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Motiei-Langroudi R, Ekanem UO. Utility of Decremental Triggered Electromyogram for Intraoperative Neuromonitoring to Identify Midline in Posterior Myelotomy for Spinal Cord Intramedullary Lesions: Technical Note of a Novel Method. Oper Neurosurg (Hagerstown) 2024; 26:463-467. [PMID: 37976147 DOI: 10.1227/ons.0000000000000989] [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: 08/02/2023] [Accepted: 09/26/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Intramedullary spinal cord lesions are eloquent lesions that are surgically resected via posterior midline myelotomy (PMM). This treatment method carries the risk of postoperative neurological deficits. Various intraoperative neuromonitoring techniques have been used to address this concern. Our study aimed to highlight a newly developed monitoring technique (decremental-triggered electromyogram [dtEMG]) as a novel method to identify the spinal cord midline during PMM. CLINICAL PRESENTATION Seven patients in prone position underwent PMM for an intramedullary lesion using dtEMG for neuromonitoring. dtEMG was used to determine the threshold amplitude (ie, the lowest amplitude to elicit an EMG response) as well as a silent zone, which was determined to be the midline. The age range was 26-73 years. dtEMG detected a silent zone in 6/7 patients. The only patient in whom dtEMG was not useful was a patient with complete paraplegia and sensory loss before surgery. There were no motor evoked or somatosensory evoked potential changes related to PMM in these patients. DISCUSSION Although the commonly used neuromonitoring techniques, including motor and sensory evoked potentials and free-run electromyograms are of utmost importance in spinal cord surgery, they lack the potential to identify midline in such cases. The currently available tools, including dorsal column mapping, are more cumbersome to use. CONCLUSION The newly proposed dtEMG technique can safely and efficiently identify the midline when used as an intraoperative neuromonitoring technique in PMM for spinal cord intramedullary lesion resection.
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2
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Darwazeh R, Smaili HY, Schuhmann MU. Intraoperative High-Resolution Color-Coded Ultrasound to Identify the Posterior Median Sulcus for Midline Myelotomy in Intramedullary Spinal Cord Surgery. World Neurosurg 2024; 184:185-187. [PMID: 38309651 DOI: 10.1016/j.wneu.2024.01.141] [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: 10/10/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/05/2024]
Abstract
A 14-year-old boy presented with a 2-year history of slowly increasing weakness and atrophy in the right forearm and leg. Magnetic resonance imaging (MRI) revealed an intramedullary diffusely infiltrating lateralized tumor at C3-7. An extended biopsy was planned. After laminotomy and durotomy, the swollen spinal cord was noted to be rotated by 45° with the right dorsal root entry zone being in the midline. A 15 MHz linear ultrasound probe was used to identify the midline by visualizing the dorsal median sulcal vein within the midline raphe. A myelotomy was made in that zone without deterioration of somatosensory evoked potentials (SEPs) and an extended biopsy was performed. Histological examination revealed a pilocytic astrocytoma. Modern intraoperative high-resolution color-coded ultrasound enables the identification of the midline in intramedullary spinal cord lesions even when the spinal cord anatomy is distorted.
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Affiliation(s)
- Rami Darwazeh
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Tübingen, Germany.
| | - Hamzah Youssef Smaili
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Tübingen, Germany
| | - Martin U Schuhmann
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Tübingen, Germany
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3
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Seidel K, Deletis V, Raabe A, Lutz K, Schucht P. Intraoperative Neurophysiologic Monitoring and Mapping During Surgery on Intramedullary Spinal Cord Tumors in Children and Adolescents. J Clin Neurophysiol 2024; 41:116-122. [PMID: 38306219 DOI: 10.1097/wnp.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024] Open
Abstract
SUMMARY Surgical resection of intramedullary spinal cord tumors carries significant risks of neurologic deficits, especially in cases of infiltrative tumors. In pediatric patients, this type of surgery may be associated with a high risk of poor neurologic outcome. Intraoperative neurophysiologic monitoring has been adopted as part of the clinical routine by many centers as a useful adjunct for intraoperative assessment of neurologic integrity. To what extent intraoperative neurophysiologic mapping strategies may further support intraoperative decision-making is still a matter of debate. Here, we report on a small cohort of five pediatric patients in whom mapping with the double-train paradigm was used to identify the dorsal column and corticospinal tract and to guide the surgical resection. We also discuss the possible benefits and challenges regarding the available literature.
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Affiliation(s)
- Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Vedran Deletis
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia; and
- Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Katharina Lutz
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Philippe Schucht
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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4
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Tropeano MP, Rossini Z, Franzini A, Capo G, Olei S, De Robertis M, Milani D, Fornari M, Pessina F. Multimodal Intraoperative Neurophysiological Monitoring in Intramedullary Spinal Cord Tumors: A 10-Year Single Center Experience. Cancers (Basel) 2023; 16:111. [PMID: 38201539 PMCID: PMC10778263 DOI: 10.3390/cancers16010111] [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: 09/20/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE The study aimed at evaluating the efficacy and the ability of D-wave monitoring combined with somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) to predict functional outcomes in intramedullary spinal cord tumor (IMSCT) surgery. METHODS Between December 2011 and December 2020, all patients harboring IMSCT who underwent surgery at our institution were prospectively collected in a surgical spinal registry and retrospectively analyzed. Patient charts and surgical and histological reports were analyzed. The multimodal IONM included SSEPs, MEPs, and-whenever possible-D-waves. All patients were evaluated using the modified McCormick and Frankel grade at admission and 3, 6, and 12 months of follow-up. RESULTS Sixty-four patients were enrolled in the study. SSEP and MEP monitoring was performed in all patients. The D-wave was not recordable in seven patients (11%). Significant IONM changes (at least one evoked potential modality) were registered in 26 (41%) of the 64 patients. In five cases (8%) where the SSEPs and MEPs lost and the D-wave permanently dropped by about 50%, patients experienced a permanent deterioration of their neurological status. Multimodal IONM (SSEP, MEP, and D-wave neuromonitoring) significantly predicted postoperative deficits (p = 0.0001), with a sensitivity of 100.00% and a specificity of 95.65%. However, D-waves demonstrated significantly higher sensitivity (100%) than MEPs (62.5%) and SSEPs (71.42%) alone. These tests' specificities were 85.10%, 13.89%, and 17.39%, respectively. Comparing the area under ROC curves (AUCs) of these evoked potentials in 53 patients (where all three modalities of IONM were registered) using the pairwise t-test, D-wave monitoring appeared to have higher accuracy and ability to predict postoperative deficits with strong statistical significance compared with MEP and SSEP alone (0.992 vs. 0.798 vs. 0.542; p = 0.018 and p < 0.001). CONCLUSION The use of multimodal IONM showed a statistically significant greater ability to predict postoperative deficits compared with SSEP, MEP, and D-wave monitoring alone. D-wave recording significantly increased the accuracy and clinical value of neurophysiological monitoring in IMSCT tumor resection.
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Affiliation(s)
- Maria Pia Tropeano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy (F.P.)
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
| | - Zefferino Rossini
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
| | - Andrea Franzini
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
| | - Gabriele Capo
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
| | - Simone Olei
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy (F.P.)
| | - Mario De Robertis
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy (F.P.)
| | - Daniela Milani
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
| | - Maurizio Fornari
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
| | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy (F.P.)
