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Al-Qudah AM, Thirumala PD, Anetakis KM, Crammond DJ, Algarni SA, AlMajali M, Shandal V, Gross BA, Lang M, Bhatt NR, Al-Bayati AR, Nogueira RG, Balzer JR. Intraoperative neuromonitoring as real-time diagnostic for cerebral ischemia in endovascular treatment of ruptured brain aneurysms. Clin Neurophysiol 2024; 161:69-79. [PMID: 38452426 DOI: 10.1016/j.clinph.2024.02.024] [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: 05/28/2023] [Revised: 01/11/2024] [Accepted: 02/19/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of intraoperative neurophysiological monitoring (IONM) during endovascular treatment (EVT) of ruptured intracranial aneurysms (rIA). METHODS IONM and clinical data from 323 patients who underwent EVT for rIA from 2014-2019 were retrospectively reviewed. Significant IONM changes and outcomes were evaluated based on visual review of data and clinical documentation. RESULTS Of the 323 patients undergoing EVT, significant IONM changes were noted in 30 patients (9.29%) and 46 (14.24%) experienced postprocedural neurological deficits (PPND). 22 out of 30 (73.33%) patients who had significant IONM changes experienced PPND. Univariable analysis showed changes in somatosensory evoked potential (SSEP) and electroencephalogram (EEG) were associated with PPND (p-values: <0.001 and <0.001, retrospectively). Multivariable analysis showed that IONM changes were significantly associated with PPND (Odd ratio (OR) 20.18 (95%CI:7.40-55.03, p-value: <0.001)). Simultaneous changes in both IONM modalities had specificity of 98.9% (95% CI: 97.1%-99.7%). While sensitivity when either modality had a change was 47.8% (95% CI: 33.9%-62.0%) to predict PPND. CONCLUSIONS Significant IONM changes during EVT for rIA are associated with an increased risk of PPND. SIGNIFICANCE IONM can be used confidently as a real time neurophysiological diagnostic guide for impending neurological deficits during EVT treatment of rIA.
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Affiliation(s)
- Abdullah M Al-Qudah
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Saleh A Algarni
- Department of Clinical Neurosciences, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia; Neuroscience Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Mohammad AlMajali
- Department of Neurology, University of Iowa College of Medicine, Iowa City, IA, USA
| | - Varun Shandal
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Lang
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nirav R Bhatt
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Raul G Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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Shimony N, Fehnel K, Abbott IR, Jallo GI. The evolution of spinal cord surgery: history, people, instruments, and results. Childs Nerv Syst 2023; 39:2687-2700. [PMID: 37658937 DOI: 10.1007/s00381-023-06128-3] [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: 08/01/2023] [Accepted: 08/12/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Spinal cord surgery has and always will be a challenging operation with satisfying results, but also with potentially devastating results. Over the last century, there has been an evolution in the way we perceive and conduct spinal cord surgery. The phenomenal evolution in technology from the very first x-ray pictures helps to localize the spinal pathology through the use of high-resolution MRI and ultrasonography that allows for high precision surgery with relatively minimal exposure. METHODS The advancements in the surgical technique and the utilization of neuromonitoring allow for maximal safe resection of these delicate and intricate tumors. We also are beginning to understand the biology of spinal cord tumors and vascular lesions, as in the recent 2021 WHO classification which identifies specific entities such as spinal ependymomas, MYCN-amplified, as separate entity from the other subtypes of ependymomas. Surgeons have also accepted the importance of maximal safe resection for most of the spinal cord pathologies rather than just performing biopsy and adjuvant treatment. CONCLUSION There have been significant advances since the first resection of an intramedullary tumor including diagnosis, imaging, and surgical technique for children. These advances have improved the prognosis and outcome in these children.
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Affiliation(s)
- Nir Shimony
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
- Department of Neurological Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
- Semmes-Murphey Clinic, Memphis, TN, USA
| | - Katie Fehnel
- Department of Neurological Surgery, Harvard Medical School, Boston, MA, USA
- Department of Neurological Surgery, Dana Farber Institute, Boston Children's Hospital, Boston, MA, USA
| | - I Rick Abbott
- Division of Pediatric Neurosurgery, Albert Einstein College of Medicine, New York, NY, USA
| | - George I Jallo
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
- Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, 600 5Th Street South, St Petersburg, FL, 33701, USA.
