) were recorded successfully in all cases. Thirteen cases expressed significant alert to prompt reversal of intervention. All these 13 cases with significant alert had detectable NMEP alerts, whereas significant SSEP alert was detected in 8 cases. Two patients awoke with new neurological deficit (0.56%) and had significant intraoperative SSEP + NMEP alerts. There were no false positives with SSEP (high specificity) but 5 patients with false negatives with SSEP (38%) reduced its sensitivity. There was no false negative with NMEP but 2 of 13 cases were false positive with NMEP (15%). The specificity of SSEP (100%) is higher than NMEP (96%); however, the sensitivity of NMEP (100%) is far better than SSEP (51%). Due to these results, the overall sensitivity, specificity and positive predictive value of combined multimodality neuromonitoring in this adult deformity series was 100, 98.5 and 85%, respectively. CONCLUSION Neurogenic motor-evoked potential (NMEP) monitoring appears to be superior to conventional SSEP monitoring for identifying evolving spinal cord injury. Used in conjunction, the sensitivity and specificity of combined neuromonitoring may reach up to 100%. Multimodality monitoring with SSEP + NMEP should be the standard of care.
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Affiliation(s)
- Vishal K Kundnani
- University Spine Center, National University Hospital, Singapore,Address for correspondence: Dr. Vishal Kundnani, Bombay Hospital & Medical Research Centre, 12, Marine Lines, Mumbai. E-mail:
| | - Lisa Zhu
- University Spine Center, National University Hospital, Singapore
| | - HH Tak
- University Spine Center, National University Hospital, Singapore
| | - HK Wong
- University Spine Center, National University Hospital, Singapore
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Epidural analgesia after scoliosis surgery: electrophysiologic and clinical assessment of the effects of bupivacaine 0.125% plus morphine versus ropivacaine 0.2% plus morphine. J Clin Anesth 2008; 20:17-24. [DOI: 10.1016/j.jclinane.2007.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2006] [Revised: 07/05/2007] [Accepted: 07/07/2007] [Indexed: 12/13/2022]
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Deletis V. Basic methodological principles of multimodal intraoperative monitoring during spine surgeries. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2007; 16 Suppl 2:S147-52. [PMID: 17623112 PMCID: PMC2072896 DOI: 10.1007/s00586-007-0429-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/07/2007] [Indexed: 10/23/2022]
Affiliation(s)
- Vedran Deletis
- Institute for Neurology and Neurosurgery, Albert Einstein-College of Medicine, St Luke's-Roosevelt Hospital, 11C-08, 1000 Tenth Avenue, New York, NY 10019, USA.
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Magit DP, Hilibrand AS, Kirk J, Rechtine G, Albert TJ, Vaccaro AR, Simpson AK, Grauer JN. Questionnaire Study of Neuromonitoring Availability and Usage for Spine Surgery. ACTA ACUST UNITED AC 2007; 20:282-9. [PMID: 17538352 DOI: 10.1097/01.bsd.0000211286.98895.ea] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Questionnaire study presented to practicing spine surgeons. OBJECTIVE To evaluate surgeon preference and availability of selected electrophysiologic neuromonitoring for different spine surgeries. SUMMARY OF BACKGROUND DATA Maximizing the safety of spinal procedures and limiting potential iatrogenic neurologic injury has made intraoperative neuromonitoring an attractive option. METHODS We distributed a questionnaire to 180 orthopedic spine surgeons and neurosurgeons at a clinically oriented spine meeting asking surgeon preference and availability of various types of intraoperative neuromonitoring modalities for different types of surgical procedures. Demographic data were also gathered. RESULTS Somatosensory evoked potentials (SSEPs) were the most available neuromonitoring modality, followed by electromyographies and motor-evoked potentials. In both anterior and posterior cervical surgery, SSEPs were the most preferred modality. MEPs were frequently preferred in myelopathic cervical cases. Almost 70% preferred some neuromonitoring for anterior thoracic/thoracolumbar cases and 55% for posterior thoracic/thoracolumbar cases. Surgeon satisfaction was related to the number of available neuromonitoring modalities. No significant differences were found between orthopedist and neurosurgeon preferences. Fellowship-trained surgeons were more likely to use neuromonitoring for specific indications. CONCLUSIONS SSEPs remains the most widely available and preferred type of neuromonitoring for spine surgeons. The type of case and neurologic status of patient (eg, presence of myelopathy) affects these choices. Surgeons were more satisfied with greater neuromonitoring availability, and were more likely to use neuromonitoring if they had a fellowship background.