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
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5
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Liu K, Ma C, Li D, Li H, Dong X, Liu B, Yu Y, Fan Y, Song H. The role of intraoperative neurophysiological monitoring in intramedullary spinal cord tumor surgery. Chin Neurosurg J 2023; 9:33. [PMID: 38031178 PMCID: PMC10685460 DOI: 10.1186/s41016-023-00348-x] [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: 08/29/2022] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Abstract
Intramedullary tumors are a class of central nervous system tumors with an incidence of 2 to 4%. As they are located very deep and frequently cause postoperative neurological complications, surgical resection is difficult. In recent years, many surgeons have performed electrophysiological monitoring to effectively reduce the occurrence of postoperative neurological complications. Modern electrophysiological monitoring technology has advanced considerably, leading to the development of many monitoring methods, such as SSEPs, MEPs, DCM, and EMG, to monitor intramedullary tumors. However, electrophysiological monitoring in tumor resection is still being studied. In this article, we discussed the different monitoring methods and their role in monitoring intramedullary tumors by reviewing previous studies. Intratumorally tumors need to be monitored for a summary of the condition of the patient. Only by using various monitoring methods flexibly and through clear communication between surgeons and neurophysiological experts can good decisions be made during surgery and positive surgical results be achieved.
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Affiliation(s)
- Kai Liu
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Chengyuan Ma
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Dapeng Li
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Haisong Li
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Xuechao Dong
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Bo Liu
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Ying Yu
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Yuxiang Fan
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Hongmei Song
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China.
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6
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Ueberschaer M, Breitkopf K, Siller S, Katzendobler S, Weller J, Greve T, Zausinger S, Tonn JC, Szelenyi A. Dorsal column mapping in resection of intramedullary spinal cord tumors: a prospective comparison of two methods and neurological follow-up. Acta Neurochir (Wien) 2023; 165:3493-3504. [PMID: 36930366 PMCID: PMC10624746 DOI: 10.1007/s00701-023-05554-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/25/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE In surgery for intramedullary spinal cord tumors (imSCT), distortion of the anatomy challenges the visual identification of dorsal columns (DC) for midline myelotomy. Dorsal column mapping (DCM) and spinal cord stimulation (SCS) can identify DC neurophysiologically. We compare application and feasibility of both methods. METHODS Patients with surgically treated imSCT were prospectively included between 04/2017 and 06/2019. The anatomical midline (AM) was marked. SSEPs at the DC after stimulation of tibial/median nerve with an 8-channel DCM electrode and cortical SSEP phase reversal at C3/C4 after SCS using a bipolar concentric probe were recorded. Procedural and technical aspects were compared. Standardized neurological examinations were performed preoperatively, 1 week postoperatively and after more than 12 months. RESULTS The DCM electrode detected the midline in 9/13 patients with handling limitations in the remaining patients. SCS was applicable in all patients with determination of the midline in 9/13. If both recordings could be acquired (6/13), concordance was 100%. If baseline SSEPs were poor, both methods were limited. SCS was less time-consuming (p = 0.001), cheaper, and easier to handle. In 92% of cases, the AM and neurophysiologic midlines were concordant. After myelotomy, 3 patients experienced > 50% reduction in amplitude of SSEPs. Despite early postoperative worsening of DC function, long-term follow-up showed significant recovery and improvement in quality of life. CONCLUSION DCM and SCS may help confirm and correct the AM for myelotomy in imSCT, leading to a favorable long-term neurological outcome in this cohort. SCS evolved to be superior concerning applicability, cost-effectiveness, and time expenditure.
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Affiliation(s)
- Moritz Ueberschaer
- Department of Neurosurgery, Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany.
| | | | - Sebastian Siller
- Department of Neurosurgery, Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany
| | - Sophie Katzendobler
- Department of Neurosurgery, Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany
| | - Jonathan Weller
- Department of Neurosurgery, Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany
| | - Tobias Greve
- Department of Neurosurgery, Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany
| | - Stefan Zausinger
- Department of Neurosurgery, Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany
| | - Andrea Szelenyi
- Department of Neurosurgery, Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany
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7
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Restelli F, Mazzapicchi E, Cazzato D, Bonomo G, Labiad I, Asteggiano F, Lanteri P, Costa F. Exoscopic Removal of a Symptomatic Vth Ventricle Cyst (Kraus Ventriculus Terminalis) Under Ultrasonography and Neurophysiological Assistance: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e292-e293. [PMID: 37578263 DOI: 10.1227/ons.0000000000000853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/01/2023] [Indexed: 08/15/2023] Open
Affiliation(s)
- Francesco Restelli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, University of Milan, Milan, Italy
| | - Elio Mazzapicchi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, University of Milan, Milan, Italy
| | - Daniele Cazzato
- Neurophysiopathology Unit, Fondazione IRCCS Istituto Neurologico C. Besta, University of Milan, Milan, Italy
| | - Giulio Bonomo
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, University of Milan, Milan, Italy
- Department of Neurosurgery, "G.Rodolico" University Hospital, Catania, Italy
| | - Ikrame Labiad
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, University of Milan, Milan, Italy
| | | | - Paola Lanteri
- Neurophysiopathology Unit, Fondazione IRCCS Istituto Neurologico C. Besta, University of Milan, Milan, Italy
| | - Francesco Costa
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, University of Milan, Milan, Italy
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8
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Elbeltagy M, Abbassy M. Neurofibromatosis type1, type 2, tuberous sclerosis and Von Hippel-Lindau disease. Childs Nerv Syst 2023; 39:2791-2806. [PMID: 37819506 DOI: 10.1007/s00381-023-06160-3] [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: 08/12/2023] [Accepted: 09/16/2023] [Indexed: 10/13/2023]
Abstract
Neurocutaneous syndromes (also known as phakomatoses) are heterogenous group of disorders that involve derivatives of the neuroectoderm. Each disease has diagnostic and pathognomonic criteria, once identified, thorough clinical examination to the patient and the family members should be done. Magnetic resonance imaging (MRI) is used to study the pathognomonic findings withing the CNS (Evans et al. in Am J Med Genet A 152A:327-332, 2010). This chapter includes the 4 most common syndromes faced by neurosurgeons and neurologists; neurofibromatosis types 1 and 2, tuberous sclerosis and Von Hippel-Lindau disease. Each syndrome has specific genetic anomaly that involves a tumor suppressor gene and the loss of inhibition of specific pathways. The result is a spectrum of cutaneous manifestations and neoplasms.
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Affiliation(s)
- M Elbeltagy
- Department of Neurosurgery, Cairo University, 1 University Street, Giza Governorate, 12613, Egypt.
- Department of Neurosurgery, Children's Cancer Hospital Egypt, Sekat Hadid Al Mahger, Zeinhom, El Sayeda Zeinab, Cairo Governorate, 4260102, Egypt.
| | - M Abbassy
- Department of Neurosurgery, Children's Cancer Hospital Egypt, Sekat Hadid Al Mahger, Zeinhom, El Sayeda Zeinab, Cairo Governorate, 4260102, Egypt
- Department of Neurosurgery, Alexandria University, 22 El-Gaish Rd, Al Azaritah WA Ash Shatebi, Bab Sharqi, Alexandria Governorate, 5424041, Egypt
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9
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Sánchez Roldán MÁ, Moncho D, Rahnama K, Santa-Cruz D, Lainez E, Baiget D, Chocrón I, Gándara D, Bescós A, Sahuquillo J, Poca MA. Intraoperative Neurophysiological Monitoring in Syringomyelia Surgery: A Multimodal Approach. J Clin Med 2023; 12:5200. [PMID: 37629243 PMCID: PMC10455553 DOI: 10.3390/jcm12165200] [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: 06/29/2023] [Revised: 07/20/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
Syringomyelia can be associated with multiple etiologies. The treatment of the underlying causes is first-line therapy; however, a direct approach to the syrinx is accepted as rescue treatment. Any direct intervention on the syrinx requires a myelotomy, posing a significant risk of iatrogenic spinal cord (SC) injury. Intraoperative neurophysiological monitoring (IONM) is crucial to detect and prevent surgically induced damage in neural SC pathways. We retrospectively reviewed the perioperative and intraoperative neurophysiological data and perioperative neurological examinations in ten cases of syringomyelia surgery. All the monitored modalities remained stable throughout the surgery in six cases, correlating with no new postoperative neurological deficits. In two patients, significant transitory attenuation, or loss of motor evoked potentials (MEPs), were observed and recovered after a corrective surgical maneuver, with no new postoperative deficits. In two cases, a significant MEP decrement was noted, which lasted until the end of the surgery and was associated with postoperative weakness. A transitory train of neurotonic electromyography (EMG) discharges was reported in one case. The surgical plan was adjusted, and the patient showed no postoperative deficits. The dorsal nerve roots were stimulated and identified in the seven cases where the myelotomy was performed via the dorsal root entry zone. Dorsal column mapping guided the myelotomy entry zone in four of the cases. In conclusion, multimodal IONM is feasible and reliable and may help prevent iatrogenic SC injury during syringomyelia surgery.