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Pio L, Guérin F, Martucci C, Martelli H, Gauthier F, Branchereau S. The Use of Cavitron Ultrasonic Surgical Aspirator for High-Risk Neuroblastoma with Image-Defined Risk Factors in Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10010089. [PMID: 36670640 PMCID: PMC9857095 DOI: 10.3390/children10010089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 12/26/2022] [Accepted: 12/31/2022] [Indexed: 01/03/2023]
Abstract
Aim of the study: The cavitron ultrasonic surgical aspirator (CUSA) has gained popularity in adult surgical oncology, but its application in children is limited to liver surgery and neurosurgical procedures. The complete resection of neuroblastoma with image-defined risk factors (IDRFs) is still considered one of the most difficult procedures to achieve in pediatric surgical oncology, with a high morbidity rate and potential risk of intraoperative mortality. The aim of our study is to describe the application of ultrasonic dissection in neuroblastoma with IDRFs. Methods: A retrospective study was performed, analyzing patients operated on from 2000 to 2018. Patient characteristics, resection completeness, and postoperative surgical and oncology outcomes were analyzed. Main results: Twenty-six patients with high-risk neuroblastoma and IDRFs were operated on in the study period with a CUSA. A complete macroscopic resection was performed in 50% of patients, while the other half was operated on with minimal residual (<5 mL). Six post-operative complications occurred without the need for surgery (Clavien−Dindo < 3). The overall survival was 50%, with a median follow-up of 69.6 months (5.6−140.4). Conclusions: The application of the CUSA in neuroblastoma with IDRFs can be considered an effective and safe alternative technique to achieve a radical resection.
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Affiliation(s)
- Luca Pio
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA
- Paediatric Surgery Department, Hôpital Bicêtre APHP, Paris Saclay University, 91190 Paris, France
- Correspondence:
| | - Florent Guérin
- Paediatric Surgery Department, Hôpital Bicêtre APHP, Paris Saclay University, 91190 Paris, France
| | - Cristina Martucci
- Paediatric Surgery Department, Hôpital Bicêtre APHP, Paris Saclay University, 91190 Paris, France
| | - Helene Martelli
- Paediatric Surgery Department, Hôpital Bicêtre APHP, Paris Saclay University, 91190 Paris, France
| | - Frédéric Gauthier
- Paediatric Surgery Department, Hôpital Bicêtre APHP, Paris Saclay University, 91190 Paris, France
| | - Sophie Branchereau
- Paediatric Surgery Department, Hôpital Bicêtre APHP, Paris Saclay University, 91190 Paris, France
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Antkowiak L, Putz M, Sordyl R, Pokora S, Mandera M. Predictive Value of Motor Evoked Potentials in the Resection of Intradural Extramedullary Spinal Tumors in Children. J Clin Med 2022; 12:jcm12010041. [PMID: 36614841 PMCID: PMC9821272 DOI: 10.3390/jcm12010041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/04/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
This study aimed to evaluate the predictive value of motor evoked potentials (MEP) in the resection of pediatric intradural extramedullary (IDEM) tumors. Additionally, we aimed to assess the impact of MEP alerts on the extent of tumor resection. Medical records of pediatric patients who underwent resection of IDEM tumors with the assistance of MEP between March 2011 and October 2020 were reviewed. The occurrence of postoperative motor deficits was correlated with intraoperative MEP alerts. Sixteen patients were included. MEP alerts appeared in 2 patients (12.5%), being reflective of new postoperative motor deficits. Among the remaining 14 patients without any intraoperative MEP alerts, no motor decline was found. Accordingly, MEP significantly predicted postoperative motor deficits, reaching sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 100% (p < 0.001). In the absence of MEP alerts, 11 out of 14 patients (78.6%) underwent GTR, while no patient with intraoperative IONM alerts underwent GTR (p = 0.025). Although MEP alerts limit the extent of tumor resection, the high sensitivity and PPV of MEP underline its importance in avoiding iatrogenic motor deficits. Concurrently, high specificity and NPV ensure safer tumor excision. Therefore, MEP can reliably support surgical decisions in pediatric patients with IDEM tumors.