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Affiliation(s)
- David P Magit
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 065120-8071, USA
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Accadbled F, Henry P, de Gauzy JS, Cahuzac JP. Spinal cord monitoring in scoliosis surgery using an epidural electrode. Results of a prospective, consecutive series of 191 cases. Spine (Phila Pa 1976) 2006; 31:2614-23. [PMID: 17047554 DOI: 10.1097/01.brs.0000240642.28495.99] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of a prospectively accrued series of 191 consecutive patients who underwent intraoperative neurophysiologic monitoring during scoliosis corrective surgery. OBJECTIVES To compare the monitoring outcome of idiopathic and neuromuscular scoliosis. To demonstrate the usefulness of the epidural electrode. To report sensitivity and specificity of the monitoring method employed at a single institution. SUMMARY OF BACKGROUND DATA Reports in the literature emphasized the difficulty to obtain data in neuromuscular patients. Multimodality spinal cord monitoring has been recommended. Despite their still debated composition, neurogenic motor-evoked potentials have proven their validity in clinical practice. METHODS Somatosensory and neurogenic evoked potentials were attempted in all patients presenting for scoliosis correction between 1999 and 2005. Study patients were divided into 3 groups: group 1, idiopathic; group 2, neuromuscular; and group 3, miscellaneous origins. RESULTS The use of the epidural electrode demonstrated significant usefulness in the ability of monitoring otherwise nonmonitored patients, especially in group 2. Inability to obtain any evoked potentials occurred in 4 cases (2.1%). Five cases were found to be true positives. An adapted and rapid intervention permitted to avoid new postoperative deficit in all cases. There was no instance of false-negative data. The overall method sensitivity was 100%, and specificity was 52.69%. CONCLUSIONS The use of a single epidural electrode allowing somatosensory evoked potentials recording and spinal cord stimulation alternately is a safe and valid method of intraoperative monitoring.
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Affiliation(s)
- Franck Accadbled
- Department of Pediatric Orthopedic Surgery, Children's Hospital, Toulouse, France.
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Macdonald DB. Intraoperative Motor Evoked Potential Monitoring: Overview and Update. J Clin Monit Comput 2006; 20:347-77. [PMID: 16832580 DOI: 10.1007/s10877-006-9033-0] [Citation(s) in RCA: 192] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Accepted: 05/23/2006] [Indexed: 01/20/2023]
Abstract
Amidst controversy about methodology and safety, intraoperative neurophysiology has entered a new era of increasingly routine transcranial and direct electrical brain stimulation for motor evoked potential (MEP) monitoring. Based on literature review and illustrative clinical experience, this tutorial aims to present a balanced overview for experienced practitioners, surgeons and anesthesiologists as well as those new to the field. It details the physiologic basis, indications and methodology of current MEP monitoring techniques, evaluates their safety, explores interpretive controversies and outlines some applications and results, including aortic aneurysm, intramedullary spinal cord tumor, spinal deformity, posterior fossa tumor, intracranial aneurysm and peri-rolandic brain surgeries. The many advances in motor system assessment achieved in the last two decades undoubtedly improve monitoring efficacy without unduly compromising safety. Future studies and experience will likely clarify existing controversies and bring further advances.
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Affiliation(s)
- David B Macdonald
- Department of Neurosciences, King Faisal Specialist Hospital & Research Center, MBC 76, PO Box 3354, Riyadh 11211, Saudi Arabia.
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Guigui P, Blamoutier A. [Complications of surgical treatment of spinal deformities: a prospective multicentric study of 3311 patients]. ACTA ACUST UNITED AC 2005; 91:314-27. [PMID: 16158546 DOI: 10.1016/s0035-1040(05)84329-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE OF THE STUDY The incidence of complications secondary to surgical treatment of spinal deformations remains imprecise. The purpose of this prospective multicentric observational study was to assess the incidence of intra- and postoperative complications secondary to this type of surgery to detail the observed complications and to identify favoring factors. MATERIAL AND METHODS For this study, we included 3311 patients who underwent surgery during a 12-month period for spinal deformation, defined as idiopathic or secondary scoliosis or kyphosis, irrespective of the localization, severity, or type of surgery performed. Four main categories of complications were studied: general, infectious, neurological, and mechanical. Pre- and intraoperative variables recorded were: epidemiological and morphological data, history of surgery for the same spinal deformation, comorbid conditions, type of deformation treated (nature, anatomic localization, severity, reducibility), type of surgery performed (approach, duration of the operation), operative blood loss, extent and localization of the fusion, associated neurological release, vertebral osteotomy or not, type of graft used. Two types of analysis were performed. The first was a descriptive analysis to detail the overall incidence of complications and the incidence of each of the four main categories. The second was a multivariate analysis designed to determine factors significantly associated with complication occurrence. RESULTS Mean age of the cohort was 27 +/- 18 years; 6.8% of the patients had had a prior operation for the spinal deformation. The deformation was scoliosis in 90% (mean angle 56 +/- 20 degrees) and kyphosis in 10% (mean angle 47 +/- 23 degrees). An isolated posterior approach was used for 72.5% of patients, an isolated anterior approach for 6.4%, and a combined anteroposterior approach for 21.1%. Seven hundred four patients (21.3%) had one or more complications (850 complications) during or shortly after their operation. The incidences of general, infectious, mechanical and neurological complications were: 5.7%, 4.7%, 11.5%, and 1.8% respectively. Globally, considering all types of complications, the following factors were found to be significantly associated with complication occurrence: patient age, ASA score, extent of the fusion, presence of vertebral osteotomy, inclusion of the sacrum in the arthrodesis, and initial angle of the treated deformation. For patients with scoliosis, the following factors were significantly associated with a secondary central neurological disorder: initial angle of the deformation, use of vertebral osteotomy, type of curvature with greater risk for thoracic curvatures and double thoracic and lumbar curvatures. CONCLUSION This work enabled us to determine the overall rate of complications after surgical treatment of spinal deformations. Certain risk factors related with complication occurrence were identified, but the heterogeneous nature of the population and the methodology used to identify these factors only allowed detection of trends. A future study by etiological group or focusing on specific complications should allow a more precise analysis of these risk factors. This overall rate of complications should be used to better inform patients and their family about the risks of this type of surgery.
