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Srivastava A, Hanasoge V, Gupta A, Jayaswal A. Use of transcranial motor evoked potentials (TcMEPs) in spine deformity surgery in a case of Charcot-Marie-tooth disease-what we should know? A case report. Spinal Cord Ser Cases 2024; 10:38. [PMID: 38796453 PMCID: PMC11127915 DOI: 10.1038/s41394-024-00648-z] [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: 08/25/2023] [Revised: 04/21/2024] [Accepted: 05/09/2024] [Indexed: 05/28/2024] Open
Abstract
INTRODUCTION Charcot Marie tooth disease (CMTD) is also known as Hereditary sensory motor neuropathy. It poses difficulties in attaining intra-operative neuromonitoring signals for deformity correction surgery. In this case report, we intent to mention key points for obtaining good neuromonitoring signals in these cases which increases the safety in scoliosis surgery. CASE PRESENTATION We present a 14-year-old boy, known case of CMTD, presented with progressive deformity of the back. The child was wheelchair-bound and could walk only a few steps with support. He was unable to maintain a sitting balance without using upper limbs making him functionally quadriparatic. The radiographs showed a double scoliotic curve with costo-pelvic impingement. At the onset, no signals were obtained with routine intra-operative neuromonitoring settings. DISCUSSION Increasing the sweep length and voltage in our neuro-monitors helped in acquiring the baseline signals and we went ahead to proceed the deformity correction.
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Affiliation(s)
- Abhishek Srivastava
- Department of Spine Surgery, Max Superspeciality Hospital, Vaishali, Ghaziabad, India
| | - Vikas Hanasoge
- Department of Spine Surgery, Kothari Medical Center, Kolkata, India
| | - Anuj Gupta
- Department of Spine Surgery, Max Superspeciality Hospital, Vaishali, Ghaziabad, India.
| | - Arvind Jayaswal
- Department of Spine Surgery, Max Superspeciality Hospital, Vaishali, Ghaziabad, India
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Badhiwala JH, Witiw CD, Wilson JR, da Costa LB, Nathens AB, Fehlings MG. Treatment of Acute Traumatic Central Cord Syndrome: A Study of North American Trauma Centers. Neurosurgery 2024; 94:700-710. [PMID: 38038474 DOI: 10.1227/neu.0000000000002767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/25/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Central cord syndrome (CCS) is expected to become the most common traumatic spinal cord injury, yet its optimal management remains unclear. This study aimed to evaluate variability in nonoperative vs operative treatment for CCS between trauma centers in the American College of Surgeons Trauma Quality Improvement Program, identify patient- and hospital-level factors associated with treatment, and determine the association of treatment with outcomes. METHODS Adults with CCS were identified from the Trauma Quality Improvement Program database (2014-2016). Mixed-effects modeling with a random intercept for trauma centers was used to examine the adjusted association of patient- and hospital-level variables with nonoperative treatment. The random-effects output of the model assessed the risk-adjusted variability in nonoperative treatment across centers. Outlier hospitals were identified, and the median odds ratio was calculated. The adjusted effect of nonoperative treatment on mortality, morbidity, and hospital length of stay (LOS) was examined at the patient and hospital level by mixed-effects regression. RESULTS Three thousand, nine hundred twenty-eight patients across 255 centers were eligible; of these, 1523 (38.8%) were treated nonoperatively. Older age, noncommercial insurance (odds ratio [OR] 1.26, 95% CI 1.08-1.48, P = .004), absence of fracture (OR 0.58, 95% CI 0.49-0.68, P < .001), severe head injury (OR 1.41, 95% CI 1.09-1.82, P = .008), and comatose presentation (1.82, 95% CI 1.15-2.89, P = .011) were associated with nonoperative treatment. Twenty-eight hospitals were outliers, and the median odds ratio was 2.02. Patients receiving nonoperative treatment had shorter LOS (mean difference -4.65 days). Nonoperative treatment was associated with lesser in-hospital morbidity (OR 0.49, 95% CI 0.37-0.63, P < .001) at the patient level. There was no difference in mortality. CONCLUSION Operative decision-making for CCS is influenced by patient factors. There remains substantial variability between trauma centers not explained by case-mix differences. Nonoperative treatment was associated with shorter hospital LOS and lesser inpatient morbidity.
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Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
| | - Christopher D Witiw
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, Toronto , Ontario , Canada
| | - Jefferson R Wilson
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, Toronto , Ontario , Canada
| | - Leodante B da Costa
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto , Ontario , Canada
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto , Ontario , Canada
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Clinical Epidemiology Program, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto , Ontario , Canada
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Liu T, Qi H, Yan L, Liu X, Yuan T, Wang R, Zhao S, Wang W, Xiao L, Luo Z, Yu P, Wang F, Li H, Wang G. Variability of somatosensory evoked potential and motor evoked potential change criteria in thoracic spinal decompression surgery based on preoperative motor status. Spine J 2024; 24:506-518. [PMID: 37871658 DOI: 10.1016/j.spinee.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/21/2023] [Accepted: 10/14/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND CONTEXT Combined somatosensory- and motor-evoked potential (SSEP and MEP) changes for predicting prognosis in thoracic spinal surgery have been variably reported. PURPOSE We aimed to explore the validity of combined SSEP and MEP for predicting postoperative motor deficits (PMDs) in thoracic spinal decompression surgery (TSDS) and identify a relatively optimal neurophysiological predictor of PMDs in patients based on preoperative motor status. STUDY SETTING Retrospective study. PATIENT SAMPLE A total of 475 patients were analyzed. OUTCOME MEASURES A reduction in muscle strength by more than or equal to one manual muscle testing (MMT) grade postoperatively compared with the preoperative MMT grade was identified as PMDs. Postoperative motor deficits were detected by comparing the preoperative and postoperative physical examination findings in short- and long-term follow-up visits. METHODS All patients were divided into two subgroups according to preoperative motor status. The following data were collected: (1) demographic data; (2) IONM (intraoperative neuromonitoring) data; and (3) postoperative motor outcomes. Binary logistic regression analysis was performed to assess the efficacy of IONM change to predict PMDs. A receiver operating characteristic curve (ROC) was used to establish optimal IONM warning criteria. RESULTS Ninety-eight patients had severe preoperative motor deficits (Group S), and 377 patients did not (Group N). MEP and SSEP change was effective for predicting PMDs in the short term (p<.01) and long term (p<.01) for TSDS patients. In Group N, the cutoff values for predicting PMDs in the short term were a decrease of 65% in SSEP amplitude and 89.5% in MEP amplitude of the baseline value. Furthermore, the cutoff values for predicting PMDs in the short term were durations of change of 24.5 minutes for SSEP and 32.5 minutes for MEP. In Group S, however, the cutoff values for predicting PMDs in the short term were a decrease of 36.5% in SSEP amplitude and 59.5% in MEP amplitude of the baseline value. Moreover, the critical values for predicting short-term PMDs were durations of change of 16.5 minutes for SSEP and 17.5 minutes for MEP. CONCLUSIONS The optimal IONM changes for prediction vary depending on preoperative motor status. Combined SSEP and MEP are excellent for predicting PMDs in TSDS.
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Affiliation(s)
- Tun Liu
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, P.R. China.
| | - Huaguang Qi
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, P.R. China
| | - Liang Yan
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, P.R. China
| | - Xuemei Liu
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, P.R. China
| | - Tao Yuan
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, P.R. China
| | - Ruiguo Wang
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, P.R. China
| | - Songchuan Zhao
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, P.R. China
| | - Wentao Wang
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, P.R. China
| | - Li Xiao
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, P.R. China
| | - Zhenguo Luo
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, P.R. China
| | - Pengfei Yu
- Department of Gastrointestinal Surgery, Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, P.R. China
| | - Fei Wang
- Institute of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, P.R. China
| | - Houkun Li
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, P.R. China
| | - Gang Wang
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Institute of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi Province, P.R. China
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Kim ST, Jin SC, Jeong HW, Baek JW, Jeong YG. Correlation between contrast leakage period of procedural rupture and clinical outcomes in endovascular coiling for cerebral aneurysms. J Cerebrovasc Endovasc Neurosurg 2023; 25:420-428. [PMID: 38018076 PMCID: PMC10774684 DOI: 10.7461/jcen.2023.e2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/09/2023] [Accepted: 09/12/2023] [Indexed: 11/30/2023] Open
Abstract
OBJECTIVE Intraprocedural rupture (IPR) is a fatal complication of endovascular coiling for cerebral aneurysms. We hypothesized that contrast leakage period may be related to poor clinical outcomes. This study aimed to retrospectively evaluate the relationship between clinical outcomes and contrast leakage period. METHODS Data from patients with cerebral aneurysms treated via endovascular coiling between January 2010 and October 2018 were retrospectively assessed. The enrolled patient's demographic data, the aneurysm related findings, endovascular treatment and IPR related findings, rescue treatment, and clinical outcome were analyzed. RESULTS In total, 2,859 cerebral aneurysms were treated using endovascular coiling during the study period, with IPR occurring in 18 (0.63 %). IPR occurred during initial frame coiling (n=4), coil packing (n=5), stent deployment (n=7), ballooning (n=1), and microcatheter removal after coiling (n=1). Tear sites included the dome (n=14) and neck (n=4). All IPRs were controlled and treated with coil packing, with or without stenting. Flow arrest of the proximal balloon was not observed. Temporary focal neurological deficits developed in two patients (11.1%). At clinical follow-up, 14 patients were classified as modified Rankin Scale (mRS) 0, three as mRS 2, and one as mRS 4. The mean contrast leakage period of IPR was 11.2 min (range: 1-31 min). Cerebral aneurysms with IPR were divided into late (n=9, mean time: 17.11 min) and early (n=9, mean time: 5.22 min) control groups based on the criteria of 10 min of contrast leakage period. No significant between-group differences regarding clinical outcomes were observed after IPR (p=1). CONCLUSIONS In our series, all patients with IPR were controlled with further coil packing or stenting without proximal balloon occlusion within 31 min of contrast leakage. There was no difference in clinical outcomes when the long contrast leakage period group and short contrast leakage period group were compared.
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Affiliation(s)
- Sung-Tae Kim
- Department of Neurosurgery, Inje University Busan Paik Hospital, Busan, Korea
| | - Sung-Chul Jin
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Hae Woong Jeong
- Department of Radiology, Inje University Busan Paik Hospital, Busan, Korea
| | - Jin Wook Baek
- Department of Radiology, Inje University Busan Paik Hospital, Busan, Korea
| | - Young Gyun Jeong
- Department of Neurosurgery, Inje University Busan Paik Hospital, Busan, Korea
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Wilczyński B, Śnieżyński J, Nowakowska M, Wallner G. Neurological complications in patients undergoing general surgery: A literature review. POLISH JOURNAL OF SURGERY 2023; 96:71-77. [PMID: 38348989 DOI: 10.5604/01.3001.0053.6869] [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] [Indexed: 02/15/2024]
Abstract
Surgical procedures are extremely burdensome for patients, as in addition to complications directly related to the intervention, they expose the patient to further complications resulting from the disturbance of key functions of homeostasis in the body's systems, particularly the circulatory, respiratory, and nervous systems. Furthermore, they may contribute to the exacerbation of symptoms of underlying chronic diseases. This paper focuses on the most common possible neurological complications that may occur after surgical procedures and includes topics such as stroke, chronic pain, neuropathy, and delirium. The risk factors for neurological deficits, their known or possible etiology, the most characteristic symptoms, and potential preventive actions are discussed. The paper analyzes articles from the PubMed, ResearchGate, and Scopus databases. A surge0on's knowledge of possible complications that may occur in the perioperative period enables early recognition and effective reduction of their negative impact on the patient's functioning and quality of life after surgery, contributing to better overall treatment outcomes.