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Affiliation(s)
- M. Ángeles Sánchez Roldán
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (K.R.); (D.S.-C.); (D.B.)
| | - Dulce Moncho
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (K.R.); (D.S.-C.); (D.B.)
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
| | - Kimia Rahnama
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (K.R.); (D.S.-C.); (D.B.)
| | - Daniela Santa-Cruz
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (K.R.); (D.S.-C.); (D.B.)
| | - Elena Lainez
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (K.R.); (D.S.-C.); (D.B.)
| | - Daniel Baiget
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (K.R.); (D.S.-C.); (D.B.)
| | - Ivette Chocrón
- Department of Anesthesiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
| | - Darío Gándara
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.G.); (A.B.)
| | - Agustín Bescós
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.G.); (A.B.)
| | - Juan Sahuquillo
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.G.); (A.B.)
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
| | - María A. Poca
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.G.); (A.B.)
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10
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Iess G, Bonomo G, Amato A, Ferroli P, Devigili G, Melillo Y, Schiariti M. Intraoperative Neurophysiologic and Angiographic Techniques to Identify the Posterior Median Sulcus for Midline Myelotomy. World Neurosurg 2023; 171:103. [PMID: 36410706 DOI: 10.1016/j.wneu.2022.11.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 11/20/2022]
Abstract
Accurate midline myelotomy through the posterior median sulcus (PMS) is the key step to minimize surgical morbidity during intramedullary tumor removal.1,2 When an intramedullary mass is present, the cord is usually rotated and it may be difficult to distinguish its sulci.2-4 Inadvertent dissection through the dorsal columns exposes the patient to disabling postoperative deficits.5 In recent years, together with the well-established neurophysiologic phase-reversal method, newer intraoperative angiographic techniques have been developed to identify the PMS.1-4 In order to illustrate the combination of the 2, we present the case of a 31-year-old man with a right claw hand syndrome who underwent surgical excision of a C6-D1 ependymoma (Video 1).6,7 After localizing the tumor with ultrasound, somatosensory evoked potentials (obtained by stimulating the dorsal columns with the use of a bipolar handheld neurostimulator) were employed to identify the PMS by means of the phase reversal technique, which uncovered the silent central line corresponding to the PMS. Use of indocyanine green fluorescence (ICG) later confirmed with certainty the location of the spinal cord's midline by enabling identification of the dorsal medullary veins exiting the PMS. As expected, the midline was significantly laterally displaced by the tumor. After penetrating the PMS, gentle dissection between the 2 posterior chordae enabled the surgeon to reach and enucleate the tumor in a minimally traumatic fashion. No postoperative deficits were reported. This method represents a direct and effective way to reduce morbidity resulting from this type of surgery.
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Affiliation(s)
- Guglielmo Iess
- Department of Neurosurgery, IRCCS Carlo Besta Neurological Institute Foundation, Milan, Italy; University of Milan, Milan, Italy.
| | - Giulio Bonomo
- Department of Neurosurgery, IRCCS Carlo Besta Neurological Institute Foundation, Milan, Italy; University of Milan, Milan, Italy
| | | | - Paolo Ferroli
- Department of Neurosurgery, IRCCS Carlo Besta Neurological Institute Foundation, Milan, Italy
| | - Grazia Devigili
- Neurophysiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Ylenia Melillo
- Neurophysiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, IRCCS Carlo Besta Neurological Institute Foundation, Milan, Italy
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11
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Russman SM, Cleary DR, Tchoe Y, Bourhis AM, Stedelin B, Martin J, Brown EC, Zhang X, Kawamoto A, Ryu WHA, Raslan AM, Ciacci JD, Dayeh SA. Constructing 2D maps of human spinal cord activity and isolating the functional midline with high-density microelectrode arrays. Sci Transl Med 2022; 14:eabq4744. [PMID: 36170445 DOI: 10.1126/scitranslmed.abq4744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Intraoperative neuromonitoring (IONM) is a widely used practice in spine surgery for early detection and minimization of neurological injury. IONM is most commonly conducted by indirectly recording motor and somatosensory evoked potentials from either muscles or the scalp, which requires large-amplitude electrical stimulation and provides limited spatiotemporal information. IONM may inform of inadvertent events during neurosurgery after they occur, but it does not guide safe surgical procedures when the anatomy of the diseased spinal cord is distorted. To overcome these limitations and to increase our understanding of human spinal cord neurophysiology, we applied a microelectrode array with hundreds of channels to the exposed spinal cord during surgery and resolved spatiotemporal dynamics with high definition. We used this method to construct two-dimensional maps of responsive channels and define with submillimeter precision the electrophysiological midline of the spinal cord. The high sensitivity of our microelectrode array allowed us to record both epidural and subdural responses at stimulation currents that are well below those used clinically and to resolve postoperative evoked potentials when IONM could not. Together, these advances highlight the potential of our microelectrode arrays to capture previously unexplored spinal cord neural activity and its spatiotemporal dynamics at high resolution, offering better electrophysiological markers that can transform IONM.