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Affiliation(s)
- P Guigui
- Service de Chirurgie Orthopédique, Hôpital Beaujon, 100, boulevard du Général-Leclerc, 92110 Clichy.
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Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 15: electrophysiological monitoring and lumbar fusion. J Neurosurg Spine 2005; 2:725-32. [PMID: 16028743 DOI: 10.3171/spi.2005.2.6.0725] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Based on the medical evidence provided by the literature reviewed, there does not appear to be support for the hypothesis that any form of intraoperative monitoring improves patient outcomes following lumbar decompression or fusion procedures for degenerative spinal disease. Evidence does indicate that a normal evoked EMG response is predictive for intrapedicular screw placement (high NPV for breakout). The presence of an abnormal EMG response does not, however, exclude intrapedicular screw placement (low PPV). The majority of clinically apparent postoperative nerve injuries are associated with intraoperative changes in SSEP and/or DSEP monitoring. For this reason, changes in DSEP/SSEP monitoring appear to be sensitive to nerve root injury. There is a high-false positive rate, however, and changes in DSEP and SSEP recordings are frequently not related to nerve injury. A normal study has been shown to correlate with the lack of a significant postoperative nerve injury. There is no substantial evidence to indicate that the use of intraoperative monitoring of any kind provides useful information to the surgeon in terms of assessing the adequacy of nerve root decompression at the time of surgery.
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Affiliation(s)
- Daniel K Resnick
- Department of Neurosurgery, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA.
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Skinner SA, Nagib M, Bergman TA, Maxwell RE, Msangi G. The Initial Use of Free-running Electromyography to Detect Early Motor Tract Injury during Resection of Intramedullary Spinal Cord Lesions. Oper Neurosurg (Hagerstown) 2005; 56:299-314; discussion 299-314. [PMID: 15794827 DOI: 10.1227/01.neu.0000156545.33814.8d] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2004] [Accepted: 09/20/2004] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
The resection of intramedullary spinal cord lesions (ISCLs) can be complicated by neurological deficits. Neuromonitoring has been used to reduce intraoperative risk. We have used somatosensory evoked potentials (SEPs) and muscle-derived transcranial electrical motor evoked potentials (myogenic TCE-MEPs) to monitor ISCL removal. We report our retrospective experience with the addition of free-running electromyography (EMG).
METHODS:
Thirteen patients underwent 14 monitored ISCL excisions. Anesthesia was maintained with minimal inhalant to reduce motoneuron suppression and enhance the myogenic TCE-MEPs. Free-running EMG was examined in the four limbs for evidence of abnormal bursts, prolonged tonic discharge, or sudden electrical silence. Warning of an electromyographic abnormality or myogenic TCE-MEP loss prompted interventions, including blood pressure elevation, a pause in surgery, a wake-up test, or termination of surgery. Pre- and postoperative neurological examinations determined the incidence of new deficits.
RESULTS:
The combined use of free-running EMG and myogenic TCE-MEPs detected all eight patients with a new motor deficit after surgery; there was one false-positive report. In three of the eight true-positive cases, an electromyographic abnormality immediately anticipated loss of the myogenic TCE-MEPs. Two patients with abnormal EMGs but unchanged myogenic TCE-MEPs experienced mild postoperative worsening of motor deficits; myogenic TCE-MEPs alone would have generated false-negative reports in these cases.
CONCLUSION:
During resection of ISCLs, free-running EMG can supplement motor tract monitoring by TCE-MEPs. Segmental and suprasegmental elicitation of neurotonic discharges can be observed in four-limb EMG. Abnormal electromyographic bursts, tonic discharge, or abrupt electromyographic silence may anticipate myogenic TCE-MEP loss and predict a postoperative motor deficit.
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Affiliation(s)
- Stanley A Skinner
- Department of Intraoperative Monitoring, Abbott Northwestern Hospital, Minneapolis, Minnesota 55407-3799, USA.