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Mohanty C, Shandilya K, Deopujari CE, Gupta G, Karmarkar V, Jaggi S. Cervicomedullary glioblastoma: A report of two cases with review of literature. Surg Neurol Int 2022; 13:579. [PMID: 36600754 PMCID: PMC9805658 DOI: 10.25259/sni_581_2022] [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: 06/28/2022] [Accepted: 11/26/2022] [Indexed: 12/23/2022] Open
Abstract
Background Cervicomedullary glioblastoma is an extremely rare clinical entity and the principles of its management are not well understood. Case Description We report two cases of cervicomedullary glioblastoma in young patients aged 12 and 30 years with contrasting clinical presentation and outcomes. The 12-year-old child had rapid onset bulbar symptoms, with frank infiltration of the medulla due to which the patient succumbed within 4 weeks of surgery. The 30-year-old adult had a relatively slow disease onset and progression and made a good neurological recovery without disease progression at 16 months after surgery. To the best of our knowledge, we also report only the second adult patient in the literature with a dorsally exophytic cervicomedullary glioblastoma. Difficulties in diagnosis and management are discussed with a review of the pertinent literature. Conclusion The overall outcome depends on the rapid progression and severity of preoperative symptoms and the degree of tumor infiltration noted in imaging and during surgery.
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Affiliation(s)
- Chandan Mohanty
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India.,Corresponding author: Chandan Mohanty, Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India.
| | - Kalp Shandilya
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | | | - Gaurav Gupta
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Vikram Karmarkar
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Sunila Jaggi
- Department of Radiology, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
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Hersh AM, Jallo GI, Shimony N. Surgical approaches to intramedullary spinal cord astrocytomas in the age of genomics. Front Oncol 2022; 12:982089. [PMID: 36147920 PMCID: PMC9485889 DOI: 10.3389/fonc.2022.982089] [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: 06/30/2022] [Accepted: 08/11/2022] [Indexed: 11/25/2022] Open
Abstract
Intramedullary astrocytomas represent approximately 30%–40% of all intramedullary tumors and are the most common intramedullary tumor in children. Surgical resection is considered the mainstay of treatment in symptomatic patients with neurological deficits. Gross total resection (GTR) can be difficult to achieve as astrocytomas frequently present as diffuse lesions that infiltrate the cord. Therefore, GTR carries a substantial risk of new post-operative deficits. Consequently, subtotal resection and biopsy are often the only surgical options attempted. A midline or paramedian sulcal myelotomy is frequently used for surgical resection, although a dorsal root entry zone myelotomy can be used for lateral tumors. Intra-operative neuromonitoring using D-wave integrity, somatosensory, and motor evoked potentials is critical to facilitating a safe resection. Adjuvant radiation and chemotherapy, such as temozolomide, are often administered for high-grade recurrent or progressive lesions; however, consensus is lacking on their efficacy. Biopsied tumors can be analyzed for molecular markers that inform clinicians about the tumor’s prognosis and response to conventional as well as targeted therapeutic treatments. Stratification of intramedullary tumors is increasingly based on molecular features and mutational status. The landscape of genetic and epigenetic mutations in intramedullary astrocytomas is not equivalent to their intracranial counterparts, with important difference in frequency and type of mutations. Therefore, dedicated attention is needed to cohorts of patients with intramedullary tumors. Targeted therapeutic agents can be designed and administered to patients based on their mutational status, which may be used in coordination with traditional surgical resection to improve overall survival and functional status.