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Affiliation(s)
- Bartosz Wilczyński
- Second Department of General & Gastrointestinal Surgery & Surgical Oncology of the Alimentary Tract, Medical University of Lublin, Poland
| | - Jan Śnieżyński
- Second Department of General & Gastrointestinal Surgery & Surgical Oncology of the Alimentary Tract, Medical University of Lublin, Poland
| | | | - Grzegorz Wallner
- Second Department of General & Gastrointestinal Surgery & Surgical Oncology of the Alimentary Tract, Medical University of Lublin, Poland
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Li H, Gao S, Li R, Cui H, Huang W, Huang Y, Hu Y. Identifying Intraoperative Spinal Cord Injury Location from Somatosensory Evoked Potentials' Time-Frequency Components. Bioengineering (Basel) 2023; 10:707. [PMID: 37370638 DOI: 10.3390/bioengineering10060707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Excessive distraction in corrective spine surgery can lead to iatrogenic distraction spinal cord injury. Diagnosis of the location of the spinal cord injury helps in early removal of the injury source. The time-frequency components of the somatosensory evoked potential have been reported to provide information on the location of spinal cord injury, but most studies have focused on contusion injuries of the cervical spine. In this study, we established 19 rat models of distraction spinal cord injury at different levels and collected the somatosensory evoked potentials of the hindlimb and extracted their time-frequency components. Subsequently, we used k-medoid clustering and naive Bayes to classify spinal cord injury at the C5 and C6 level, as well as spinal cord injury at the cervical, thoracic, and lumbar spine, respectively. The results showed that there was a significant delay in the latency of the time-frequency components distributed between 15 and 30 ms and 50 and 150 Hz in all spinal cord injury groups. The overall classification accuracy was 88.28% and 84.87%. The results demonstrate that the k-medoid clustering and naive Bayes methods are capable of extracting the time-frequency component information depending on the spinal cord injury location and suggest that the somatosensory evoked potential has the potential to diagnose the location of a spinal cord injury.
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Affiliation(s)
- Hanlei Li
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Songkun Gao
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Rong Li
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Hongyan Cui
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Wei Huang
- Department of Rehabilitation, The 2nd Affiliated Hospital of Guangdong Medical University, Zhanjiang 524255, China
| | - Yongcan Huang
- Shenzhen Engineering Laboratory of Orthopaedic Regenerative Technologies, Orthopaedic Research Center, Peking University Shenzhen Hospital, Shenzhen 518036, China
| | - Yong Hu
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
- Department of Rehabilitation, The 2nd Affiliated Hospital of Guangdong Medical University, Zhanjiang 524255, China
- Department of Orthopedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
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San-Juan D, Vanegas JAV, López RA, Jiménez CR, Reyes LADLC. Pediatric Intraoperative Neurophysiological Monitoring and Long-Term Outcomes in a Developing Country. J Clin Neurophysiol 2023; Publish Ahead of Print:00004691-990000000-00094. [PMID: 37200528 DOI: 10.1097/wnp.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
PURPOSE Pediatric intraoperative neurophysiological monitoring (IONM) has been shown to be effective in preventing and reversing postoperative neurological deficits in developed countries. There are currently no published studies from developing countries that describe neurophysiological findings and postoperative outcomes. Our study aims to address these gaps in children undergoing neurosurgical procedures in a single center. METHODS We conducted a retrospective study of case series of children who underwent IONM (2014-2020) in the State of Mexico, Mexico. Sociodemographic characteristics, IONM modalities, changes during procedures, and short-term and long-term postoperative results were recorded. Descriptive statistics were used. RESULTS We included 35 patients (≤18 years of age), 57% (20/35) boys. A relative increase of up to 5 times in the use of IONM is observed from 2014 (5.7%) to 2020 (25.7%) in our center. The most frequent preoperative pathologies were located at the infratentorial cranium (40%), followed by the spine and spinal cord (37.1%). The IONM modalities were as follows: free-running EMG 94.3%, transcranial electrical stimulation motor-evoked potentials 91.4%, somatosensory-evoked potentials 85.7%, triggered EMG 28.6%, EEG 25.7%, and visual-evoked potentials 5.7%. Only in 8.3%, we did not obtain sufficient evoked potential baseline signals. At 24 hours postoperatively true negatives were 100%. Long-term follow-up was completed in 22/35 (63%) at 3 months, 12/35 (34.2%) at 6 months, and 5/35 (14.3%) at 12 months with progressive motor and sensory improvement. CONCLUSIONS Pediatric multimodal IONM in neurosurgeries from a single center in a developing country is mainly used in pathologies of the posterior fossa, spine, and spinal cord, with true negatives in 100% of those monitored, preventing and avoiding postoperative sequelae.
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Affiliation(s)
- Daniel San-Juan
- Clinical Neurophysiology Department, National Institute of Neurology and Neurosurgery, Mexico City, Mexico; and
| | | | - Raúl Aguilar López
- Neurosurgery Department, Maternal and Child Hospital, ISSEMyM, Mexico State, Mexico
| | - Christian Ramos Jiménez
- Clinical Neurophysiology Department, National Institute of Neurology and Neurosurgery, Mexico City, Mexico; and
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San-Juan D, Mercado WP, Lorenzana ÁL, Torres JEG, Delgado CAR, Leyva Oceguera RA, Lee Á, Kimaid PAT. Intraoperative neurophysiological monitoring in Latin America: A bibliometric analysis. J Clin Monit Comput 2022; 36:1827-1832. [PMID: 35235105 DOI: 10.1007/s10877-022-00831-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 02/07/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Intraoperative Neurophysiological Monitoring (IOMM) has been used worldwide in the attempt to reduce postsurgical neurological deficits, however, most of the publications are from developed countries. There is a global bibliometric analysis of IOMN in spinal surgery, however, the contribution of Latin America (LA) is not mentioned. The aim of this study is to describe scientific productivity, patterns of publications, and thematic trends of IONM in LA. METHODS Data was collected using Scopus database, by searching scientific articles with LA affiliation, using 18 keywords. We excluded duplicates, not original articles, reviews, surveys, and articles not related to humans. Articles were analyzed and classified as follows: year of publication, language of the original document, journals metrics, country, IONM modality, etiology, location of surgery, medical specialties, and outcome. Descriptive statistics were used. RESULTS We obtained 8,699 scientific articles of which 41 scientific articles from 7 LA countries were selected. Mexico has the highest number of publications. In most countries, supratentorial location showed the highest frequency. Somatosensory evoked potentials and electrocorticography were the most performed modalities. Neurosurgery was the most involved specialty of our 41 scientific articles, and 95.1% of these publications concluded that IONM is useful to guide surgical procedures. CONCLUSIONS Mexico and Brazil have led IONM publications in LA. The lower reference in publications of visual evoked potentials and brainstem auditory evoked potentials IONM modalities, could be considered in the future to boost tailored research in LA.
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Affiliation(s)
- Daniel San-Juan
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery Manuel Velasco Suárez, Juan. Av. Insurgentes Sur 3877, Col. La Fama, 14269, Tlalpan, Mexico.
| | - Wirton Peña Mercado
- Clinical Neurophysiology Department, Centro Medico Nacional 20 de Noviembre, Mexico, Mexico
| | - Ángel Labra Lorenzana
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery Manuel Velasco Suárez, Juan. Av. Insurgentes Sur 3877, Col. La Fama, 14269, Tlalpan, Mexico
| | - Jacob Eli García Torres
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery Manuel Velasco Suárez, Juan. Av. Insurgentes Sur 3877, Col. La Fama, 14269, Tlalpan, Mexico
| | - César Alessandro Ramos Delgado
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery Manuel Velasco Suárez, Juan. Av. Insurgentes Sur 3877, Col. La Fama, 14269, Tlalpan, Mexico
| | - Rodolfo Alejandro Leyva Oceguera
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery Manuel Velasco Suárez, Juan. Av. Insurgentes Sur 3877, Col. La Fama, 14269, Tlalpan, Mexico
| | - Ángel Lee
- Comision Coordinadora de Institutos Nacionales de Salud, Mexico, Mexico
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BASILE G, PASSERI A, ARENSI F, AMADEI F. The medico-legal implications of intraoperative neurophysiological monitoring, in compliance with good clinical-assistance practices, according to the current Italian legal system. J Neurosurg Sci 2022; 66:384-385. [DOI: 10.23736/s0390-5616.22.05734-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Liu T, Yan L, Qi H, Luo Z, Liu X, Yuan T, Dong B, Zhao Y, Zhao S, Li H, Liu Z, Wu X, Wang F, Wang W, Huang Y, Wang G. Diagnostic Value of Multimodal Intraoperative Neuromonitoring by Combining Somatosensory-With Motor-Evoked Potential in Posterior Decompression Surgery for Thoracic Spinal Stenosis. Front Neurosci 2022; 16:879435. [PMID: 35757555 PMCID: PMC9226726 DOI: 10.3389/fnins.2022.879435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Intraoperative neuromonitoring (IONM) has become an increasingly essential technique in spinal surgery. However, data on the diagnostic value of IONM in predicting impending postoperative neurological deficits (PONDs) for patients who underwent posterior decompression surgery for thoracic spinal stenosis (TSS) are limited. Furthermore, patients who are at the highest risk of waveform changes during the surgery remain unknown. Our purpose was to (1) assess the diagnostic accuracy of IONM by combining somatosensory-evoked potential (SSEP) with motor-evoked potential (MEP) in predicting PONDs for patients who underwent the surgery and (2) identify the independent risk factors correlated with IONM changes in our study population. Methods A total of 326 consecutive patients who underwent the surgery were identified and analyzed. We collected the following data: (1) demographic and clinical data; (2) IONM data; and (3) outcome data such as details of PONDs, and recovery status (complete, partial, or no recovery) at the 12-month follow-up visit. Results In total, 27 patients developed PONDs. However, 15, 6, and 6 patients achieved complete recovery, partial recovery, and no recovery, respectively, at the 12-month follow-up. SSEP or MEP change monitoring yielded better diagnostic efficacy in predicting PONDs as indicated by the increased sensitivity (96.30%) and area under the receiver operating characteristic (ROC) curve (AUC) value (0.91). Only one neurological deficit occurred without waveform changes. On multiple logistic regression analysis, the independent risk factors associated with waveform changes were as follows: preoperative moderate or severe neurological deficits (p = 0.002), operating in the upper- or middle-thoracic spinal level (p = 0.003), estimated blood loss (EBL) ≥ 400 ml (p < 0.001), duration of symptoms ≥ 3 months (p < 0.001), and impairment of gait (p = 0.001). Conclusion Somatosensory-evoked potential or MEP change is a highly sensitive and moderately specific indicator for predicting PONDs in posterior decompression surgery for TSS. The independent risks for IONM change were as follows: operated in upper- or middle-thoracic spinal level, presented with gait impairment, had massive blood loss, moderate or severe neurological deficits preoperatively, and had a longer duration of symptoms. Clinical Trial Registration [http://www.chictr.org.cn]; identifier [ChiCTR 200003 2155].