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Hargreaves SJ, Watt JWH. Intravenous anaesthesia and repetitive transcranial magnetic stimulation monitoring in spinal column surgery. Br J Anaesth 2005; 94:70-3. [PMID: 15465838 DOI: 10.1093/bja/aeh284] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Transcranial magnetic stimulation with motor evoked potential monitoring is a non-invasive method for monitoring motor tracts during surgery. However, anaesthetic agents such as propofol and volatile agents reduce responses to single transcranial magnetic stimulation. We assessed an intravenous technique for anaesthesia to allow motor evoked potentials (MEPs) to be monitored using repetitive transcranial magnetic stimulation (rTMS). METHODS We applied three-pulse rTMS (TriStim) in 11 patients undergoing spinal column surgery after spinal column injury and recorded the latency and peak-to-peak amplitude of MEPs. Anaesthesia was maintained with propofol and remifentanil. RESULTS MEPs were monitored successfully intraoperatively in all patients. CONCLUSIONS It is possible to monitor intraoperative MEP using rTMS during anaesthesia with propofol and remifentanil.
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Affiliation(s)
- S J Hargreaves
- Spinal Injuries Unit, Southport and Ormskirk Hospital NHS Trust, Town Lane, Southport PR8 6PN, UK
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Dabney KW, Ehrenshteyn M, Agresta CA, Twiss JL, Stern G, Tice L, Salzman SK. A model of experimental spinal cord trauma based on computer-controlled intervertebral distraction: characterization of graded injury. Spine (Phila Pa 1976) 2004; 29:2357-64. [PMID: 15507795 DOI: 10.1097/01.brs.0000143108.65385.74] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN : A new model of experimental spinal cord injury is detailed based on the application of tensile (distraction) force to the vertebral column of the rat. OBJECTIVES : To develop an experimental model of graded spinal cord injury by application of tensile forces to the vertebral column. SUMMARY OF BACKGROUND DATA : Distraction is frequently an integral component of human spinal cord injury, but the acute application of tensile forces to the spinal cord has not been modeled rigorously. METHODS : A computer-controlled, motorized outrigger device was used to apply a longitudinal stretching force to sublaminar hooks oriented proximally at T9 and distally at T11. Distraction force was applied using a program that varied the length, speed, and duration of its distraction. A modified 14-point Tarlov score was used to establish the presence of hindlimb dysfunction. This score was correlated with acute changes in somatosensory-evoked potential amplitude, the comprehensive open-field test of locomotor function at 4 weeks, and postmortem measurements of serotonin content and metabolism in spinal cord rostral and distal to the site of injury. RESULTS : Of distraction parameters, only length of distraction correlated significantly with each outcome measure. For outcome measures, open-field test inventory and distal/proximal ratio of the spinal content of serotonin were correlated most closely with final Tarlov scores. Acute somatosensory-evoked potential amplitudes proved to be an excellent index of the acute injury but were poor measures of long-term outcome. CONCLUSIONS : Distraction-induced spinal cord injury was uniformly mild in rats with intact facet capsular ligaments, regardless of distraction parameters. Cutting the facet joint ligaments consistently generated outcome measures associated with mild, moderate, and severe spinal cord injury at 3-, 5-, and 7-mm distraction lengths, respectively.
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Affiliation(s)
- Kirk W Dabney
- Spinal Trauma Research Laboratory, Nemours Biomedical Research, and Department of Orthopaedic Surgery, Nemours Children's Clinic-Wilmington, Alfred I. duPont Hospital for Children, Wilmington, Delaware 19803, USA.
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Grottke O, Dietrich PJ, Wiegels S, Wappler F. Intraoperative Wake-Up Test and Postoperative Emergence in Patients Undergoing Spinal Surgery: A Comparison of Intravenous and Inhaled Anesthetic Techniques Using Short-Acting Anesthetics. Anesth Analg 2004; 99:1521-1527. [PMID: 15502058 DOI: 10.1213/01.ane.0000134684.25322.26] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Surgical procedures on the vertebral column may result in spinal cord damage, leading to neurological deficits that demand immediate therapeutical intervention. We designed this study to determine which anesthetic regimen allows a rapid wake-up test during and after surgery to detect neurological deficits. Fifty-four patients were randomly allocated to the following groups: group PR (propofol/remifentanil): target-controlled infusion with propofol (plasma concentration, 2-4 microg/mL) and remifentanil 0.2-0.5 microg . kg(-1) . min(-1); group PS (propofol/sufentanil): propofol (2-4 microg/mL) and repetitive boluses of 0.1-0.2 microg/kg of sufentanil adjusted to patients requirements; and group DR (desflurane/remifentanil): desflurane/air 3.0-4.0 vol% combined with remifentanil 0.2-0.5 microg . kg(-1) . min(-1). Group PS required significantly longer times for the onset of breathing (8.9 +/- 1.6 min), elevation of the head (17.0 +/- 3.8 min), and motion of the feet (17.0 +/- 7.4 min) than group PR (6.9 +/- 2.6 min, 9.3 +/- 2.2 min, and 9.4 +/- 2.4 min, respectively) or group DR (5.4 +/- 0.8 min, 6.1 +/- 1.0 min, and 6.2 +/- 1.0 min, respectively). The anesthetic regimen with desflurane and remifentanil allowed faster awakening during and after surgery that permitted immediate neurological examination after spinal surgery compared with propofol/remifentanil.