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Affiliation(s)
- Andrew M. Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - George I. Jallo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurosurgery, Johns Hopkins Medicine, Institute for Brain Protection Sciences, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, United States
- *Correspondence: George I. Jallo,
| | - Nir Shimony
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Le Bonheur Neuroscience Institute, Le Bonheur Children’s Hospital, Memphis, TN, United States
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, United States
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Antkowiak L, Putz M, Sordyl R, Pokora S, Mandera M. Relevance of intraoperative motor evoked potentials and D-wave monitoring for the resection of intramedullary spinal cord tumors in children. Neurosurg Rev 2022; 45:2723-2731. [PMID: 35416529 DOI: 10.1007/s10143-022-01788-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/17/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to evaluate the reliability of motor evoked potentials (MEP), somatosensory evoked potentials (SSEP), and D-wave monitoring as predictors of postoperative neurological deficits in pediatric patients undergoing resection of intramedullary spinal cord tumors (IMSCTs). Additionally, we aimed to determine whether alerts in the intraoperative neurophysiological monitoring (IONM) influenced the extent of resection (EOR). A retrospective analysis of the pediatric patients who underwent resection of IMSCT between March 2010 and April 2021 with an IONM guidance was performed. IONM alerts were recorded and correlated with patients' clinical status at discharge. Twenty three pediatric patients were included. MEP and SSEP were successfully elicited in all patients, while D-wave monitoring was feasible for 14 of them (60.9%). Significant IONM alerts occurred in 6 individuals (26.1%) with monitorable MEP and SSEP and 2 patients with monitorable D-waves (14.3%). The sensitivity, specificity, positive predictive value, and negative predictive value accounted for 100%, 81.8%, 20%, 100% for MEP, 100%, 92.3%, 50%, 100% for D-wave, and 50%, 81%, 20%, 94.44% for SSEP, respectively. Both MEP (p < 0.001) and D-wave monitoring (p < 0.001) accurately predicted postoperative motor deficits, while SSEP failed to provide significant accuracy regarding sensory deficits (p = 0.491). Gross-total tumor resection was performed in 29.4% of patients without IONM alerts and 33.3% of patients with IONM alerts, indicating that IONM alerts did not limit the EOR (p = 0.0857). MEP and D-wave monitoring can be perceived as reliable IONM modalities in pediatric IMSCTs surgery. Caution is needed with the implementation of SSEP to guide surgical decisions.
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Affiliation(s)
- Lukasz Antkowiak
- Department of Pediatric Neurosurgery, Medical University of Silesia, Katowice, Poland.
| | - Monika Putz
- Department of Pediatric Neurosurgery, Medical University of Silesia, Katowice, Poland
| | - Ryszard Sordyl
- Department of Pediatric Neurosurgery, Medical University of Silesia, Katowice, Poland
| | - Szymon Pokora
- Department of Pediatric Neurosurgery, Medical University of Silesia, Katowice, Poland
| | - Marek Mandera
- Department of Pediatric Neurosurgery, Medical University of Silesia, Katowice, Poland
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Herta J, Yildiz E, Marhofer D, Czech T, Reinprecht A, Rössler K, Novak K. Feasibility of intraoperative motor evoked potential monitoring during tethered cord surgery in infants younger than 12 months. Childs Nerv Syst 2022; 38:397-405. [PMID: 34604917 PMCID: PMC8789636 DOI: 10.1007/s00381-021-05316-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/29/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Feasibility, reliability, and safety assessment of transcranial motor evoked potentials (MEPs) in infants less than 12 months of age. METHODS A total of 22 patients with a mean age of 33 (range 13-49) weeks that underwent neurosurgery for tethered cord were investigated. Data from intraoperative MEPs, anesthesia protocols, and clinical records were reviewed. Anesthesia during surgery was maintained by total intravenous anesthesia (TIVA). RESULTS MEPs were present in all patients for the upper extremities and in 21 out of 22 infants for the lower extremities. Mean baseline stimulation intensity was 101 ± 20 mA. If MEPs were present at the end of surgery, no new motor deficit occurred. In the only case of MEP loss, preoperative paresis was present, and high baseline intensity thresholds were needed. MEP monitoring did not lead to any complications. TIVA was maintained with an average propofol infusion rate of 123.5 ± 38.2 µg/kg/min and 0.46 ± 0.17 µg/kg/min for remifentanil. CONCLUSION In spinal cord release surgery, the use of intraoperative MEP monitoring is indicated regardless of the patient's age. We could demonstrate the feasibility and safety of MEP monitoring in infants if an adequate anesthetic regimen is applied. More data is needed to verify whether an irreversible loss of robust MEPs leads to motor deficits in this young age group.