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Affiliation(s)
- Samantha M Russman
- Department of Bioengineering, University of California, San Diego, La Jolla, CA 92093, USA.,Integrated Electronics and Biointerfaces Laboratory, Department of Electrical and Computer Engineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Daniel R Cleary
- Integrated Electronics and Biointerfaces Laboratory, Department of Electrical and Computer Engineering, University of California, San Diego, La Jolla, CA 92093, USA.,Department of Neurosurgery, University of California, San Diego, La Jolla, CA 92093, USA
| | - Youngbin Tchoe
- Integrated Electronics and Biointerfaces Laboratory, Department of Electrical and Computer Engineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Andrew M Bourhis
- Integrated Electronics and Biointerfaces Laboratory, Department of Electrical and Computer Engineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Brittany Stedelin
- Department of Neurosurgery, Oregon Health & Science University, Portland, OR 97239, USA
| | - Joel Martin
- Integrated Electronics and Biointerfaces Laboratory, Department of Electrical and Computer Engineering, University of California, San Diego, La Jolla, CA 92093, USA.,Department of Neurosurgery, University of California, San Diego, La Jolla, CA 92093, USA
| | - Erik C Brown
- Department of Neurosurgery, Oregon Health & Science University, Portland, OR 97239, USA
| | - Xinlian Zhang
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health, University of California, San Diego, La Jolla, CA 92093, USA
| | - Aaron Kawamoto
- Department of Neurosurgery, Oregon Health & Science University, Portland, OR 97239, USA
| | - Won Hyung A Ryu
- Department of Neurosurgery, Oregon Health & Science University, Portland, OR 97239, USA
| | - Ahmed M Raslan
- Department of Neurosurgery, Oregon Health & Science University, Portland, OR 97239, USA
| | - Joseph D Ciacci
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA 92093, USA
| | - Shadi A Dayeh
- Department of Bioengineering, University of California, San Diego, La Jolla, CA 92093, USA.,Integrated Electronics and Biointerfaces Laboratory, Department of Electrical and Computer Engineering, University of California, San Diego, La Jolla, CA 92093, USA
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12
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Skrap B, Tramontano V, Faccioli F, Meglio M, Pinna G, Sala F. Surgery for intramedullary spinal cord ependymomas in the neuromonitoring era: results from a consecutive series of 100 patients. J Neurosurg Spine 2022; 36:858-868. [PMID: 34891138 DOI: 10.3171/2021.7.spine21148] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 07/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The established treatment of intramedullary spinal cord ependymomas (ISCEs) is resection. Surgical series reporting treatment results often lack homogeneity, as these are collected over long time spans and their analysis is plagued by surgical learning curves and inconsistent use of intraoperative neurophysiological monitoring (IONM). The authors report the oncological and functional long-term outcomes in a modern series of 100 consecutive ISCEs that were resected between 2000 and 2015 by a surgically experienced team that consistently utilized IONM. METHODS In this retrospective study, the authors tailored surgical strategy and multimodal IONM, including somatosensory evoked potentials, muscle motor evoked potentials (mMEPs), and D-waves, with the aim of gross-total resection (GTR). Preservation of the D-wave was the primary objective, and preservation of mMEPs was the second functional objective. Functional status was evaluated using the modified McCormick Scale (MMS) preoperatively, postoperatively, and at follow-up. RESULTS Preoperatively, 89 patients were functionally independent (MMS grade I or II). A GTR was achieved in 89 patients, 10 patients had a stable residual, and 1 patient underwent reoperation for tumor progression. At a mean follow-up of 65.4 months, 82 patients were functionally independent, and 11 lost their functional independence after surgery (MMS grades III-V). Muscle MEP loss predicted short-term postoperative worsening (p < 0.0001) only, while the strongest predictors of a good functional long-term outcome were lower preoperative MMS grades (p < 0.0001) and D-wave preservation. D-wave monitorability was 67%; it was higher with lower preoperative MMS grades and predicted a better recovery (p = 0.01). CONCLUSIONS In this large series of ISCEs, a high rate of GTR and long-term favorable functional outcome were achieved. Short- and long-term functional outcomes were best reflected by mMEPs and D-wave monitoring, respectively.
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Affiliation(s)
- Benjamin Skrap
- 1Section of Neurosurgery, Department of Neurosciences Biomedicine and Movement Sciences, University Hospital, Verona
- 3Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Vincenzo Tramontano
- 1Section of Neurosurgery, Department of Neurosciences Biomedicine and Movement Sciences, University Hospital, Verona
| | - Franco Faccioli
- 2Institute of Neurosurgery, University Hospital, Verona; and
| | - Mario Meglio
- 1Section of Neurosurgery, Department of Neurosciences Biomedicine and Movement Sciences, University Hospital, Verona
| | | | - Francesco Sala
- 1Section of Neurosurgery, Department of Neurosciences Biomedicine and Movement Sciences, University Hospital, Verona
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13
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Horváth Z, Lukács M, Szívos L, Barzó P. Localization of macroscopically undetectable intramedullary hematoma by intraoperative epidural motor evoked potential. Clin Neurophysiol Pract 2022; 7:129-134. [PMID: 35586312 PMCID: PMC9108512 DOI: 10.1016/j.cnp.2022.04.001] [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: 01/14/2022] [Revised: 04/07/2022] [Accepted: 04/14/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Intramedullary hematoma is an uncommon, serious neurological disease, representing a diagnostic challenge. The preferred treatment is surgical. In most of the cases the lesion can be identified macroscopically. Otherwise, finding the optimal place to perform myelotomy is demanding. Intraoperative neurophysiological monitoring plays an important role in preventing surgical complications, but its versatility for localization has not been studied so far. Case report The present case report describes a 17-year-old patient with flaccid right inferior monoparesis (later paraparesis), ipsilateral loss of proprioception and vibration sense, contralateral analgesia below the T10 dermatome level and urinary retention (Brown-Séquard syndrome). The MRI revealed an intramedullary hematoma at the level of T8-T9 vertebral bodies. Digital subtraction angiography did not identify any vascular malformation. Urgent surgical intervention was performed. In order to prevent any complication somatosensory-evoked potential (SSEP), transcranial and epidural motor-evoked potential (tcMEP, eMEP) recordings were planned. SSEP in response to right tibial nerve stimulation and tcMEP were absent bilaterally. From electrophysiological point of view, the eMEP revealed a total conduction block of the corticospinal tract. In the absence of typical macroscopic signs (discoloration, swelling, abnormal vascularization etc.), the small intramedullary hematoma could not be identified. Therefore, it was decided to adopt eMEP technique for mapping and localizing the conduction block intraoperatively by changing the distance between the two electrodes used for recording. The hematoma was precisely localized and successfully evacuated. Postoperatively, a slow but continuous improvement was noted. Conclusion Intraoperative neurophysiological monitoring has been suggested to play crucial role in spinal cord surgery. To our knowledge, this is the first case report using eMEP recording for guiding and localizing of an intramedullary hematoma. Beside the clear limitations of our study, it could result in a novel application of the aforementioned monitoring technique.
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Affiliation(s)
- Zoltán Horváth
- Department of Neurosurgery, University of Szeged, Hungary
- Department of Neurology, University of Szeged, Hungary
| | - Melinda Lukács
- Department of Neurosurgery, University of Szeged, Hungary
- Department of Neurology, University of Szeged, Hungary
| | - László Szívos
- Department of Neurosurgery, University of Szeged, Hungary
| | - Pál Barzó
- Department of Neurosurgery, University of Szeged, Hungary
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14
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Ojukwu DI, Hoffman HA, Song R, Galgano MA. Intraspinal pilocytic astrocytomas: An overview and 2-D illustrative resection technique video. Surg Neurol Int 2022; 13:41. [PMID: 35242407 PMCID: PMC8888285 DOI: 10.25259/sni_1254_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Spinal cord pilocytic astrocytomas (PAs) are rare and typically occur in pediatric patients. While PAs are often well-circumscribed and amenable to gross total resection, they sometimes harbor infiltrative components that can invade normal cord parenchyma. Methods: Here, we present a 59-year-old female with a progressive right-sided hemi-sensory loss, right-sided hemiparesis, and gait imbalance. The preoperative T2 magnetic resonance imaging revealed a large loculated cystic tumor that focally compressed the dorsal medulla, while the contrast study revealed a 1.3 cm homogenously enhancing expansile intramedullary mass centered at the C1 level. Results: The patient underwent a C1-2 laminectomy followed by gross total intramedullary tumor resection utilizing intraoperative dorsal column mapping. There were no operative complications. The patient had preserved motor strength and an expected dorsal column dysfunction, which largely resolved over 9 months postoperatively. Conclusion: Here, we provide a broad overview of PAs, in addition to a case study/technical note that includes a 2-D intraoperative video detailing the resection technique.
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Affiliation(s)
- Disep I. Ojukwu
- School of Medicine, St. George’s University, Great River, New York, United States,
| | - Haydn A. Hoffman
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York, United States
| | - Rui Song
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York, United States
| | - Michael A. Galgano
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York, United States
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15
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Sala F, Skrap B, Kothbauer KF, Deletis V. Intraoperative neurophysiology in intramedullary spinal cord tumor surgery. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:229-244. [PMID: 35772888 DOI: 10.1016/b978-0-12-819826-1.00019-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Intramedullary spinal cord tumor (ISCT) surgery is challenged by a significant risk of neurological injury. Indeed, while most ISCT patients arrive to surgery in good neurological condition due to early diagnosis, many experience some degree of postoperative sensorimotor deficit. Thus, intraoperative neuromonitoring (IONM) is invaluable for providing functional information that helps neurosurgeons tailor the surgical strategy to maximize resection while minimizing morbidity. Somatosensory evoked potential (SEP), muscle motor evoked potential (mMEP), and D-wave monitoring are routinely used to continuously assess the functional integrity of the long pathways within the spinal cord. More recently, mapping techniques have been introduced to identify the dorsal columns and the corticospinal tracts. Intraoperative SEP decline is not a sufficient reason to abandon surgery, since SEPs are very sensitive to anesthesia and surgical maneuvers. Yet, a severe proprioceptive deficit may adversely impact daily life, and the value of SEPs should be reconsidered. While mMEPs are good predictors of short-term motor outcome, the D-wave is the strongest predictor of long-term motor outcome, and its preservation during surgery is essential. Mapping techniques are promising but still need validation in large cohorts of patients to determine their impact on clinical outcome. The therapeutic rather than merely diagnostic value of IONM in spine surgery is still debated, but there is emerging evidence that IONM provides an essential adjunct in ISCT surgery.