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Affiliation(s)
- Oliver Grottke
- *Department of Anesthesiology, University Hospital Eppendorf, Hamburg, Germany; and †Department of Anesthesiology, University Witten/Herdecke, Cologne, Germany
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Nathan N, Tabaraud F, Lacroix F, Mouliès D, Viviand X, Lansade A, Terrier G, Feiss P. Influence of propofol concentrations on multipulse transcranial motor evoked potentials. Br J Anaesth 2003; 91:493-7. [PMID: 14504148 DOI: 10.1093/bja/aeg211] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Motor evoked potentials can be affected by propofol anaesthesia. We studied how increasing target concentrations of propofol altered transcranial motor evoked potentials (tcMEP) during scoliosis surgery. METHODS Fifteen patients undergoing surgery for scoliosis were anaesthetized with remifentanil and propofol without nitrous oxide or neuromuscular blocking agents (BIS<60). tcMEP were elicited by transcranial electric multipulse stimulation of the motor cortex and recording of compound action potentials from the anterior tibialis muscle. tcMEP were obtained before surgery with propofol target values set from 4 to 8 mg litre(-1), and then during surgery. Arterial propofol concentrations were measured for each tcMEP recording. RESULTS Before surgery, increasing propofol reduced tcMEP amplitude in a dose-dependent manner, with no effect on latency. During surgery, at equivalent propofol concentrations, tcMEP were not statistically different from those obtained before surgery. In all except one patient, tcMEP signals were present during the entire procedure. In this patient the loss of tcMEP was unfortunately related to an anterior spinal cord lesion, which was confirmed by a wake-up test. CONCLUSION We found that, although propofol had a dose-dependent effect on tcMEP amplitude, anaesthesia could be maintained with remifentanil and propofol to allow recording and interpretation of tcMEP signals.
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Affiliation(s)
- N Nathan
- Département d'Anesthésie Réanimation Chirurgicale, CHU Dupuytren, 2 Avenue Martin Luther King, 87042 Limoges, France.
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Gundanna M, Eskenazi M, Bendo J, Spivak J, Moskovich R. Somatosensory evoked potential monitoring of lumbar pedicle screw placement for in situ posterior spinal fusion. Spine J 2003; 3:370-6. [PMID: 14588949 DOI: 10.1016/s1529-9430(03)00144-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Somatosensory evoked potentials (SSEP) are commonly used to monitor the spinal cord and nerve roots during operative procedures that put those structures at risk. The utility of SSEPs to evaluate cauda equina and nerve root function during posterior spinal arthrodesis with pedicular fixation for degenerative lumbar disease has been reported anecdotally and remains controversial. PURPOSE An institution-wide review of the ability of SSEP readings to monitor nerve function during posterior lumbar spinal arthrodeses with transpedicular fixation for degenerative lumbar spinal disorders was undertaken. STUDY DESIGN/SETTING A retrospective review was undertaken. Patient history, preoperative physical examination, intraoperative anesthesia, SSEP records and the postoperative course were reviewed. METHODS A total of 186 consecutive arthrodeses as described above were reviewed. Patients who had anterior procedures, spondyloreduction or scoliosis correction were excluded from the study. There were 76 male and 110 female patients. Five fellowship-trained spine surgeons placed a total of 888 pedicle screws. Sixty-five percent of the patients had a principal preoperative diagnosis of spinal stenosis with degenerative spondylolisthesis. Other common diagnoses were isthmic spondylolisthesis and degenerative scoliosis. Ninety-three percent of the cases involved decompressive laminectomy. Eight percent had posterior interbody fusions. All pedicle screws were placed without the assistance of fluoroscopy or stereotactic computer-assisted guidance. Screw position was evaluated intraoperatively with standard posteroanterior and lateral radiographs. Anesthetic agents compatible with SSEP monitoring were used in all patients. SSEP baseline readings were obtained in all patients in the operating room soon after induction of general anesthesia. An acute and sustained loss of 50% of the SSEP amplitude and/or increase by 10% of latency from baseline was considered to be pathologic. RESULTS None of the 186 patients had significant SSEP changes. There were, however, 5 patients with postoperative radiculopathies distinct from their preoperative presentations. Early postoperative plain radiographs and computed assisted tomography (CAT) scans revealed malpositioned pedicle screws. Consequently, eight pedicle screws were either revised or removed. All patients had partial or full recovery of their new deficits after revision surgery. CONCLUSION We conclude that the use of SSEPs in evaluating pedicle screw placement during lumbar arthrodesis is limited. In this setting, if monitoring is required, alternative methods with greater sensitivity and efficacy should be explored.