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Affiliation(s)
- Tun Liu
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Liang Yan
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Huaguang Qi
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Zhenguo Luo
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Xuemei Liu
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Tao Yuan
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Buhuai Dong
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Yuanting Zhao
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Songchuan Zhao
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Houkun Li
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Zhian Liu
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Institute of Biomedical Engineering, School of Life Sciences and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Xucai Wu
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Fei Wang
- Institute of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wentao Wang
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Yunfei Huang
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Gang Wang
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Institute of Biomedical Engineering, School of Life Sciences and Technology, Xi'an Jiaotong University, Xi'an, China
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Liu T, Qin Y, Qi H, Luo Z, Yan L, Yu P, Dong B, Zhao S, Wu X, Chang Z, Liu Z, Liu X, Yuan T, Li H, Xiao L, Wang G. A Loading Dose of Dexmedetomidine With Constant Infusion Inhibits Intraoperative Neuromonitoring During Thoracic Spinal Decompression Surgery: A Randomized Prospective Study. Front Pharmacol 2022; 13:840320. [PMID: 35330828 PMCID: PMC8940210 DOI: 10.3389/fphar.2022.840320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background: The effect of a bolus dose of dexmedetomidine on intraoperative neuromonitoring (IONM) parameters during spinal surgeries has been variably reported and remains a debated topic. Methods: A randomized, double-blinded, placebo-controlled study was performed to assess the effect of dexmedetomidine (1 μg/kg in 10 min) followed by a constant infusion rate on IONM during thoracic spinal decompression surgery (TSDS). A total of 165 patients were enrolled and randomized into three groups. One group received propofol- and remifentanil-based total intravenous anesthesia (TIVA) (T group), one group received TIVA combined with dexmedetomidine at a constant infusion rate (0.5 μg kg−1 h−1) (D1 group), and one group received TIVA combined with dexmedetomidine delivered in a loading dose (1 μg kg−1 in 10 min) followed by a constant infusion rate (0.5 μg kg−1 h−1) (D2 group). The IONM data recorded before test drug administration was defined as the baseline value. We aimed at comparing the parameters of IONM. Results: In the D2 group, within-group analysis showed suppressive effects on IONM parameters compared with baseline value after a bolus dose of dexmedetomidine. Furthermore, the D2 group also showed inhibitory effects on IONM recordings compared with both the D1 group and the T group, including a statistically significant decrease in SSEP amplitude and MEP amplitude, and an increase in SSEP latency. No significance was found in IONM parameters between the T group and the D1 group. Conclusion: Dexmedetomidine delivered in a loading dose can significantly inhibit IONM parameters in TSDS. Special attention should be paid to the timing of a bolus dose of dexmedetomidine under IONM. However, dexmedetomidine delivered at a constant speed does not exert inhibitory effects on IONM data.
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Affiliation(s)
- Tun Liu
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Yue Qin
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Huaguang Qi
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Zhenguo Luo
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Liang Yan
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Pengfei Yu
- Department of Gastrointestinal Surgery, Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Buhuai Dong
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Songchuan Zhao
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Xucai Wu
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Zhen Chang
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Zhian Liu
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, School of Life Science and Technology, Institute of Biomedical Engineering, Xi'an Jiaotong University, Xi'an, China
| | - Xuemei Liu
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Tao Yuan
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Houkun Li
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Li Xiao
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Gang Wang
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, School of Life Science and Technology, Institute of Biomedical Engineering, Xi'an Jiaotong University, Xi'an, China
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Peck J, Poppino K, Sparagana S, Rampy P, Freeman S, Jo CH, Sucato D. Use of transcranial motor-evoked potentials to provide reliable intraoperative neuromonitoring for the Charcot-Marie-Tooth population undergoing spine deformity surgery. Spine Deform 2022; 10:411-418. [PMID: 34561841 DOI: 10.1007/s43390-021-00409-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 08/28/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Intraoperative neuromonitoring (IONM) has historically been difficult to obtain in patients with Charcot-Marie-Tooth (CMT) disease. Transcranial motor-evoked potentials (TcMEPs) have been found to be safe and effective for other spinal deformity patients. Our objective was to determine the effectiveness of TcMEP monitoring in patients with CMT. METHODS An IRB-approved, retrospective review of CMT patients undergoing spinal deformity surgery assessing TcMEP, somatosensory-evoked potential (SSEP), and neurogenic motor evoked potential (NMEP) IONM was performed. A 2:1 matched cohort control group of idiopathic spinal deformity patients was used. A waveform grading system was applied to review baseline TcMEP reliability and quality, which was validated via intraclass correlation coefficient amongst five raters. RESULTS Twenty-three CMT patients (26 surgical cases) were identified. The use of TcMEP improved the ability to obtain baseline IONM when compared to SSEP (83% vs. 20%; p < 0.001) and NMEP (83% vs. 18%; p = 0.003). Baseline monitoring was obtained less often for CMT patients using SSEP (20% vs. 100%; p < 0.001) and TcMEP (83% vs. 100%; p = 0.111) compared to idiopathic patients. Sweep length (time from stimulation waveform evaluation) and maximum stimulation voltage were higher in the CMT group (289 ms vs. 111 ms p = 0.007 and 740 V vs. 345 V p = 0.089, respectively). CONCLUSION TcMEP monitoring significantly improves the ability to provide IONM for CMT patients undergoing spinal deformity surgery. Utilizing longer sweep lengths enhances the ability to attain baseline TcMEP readings, allowing surgeons to more safely proceed with surgery for these complex patients. LEVEL OF EVIDENCE Therapeutic-Level III.
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Affiliation(s)
- Jeffrey Peck
- Division of Pediatric Orthopaedic Surgery, Children's National Hospital, Washington, DC, 20010, USA
| | - Kiley Poppino
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn Street, Dallas, TX, 75219, USA
| | - Steven Sparagana
- Department of Neurology and Rehabilitation Medicine, Texas Scottish Rite Hospital, University of Texas Southwestern Medical Center, Dallas, TX, 75219, USA
| | - Patricia Rampy
- Department of Neurology and Rehabilitation Medicine, Texas Scottish Rite Hospital, University of Texas Southwestern Medical Center, Dallas, TX, 75219, USA
| | - Spencer Freeman
- Department of Neurology and Rehabilitation Medicine, Texas Scottish Rite Hospital, University of Texas Southwestern Medical Center, Dallas, TX, 75219, USA
| | - Chan-Hee Jo
- Research Department, Texas Scottish Rite Hospital, Dallas, TX, 75219, USA
| | - Daniel Sucato
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn Street, Dallas, TX, 75219, USA.
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13
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Intraoperative neurophysiologic monitoring in thoracoabdominal aortic aneurysm surgery can provide real-time feedback for strategic decision making. Neurophysiol Clin 2022; 52:232-241. [PMID: 34998631 DOI: 10.1016/j.neucli.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Despite the introduction of several adjuncts to improve spinal perfusion, spinal cord ischemia (SCI) remains a devastating complication of thoracoabdominal aortic aneurysm (TAAA) repair. Our aim was to assess the effects on clinical outcome of interventions triggered by motor evoked potentials (MEP) alerts. Furthermore, we want to assess whether a multimodal intraoperative neurophysiologic monitoring (IONM) protocol is helpful for stratifying patients according to the risk of SCI at the end of the vascular phase of surgery. METHODS We prospectively studied one-hundred consecutive patients who underwent TAAA repair. We applied a multimodal IONM including MEP, somatosensory evoked potentials (SEP) and peripheral nerve monitoring techniques. Signal deteriorations were classified as reversible/irreversible according to whether they recovered or not at the end of monitoring (EOM), set at the end of the vascular phase of surgery. Significant MEP changes drove a series of corrective measures aimed to improve spinal perfusion. RESULTS The rate of immediate postoperative motor deficits consistent with SCI was significantly higher with irreversible MEP deteriorations compared to reversible ones. The interpretation of MEP findings at the EOM led to the development of risk categories for SCI, based on the association between MEP results and motor outcome. CONCLUSIONS Our data seem to justify interventions made to reverse MEP deterioration in order to improve the clinical outcome. A multimodal IONM protocol could improve MEP interpretation at the end of the vascular phase of surgery, supporting the surgeon in their decision-making, before concluding vascular maneuvers.
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Steffner KR, Cheung AT. Preservation of Spinal Cord Function. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00023-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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15
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Nuwer MR, MacDonald DB, Gertsch J. Monitoring scoliosis and other spinal deformity surgeries. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:179-204. [PMID: 35772886 DOI: 10.1016/b978-0-12-819826-1.00014-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Surgery to correct a spinal deformity incurs a risk of injury to the spinal cord and roots. Injuries include postoperative paraplegia. Surgery for cervical myelopathy also incurs risk for postoperative motor deficits, as well as nerve injury most commonly at the C5 root. Risks can be mitigated by monitoring the nervous system during surgery. Ideally, monitoring detects an impending injury in time to intervene and correct the impairment before it becomes permanent. Monitoring includes several modalities of testing. Somatosensory evoked potentials measure axonal conduction in the spinal cord posterior columns. This can be checked almost continuously during surgery. Motor evoked potentials measure conduction along the lateral corticospinal tracts. Because motor pathway stimulation often produces a patient movement on the table, these often are tested periodically rather than continuously. Electromyography observes for spontaneous discharges accompanying injuries, and is useful to assess misplacement of pedicle screws. Literature demonstrates the usefulness of these techniques, their association with reducing motor adverse outcomes, and the relative value of the techniques. Neurophysiologic monitoring for scoliosis, kyphosis, and cervical myelopathy surgery are addressed, along with background information about those conditions.
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Affiliation(s)
- Marc R Nuwer
- Departments of Neurology and Clinical Neurophysiology, David Geffen School of Medicine, University of California Los Angeles, and Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States.
| | | | - Jeffrey Gertsch
- Department of Neurology, UC San Diego Health, San Diego, CA, United States
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16
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Galloway G, Sala F. Mapping and monitoring of tethered cord and cauda equina surgeries. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:257-270. [PMID: 35772890 DOI: 10.1016/b978-0-12-819826-1.00018-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Surgery involving the cauda equina and tethered cord can be associated with significant functional disability including pain, motor and sensory deficits, as well as bladder, bowel, and sexual dysfunction. Neurophysiologic intraoperative monitoring and mapping during these surgeries using a variety of techniques and applications contributes to lessen the risk of permanent injury. This chapter reviews the anatomy of the pelvic floor, describes the techniques involved in monitoring and mapping this area, and describes the limitations of neurophysiology applications. Additionally, this chapter details mapping and monitoring techniques as they apply to tethered cord surgical release in both children and adults with review of outcome studies, and describes complications which can arise from tethered cord repair and injury to the cauda equina despite appropriate neurophysiologic intraoperative involvement.
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Affiliation(s)
- Gloria Galloway
- Department of Neurology, Wexner Medical Center, Ohio State University Medical Center, Columbus, OH, United States.
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
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Ali L, Jahangiri FR, Ali A, Belkhair S, Elalamy O, Adeli G, Alghazow M, Krishnan R, Karim F, Iqrar A, Raza A. Emerging Super-specialty of Neurology: Intraoperative Neurophysiological Monitoring (IONM) and Experience in Various Neurosurgeries at a Tertiary Care Hospital in Doha, Qatar. Cureus 2021; 13:e20432. [PMID: 35047269 PMCID: PMC8759984 DOI: 10.7759/cureus.20432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Intraoperative neurophysiological monitoring (IONM) helps in better patient outcomes by minimizing risks related to the functional status of the nervous system during surgical procedures. An IONM alert to the surgical team during the surgery can help them identify the cause and take immediate corrective action. IONM confers possible benefits, including improved surgical morbidity and mortality, better patient care, minimal neurological deficits, reduced hospital stay, medical costs, and litigation risk. In addition, a highly skilled IONM team will make a better patient outcome. Methods We retrospectively reviewed 62 consecutive patients who underwent intracranial and spinal neurosurgical procedures. Multimodality IONM was utilized, including somatosensory evoked potentials, transcranial electrical motor evoked potential, spontaneous and triggered electromyography, electroencephalography, electrocorticography, cortical sensory mapping, and direct electrical cortical stimulation. Of a total of 62 patients, two patients revealed neurotonic EMG discharges during IONM, and most patients woke up without any new neurological deficit. Results Sixty-two patients were included, ranging from age 5 to 77 years (mean 43.5 years), with 54.8% men and 45.2% female. Multimodality IONM was used in all patients. Two EMG alerts were recorded during IONM, during a brain tumor resection, and right acetabular hip surgery with postoperative right foot drop. Conclusion Multimodality IONM is the gold standard of care for any surgical services and is used as real-time monitoring of functional integrity of neural structures at risk. If utilized by trained and expert teams, numerous surgeries may benefit from multimodality intraoperative neurophysiologic monitoring.