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Affiliation(s)
- Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy.
| | - Benjamin Skrap
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Karl F Kothbauer
- Formerly Department of Neurosurgery, University of Basel and Division of Neurosurgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Vedran Deletis
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia; Albert Einstein College of Medicine, New York, NY, United States
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16
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Abstract
There are many recent advances in intraoperative evoked potential techniques for mapping and monitoring neural function during surgery. In particular, somatosensory evoked potential optimization speeds surgical feedback, motor evoked potentials provide selective motor system information, and new visual evoked potential methods promise reliable visual system monitoring. This chapter reviews these advances and provides a comprehensive background for understanding their context and importance.
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Affiliation(s)
| | - Charles C Dong
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Alberto Uribe
- Department of Anesthesiology, Ohio State University, Columbus, OH, United States
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17
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Ille S, Wagner A, Joerger AK, Wostrack M, Meyer B, Shiban E. Predictive Value of Transcranial Evoked Potential Monitoring for Intramedullary Spinal Cord Tumors. J Neurol Surg A Cent Eur Neurosurg 2021; 82:325-332. [PMID: 33477187 DOI: 10.1055/s-0040-1710504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Intraoperative neurophysiologic monitoring (IONM) has increased patient safety and extent of resection in patients with eloquent brain tumors. Despite its comprehensive capability for the resection of intramedullary spinal cord tumors (ISCTs), the application during the resection of these tumors is controversial. METHODS We retrospectively analyzed the resection of ISCTs in 83 consecutive cases. IONM was performed in all cases. Each patient's motor status and the McCormick scale was determined preoperatively, directly after surgery, at the day of discharge, and at long-term follow-up. RESULTS IONM was feasible in 71 cases (85.5%). Gross total resection was performed in 75 cases (90.4%). Postoperatively, patients showed new transient deficits in 12 cases (14.5%) and new permanent deficits in 12 cases (14.5%). The mean McCormick variance between baseline and long-term follow-up was - 0.08 ± 0.54. IONM's sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the patient's motor status at the day of discharge was 75.0%, 64.7%, 45.5%, and 86.8%. It was 88.9%, 59.7%, 24.2%, and 97.4% for the motor outcome at long-term follow-up. Patients experienced postoperative complications in 15 cases (18.1%). CONCLUSION IONM, as performed in the present study, shows a high sensitivity and NPV but low specificity and PPV, particularly for the patient's motor status at the long-term follow-up. As far as practicable by a retrospective study on IONM, our results confirm IONM's usefulness for its application during the resection of ISCTs. However, these results must be approved by a prospective study.
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Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, Technical University Munich Faculty of Medicine, München, Bayern, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Technical University Munich Faculty of Medicine, München, Bayern, Germany
| | - Ann Kathrin Joerger
- Department of Neurosurgery, Technical University Munich Faculty of Medicine, München, Bayern, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Technical University Munich Faculty of Medicine, München, Bayern, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich Faculty of Medicine, München, Bayern, Germany
| | - Ehab Shiban
- Department of Neurosurgery, Technical University Munich Faculty of Medicine, München, Bayern, Germany.,Department of Neurosurgery, University of Augsburg, Augsburg, Bayern, Germany
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18
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Park J, Cho YE, Park M, Lee J, Kim D, Park YG. Correlation between preoperative somatosensory evoked potentials and intraoperative neurophysiological monitoring in spinal cord tumors. J Clin Monit Comput 2020; 35:979-991. [PMID: 32990900 DOI: 10.1007/s10877-020-00584-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/21/2020] [Indexed: 11/30/2022]
Abstract
Intraoperative neurophysiological monitoring (IONM) is widely used in spinal cord tumors (SCTs) removal surgery. This study mainly hypothesized that patients with prolonged latency of preoperative somatosensory evoked potentials (preSEPLat) would have more deteriorated intraoperative evoked potentials. Among 506 patients who underwent SCTs removal surgery, 74 underwent both preSEPs and IONM. The correlation between preSEPLat and intraoperative SEPs (ioSEPs) was mainly analyzed, and subgroup analysis according to anatomical type was also conducted. Secondly, whether preSEPLat related to intraoperative motor evoked potentials (ioMEPs) or postoperative motor deterioration (PMD) was analyzed. In addition, risk factors for PMD were examined among anatomical factors, including operation level, tumor-occupying area ratio, and anatomical type, as well as electrophysiological factors, such as preSEPLat, ioSEPs, and ioMEPs. Changes in ioSEP and ioMEP were considered significant even if they were recovered before the end of the monitoring. Patients with prolonged preSEPLat were more likely to have significant ioSEP changes for intradural-extramedullary (IDEM) but not for intramedullary or extradural tumors. The anatomical type and tumor-occupying area ratio were prognostic factors for transient PMD, while the ioSEPs were the only prognostic factor for persisted PMD over 4 weeks after surgery. PreSEPs are helpful in predicting the significant changes in ioSEPs during IDEM tumor removal surgery. The tumor-occupying area ratio and anatomical type are contributing factors for the transient PMD, whereas ioSEPs are prognostic factors in predicting the PMD that persists over 4 weeks after SCTs removal surgery. To our knowledge, this is the first study that mainly focused on the correlations of preoperative and intraoperative evoked potentials.
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Affiliation(s)
- Jinyoung Park
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Eun Cho
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Mina Park
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joowon Lee
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dawoon Kim
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yoon Ghil Park
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea. .,Department of Rehabilitation Medicine, Gangnam Severance Hospital, Yonsei University, 20, Eonju-ro 63-gil, Gangnam-gu, Seoul, 06229, Republic of Korea.
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19
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Tsetsou S, Butler W, Borges L, Eskandar EN, Fehnel KP, See RB, Simon MV. Dynamic mapping of the corticospinal tract in open cordotomy and myelomeningocele surgery. J Clin Neurosci 2020; 74:225-231. [PMID: 31973921 DOI: 10.1016/j.jocn.2020.01.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/11/2020] [Indexed: 11/25/2022]
Abstract
OBJECT Spinal cord surgeries carry a high risk for significant neurological impairments. The initial techniques for spinal cord mapping emerged as an aid to identify the dorsal columns and helped select a safe myelotomy site in intramedullary tumor resection. Advancements in motor mapping of the cord have also been made recently, but exclusively with tumor surgery. We hereby present our experiences with dynamic mapping of the corticospinal tract (CST) in other types of spinal cord procedures that carry an increased risk of postoperative motor deficit, and thus could directly benefit from this technique. CASE REPORTS Two patients with intractable unilateral lower extremity pain due to metastatic disease of the sacrum and a thoraco-lumbar chordoma, respectively underwent thoracic cordotomy to interrupt the nociceptive pathways. A third patient with progressive leg weakness underwent cord untethering and surgical repair of a large thoracic myelomeningocele. In all three cases, multimodality intraoperative neurophysiologic testing included somatosensory and motor evoked potentials monitoring as well as dynamic mapping of the CST. CONCLUSION CST mapping allowed safe advancement of the cordotomy probe and exploration of the meningocele sac with untethering of the anterior-lateral aspect of the cord respectively, resulting in postoperative preservation or improvement of motor strength from the pre-operative baseline. Stimulus thresholds varied likely with the distance between the stimulating probe and the CST as well as with the baseline motor strength in the mapped myotomes.