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Affiliation(s)
- Mukund Gundanna
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10017, USA
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Nollet H, Van Ham L, Deprez P, Vanderstraeten G. Transcranial magnetic stimulation: review of the technique, basic principles and applications. Vet J 2003; 166:28-42. [PMID: 12788015 DOI: 10.1016/s1090-0233(03)00025-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Transcranial magnetic stimulation is rapidly developing as a powerful, non-invasive tool for studying the descending motor tracts in humans. The applications of the test in animals are for the moment restricted to small animals. However, this non-invasive, sensitive and painless technique appears promising as a test of motor tract function in horses where the neurological examination is mainly restricted to clinical evaluation and some ancillary tests, such as radiography, cerebrospinal fluid analysis and electromyography. In this review, we want to discuss the history, basic principles, technique and applications of transcranial magnetic stimulation in humans and small animals and indicate the possibilities for its use in horses. Since the great portion of this review is based on human studies, it is worthwhile to mention that the reports being described are from humans unless otherwise specified.
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Affiliation(s)
- H Nollet
- Department of Internal Medicine and Clinical Biology of Large Animals, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium.
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MacDonald DB, Al Zayed Z, Khoudeir I, Stigsby B. Monitoring scoliosis surgery with combined multiple pulse transcranial electric motor and cortical somatosensory-evoked potentials from the lower and upper extremities. Spine (Phila Pa 1976) 2003; 28:194-203. [PMID: 12544939 DOI: 10.1097/00007632-200301150-00018] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective case review was performed. OBJECTIVE To assess the value, rapidity, and safety of combined multiple-pulse transcranial electric stimulation motor-evoked potential and somatosensory-evoked potential monitoring during scoliosis surgery. SUMMARY OF BACKGROUND DATA Leg somatosensory-evoked potentials can miss motor deficits, and a 50% amplitude warning criterion can produce false alarms. METHODS For this study, 33 scoliosis surgeries in neurologically normal patients under propofol/fentanyl anesthesia omitting neuromuscular blockade were monitored with four-extremity multiple-pulse transcranial electric stimulation muscle motor-evoked potentials and cortical somatosensory-evoked potentials. Instead of amplitude criteria, parallel (same-direction) change was used to identify systemic alteration and nonparallel (one- or two-limb) deterioration to identify focal neurologic compromise. Clinical observation and intraoperative electroencephalography were used to assess adverse effects. RESULTS Instantaneous motor-evoked potentials and rapidly reproducible cortical somatosensory-evoked potentials provided comprehensive feedback every 0.8 to 6.7 minutes (median, 2.4 minutes) without adverse effects. Parallel (systemic) changes without alarm or deficit included motor-evoked potential fading or temporary loss and leg somatosensory-evoked potential amplitudes below 50% of initial, maximum, or median intraoperative values in 10% to 37% of the cases. Three nonparallel changes occurred: 1) abrupt bilateral leg somatosensory-evoked potential 20% to 30% reduction without motor-evoked potential change during instrumentation resolving spontaneously over 30 minutes, with transient postoperative sensory symptoms; 2) right-arm somatosensory-evoked potential and motor-evoked potential reduction during hyperabduction restored after repositioning, without deficit; 3) abrupt bilateral leg motor-evoked potential loss preceding 30% to 60% somatosensory-evoked potential reduction during derotation rapidly restored after instrumentation release, without deficit. CONCLUSIONS In neurologically normal patients, the combined methods are safe and rapid, and could improve the sensitivity and specificity of scoliosis monitoring. Arm controls facilitate differentiation between systemic alterations and focal neurologic compromise.
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Affiliation(s)
- David B MacDonald
- Section of Clinical Neurophysiology, Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
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MacDonald DB. Safety of intraoperative transcranial electrical stimulation motor evoked potential monitoring. J Clin Neurophysiol 2002; 19:416-29. [PMID: 12477987 DOI: 10.1097/00004691-200210000-00005] [Citation(s) in RCA: 175] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This article reviews intraoperative transcranial electrical stimulation (TES) motor evoked potential (MEP) monitoring safety based on comparison with other clinical and experimental brain stimulation methods and clinical experience in more than 15000 cases. Comparative analysis indicates that brain damage and kindling are highly unlikely. There have been remarkably few adverse events. Pulse train TES-induced or coincidental seizures (n = 5) are rare, probably because of very brief (<0.03 second) stimuli, anesthesia, and the general absence of predisposing cerebral conditions. Soft bite blocks may prevent tongue or lip laceration (n = 29) or mandibular fracture (n = 1). Rare cardiac arrhythmia (n = 5) and intraoperative awareness (n = 1) may be coincidental. Minor scalp burns (n = 2) are rare. Although possible, no spinal epidural recording electrode complications or injuries resulting from TES-induced movement were found. There have been no recognized adverse neuropsychological effects, headaches, or endocrine disturbances. Comprehensive relative contraindications include epilepsy, cortical lesions, convexity skull defects, raised intracranial pressure, cardiac disease, proconvulsant medications or anesthetics, intracranial electrodes, vascular clips or shunts, and cardiac pacemakers or other implanted biomedical devices. Otherwise unexplained intraoperative seizures and possibly arrhythmias are indications to abort TES. With appropriate precautions in expert hands, the well-established benefits of TES MEP monitoring decidedly outweigh the associated risks.