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The Prognostic Value of Intraoperative Neuromonitoring by Combining Somatosensory- and Motor-Evoked Potentials for Thoracic Spinal Decompression Surgery in Patients with Neurological Deficit. Spine (Phila Pa 1976) 2021; 46:1226-1233. [PMID: 34435985 DOI: 10.1097/brs.0000000000003989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To explore a relation between somatosensory- and motor-evoked potential (SEPs, MEPs) and corresponding thoracic cord function for thoracic spinal decompression surgery (TSDS) in patients with neurological deficit. SUMMARY OF BACKGROUND DATA Although SEPs and MEPs monitoring has been developed as an essential technique in spinal surgery. There are limited data on the reliability of using SEPs and MEPs for TSDS and its prognosis. METHODS One hundred twenty patients underwent TSDS in our hospital, 91 patients completed the trial. All the patients were divided into three subgroups according to the changes of MEPs and SEPs: neither SEPs nor MEP deteriorated -. Simply MEP deteriorated and both SEPs and MEP deteriorated -. Bispectral (BIS) was used to monitor the depth of sedation, which ranged from 40 to 60 by varying the infusion speed of anesthetics. The pre- and postoperative spinal function was assessed by muscle strength and Japanese Orthopaedic Association (JOA) score at three time points:1) before surgery; 2) immediately after general anesthesia recovery; 3) after 3-month follow-up. RESULTS Sixty-nine cases showed neither SEPs nor MEP deteriorated -, 10 cases showed only MEP deteriorated, and 12 cases showed both SEPs and MEP deteriorated -. The patients in the group where neither SEPs nor MEP deteriorated had the best recovery of the extremity muscle strength, the shortest recovery time (8.10 ± 1.60, P < 0.05), and toe movement time (8.50 ± 1.60, P < 0.05). There is a strong correlation between SEPs variability ratio at T4 time point and JOA recovery ratio (JOA RR) in the 3-month follow-up. CONCLUSION Combined SEPs and MEPs monitoring are important for TSDS in patients with neurological deficit and it is helpful for evaluating postoperative prognosis. It is more accurate to record SEPs at T4 time point to predict the patients' prognosis.Level of Evidence: 3.
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Busch DR, Lin W, Goh CC, Gao F, Larson N, Wahl J, Bilfinger TV, Yodh AG, Floyd TF. Towards rapid intraoperative axial localization of spinal cord ischemia with epidural diffuse correlation monitoring. PLoS One 2021; 16:e0251271. [PMID: 33970932 PMCID: PMC8109798 DOI: 10.1371/journal.pone.0251271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/23/2021] [Indexed: 11/19/2022] Open
Abstract
Spinal cord ischemia leads to iatrogenic injury in multiple surgical fields, and the ability to immediately identify onset and anatomic origin of ischemia is critical to its management. Current clinical monitoring, however, does not directly measure spinal cord blood flow, resulting in poor sensitivity/specificity, delayed alerts, and delayed intervention. We have developed an epidural device employing diffuse correlation spectroscopy (DCS) to monitor spinal cord ischemia continuously at multiple positions. We investigate the ability of this device to localize spinal cord ischemia in a porcine model and validate DCS versus Laser Doppler Flowmetry (LDF). Specifically, we demonstrate continuous (>0.1Hz) spatially resolved (3 locations) monitoring of spinal cord blood flow in a purely ischemic model with an epidural DCS probe. Changes in blood flow measured by DCS and LDF were highly correlated (r = 0.83). Spinal cord blood flow measured by DCS caudal to aortic occlusion decreased 62%. This monitor demonstrated a sensitivity of 0.87 and specificity of 0.91 for detection of a 25% decrease in flow. This technology may enable early identification and critically important localization of spinal cord ischemia.
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Affiliation(s)
- David R. Busch
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Wei Lin
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, United States of America
| | - Chia Chieh Goh
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, United States of America
| | - Feng Gao
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Nicholas Larson
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Joseph Wahl
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Thomas V. Bilfinger
- Department of Surgery, Stony Brook University, Stony Brook, New York, United States of America
| | - Arjun G. Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Thomas F. Floyd
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- * E-mail:
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20
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De la Maza Krzeptowsky LC, San-Juan D, Ximénez Camilli C, Alvarez Perera LÁ, Valdez Ruvalcaba H, Morales Báez JA, Anschel DJ. Neurophysiological Intraoperative Monitoring in the Elderly. J Clin Neurophysiol 2021; 38:231-236. [PMID: 32141983 DOI: 10.1097/wnp.0000000000000689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Intraoperative neurophysiological monitoring (IONM) is widely used to prevent nervous system injury during surgeries in elderly patients. However, there are no studies that describe the characteristics and changes in neurophysiological tests during the IONM of patients aged 60 years and older. The study aims to describe and compare IONM changes during surgeries in adult patients aged 18 to 59 years with those aged 60 years and older. METHODS We performed a comparative retrospective study of patients aged 18 to 59 years versus those 60 aged years and older who underwent IONM during 2013 to 2018 in Mexico City. Sociodemographic characteristics were recorded and compared. Intraoperative neurophysiological monitoring techniques, their changes, and surgical procedures for both groups were analyzed and compared using descriptive statistics, Mann-Whitney U, Fisher, and χ2 tests. The sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS In total, 195 patients were analyzed: 104 patients, 68.63 ± 6.54 years old (elderly group) and 91 patients, 42.3 ± 10.5 years old (younger group). No differences were found in the rates of signal change during IONM between the group of elderly patients and the younger group. The sensitivity, specificity, and positive and negative predictive values were 80%, 99%, 80%, and 99%, respectively. CONCLUSIONS Elderly patients have a similar rate of changes in IONM signals compared with younger patients during heterogeneous surgeries guided by IONM.
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Affiliation(s)
| | - Daniel San-Juan
- Neurophysiology Department, Hospital Ángeles del Pedregal, México City, Mexico
- Neurology Department, National Institute of Neurology, Mexico City, Mexico
| | | | - Luis Á Alvarez Perera
- Neurophysiology Department, Hospital Ángeles del Pedregal, México City, Mexico
- Neurology Department, National Institute of Neurology, Mexico City, Mexico
| | | | | | - David J Anschel
- Comprehensive Epilepsy Center of Long Island, Port Jefferson, New York, U.S.A
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Shim HK, Lee JM, Kim DH, Nam KH, Choi BK, Han IH. Successful Motor Evoked Potential Monitoring in Cervical Myelopathy : Related Factors and the Effect of Increased Stimulation Intensity. J Korean Neurosurg Soc 2020; 64:78-87. [PMID: 33355842 PMCID: PMC7819792 DOI: 10.3340/jkns.2020.0111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/08/2020] [Indexed: 11/27/2022] Open
Abstract
Objective Intraoperative neurophysiological monitoring (IONM) has been widely used during spine surgery to reduce or prevent neurologic deficits, however, its application to the surgical management for cervical myelopathy remains controversial. This study aimed to assess the success rate of IONM in patients with cervical myelopathy and to investigate the factors associated with successful baseline monitoring and the effect of increasing the stimulation intensity by focusing on motor evoked potentials (MEPs).
Methods The data of 88 patients who underwent surgery for cervical myelopathy with IONM between January 2016 and June 2018 were retrospectively reviewed. The success rate of baseline MEP monitoring at the initial stimulation of 400 V was investigated. In unmonitorable cases, the stimulation intensity was increased to 999 V, and the success rate final MEP monitoring was reinvestigated. In addition, factors related to the success rate of baseline MEP monitoring were investigated using independent t-test, Wilcoxon rank-sum test, chi-squared test, and Fisher’s exact probability test for statistical analysis. The factors included age, sex, body mass index, diabetes mellitus, smoking history, symptom duration, Torg-Pavlov ratio, space available for the cord (SAC), cord compression ratio (CCR), intramedullary increased signal intensity (SI) on magnetic resonance imaging, SI length, SI ratio, the Medical Research Council (MRC) grade, the preoperative modified Nurick grade and Japanese Orthopedic Association (JOA) score.
Results The overall success rate for reliable MEP response was 52.3% after increasing the stimulation intensity. No complications were observed to be associated with increased intensity. The factors related to the success rate of final MEP monitoring were found to be SAC (p<0.001), CCR (p<0.001), MRC grade (p<0.001), preoperative modified Nurick grade (p<0.001), and JOA score (p<0.001). The cut-off score for successful MEP monitoring was 5.67 mm for SAC, 47.33% for the CCR, 3 points for MRC grade, 2 points for the modified Nurick grade, and 12 points for the JOA score.
Conclusion Increasing the stimulation intensity could significantly improve the success rate of baseline MEP monitoring for unmonitorable cases at the initial stimulation in cervical myelopathy. In particular, the SAC, CCR, MRC grade, preoperative Nurick grade and JOA score may be considered as the more important related factors associated with the success rate of MEP monitoring. Therefore, the degree of preoperative neurological functional deficits and the presence of spinal cord compression on imaging could be used as new detailed criteria for the application of IONM in patients with cervical myelopathy.
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Affiliation(s)
- Hyok Ki Shim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jae Meen Lee
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Dong Hwan Kim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Kyoung Hyup Nam
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Byung Kwan Choi
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - In Ho Han
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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22
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Cofano F, Giambra C, Costa P, Zeppa P, Bianconi A, Mammi M, Monticelli M, Di Perna G, Junemann CV, Melcarne A, Massaro F, Ducati A, Tartara F, Zenga F, Garbossa D. Management of Extramedullary Intradural Spinal Tumors: The Impact of Clinical Status, Intraoperative Neurophysiological Monitoring and Surgical Approach on Outcomes in a 12-Year Double-Center Experience. Front Neurol 2020; 11:598619. [PMID: 33391161 PMCID: PMC7775672 DOI: 10.3389/fneur.2020.598619] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/19/2020] [Indexed: 12/15/2022] Open
Abstract
Objective: Intradural Extramedullary (IDEM) tumors are usually treated with surgical excision. The aim of this study was to investigate the impact on clinical outcomes of pre-surgical clinical conditions, intraoperative neurophysiological monitoring (IONM), surgical access to the spinal canal, histology, degree of resection and intra/postoperative complications. Methods: This is a retrospective observational study analyzing data of patients suffering from IDEM tumors who underwent surgical treatment over a 12 year period in a double-center experience. Data were extracted from a prospectively maintained database and included: sex, age at diagnosis, clinical status according to the modified McCormick Scale (Grades I-V) at admission, discharge, and follow-up, tumor histology, type of surgical access to the spinal canal (bilateral laminectomy vs. monolateral laminectomy vs. laminoplasty), degree of surgical removal, use and type of IONM, occurrence and type of intraoperative complications, use of Ultrasonic Aspirator (CUSA), radiological follow-up. Results: A total number of 249 patients was included with a mean follow-up of 48.3 months. Gross total resection was achieved in 210 patients (84.3%) mostly in Schwannomas (45.2%) and Meningiomas (40.4%). IONM was performed in 162 procedures (65%) and D-wave was recorded in 64.2% of all cervical and thoracic locations (99 patients). The linear regression diagram for McCormick grades before and after surgery (follow-up) showed a correlation between preoperative and postoperative clinical status. A statistically significant correlation was found between absence of worsening of clinical condition at follow-up and use of IONM at follow-up (p = 0.01) but not at discharge. No associations were found between the choice of surgical approach and the extent of resection (p = 0.79), the presence of recurrence or residual tumor (p = 0.14) or CSF leakage (p = 0.25). The extent of resection was not associated with the use of IONM (p = 0.91) or CUSA (p = 0.19). Conclusion: A reliable prediction of clinical improvement could be made based on pre-operative clinical status. The use of IONM resulted in better clinical outcomes at follow-up (not at discharge), but no associations were found with the extent of resection. The use of minimally invasive approaches such as monolateral laminectomy showed to be effective and not associated with worse outcomes or increased complications.