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Affiliation(s)
- Spyridoula Tsetsou
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - William Butler
- Deparmernt of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Lawrence Borges
- Deparmernt of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Emad N Eskandar
- Deparmernt of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Department of Neurosurgery, Albert Einstein College of Medicine, New York, NY, United States
| | - Katie P Fehnel
- Deparmernt of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Reiner B See
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
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Lim SH, Park SB, Moon DY, Kim JS, Choi YD, Park SK. Principles of Intraoperative Neurophysiological Monitoring with Insertion and Removal of Electrodes. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2019. [DOI: 10.15324/kjcls.2019.51.4.453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Sung Hyuk Lim
- Department of Neurology, Institute of Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Soon Bu Park
- Physiologic Diagnostic Laboratory, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dae Young Moon
- Department of Neurosurgery, Ajou University Hospital, Suwon, Korea
| | - Jong Sik Kim
- Department of Neurology, Asan Medical Center, Seoul, Korea
| | - Young Doo Choi
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Ku Park
- Department of Neurology, Institute of Neuroscience Center, Samsung Medical Center, Seoul, Korea
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21
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Intraoperative neurophysiological mapping & localization of posterior median sulcus during intramedullary spinal cord tumor resection_technical communication. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.100525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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22
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Ren J, Hong T, He C, Li X, Ma Y, Yu J, Ling F, Zhang H. Surgical approaches and long-term outcomes of intramedullary spinal cord cavernous malformations: a single-center consecutive series of 219 patients. J Neurosurg Spine 2019; 31:123-132. [PMID: 30952112 DOI: 10.3171/2018.12.spine181263] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Optimal surgical strategies for intramedullary spinal cord cavernous malformations (ISCCMs) are not optimized and remain problematic. In this study the authors identify rational surgical strategies for ISCCMs and predictors of outcomes after resection. METHODS A single-center study was performed with 219 consecutive surgically treated patients who presented from 2002 to 2017 and were analyzed retrospectively. The American Spinal Injury Association (ASIA) Impairment Scale was used to evaluate neurological functions. Patient characteristics, surgical approaches, and immediate and long-term postoperative outcomes were identified. RESULTS The average ISCCM size was 10.5 mm. The spinal level affected was cervical in 24.8% of patients, thoracic in 73.4%, and lumbar in 1.8%. The locations of the lesions in the horizontal plane were 30.4% ventral, 41.6% dorsal, and 28.0% central. Of the 214 patients included in the cohort for operative evaluation, 62.6% had superficially located lesions, while 37.4% were embedded. Gross-total resection was achieved in 98.1% of patients. The immediate postoperative neurological condition worsened in 10.3% of the patients. Multivariate logistic regression identified mild preoperative function (p = 0.014, odds ratio [OR] 4.5, 95% confidence interval [CI] 1.4-14.8) and thoracolumbar-level lesions (p = 0.01, OR 15.7, 95% CI 1.9-130.2) as independent predictors of worsening. The mean follow-up duration in 187 patients was 45.9 months. Of these patients, 63.1% were stable, 33.2% improved, and 3.7% worsened. Favorable outcomes were observed in 86.1% of patients during long-term follow-up and were significantly associated with preoperative mild neurological and disability status (p = 0.000) and cervically located lesions (p = 0.009). The depths of the lesions were associated with worse long-term outcomes (p = 0.001), and performing myelotomy directly through a yellowish abnormal surface in moderate-depth lesions was an independent predictor of worsening (p = 0.023, OR 35.3, 95% CI 1.6-756.3). CONCLUSIONS Resection performed with an individualized surgical approach remains the primary therapeutic option in ISCCMs. Performing surgery in patients with mild symptoms at the thoracolumbar level and embedded located lesions requires more discretion.
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MacDonald D, Dong C, Quatrale R, Sala F, Skinner S, Soto F, Szelényi A. Recommendations of the International Society of Intraoperative Neurophysiology for intraoperative somatosensory evoked potentials. Clin Neurophysiol 2019; 130:161-179. [DOI: 10.1016/j.clinph.2018.10.008] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 09/27/2018] [Accepted: 10/21/2018] [Indexed: 11/25/2022]
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Deletis V, Seidel K, Sala F, Raabe A, Chudy D, Beck J, Kothbauer KF. Intraoperative identification of the corticospinal tract and dorsal column of the spinal cord by electrical stimulation. J Neurol Neurosurg Psychiatry 2018; 89:754-761. [PMID: 29436487 DOI: 10.1136/jnnp-2017-317172] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/11/2017] [Accepted: 12/27/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Anatomical identification of the corticospinal tract (CT) and the dorsal column (DC) of the exposed spinal cord is difficult when anatomical landmarks are distorted by tumour growth. Neurophysiological identification is complicated by the fact that direct stimulation of the DC may result in muscle motor responses due to the centrally activated H-reflex. This study aims to provide a technique for intraoperative neurophysiological differentiation between CT and DC in the exposed spinal cord. METHODS Recordings were obtained from 32 consecutive patients undergoing spinal cord tumour surgery from July 2015 to March 2017. A double train stimulation paradigm with an intertrain interval of 60 ms was devised with recording of responses from limb muscles. RESULTS In non-spastic patients (55% of cohort) an identical second response was noted following the first CT response, but the second response was absent after DC stimulation. In patients with pre-existing spasticity (45%), CT stimulation again resulted in two identical responses, whereas DC stimulation generated a second response that differed substantially from the first one. The recovery times of interneurons in the spinal cord grey matter were much shorter for the CT than those for the DC. Therefore, when a second stimulus train was applied 60 ms after the first, the CT-fibre interneurons had already recovered ready to generate a second response, whereas the DC interneurons were still in the refractory period. CONCLUSIONS Mapping of the spinal cord using double train stimulation allows neurophysiological distinction of CT from DC pathways during spinal cord surgery in patients with and without pre-existing spasticity.
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Affiliation(s)
- Vedran Deletis
- Institute of Neurology and Neurosurgery, Albert Einstein College of Medicine, New York, New York, USA.,Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Darko Chudy
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Juergen Beck
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Karl F Kothbauer
- Department of Neurosurgery, Cantonal Hospital of Lucerne, University of Basel, Basel, Switzerland
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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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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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Prokopienko M, Kunert P, Podgórska A, Marchel A. Surgical treatment of intramedullary ependymomas. Neurol Neurochir Pol 2017; 51:439-445. [DOI: 10.1016/j.pjnns.2017.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 04/17/2017] [Accepted: 06/30/2017] [Indexed: 11/28/2022]
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28
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Scibilia A, Terranova C, Rizzo V, Raffa G, Morelli A, Esposito F, Mallamace R, Buda G, Conti A, Quartarone A, Germanò A. Intraoperative neurophysiological mapping and monitoring in spinal tumor surgery: sirens or indispensable tools? Neurosurg Focus 2017; 41:E18. [PMID: 27476842 DOI: 10.3171/2016.5.focus16141] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal tumor (ST) surgery carries the risk of new neurological deficits in the postoperative period. Intraoperative neurophysiological monitoring and mapping (IONM) represents an effective method of identifying and monitoring in real time the functional integrity of both the spinal cord (SC) and the nerve roots (NRs). Despite consensus favoring the use of IONM in ST surgery, in this era of evidence-based medicine, there is still a need to demonstrate the effective role of IONM in ST surgery in achieving an oncological cure, optimizing patient safety, and considering medicolegal aspects. Thus, neurosurgeons are asked to establish which techniques are considered indispensable. In the present study, the authors focused on the rationale for and the accuracy (sensitivity, specificity, and positive and negative predictive values) of IONM in ST surgery in light of more recent evidence in the literature, with specific emphasis on the role of IONM in reducing the incidence of postoperative neurological deficits. This review confirms the role of IONM as a useful tool in the workup for ST surgery. Individual monitoring and mapping techniques are clearly not sufficient to account for the complex function of the SC and NRs. Conversely, multimodal IONM is highly sensitive and specific for anticipating neurological injury during ST surgery and represents an important tool for preserving neuronal structures and achieving an optimal postoperative functional outcome.