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Affiliation(s)
- David B MacDonald
- Department of Neurosciences, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.
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Péréon Y, Nguyen The Tich S, Delécrin J, Pham Dang C, Bodin J, Drouet JC, Passuti N. Combined spinal cord monitoring using neurogenic mixed evoked potentials and collision techniques. Spine (Phila Pa 1976) 2002; 27:1571-6. [PMID: 12131720 DOI: 10.1097/00007632-200207150-00017] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Neurogenic mixed evoked potentials are used routinely to monitor the spinal cord during spine surgery. This study investigates the differential sensory-motor contribution by using collision techniques. OBJECTIVE To demonstrate that neurogenic mixed evoked potentials do contain a motor component. SUMMARY OF BACKGROUND DATA Spinal cord monitoring is now routinely used during spine deformity surgery. Neurogenic mixed evoked potentials (i.e., potentials recorded from lower limb nerves after spinal cord stimulation) represent a reliable and sensitive technique. However, their specificity (sensory and motor spinal pathways) remains debated. METHODS Neurogenic mixed evoked potentials and collisions were performed in 24 consecutive patients during scoliosis surgery. Neurogenic mixed evoked potentials were elicited by a high thoracic spinal test stimulation and recorded from the tibial nerve at the ankle. A peripheral conditioning stimulation was delivered at the popliteal fossa 15 ms before spinal stimulation, inducing an ascending volley. The antidromic ascending motor component stops at the anterior horn cell level, whereas the orthodromic sensory component reaches the dorsal columns. The 15-ms interstimulus interval between peripheral conditioning and spinal test stimulation makes the collision with descending volleys occur in the spinal cord. The descending sensory volley is blocked, whereas the descending motor volley is unaffected. RESULTS Reproducible evoked potentials were recorded from the tibial nerve in all the patients studied when the conditioning stimulation was performed. These conditioned neurogenic mixed evoked potentials consist of a small and polyphasic wave whose amplitude represents approximately 26% that of the wave of unconditioned neurogenic mixed evoked potentials. It is likely that they correspond to motor spinal pathway activation. CONCLUSION Both standard and conditioned neurogenic mixed evoked potentials are proposed to provide combined sensory and motor spinal pathway monitoring.
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Affiliation(s)
- Yann Péréon
- Laboratoire d'Explorations Fonctionnelles, Hôtel-Dieu, F-44093 Nantes Cedex, France.
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Nakagawa Y, Tamaki T, Yamada H, Nishiura H. Discrepancy between decreases in the amplitude of compound muscle action potential and loss of motor function caused by ischemic and compressive insults to the spinal cord. J Orthop Sci 2002; 7:102-10. [PMID: 11819141 DOI: 10.1007/s776-002-8430-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2001] [Accepted: 08/08/2001] [Indexed: 10/27/2022]
Abstract
We examined the relationship between decreases in the amplitude of the compound muscle action potential (CMAP), caused by ischemic and compressive insults to the spinal cord, and postoperative motor deficits. Results were compared with those for other evoked potentials commonly used for multimodal monitoring of the spinal cord. CMAP was more sensitive than the other evoked potentials employed to ischemic and compressive insults to the spinal cord, although the disappearance of CMAP did not always result in a residual motor deficit. A decrease of more than 50% in the amplitude of the motor-evoked potential (MEP) from the spinal cord correlated well with the postoperative motor deficit. CMAP is a sensitive tool for the early detection of spinal cord impairment caused by ischemic or compressive insults to the spinal cord. The time after the disappearance of the CMAP amplitude was important for predicting postoperative motor deficit, but it is also necessary to employ CMAP concomitantly with other conductive potentials in spinal cord monitoring.