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Affiliation(s)
- Fabio Cofano
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy.,Ospedale Humanitas Gradenigo, Turin, Italy
| | | | - Paolo Costa
- Section of Clinical Neurophysiology, Centro Traumatologico Ortopedico Hospital, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Pietro Zeppa
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Andrea Bianconi
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Marco Mammi
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Matteo Monticelli
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Giuseppe Di Perna
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Carola Vera Junemann
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Antonio Melcarne
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Fulvio Massaro
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | | | - Fulvio Tartara
- Unit of Neurosurgery, Istituto Clinico Città Studi (ICCS), Milan, Italy
| | - Francesco Zenga
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Diego Garbossa
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
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Busch DR, Lin W, Cai C, Cutrone A, Tatka J, Kovarovic BJ, Yodh AG, Floyd TF, Barsi J. Multi-Site Optical Monitoring of Spinal Cord Ischemia during Spine Distraction. J Neurotrauma 2020; 37:2014-2022. [PMID: 32458719 DOI: 10.1089/neu.2020.7012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Optimal surgical management of spine trauma will restore blood flow to the ischemic spinal cord. However, spine stabilization may also further exacerbate injury by inducing ischemia. Current electrophysiological technology is not capable of detecting acute changes in spinal cord blood flow or localizing ischemia. Further, alerts are delayed and unreliable. We developed an epidural optical device capable of directly measuring and immediately detecting changes in spinal cord blood flow using diffuse correlation spectroscopy (DCS). Herein we test the hypothesis that our device can continuously monitor blood flow during spine distraction. Additionally, we demonstrate the ability of our device to monitor multiple sites along the spinal cord and axially resolve changes in spinal cord blood flow. DCS-measured blood flow in the spinal cord was monitored at up to three spatial locations (cranial to, at, and caudal to the distraction site) during surgical distraction in a sheep model. Distraction was halted at 50% of baseline blood flow at the distraction site. We were able to monitor blood flow with DCS in multiple regions of the spinal cord simultaneously at ∼1 Hz. The distraction site had a greater decrement in flow than sites cranial to the injury (median -40 vs. -7%,). This pilot study demonstrated high temporal resolution and the capacity to axially resolve changes in spinal cord blood flow at and remote from the site of distraction. These early results suggest that this technology may assist in the surgical management of spine trauma and in corrective surgery of the spine.
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Affiliation(s)
- David R Busch
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA.,Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas, Texas, USA
| | - Wei Lin
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Chunyu Cai
- Department of Pathology, University of Texas Southwestern, Dallas, Texas, USA
| | - Alissa Cutrone
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee, USA
| | - Jakub Tatka
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Brandon J Kovarovic
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas F Floyd
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA.,Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern, Dallas, Texas, USA.,Department of Radiology, University of Texas Southwestern, Dallas, Texas, USA
| | - James Barsi
- Department of Orthopedic Surgery, Stony Brook University, Stony Brook, New York, USA
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Holdefer RN, Skinner SA. Motor evoked potential recovery with surgeon interventions and neurologic outcomes: A meta-analysis and structural causal model for spine deformity surgeries. Clin Neurophysiol 2020; 131:1556-1566. [PMID: 32413722 DOI: 10.1016/j.clinph.2020.03.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/15/2020] [Accepted: 03/08/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To improve estimates of motor evoked potential (MEP) performance during spine deformity surgeries by accounting for potential confounders. METHODS A meta-analysis of MEPs for spine deformity surgeries determined the probability of a MEP deterioration which recovered by the end of surgery, P(RSC), and the conditional probability of no new post-operative deficit given an RSC, P(NND|RSC), stratified by category of intraoperative adverse event associated with the MEP deterioration. A structural causal model (SCM) and propensity score matching accounted for intraoperative adverse events and patient diagnosis as potential confounders. RESULTS MEPs changes (either reversible, RSC or irreversible, IRREV) were reported for 295 of 5055 cases (6%) in 21 studies. The probability of no new motor deficit, P(NND), plotted against the probability of a RSC, P(RSC), for studies in the meta-analysis was highly significant (r = 0.71, p < 0.001). P(RSC) was 0.76 for an alert associated with correction, less for osteotomies (0.48, p = 0.0008), and tended to be higher for hypotension (0.92, p = 0.06). P(NND|RSC) was 0.94 for correction, less for positioning (0.82), and osteotomies (0.86), and greater for hypotension (1.0). In the SCM, a RSC after an alert was a highly significant and independent predictor of no new motor deficits (odds 25.2, p < 0.001). CONCLUSION There are significant differences in P(RSC) for hypotension and osteotomies, and in P(NND) for osteotomies and instrumentation, compared to correction. P(RSC) is a significant and independent predictor of outcomes. SIGNIFICANCE When MEPs are used for spine deformity surgeries, accounting for adverse events associated with an alert and patient diagnosis as potential confounders is expected to improve RSC prediction of post-operative outcomes and estimates of RSC efficacy in improving outcomes.
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Affiliation(s)
- R N Holdefer
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Box 359740, Seattle, WA 98104-2499, USA.
| | - S A Skinner
- Intraoperative Monitoring, Department of Neurophysiology, Abbott Northwestern Hospital, 800 E 28th Street, Minneapolis, MN 55407, USA
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Laughlin RS, Johnson RL, Burkle CM, Staff NP. Postsurgical Neuropathy: A Descriptive Review. Mayo Clin Proc 2020; 95:355-369. [PMID: 32029088 DOI: 10.1016/j.mayocp.2019.05.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/27/2019] [Accepted: 05/21/2019] [Indexed: 11/21/2022]
Abstract
Postsurgical neuropathies represent an infrequent but potentially devastating complication of surgery that may result in significant morbidity with medicolegal implications. Elucidation of this phenomenon has evolved over the past few decades, with emerging evidence for not only iatrogenic factors contributing to this process but also inflammatory causes. This distinction can be important; for instance, cases in which inflammatory etiologies are suspected may benefit from further investigations including nerve biopsy and may benefit from treatment in the form of immunotherapy. In contrast, postsurgical neuropathies due to perioperative causes including anesthesia, traction, compression, and transection will not benefit in the same manner. This article summarizes early and current literature surrounding the frequency of new neurologic deficits after various surgical types, potential causes including anatomical and inflammatory considerations, and roles for treatment. To capture the scope of the issue, a literature review was conducted for human studies in English via MEDLINE and EMBASE from January 1, 1988 to March 31, 2018. Search terms included anesthesia and/or surgical procedures, operative, peripheral nervous system diseases, trauma, mononeuropathy, polyneuropathy, peripheral nervous system, nerve compression, neuropathy, plexopathy, postoperative, postsurgical, perioperative, complication. We excluded case series with less than 10 patients and review papers. We then narrowed the studies to those presented highlighting key concepts in postsurgical neuropathy.
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26
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Tsirikos AI, Duckworth AD, Henderson LE, Michaelson C. Multimodal Intraoperative Spinal Cord Monitoring during Spinal Deformity Surgery: Efficacy, Diagnostic Characteristics, and Algorithm Development. Med Princ Pract 2020; 29:6-17. [PMID: 31158841 PMCID: PMC7024888 DOI: 10.1159/000501256] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 06/03/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study aims to present the diagnostic characteristics of multimodal intraoperative monitoring (IOM) in spinal deformity surgery and to define and categorise the neuromonitoring events, as well as propose an algorithm of action. MATERIALS AND METHODS We reviewed 1,155 consecutive patients (807 female, 348 male) who underwent deformity correction using standardised perioperative care, cortical/cervical somatosensory evoked potentials (SSEPs), and upper/lower limb transcranial electrical motor evoked potential (MEPs) by a single surgeon. The mean age at surgery was 13.8 years (range 10-23.3). We categorised IOM events as true, transient true, and false positive or negative. Diagnostic performance criteria were calculated. RESULTS The most common diagnosis was adolescent idiopathic scoliosis in 717 (62%) patients. We identified 3 true positive monitoring events occurring in 2 patients (0.17%), 8 transient true positive (0.69%), and 8 transient false positive events (0.69%). There were no false negative events and no patient had postoperative neurological complications. The multimodal IOM technique had a sensitivity of 100%, specificity of 99.3%, positive predictive value of 55.6%, and negative predictive value of 100%. Sensitivity was 100% for MEPs and multimodal monitoring compared to 20% for cortical or cervical SSEPs. The frequency of true or transient true positive events was higher (p = 0.07) in Scheuermann's kyphosis (3/91 patients, 3.3%) compared to adolescent idiopathic scoliosis (6/717 patients, 0.84%). CONCLUSION Multimodal IOM is highly sensitive and specific for spinal cord injury. This technique is reliable for the assessment of the condition of the spinal cord during major deformity surgery. We propose an algorithm of intraoperative action to allow close cooperation between the surgical, anaesthetic, and neurophysiology teams and to prevent neurological deficits.
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Affiliation(s)
- Athanasios I Tsirikos
- Scottish National Spine Deformity Centre, Royal Hospital for Sick Children, Edinburgh, United Kingdom,
| | - Andrew D Duckworth
- Scottish National Spine Deformity Centre, Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - Lindsay E Henderson
- Scottish National Spine Deformity Centre, Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - Ciara Michaelson
- Scottish National Spine Deformity Centre, Royal Hospital for Sick Children, Edinburgh, United Kingdom
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27
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Nagarajan L, Ghosh S, Dillon D, Palumbo L, Woodland P, Thalayasingam P, Lethbridge M. Intraoperative neurophysiology monitoring in scoliosis surgery in children. Clin Neurophysiol Pract 2019; 4:11-17. [PMID: 30828671 PMCID: PMC6383123 DOI: 10.1016/j.cnp.2018.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 12/24/2018] [Accepted: 12/29/2018] [Indexed: 02/08/2023] Open
Abstract
Objective Intraoperative neurophysiology monitoring (INM) is thought to reduce the risk of postoperative neurological deficits in children undergoing scoliosis and spine deformity surgery. INM is being used increasingly despite conflicting opinions, varied results, non-standard alarm criteria and concern regarding cost effectiveness. In this paper we present our experience with INM in scoliosis and spine deformation surgery in children, propose alert criteria and preferred anaesthetics in clinical practice. Methods We retrospectively analysed our experience with INM in 56 children who had 61 scoliosis and spine deformity surgeries. Results INM was successfully undertaken with transcranial electrical motor evoked potentials (TcMEP) and somatosensory evoked potentials. There were no injuries due to INM. Four children had 5 alerts during 4 surgeries. A postoperative deficit was seen in one child only. No new postoperative deficits were seen in any child who did not have an alert during INM. Total intravenous anaesthesia was better for INM compared to inhalational anaesthetics. Conclusions INM is useful in scoliosis surgery; it is likely to mitigate the risk of new deficits following surgery. We recommend alert criteria for TcMEPs that include multiple facets - amplitude, stimulus paradigm, morphology. We recommend propofol and remifentanil, in preference to sevoflurane and remifentanil for anaesthesia during INM. Significance Our study adds to the literature supporting the role of INM in scoliosis surgery in children. We provide guidelines for alarm criteria in clinical practice and recommend the use of total intravenous anaesthesia as the preferred anaesthetic option.