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Affiliation(s)
| | | | | | - Giovanni Raffa
- Divisions of 1 Neurosurgery.,Department of Clinical and Experimental Medicine, University of Messina, Italy
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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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Jin SH, Chung CK, Kim CH, Choi YD, Kwak G, Kim BE. Multimodal intraoperative monitoring during intramedullary spinal cord tumor surgery. Acta Neurochir (Wien) 2015; 157:2149-55. [PMID: 26446854 DOI: 10.1007/s00701-015-2598-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 09/21/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this work is to evaluate the utility of multimodal intraoperative monitoring (IOM) during intramedullary spinal cord tumor (IMSCT) surgery in our institution, and to investigate which IOM events are likely to be encountered during critical surgical phases. METHODS Twenty-five patients who underwent IMSCT surgery with IOM were included in this study. Our multimodal IOM assessment included SSEP, mMEP, and fEMG monitoring. Positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity were assessed 24 h and 1 month after surgery. The IOM events during three main surgical phases were also investigated. For mMEP assessment, two warning criteria (>50 % decrease in mMEP amplitude and all-or-none mMEP amplitude presence) were employed. RESULTS Long-term outcome prediction was better when the all-or-none criterion was applied than when the >50 % amplitude decrease criterion was applied. Based on the all-or-none criterion, the PPV, NPV, sensitivity, and specificity were 60, 100, 100, and 91 %. Frequent IOM events were observed during the three major main surgical phases. Seven (29 %) patients showed SSEP events during opening of the spinal cord. During tumor removal, 21 of 25 patients (84 %) had IOM events, and 13 of 18 (72 %) of the fEMG events occurred prior to the mMEP events. CONCLUSIONS Based on the association of fEMG events with upcoming mMEP events during tumor removal, we recommend inclusion of fEMG monitoring in IOM. Multimodal IOM provides useful electrophysiological information during IMSCT surgery, especially during the main surgical phases.
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Affiliation(s)
- Seung-Hyun Jin
- Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Chun Kee Chung
- Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Korea.
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
| | - Chi Heon Kim
- Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Young Doo Choi
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Gilho Kwak
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Bo Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
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Fan T, Zhao X, Zhao H, Liang C, Wang Y, Gai Q, Zhang F. Treatment of selected syringomyelias with syringo-pleural shunt: The experience with a consecutive 26 cases. Clin Neurol Neurosurg 2015; 137:50-6. [DOI: 10.1016/j.clineuro.2015.06.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 06/09/2015] [Accepted: 06/13/2015] [Indexed: 11/27/2022]
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Park JH, Hyun SJ. Intraoperative neurophysiological monitoring in spinal surgery. World J Clin Cases 2015; 3:765-773. [PMID: 26380823 PMCID: PMC4568525 DOI: 10.12998/wjcc.v3.i9.765] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 12/30/2014] [Accepted: 06/19/2015] [Indexed: 02/05/2023] Open
Abstract
Recently, many surgeons have been using intraoperative neurophysiological monitoring (IOM) in spinal surgery to reduce the incidence of postoperative neurological complications, including level of the spinal cord, cauda equina and nerve root. Several established technologies are available and combined motor and somatosensory evoked potentials are considered mandatory for practical and successful IOM. Spinal cord evoked potentials are elicited compound potentials recorded over the spinal cord. Electrical stimulation is provoked on the dorsal spinal cord from an epidural electrode. Somatosensory evoked potentials assess the functional integrity of sensory pathways from the peripheral nerve through the dorsal column and to the sensory cortex. For identification of the physiological midline, the dorsal column mapping technique can be used. It is helpful for reducing the postoperative morbidity associated with dorsal column dysfunction when distortion of the normal spinal cord anatomy caused by an intramedullary cord lesion results in confusion in localizing the midline for the myelotomy. Motor evoked potentials (MEPs) consist of spinal, neurogenic and muscle MEPs. MEPs allow selective and specific assessment of the functional integrity of descending motor pathways, from the motor cortex to peripheral muscles. Spinal surgeons should understand the concept of the monitoring techniques and interpret monitoring records adequately to use IOM for the decision making during the surgery for safe surgery and a favorable surgical outcome.
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Ghadirpour R, Nasi D, Iaccarino C, Giraldi D, Sabadini R, Motti L, Sala F, Servadei F. Intraoperative neurophysiological monitoring for intradural extramedullary tumors: Why not? Clin Neurol Neurosurg 2015; 130:140-9. [DOI: 10.1016/j.clineuro.2015.01.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 12/15/2014] [Accepted: 01/03/2015] [Indexed: 10/24/2022]
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Arnold PM. Use of intraoperative monitoring in children. J Neurosurg Pediatr 2014; 13:589. [PMID: 24702618 DOI: 10.3171/2013.9.peds13439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Paul M Arnold
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
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35
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Cheng JS, Ivan ME, Stapleton CJ, Quinones-HinoJosa A, Gupta N, Auguste KI. Intraoperative changes in transcranial motor evoked potentials and somatosensory evoked potentials predicting outcome in children with intramedullary spinal cord tumors. J Neurosurg Pediatr 2014; 13:591-9. [PMID: 24702615 PMCID: PMC4322892 DOI: 10.3171/2014.2.peds1392] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intraoperative dorsal column mapping, transcranial motor evoked potentials (TcMEPs), and somatosensory evoked potentials (SSEPs) have been used in adults to assist with the resection of intramedullary spinal cord tumors (IMSCTs) and to predict postoperative motor deficits. The authors sought to determine whether changes in MEP and SSEP waveforms would similarly predict postoperative motor deficits in children. METHODS The authors reviewed charts and intraoperative records for children who had undergone resection for IMSCTs as well as dorsal column mapping and TcMEP and SSEP monitoring. Motor evoked potential data were supplemented with electromyography data obtained using a Kartush microstimulator (Medtronic Inc.). Motor strength was graded using the Medical Research Council (MRC) scale during the preoperative, immediate postoperative, and follow-up periods. Reductions in SSEPs were documented after mechanical traction, in response to maneuvers with the cavitational ultrasonic surgical aspirator (CUSA), or both. RESULTS Data from 12 patients were analyzed. Three lesions were encountered in the cervical and 7 in the thoracic spinal cord. Two patients had lesions of the cervicomedullary junction and upper spinal cord. Intraoperative MEP changes were noted in half of the patients. In these cases, normal polyphasic signals converted to biphasic signals, and these changes correlated with a loss of 1-2 grades in motor strength. One patient lost MEP signals completely and recovered strength to MRC Grade 4/5. The 2 patients with high cervical lesions showed neither intraoperative MEP changes nor motor deficits postoperatively. Dorsal columns were mapped in 7 patients, and the midline was determined accurately in all 7. Somatosensory evoked potentials were decreased in 7 patients. Two patients each had 2 SSEP decreases in response to traction intraoperatively but had no new sensory findings postoperatively. Another 2 patients had 3 traction-related SSEP decreases intraoperatively, and both had new postoperative sensory deficits that resolved. One additional patient had a CUSA-related SSEP decrease intraoperatively, which resolved postoperatively, and the last patient had 3 traction-related sensory deficits and a CUSA-related sensory deficit postoperatively, none of which resolved. CONCLUSIONS Intraoperative TcMEPs and SSEPs can predict the degree of postoperative motor deficit in pediatric patients undergoing IMSCT resection. This technique, combined with dorsal column mapping, is particularly useful in resecting lesions of the upper cervical cord, which are generally considered to be high risk in this population. Furthermore, the spinal cord appears to be less tolerant of repeated intraoperative SSEP decreases, with 3 successive insults most likely to yield postoperative sensory deficits. Changes in TcMEPs and SSEP waveforms can signal the need to guard against excessive manipulation thereby increasing the safety of tumor resection.