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Affiliation(s)
- Yukihiro Nakagawa
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
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Wilson-Holden TJ, VanSickle D, Lenke LG. The benefit of neurogenic mixed evoked potentials for intraoperative spinal cord monitoring during correction of severe scoliosis: a case study. Spine (Phila Pa 1976) 2002; 27:E258-65. [PMID: 12004186 DOI: 10.1097/00007632-200205150-00022] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A case report is presented. OBJECTIVE To present a case in which surgical correction of a severe scoliotic curve caused unilateral loss of neurogenic mixed evoked potential data despite unchanged somatosensory data. SUMMARY OF BACKGROUND DATA Surgical correction of large scoliotic curves presents a risk to the function of the spinal cord. Multimodality intraoperative neurophysiologic monitoring of the spinal cord is recommended during such procedures. METHODS A 13-year-old girl with severe double major scoliosis underwent a staged operative procedure for correction of her spine deformity. Intraoperative neurophysiologic monitoring using somatosensory-evoked potentials and neurogenic mixed evoked potentials was performed for each stage. RESULTS During the final stage (a T4-L5 posterior instrumentation and fusion) left neurogenic mixed evoked potential data were lost approximately 45 minutes after placement of the left-side, correcting rod. The surgeon was warned of the data change. Set bolts were loosened at all fixation points, and the data quickly returned to within normal limits of baseline. Somatosensory data never approached warning criteria at any point during surgery. The patient awakened with no neurologic deficit. CONCLUSIONS Neurophysiologic monitoring using both somatosensory-evoked potentials and neurogenic mixed evoked potentials is recommended when surgery is performed to correct spine deformity. The Stagnara wake-up test, somatosensory-evoked potentials, and neurogenic mixed evoked potentials are important components of spinal cord monitoring during surgery, and should be used together for optimal protection of neurologic function.
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Affiliation(s)
- Tracy J Wilson-Holden
- Washington University Medical Center, Department of Orthopaedic Surgery, St. Louis, Missouri, USA
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Noonan KJ, Walker T, Feinberg JR, Nagel M, Didelot W, Lindseth R. Factors related to false- versus true-positive neuromonitoring changes in adolescent idiopathic scoliosis surgery. Spine (Phila Pa 1976) 2002; 27:825-30. [PMID: 11935104 DOI: 10.1097/00007632-200204150-00009] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study of 134 adolescent patients who underwent surgical correction of idiopathic scoliosis between June 1992 and August 1998 was conducted. OBJECTIVE To examine factors related to changes in somatosensory-evoked potentials with or without neurogenic motor-evoked potentials. SUMMARY OF BACKGROUND DATA Studies document and demonstrate threshold criteria for changes in neuromonitoring that predict changes in spinal cord function. Rates of false-negative occurrences are low, yet higher rates of false-positive findings may result. METHODS All the patients had somatosensory monitoring, and 71 patients had both somatosensory-evoked potential and neurogenic motor-evoked potential monitoring. Gender, age, curve types, duration of surgery, type and amount of instrumentation, and amount of correction were examined for their effects on monitoring. Estimated blood volume loss as well as high and low mean arterial pressure and its variance were assessed at the start, middle, and conclusion of the procedure. RESULTS According to the findings, 122 patients (91%) had no monitoring changes and no postoperative neurologic deficit. Six patients (4.5%) had false-positive readings. Six patients had a postoperative motor or sensory deficit, all of which resolved within 18 months. False-positive readings were associated with greater variability in mean arterial pressure. No consistent predictions could be made about the incidence of cord injury if neuromonitoring changes returned to baseline before the end of surgery. CONCLUSIONS Questions remain about the predictive accuracy of somatosensory-evoked and neurogenic motor-evoked potentials. According to the findings in this study, in which there were no false-negative readings and a modest false-positive rate, continued use of these methods is recommended. Higher false-positive rates were seen in patients with greater lability in mean arterial pressure. A wake-up test is recommended for all cases in which threshold monitoring changes occur because cases of spinal cord injury may exist even when monitored variables return to baseline.
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Affiliation(s)
- Kenneth J Noonan
- Clinical Science Center, Madison, Wisconsin. The study was conducted at Riley Hospital for Children, Indianapolis, Indiana, USA.
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Nollet H, Deprez P, Van Ham L, Verschooten F, Vanderstraeten G. The use of magnetic motor evoked potentials in horses with cervical spinal cord disease. Equine Vet J 2002; 34:156-63. [PMID: 11902758 DOI: 10.2746/042516402776767204] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The aim of this study was to investigate the use of magnetic motor evoked potentials as an ancillary diagnostic test in horses with cervical cord lesions. Transcranial magnetic stimulation was performed in 12 ataxic horses and the results of the evoked responses were compared to those found in normal horses. The latency and peak-to-peak amplitude of the potentials in the 12 ataxic horses were significantly different from those measured in normal horses. The configuration of the abnormal potentials was also polyphasic. Normalisation of the evoked potentials occurred in none of the horses, presented after a period of clinical improvement. These findings demonstrate that the technique is also able to detect lesions in horses with subtle clinical signs of incoordination. Magnetic transcranial stimulation is a valuable ancillary test to assess the integrity of the motor tracts. The technique is painless and safe and shows good sensitivity to detect lesions along the descending motor pathways.
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Affiliation(s)
- H Nollet
- Department of Internal Medicine and Clinical Biology of Large Animals, Faculty of Veterinary Medicine, University of Ghent, Belgium
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