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Affiliation(s)
- Lakshmi Nagarajan
- Children's Neuroscience Service, Dept. of Neurology, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia.,School of Medicine, University of Western Australia, Nedlands, WA 6009, Australia.,Telethon Kids Institute, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Soumya Ghosh
- Children's Neuroscience Service, Dept. of Neurology, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia.,Centre for Neuromuscular and Neurological Disorders, University of Western Australia, Nedlands, WA 6009, Australia
| | - David Dillon
- Dept of Orthopaedics, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Linda Palumbo
- Children's Neuroscience Service, Dept. of Neurology, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Peter Woodland
- Dept of Orthopaedics, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Priya Thalayasingam
- Dept. of Anaesthetics, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Martyn Lethbridge
- Dept. of Anaesthetics, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
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28
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Kahraman S, Gocmen S, Alpsan Gokmen MH, Acka G, Pusat S. Intraoperative Neurophysiologic Monitoring for Lumbar Intradural Schwannomas: Does It Affect Clinical Outcome? World Neurosurg 2019; 124:e789-e792. [PMID: 30684697 DOI: 10.1016/j.wneu.2019.01.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/05/2019] [Accepted: 01/08/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Intraoperative multimodal neuromonitoring (IONM) is considered valuable for the early detection and prevention of any neurologic compromise during spine surgery. It has also become the standard of care at many institutions to improve the surgical outcome and be a safety net for both clinical and medicolegal concerns. METHODS Our experience and outcomes in 46 consecutive cases of lumbar intradural schwannoma resection were reviewed with respect to clinical outcomes and patient safety, before and after the integration of IONM into our clinical practice. RESULTS Total surgical resection of schwannomas in the lumbar spine led to improved health-related quality of life for patients. The standard technique for microsurgical resection of schwannomas requires identifying and resecting the fiber of origin for the schwannoma, guided with triggered electromyographic monitoring. However, whether this changed the surgical strategy, because spinal roots that gave rise to the schwannoma were frequently found to be nonfunctional during surgery, remains unclear. In our series of 46 patients, we did not recognize any additional motor deficit after the surgery, regardless of the use of IONM. CONCLUSIONS Despite our analysis proving no difference in clinical outcomes with or without the use of IONM during surgical excision of lumbar schwannomas, we still prefer using IONM as a standard approach. It adds to the confidence and ease of mind of the surgeon during resection and also provides valuable data in cases of medicolegal disputes. However, it comes with an increased cost and lengthened surgical procedure.
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Affiliation(s)
- Serdar Kahraman
- Department of Neurosurgery, Anadolu Medical Center, Kocaeli, Turkey
| | - Selcuk Gocmen
- Department of Neurosurgery, Anadolu Medical Center, Kocaeli, Turkey.
| | | | - Gokhan Acka
- Department of Neurosurgery, Anadolu Medical Center, Kocaeli, Turkey
| | - Serhat Pusat
- Department of Neurosurgery, Sultan Abdulhamithan Hospital, Istanbul, Turkey
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29
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Nuwer MR. New alert criteria for intraoperative somatosensory evoked potential monitoring. Clin Neurophysiol 2019; 130:155-156. [DOI: 10.1016/j.clinph.2018.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/02/2018] [Indexed: 10/27/2022]
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Practice guidelines for the supervising professional: intraoperative neurophysiological monitoring. J Clin Monit Comput 2018; 33:175-183. [PMID: 30374759 PMCID: PMC6420431 DOI: 10.1007/s10877-018-0201-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 09/18/2018] [Indexed: 01/29/2023]
Abstract
The American Society of Neurophysiological Monitoring (ASNM) was founded in 1989 as the American Society of Evoked Potential Monitoring. From the beginning, the Society has been made up of physicians, doctoral degree holders, Technologists, and all those interested in furthering the profession. The Society changed its name to the ASNM and held its first Annual Meeting in 1990. It remains the largest worldwide organization dedicated solely to the scientifically-based advancement of intraoperative neurophysiology. The primary goal of the ASNM is to assure the quality of patient care during procedures monitoring the nervous system. This goal is accomplished primarily through programs in education, advocacy of basic and clinical research, and publication of guidelines, among other endeavors. The ASNM is committed to the development of medically sound and clinically relevant guidelines for the performance of intraoperative neurophysiology. Guidelines are formulated based on exhaustive literature review, recruitment of expert opinion, and broad consensus among ASNM membership. Input is likewise sought from sister societies and related constituencies. Adherence to a literature-based, formalized process characterizes the construction of all ASNM guidelines. The guidelines covering the Professional Practice of intraoperative neurophysiological monitoring were initially published January 24th, 2013, and subsequently that document has undergone review and revision to accommodate broad inter- and intra-societal feedback. This current version of the ASNM Professional Practice Guideline was fully approved for publication according to ASNM bylaws on February 22nd, 2018, and thus overwrites and supersedes the initial guideline.
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31
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Schwartz SL, Kale EB, Husain AM. Lower Extremity Somatosensory Evoked Potential P37 Waveform Optimization. Neurodiagn J 2018; 58:174-181. [PMID: 30257170 DOI: 10.1080/21646821.2018.1499304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Somatosensory evoked potentials (SEPs) using tibial nerve stimulation are used during neurophysiologic intraoperative monitoring (NIOM). These SEPs produce a P37 waveform that is recorded from scalp electrodes. In this study, we attempted to determine the best derivation for recording the P37 waveform. Surgical cases using tibial nerve SEP NIOM were reviewed. Only cases in which the P37 was recorded using all of the following derivations were analyzed: centroparietal ipsilateral-centroparietal contralateral (CPi-CPc), centroparietal midline-frontopolar midline (CPz-Fpz), and CPz-CPc. The amplitude of the P37 waveform was measured in each derivation. Descriptive statistics were obtained for the P37 waveform amplitude. The mean amplitude in each of the derivations was compared using a chi-square test. Data from 39 patients (78 lower limbs) were available for analysis. The mean age of the patients was 49.64 years (range: 4-87 years); 18 were female. The highest amplitude P37 waveform was recorded from the CPz-Fpz derivation in 29 (35.4%) limbs, whereas the CPz-CPc and CPi-CPc derivations showed the highest amplitude in 29 (35.4%) and 20 (24.4%) limbs, respectively. The mean amplitudes were not significantly different between the various derivations. In only 10 (24.4%) of patients was the best derivation the same for both left and right limbs. A single best derivation was not found for recording the P37 waveform. Multiple derivations should be used to record cortical channels whenever possible. If the number of available channels is limited, using at least the CPz-Fpz and CPz-CPc derivations is recommended.
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Affiliation(s)
- Stephanie L Schwartz
- a Neurodiagnostic Ancillary Services , Duke University Medical Center , Durham , North Carolina
| | - Emily B Kale
- a Neurodiagnostic Ancillary Services , Duke University Medical Center , Durham , North Carolina
| | - Aatif M Husain
- b Department of Neurology , Duke University Medical Center , Durham , North Carolina.,c Neurodiagnostic Center, Veterans Affairs Medical Center , Durham , North Carolina.,d Neuroscience Medicine, Duke Clinical Research Institute , Durham , North Carolina
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Neurophysiological monitoring during cervical spine surgeries: Longitudinal costs and outcomes. Clin Neurophysiol 2018; 129:2245-2251. [PMID: 30216908 DOI: 10.1016/j.clinph.2018.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 08/06/2018] [Accepted: 08/23/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Well-designed longitudinal studies assessing effectiveness of intraoperative neurophysiologic monitoring (IONM) are lacking. We investigate IONM effects on cost and administrative markers for health outcomes in the year after cervical spine surgery. METHODS We identified single-level cervical spine surgeries in commercial claims. We constructed linear regression models estimating the effect of IONM (controlling for patient demographics, pre-operative health, services during index admission) on total spending, neurological complications, readmissions, and outpatient opiate usage in the year following index surgery. RESULTS IONM was associated with increased spending during index admission of $1229 (p = 0.001), but decreased spending post-discharge of $1615 (p = 0.010), for a net - $386 (p = 0.608) for the year after surgery. Shorter length of stay (0.116 days, p = 0.004) and fewer readmissions (20.5 per thousand, p = 0.036) accounted for some post-discharge savings. IONM was associated with decreased rates of nervous system complications (4/1000, p = 0.048) and post-discharge opiate use (17 prescriptions/1000, p = 0.050) in the year after index admission. CONCLUSIONS IONM was associated with administrative markers suggesting improved health outcomes after cervical spine surgery without greater costs for the year. SIGNIFICANCE This study suggests IONM may have lasting health and cost benefits.
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Hadley MN, Shank CD, Rozzelle CJ, Walters BC. In Reply: Guidelines for the Use of Electrophysiological Monitoring for Surgery of the Human Spinal Column and Spinal Cord. Neurosurgery 2018; 83:E85-E86. [DOI: 10.1093/neuros/nyy232] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Beck J, Raabe A, Schievink WI, Fung C, Gralla J, Piechowiak E, Seidel K, Ulrich CT. Posterior Approach and Spinal Cord Release for 360° Repair of Dural Defects in Spontaneous Intracranial Hypotension. Neurosurgery 2018; 84:E345-E351. [DOI: 10.1093/neuros/nyy312] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 07/10/2018] [Indexed: 01/03/2023] Open
Affiliation(s)
- Jürgen Beck
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Christian Fung
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Jan Gralla
- Institute of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Eike Piechowiak
- Institute of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Christian T Ulrich
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
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35
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Fox S, Allen L, Norton J. Neurophysiological monitoring of displaced odontoid fracture reduction in a 3-year-old male. Spinal Cord Ser Cases 2018; 4:52. [PMID: 29951277 DOI: 10.1038/s41394-018-0088-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 04/25/2018] [Accepted: 05/07/2018] [Indexed: 11/09/2022] Open
Abstract
Introduction Odontoid fractures in young children are rare. Most authors advocate for closed reduction and external stabilization as first line treatment. Unlike adults, young children are much less amenable to an awake reduction for real-time assessment of neurological function. We used spinal cord monitoring, as used in spine surgery, to assess the function of the spinal cord during the closed reduction in our 31-month-old patient. Case presentation A 31-month-old male presented with a displaced odontoid fracture and ASIA C spinal cord injury. Given his age, closed reduction and halo application were completed under general anesthesia guided by neuromonitoring. A less-than-ideal reduction initially was accepted due to a decline in motor-evoked potentials. Subsequently, there was no change in neurological status. The reduction was repeated under anesthesia, with monitoring, a number of times until good correction was achieved. Ultimately, a surgical fusion was required due to ligamentous instability. The child achieved a very good neurological outcome and a stable spine. Discussion Neuromonitoring is an important adjunct to closed reductions when complete and reliable neurological assessment is not possible.