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Affiliation(s)
- Jason S. Cheng
- Department of Neurological Surgery, University of California, San Francisco
| | - Michael E. Ivan
- Department of Neurological Surgery, University of California, San Francisco
| | | | | | - Nalin Gupta
- Department of Neurological Surgery, University of California, San Francisco,Department of Pediatrics, University of California, San Francisco
| | - Kurtis I. Auguste
- Department of Neurological Surgery, University of California, San Francisco,Department of Pediatrics, University of California, San Francisco,Children’s Hospital and Research Center, Oakland, California
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Tredway TL. Minimally Invasive Approaches for the Treatment of Intramedullary Spinal Tumors. Neurosurg Clin N Am 2014; 25:327-36. [DOI: 10.1016/j.nec.2013.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Nair D, Kumaraswamy VM, Braver D, Kilbride RD, Borges LF, Simon MV. Dorsal Column Mapping via Phase Reversal Method. Neurosurgery 2014; 74:437-46; discussion 446. [DOI: 10.1227/neu.0000000000000287] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
BACKGROUND:
Safe resection of intramedullary spinal cord tumors can be challenging, because they often alter the cord anatomy. Identification of neurophysiologically viable dorsal columns (DCs) and of neurophysiologically inert tissue, eg, median raphe (MR), as a safe incision site is crucial for avoiding postoperative neurological deficits. We present our experience with and improvements made to our previously described technique of DC mapping, successfully applied in a series of 12 cases.
OBJECTIVE:
To describe a new, safe, and reliable technique for intraoperative DC mapping.
METHODS:
The right and left DCs were stimulated by using a bipolar electric stimulator and the triggered somatosensory evoked potentials recorded from the scalp. Phase reversal and amplitude changes of somatosensory evoked potentials were used to neurophysiologically identify the laterality of DCs, the inert MR, as well as other safe incision sites.
RESULTS:
The MR location was neurophysiologically confirmed in all patients in whom this structure was first visually identified as well as in those in whom it was not, with 1 exception. DCs were identified in all patients, regardless of whether they could be visually identified. In 3 cases, negative mapping with the use of this method enabled the surgeon to reliably identify additional inert tissue for incision. None of the patients had postoperative worsening of the DC function.
CONCLUSION:
Our revised technique is safe and reliable, and it can be easily incorporated into routine intramedullary spinal cord tumor resection. It provides crucial information to the neurosurgeon to prevent postoperative neurological deficits.
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Affiliation(s)
- Dinesh Nair
- Neurophysiology Division, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Vishakhadatta M. Kumaraswamy
- Neurophysiology Division, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Neurology, Case Western Reserve University, Cleveland, Ohio
| | - Diana Braver
- Neurophysiology Division, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ronan D. Kilbride
- Neurophysiology Division, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lawrence F. Borges
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mirela V. Simon
- Neurophysiology Division, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Nagasawa DT, Smith ZA, Cremer N, Fong C, Lu DC, Yang I. Complications associated with the treatment for spinal ependymomas. Neurosurg Focus 2011; 31:E13. [DOI: 10.3171/2011.7.focus11158] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal cord ependymomas are rare neoplasms, comprising approximately 5% of all CNS tumors and 15% of all spinal cord tumors. Although surgery was once reserved for diagnosis alone, the evolution of surgical practices has elevated resection to the treatment of choice for these lesions. While technological advances continue to improve the capacity for gross-total resections and thus decrease the risk of recurrence, ependymoma spinal surgery still contains a variety of potential complications. The presence of neurological deficits and deterioration are not uncommonly associated with spinal cord ependymoma surgery, including sensory loss, dorsal column dysfunction, dysesthetic syndrome, and bowel and bladder dysfunction, particularly in the immediate postoperative period. Surgical treatment may also lead to wound complications and CSF leaks, with increased risk when radiotherapy has been involved. Radiation therapy may also predispose patients to radiation myelopathy and ultimately result in neurological damage. Additionally, resections of spinal ependymomas have been associated with postoperative spinal instability and deformities, particularly in the pediatric population. Despite the advances in microsurgical techniques and intraoperative cord monitoring modalities, there remain a number of serious complications related to the treatment of spinal ependymoma tumors. Identification and acknowledgment of these potential problems may assist in their prevention, early detection, and increased quality of life for patients afflicted with this disease.
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Affiliation(s)
- Daniel T. Nagasawa
- 1Department of Neurological Surgery, University of California Los Angeles; and
| | - Zachary A. Smith
- 2Los Angeles Spine Clinic, Good Samaritan Hospital, Los Angeles, California
| | - Nicole Cremer
- 1Department of Neurological Surgery, University of California Los Angeles; and
| | - Christina Fong
- 1Department of Neurological Surgery, University of California Los Angeles; and
| | - Daniel C. Lu
- 1Department of Neurological Surgery, University of California Los Angeles; and
| | - Isaac Yang
- 1Department of Neurological Surgery, University of California Los Angeles; and
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Simon MV, Chiappa KH, Borges LF, Nuwer MR, Deletis V. Phase Reversal of Somatosensory Evoked Potentials Triggered by Gracilis Tract Stimulation: Case Report of a New Technique for Neurophysiologic Dorsal Column Mapping. Neurosurgery 2011; 70:E783-8. [DOI: 10.1227/neu.0b013e31822e0a76] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background and Importance:
Reliable visual identification of the median raphae, essential for the preservation of function of the posterior dorsal columns during intramedullary spinal cord tumor resection, is not possible in many cases, because of distorted local anatomy. In such cases, intraoperative neurophysiologic mapping of the dorsal columns offers invaluable information to the surgeon, and guides the myelotomy. We hereby describe such a new technique.
Clinical Presentation:
A 41 -year-old man with a C3-C4 intramedullary spinal cord tumor underwent successful myelotomy and tumor resection. Dorsal column mapping was performed by use of an 8-contact minielectrode strip placed on the dorsal spinal cord. Direct electrical stimulation was applied via 2 adjacent contacts of the strip at a time, in an attempt to stimulate in succession the left and right dorsal columns. Somatosensory evoked potentials (SSEPs) were recorded after each stimulation, via scalp electrodes. A sharp change in polarity of the recorded scalp SSEPs (phase reversal) indicated when the stimulation of the opposite dorsal column occurred. Myelotomy was performed in between the minielectrode contacts identified as being situated closest to the raphe. The posterior tibial SSEPs were continuously monitored during and after myelotomy and until the dura closure. No changes from premyelotomy SSEPs were present. Postoperatively, the patient had preservation of the posterior column function.
Conclusion:
SSEP phase-reversal technique is a promising new method to identify the neurophysiologic midline in intramedullary tumor resection. Fast and easy to perform, its final role in neurophysiologic dorsal column mapping awaits confirmation in future applications.
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Affiliation(s)
- Mirela V. Simon
- Neurophysiology Division (MVS, KHC), Departments of Neurology; and Neurosurgery (LFB), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Keith H. Chiappa
- Neurophysiology Division (MVS, KHC), Departments of Neurology; and Neurosurgery (LFB), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lawrence F. Borges
- Neurophysiology Division (MVS, KHC), Departments of Neurology; and Neurosurgery (LFB), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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