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Affiliation(s)
- Shandy Fox
- Department of Surgery, University of Saskatchewan Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W6 Canada
| | - Lauren Allen
- Department of Surgery, University of Saskatchewan Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W6 Canada
| | - Jonathan Norton
- Department of Surgery, University of Saskatchewan Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W6 Canada
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Busch DR, Davis J, Kogler A, Galler RM, Parthasarathy AB, Yodh AG, Floyd TF. Laser safety in fiber-optic monitoring of spinal cord hemodynamics: a preclinical evaluation. JOURNAL OF BIOMEDICAL OPTICS 2018; 23:1-9. [PMID: 29923371 PMCID: PMC8357330 DOI: 10.1117/1.jbo.23.6.065003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/30/2018] [Indexed: 05/02/2023]
Abstract
The prevention and treatment of spinal cord injury are focused upon the maintenance of spinal cord blood flow, yet no technology exists to monitor spinal cord ischemia. We recently demonstrated continuous monitoring of spinal cord ischemia with diffuse correlation and optical spectroscopies using an optical probe. Prior to clinical translation of this technology, it is critically important to demonstrate the safety profile of spinal cord exposure to the required light. To our knowledge, this is the first report of in situ safety testing of such a monitor. We expose the spinal cord to laser light utilizing a custom fiber-optic epidural probe in a survival surgery model (11 adult Dorset sheep). We compare the tissue illumination from our instrument with the American National Standards Institute maximum permissible exposures. We experimentally evaluate neurological and pathological outcomes of the irradiated sheep associated with prolonged exposure to the laser source and evaluate heating in ex vivo spinal cord samples. Spinal cord tissue was exposed to light levels at ∼18 × the maximum permissible exposure for the eye and ∼ ( 1 / 3 ) × for the skin. Multidisciplinary testing revealed no functional neurological sequelae, histopathologic evidence of laser-related injury to the spinal cord, or significant temperature changes in ex vivo samples. Low tissue irradiance and the lack of neurological, pathological, and temperature changes upon prolonged exposure to the laser source offer evidence that spinal cord tissues can be monitored safely with near-infrared optical probes placed within the epidural space.
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Affiliation(s)
- David R. Busch
- University of Texas Southwestern, Department of Anesthesiology and Pain Management, Dallas Texas, United States
- University of Texas Southwestern, Department of Neurology and Neurotherapeutics, Dallas, Texas, United States
- University of Pennsylvania, Department of Physics and Astronomy, Philadelphia, Pennsylvania, United States
- Address all correspondence to: David R. Busch, E-mail: ; Thomas F. Floyd, E-mail:
| | - James Davis
- Stony Brook University Medical Center, Department of Pathology, Stony Brook, New York, United States
| | - Angela Kogler
- Stony Brook University Medical Center, Department of Anesthesiology, Stony Brook, New York, United States
- Stony Brook University, Department of Biomedical Engineering, Stony Brook, New York, United States
| | - Robert M. Galler
- Stony Brook University Medical Center, Department of Neurosurgery, Stony Brook, New York, United States
| | - Ashwin B. Parthasarathy
- University of South Florida, Department of Electrical Engineering, Tampa, Florida, United States
| | - Arjun G. Yodh
- University of Pennsylvania, Department of Physics and Astronomy, Philadelphia, Pennsylvania, United States
| | - Thomas F. Floyd
- University of Texas Southwestern, Department of Anesthesiology and Pain Management, Dallas Texas, United States
- Address all correspondence to: David R. Busch, E-mail: ; Thomas F. Floyd, E-mail:
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In Reply: Guidelines for the Use of Electrophysiological Monitoring for Surgery of the Human Spinal Column and Spinal Cord. Neurosurgery 2018; 82:E192-E193. [DOI: 10.1093/neuros/nyy094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kim K, Cho C, Bang MS, Shin HI, Phi JH, Kim SK. Intraoperative Neurophysiological Monitoring : A Review of Techniques Used for Brain Tumor Surgery in Children. J Korean Neurosurg Soc 2018; 61:363-375. [PMID: 29742889 PMCID: PMC5957318 DOI: 10.3340/jkns.2018.0078] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 04/16/2018] [Indexed: 11/27/2022] Open
Abstract
Intraoperative monitoring (IOM) utilizes electrophysiological techniques as a surrogate test and evaluation of nervous function while a patient is under general anesthesia. They are increasingly used for procedures, both surgical and endovascular, to avoid injury during an operation, examine neurological tissue to guide the surgery, or to test electrophysiological function to allow for more complete resection or corrections. The application of IOM during pediatric brain tumor resections encompasses a unique set of technical issues. First, obtaining stable and reliable responses in children of different ages requires detailed understanding of normal ageadjusted brain-spine development. Neurophysiology, anatomy, and anthropometry of children are different from those of adults. Second, monitoring of the brain may include risk to eloquent functions and cranial nerve functions that are difficult with the usual neurophysiological techniques. Third, interpretation of signal change requires unique sets of normative values specific for children of that age. Fourth, tumor resection involves multiple considerations including defining tumor type, size, location, pathophysiology that might require maximal removal of lesion or minimal intervention. IOM techniques can be divided into monitoring and mapping. Mapping involves identification of specific neural structures to avoid or minimize injury. Monitoring is continuous acquisition of neural signals to determine the integrity of the full longitudinal path of the neural system of interest. Motor evoked potentials and somatosensory evoked potentials are representative methodologies for monitoring. Free-running electromyography is also used to monitor irritation or damage to the motor nerves in the lower motor neuron level : cranial nerves, roots, and peripheral nerves. For the surgery of infratentorial tumors, in addition to free-running electromyography of the bulbar muscles, brainstem auditory evoked potentials or corticobulbar motor evoked potentials could be combined to prevent injury of the cranial nerves or nucleus. IOM for cerebral tumors can adopt direct cortical stimulation or direct subcortical stimulation to map the corticospinal pathways in the vicinity of lesion. IOM is a diagnostic as well as interventional tool for neurosurgery. To prove clinical evidence of it is not simple. Randomized controlled prospective studies may not be possible due to ethical reasons. However, prospective longitudinal studies confirming prognostic value of IOM are available. Furthermore, oncological outcome has also been shown to be superior in some brain tumors, with IOM. New methodologies of IOM are being developed and clinically applied. This review establishes a composite view of techniques used today, noting differences between adult and pediatric monitoring.
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Affiliation(s)
- Keewon Kim
- Department of Rehabilitation Medicine, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Charles Cho
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Moon-Suk Bang
- Department of Rehabilitation Medicine, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Hoon Phi
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Seung-Ki Kim
- Department of Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
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To warn or not to warn: A reappraisal of brainstem auditory evoked potential warning criteria during surgery. Clin Neurophysiol 2018; 129:1053-1055. [PMID: 29500046 DOI: 10.1016/j.clinph.2018.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 02/01/2018] [Indexed: 11/24/2022]
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Norton JA, Peeling L, Meguro K, Kelly M. Phenomenology of neurophysiologic changes during surgical treatment of carotid stenosis using signal analysis. Clin Neurophysiol Pract 2018; 3:28-32. [PMID: 30215004 PMCID: PMC6133780 DOI: 10.1016/j.cnp.2017.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 12/12/2017] [Accepted: 12/20/2017] [Indexed: 11/02/2022] Open
Abstract
Objective To describe the changes in the shape and topology of the somatosensory evoked potential (SSEP) during carotid endarterectomy, with particular reference to the time of clamping. Methods Routine intraoperative monitoring was performed on 30 patients undergoing carotid endarterectomy (15) or undergoing stenting (15) using median nerve SSEPs. Post-operatively the first and second derivatives of the potential were examined. Separate analysis of the SSEP using wavelets was also performed. Results In no instances did changes in the SSEP reach clinical significance. The first derivative showed significant changes that were temporally related to the clamp period. After clamping the 'velocity' was higher than baseline. There were changes in the wavelets related to the clamp period with more marked spectral edges at the conclusion of the procedure than baseline. In all instances the patient had a good clinical outcome. Conclusions Wavelet and derivative analysis of evoked potentials show changes that are not apparent with measures of amplitude and latency. The clinical relevance of these changes remains uncertain and await larger studies. Significance Increased velocity and spectral edges may be markers of increased cerebral blood flow, at least in the setting of pre-existing carotid stenosis.
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Affiliation(s)
- Jonathan A Norton
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Canada
| | - Lissa Peeling
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Canada
| | - Kotoo Meguro
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Canada
| | - Mike Kelly
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Canada
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Abstract
Motor evoked potentials (MEPs) are commonly used during neurophysiologic intraoperative monitoring. Anesthetic, homeostatic, surgical, and technical factors can cause a change in MEPs. The authors describe a case in which a bolus of magnesium sulfate resulted in a loss of amplitude of MEPs. Responses returned to near baseline about 20 minutes later. The patient did not have any new postoperative deficits. When MEP changes occur, in addition to evaluating other causes, magnesium sulfate administration should be considered.
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Affiliation(s)
- Tucker Johnson
- a Duke University Medical Center , Durham , North Carolina
| | - Emily B Kale
- a Duke University Medical Center , Durham , North Carolina
| | - Aatif M Husain
- a Duke University Medical Center , Durham , North Carolina
- b Veterans Affairs Medical Center , Durham , North Carolina
- c Duke Clinical Research Institute , Durham , North Carolina
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Olesnicky BL, D'Souza RJ, Jayram D, Kim OMO, Rehak A. The Establishment of An Anaesthetist-Managed Intraoperative Neurophysiological Monitoring Service and Initial Outcome Data. Anaesth Intensive Care 2018; 46:74-78. [DOI: 10.1177/0310057x1804600111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Neurophysiological monitoring has been recommended to reduce the risk of neurological damage during a wide variety of surgeries. While the concept of an anaesthesia-led intraoperative neurophysiological monitoring (IONM) service is not new, the quality of this service provision has not been studied. In this article, we present our experience with the establishment of this service, and the results of our audit of 302 cases monitored over the initial four years. Our results identified that an anaesthesia-led IONM service was able to achieve a reliable signal in 95.4% of cases and capture significant alerts in 15.6% of these cases with sensitivity, specificity, false positive and negative rates consistent with published data. Our results indicate an anaesthesia-led IONM service is effective in identifying patients at an increased risk of an adverse outcome.
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Affiliation(s)
- B. L. Olesnicky
- VMO Anaesthetist, Royal North Shore Hospital, North Shore Private Hospital, Sydney, New South Wales
| | - R. J. D'Souza
- VMO Anaesthetist, Royal North Shore Hospital, North Shore Private Hospital, Sydney, New South Wales
| | - D. Jayram
- VMO Anaesthetist, Royal North Shore Hospital, North Shore Private Hospital, Sydney, New South Wales
| | - O. M. O. Kim
- Westmead Hospital, VMO Anaesthetist, Westmead Private Hospital, North Shore Private Hospital, Sydney, New South Wales
| | - A. Rehak
- VMO Anaesthetist, Royal North Shore Hospital, North Shore Private Hospital, Sydney, New South Wales
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Urban MK, Fields K, Donegan SW, Beathe JC, Pinter DW, Boachie-Adjei O, Emerson RG. A randomized crossover study of the effects of lidocaine on motor- and sensory-evoked potentials during spinal surgery. Spine J 2017; 17:1889-1896. [PMID: 28666848 DOI: 10.1016/j.spinee.2017.06.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/23/2017] [Accepted: 06/21/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lidocaine has emerged as a useful adjuvant anesthetic agent for cases requiring intraoperative monitoring of motor-evoked potentials (MEPs) and somatosensory-evoked potentials (SSEPs). A previous retrospective study suggested that lidocaine could be used as a component of propofol-based intravenous anesthesia without adversely affecting MEP or SSEP monitoring, but did not address the effect of the addition of lidocaine on the MEP and SSEP signals of individual patients. PURPOSE The purpose of this study was to examine the intrapatient effects of the addition of lidocaine to balanced anesthesia on MEPs and SSEPs during multilevel posterior spinal fusion. STUDY DESIGN This is a prospective, two-treatment, two-period crossover randomized controlled trial with a blinded primary outcome assessment. PATIENT SAMPLE Forty patients undergoing multilevel posterior spinal fusion were studied. OUTCOME MEASURES The primary outcome measures were MEP voltage thresholds and SSEP amplitudes. Secondary outcome measures included isoflurane concentrations and hemodynamic parameters. METHODS Each participant received two anesthetic treatments (propofol 50 mcg/kg/h and propofol 25 mcg/kg/h+lidocaine 1 mg/kg/h) along with isoflurane, ketamine, and diazepam. In this manner, each patient served as his or her own control. The order of administration of the two treatments was determined randomly. RESULTS There were no significant within-patient differences between MEP threshold voltages or SSEP amplitudes during the two anesthetic treatments. CONCLUSIONS Lidocaine may be used as a component of balanced anesthesia during multilevel spinal fusions without adversely affecting the monitoring of SSEPs or MEPs in individual patients.
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Affiliation(s)
- Michael K Urban
- Healthcare Research Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA; Department of Anesthesia, Weill Cornell Medical College, 1305 York Ave, New York, NY 10021, USA
| | - Kara Fields
- Healthcare Research Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Sean W Donegan
- Orthopedics, The Foundation of Orthopedics and Complex Spine (FOCOS), 226 East 54th Street, Suite 306, New York, NY 10022, USA
| | - Jonathan C Beathe
- Healthcare Research Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA; Department of Anesthesia, Weill Cornell Medical College, 1305 York Ave, New York, NY 10021, USA
| | - David W Pinter
- Department of Neurology, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Oheneba Boachie-Adjei
- Orthopedics, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA; Orthopedics, The Foundation of Orthopedics and Complex Spine (FOCOS), 226 East 54th Street, Suite 306, New York, NY 10022, USA
| | - Ronald G Emerson
- Healthcare Research Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA; Department of Neurology, Weill Cornell Medical College, 1305 York Ave, New York, NY 10021, USA.
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André-Obadia N, Mauguière F. Les explorations neurophysiologiques dans les tumeurs médullaires. Neurochirurgie 2017; 63:356-365. [DOI: 10.1016/j.neuchi.2016.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 08/08/2015] [Accepted: 06/12/2016] [Indexed: 11/28/2022]
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Hadley MN, Shank CD, Rozzelle CJ, Walters BC. Guidelines for the Use of Electrophysiological Monitoring for Surgery of the Human Spinal Column and Spinal Cord. Neurosurgery 2017; 81:713-732. [DOI: 10.1093/neuros/nyx466] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/05/2017] [Indexed: 01/12/2023] Open
Affiliation(s)
- Mark N Hadley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christopher D Shank
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Curtis J Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beverly C Walters
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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Neurophysiological Monitoring in Radiofrequency Ablation of Spinal Osteoid Osteoma With a Progressive Time and Temperature Protocol in Children. Spine Deform 2017; 5:351-359. [PMID: 28882353 DOI: 10.1016/j.jspd.2017.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 01/21/2017] [Accepted: 03/03/2017] [Indexed: 11/22/2022]
Abstract
STUDY DESIGN Retrospective. Level IV Evidence. OBJECTIVE To assess the utility of intraoperative neurophysiological monitoring (IONM) to detect and eventually prevent impending neurovascular damage during computed tomography (CT)-guided radiofrequency ablation (RFA) of spinal osteoid osteoma (OO) in children. SUMMARY AND BACKGROUND DATA To our knowledge, this is the first case series of spinal OO in pediatric patients treated at a single center employing IONM during RFA. METHODS This is a retrospective study of seven consecutive patients (3 girls and 4 boys, mean age: 9 years 4 months) with imaging and clinical signs compatible with spinal OO who underwent CT-guided RFA, under general anesthesia, and IONM in a single center between 2011 and 2015. Before the RFA procedure, a CT-guided percutaneous biopsy of the nidus was performed in the same setting. RFA was divided into four cycles of increasing time and temperature and performed under IONM in every patient. RESULTS Two patients had lesions located in the thoracic spine and five patients had lumbar involvement. The RFA technical and clinical success was 85.7%. Six patients presented with reversible neurophysiological changes either during biopsy needle positioning or RFA cycles. In the remaining case, as IONM changes did not improve after several minutes of neuroprotective hypertension, the procedure was interrupted. Neither neurologic nor vascular complications were observed after RFA treatment. In only one biopsy sample, OO was confirmed by histopathologic studies. CONCLUSION CT-guided RFA is an accepted minimally invasive technique for the treatment of spinal OO in children. IONM may be a helpful tool that requires minimal additional time and provides feedback on the state of the spinal cord and nerves at risk during the procedure. We promote the use of IONM during these procedures to detect and possibly prevent impending neurologic damage. LEVEL OF EVIDENCE Level IV.
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Ushio S, Kawabata S, Sumiya S, Kato T, Yoshii T, Yamada T, Enomoto M, Okawa A. A multi-train electrical stimulation protocol facilitates transcranial electrical motor evoked potentials and increases induction rate and reproducibility even in patients with preoperative neurological deficits. J Clin Monit Comput 2017; 32:549-558. [PMID: 28710663 DOI: 10.1007/s10877-017-0045-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 07/11/2017] [Indexed: 11/28/2022]
Abstract
This study sought to evaluate the facilitation effect of repetitive multi-train transcranial electrical stimulation (mt-TES) at 2 repetition rates on transcranial electrical motor evoked potential (Tc-MEP) monitoring during spinal surgery, and to assess the induction rate in patients with impaired motor function from a compromised spinal cord or spinal nerve. We studied 32 consecutive patients with impaired motor function undergoing cervical or thoracic spinal surgery (470 muscles). A series of 10 TESs with 5 pulse trains were preoperatively delivered at 2 repetition rates (1 and 5 Hz). All peak-topeak amplitudes of the MEPs of the upper and lower extremity muscles elicited by the 10 TESs were measured. The induction rates of the lower extremity muscles were also assessed with muscle and preoperative lower extremity motor function scores. In each of the muscles, MEP amplitudes were augmented by about 2-3 times at 1 Hz and 5-6 times at 5 Hz. Under the 5-Hz condition, all limb muscles showed significant amplification. Also, in all preoperative motor function score groups, the amplitudes and induction rates of the lower extremity muscles were significantly increased. Moreover, the facilitation effects tended to peak in the last half of the series of 10 TESs. In all score groups of patients with preoperative neurological deficits, repetitive mt-TES delivered at a frequency of 5 Hz markedly facilitated the MEPs of all limb muscles and increased the induction rate. We recommend this method to improve the reliability of intraoperative monitoring during spinal surgery.
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Affiliation(s)
- Shuta Ushio
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan. .,Department of Advanced Technology of Medicine, Graduate School of Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Shigenori Kawabata
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.,Department of Advanced Technology of Medicine, Graduate School of Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Satoshi Sumiya
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Tsuyoshi Kato
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Toshitaka Yoshii
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Tsuyoshi Yamada
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Mitsuhiro Enomoto
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Atsushi Okawa
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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Tamkus A, Rice KS, Kim HL. Intraoperative Neuromonitoring Alarms: Relationship of the Surgeon's Decision to Intervene (or Not) and Clinical Outcomes in a Subset of Spinal Surgical Patients with a New Postoperative Neurological Deficit. Neurodiagn J 2017; 57:276-287. [PMID: 29236604 DOI: 10.1080/21646821.2017.1369236] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND The goal of intraoperative neurophysiologic monitoring (IONM) is to minimize neurologic injury during surgery, yet patients still emerge with postoperative deficits. Few studies focus on outcomes relative to IONM alarms and interventions in this population. The authors sought to analyze the influence of IONM alarms with and without surgical intervention on patient outcome in spinal surgical patients who suffered immediate postoperative neurologic deficits. METHODS Of 62,038 spinal surgeries with multimodality IONM, 90 patients with new or worsened postoperative neurologic deficits and whose outcomes were reported immediate to the surgery and at discharge were analyzed. Outcomes at discharge were compared for surgeries in which an IONM alarm versus no alarm occurred. Outcomes where surgical intervention was performed versus not performed were also compared. RESULTS By discharge, 48 (53.3%) of 90 patients had complete or partial recovery of their postoperative deficit. Patients with IONM alarms and surgical interventions had an 80% (39/49) recovery rate overall versus only 26% (7/27) recovery rate of patients with IONM alarms but no interventions, and only 14% (2/14) of patients without IONM alarms and without interventions (P < 0.001). CONCLUSIONS These data showed significantly more patients recovered by the time of discharge when a surgical intervention was precipitated by an IONM alarm versus when it was not. The authors conclude that surgical interventions based on IONM alarms do improve patient outcomes despite immediate postoperative deficit.
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Affiliation(s)
- Arvydas Tamkus
- a Nuvasive Clinical Services (formerly Biotronic NeuroNetwork) , Ann Arbor , Michigan
| | - Kent S Rice
- a Nuvasive Clinical Services (formerly Biotronic NeuroNetwork) , Ann Arbor , Michigan
| | - Howard L Kim
- b Kaiser Permanente Oakland Medical Center , Oakland , California
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Verla T, Fridley JS, Khan AB, Mayer RR, Omeis I. Neuromonitoring for Intramedullary Spinal Cord Tumor Surgery. World Neurosurg 2016; 95:108-116. [DOI: 10.1016/j.wneu.2016.07.066] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/17/2016] [Accepted: 07/18/2016] [Indexed: 11/27/2022]
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Kim DG, Choi YD, Jin SH, Kim CH, Lee KW, Park KS, Chung CK, Kim SM. Intraoperative Motor-Evoked Potential Disappearance versus Amplitude-Decrement Alarm Criteria During Cervical Spinal Surgery: A Long-Term Prognosis. J Clin Neurol 2016; 13:38-46. [PMID: 27730765 PMCID: PMC5242147 DOI: 10.3988/jcn.2017.13.1.38] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 06/19/2016] [Accepted: 06/20/2016] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose We studied the clinical significance of amplitude-reduction and disappearance alarm criteria for transcranial electric muscle motor-evoked potentials (MEPs) during cervical spinal surgery according to different lesion locations [intramedullary (IM) vs. nonintramedullary (NIM)] by evaluating the long-term postoperative motor status. Methods In total, 723 patients were retrospectively dichotomized into the IM and NIM groups. Each limb was analyzed respectively. One hundred and sixteen limbs from 30 patients with IM tumors and 2,761 limbs from 693 patients without IM tumors were enrolled. Postoperative motor deficits were assessed up to 6 months after surgery. Results At the end of surgery, 61 limbs (2.2%) in the NIM group and 14 limbs (12.1%) in the IM group showed MEP amplitudes that had decreased to below 50% of baseline, with 13 of the NIM limbs (21.3%) and 2 of the IM limbs (14.3%) showing MEP disappearance. Thirteen NIM limbs (0.5%) and 5 IM limbs (4.3%) showed postoperative motor deficits. The criterion for disappearance showed a lower sensitivity for the immediate motor deficit than did the criterion for amplitude decrement in both the IM and NIM groups. However, the disappearance criterion showed the same sensitivity as the 70%-decrement criterion in IM (100%) and NIM (83%) surgeries for the motor deficit at 6 months after surgery. Moreover, it has the highest specificity for the motor deficits among diverse alarm criteria, from 24 hours to 6 months after surgery, in both the IM and NIM groups. Conclusions The MEP disappearance alarm criterion had a high specificity in predicting the long-term prognosis after cervical spinal surgery. However, because it can have a low sensitivity in predicting an immediate postoperative deficit, combining different MEP alarm criteria according to the aim of specific instances of cervical spinal surgery is likely to be useful in practical intraoperative monitoring.
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Affiliation(s)
- Dong Gun Kim
- Department of Neurology, Myung Diagnostic Radiology Clinic, Seoul, Korea
| | - Young Doo Choi
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Hyun Jin
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang Woo Lee
- Department of Neurology, Gachon University Gil Medical Center, Inchon, Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Sung Min Kim
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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