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Affiliation(s)
- Johannes Herta
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria.
| | - Erdem Yildiz
- Department of Otorhinolaryngology, Medical University of Vienna, Vienna, Austria
| | - Daniela Marhofer
- Department of Anaesthesiology, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Thomas Czech
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Andrea Reinprecht
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Rössler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Klaus Novak
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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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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Myrseth E, Habiba S, Rekand T, Sætran HA, Mørk S, Grønning M. Intramedullary spinal cord and filum tumours-long-term outcome: single institution case series. Acta Neurochir (Wien) 2022; 164:3047-3056. [PMID: 36166105 PMCID: PMC9613747 DOI: 10.1007/s00701-022-05350-3] [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: 03/10/2022] [Accepted: 08/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intramedullary spinal cord tumours are rare and account for about 2-4% of primary CNS tumours. Ependymomas and astrocytomas are most frequent. The aim of this study was to evaluate the long-term neurological outcome, quality of life (QoL), survival, need for additional treatment and frequency of neuropathic pain in a patient group treated at a tertiary university hospital. METHOD Retrospective descriptive study of 52 long-term survivors with intramedullary or filum tumours consenting to participate in this study. Fifty-six operations were performed in 48 patients. Clinical and radiological follow-up period was 113 and 117 months, respectively. RESULTS Good neurological outcome (ASIA score D or E, modified McCormick grade 1 or 2) was achieved in 88%. We found two negative prognostic factors in regards of severe disability which were large craniocaudal tumour size (p = 0.004) and histologic verified astrocytomas (p = 0.002). SF-36 results showed significantly lower results on all five subdomains concerning physical function, whereas scores for mental health and role emotional showed no significant differences compared to Norwegian norms. Ten patients including all astrocytoma patients, one primitive neuroectodermal tumour and three recurrent tumours of filum terminale had adjuvant therapy. None of the patients with intramedullary ependymoma had adjuvant therapy. Neuropathic pain was present in 54% of patients at the last follow-up. CONCLUSION This series shows that good results can be obtained with surgery for intramedullary tumours, even without perioperative neurophysiological monitoring. Multicentre studies are needed for further evaluation of negative and positive prognostic factors to further improve outcome.
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Affiliation(s)
- Erling Myrseth
- Department of Neurosurgey, Haukeland University Hospital, Bergen, Norway
| | - S. Habiba
- Department of Neurosurgey, Haukeland University Hospital, Bergen, Norway
| | - T. Rekand
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - H. A. Sætran
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - S. Mørk
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - M. Grønning
- Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
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11
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Massaad E, Ha Y, Shankar GM, Shin JH. Clinical Prediction Modeling in Intramedullary Spinal Tumor Surgery. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 134:333-339. [PMID: 34862557 DOI: 10.1007/978-3-030-85292-4_37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Artificial intelligence is poised to influence various aspects of patient care, and neurosurgery is one of the most uprising fields where machine learning is being applied to provide surgeons with greater insight about the pathophysiology and prognosis of neurological conditions. This chapter provides a guide for clinicians on relevant aspects of machine learning and reviews selected application of these methods in intramedullary spinal cord tumors. The potential areas of application of machine learning extend far beyond the analyses of clinical data to include several areas of artificial intelligence, such as genomics and computer vision. Integration of various sources of data and application of advanced analytical approaches could improve risk assessment for intramedullary tumors.
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Affiliation(s)
- Elie Massaad
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Ganesh M Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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12
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Bidkar PU, Thakkar A, Manohar N, Rao KS. Intraoperative neurophysiological monitoring in paediatric neurosurgery. Int J Clin Pract 2021; 75:e14160. [PMID: 33749944 DOI: 10.1111/ijcp.14160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/17/2021] [Indexed: 12/17/2022] Open
Abstract
Intraoperative neurophysiological monitoring (IONM) is commonly used in various surgical procedures in adults, but with technological and anaesthetic advancements, its use has extended to the paediatric population. The use of IONM in children poses a unique set of challenges considering the anatomical and physiological differences in this group of patients. The use of IONM aids in the localization of neural structures and enables surgeons to preserve the functional neural structures leading to decreased incidence of postoperative neurological deficits and better patient outcomes. In this article, we review the use of IONM in paediatric patients undergoing various spinal and cranial neurosurgical procedures. We discuss the patient characteristics, type of surgeries, and technical and anaesthetic considerations about IONM in this population.
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Affiliation(s)
- Prasanna U Bidkar
- Division of Neuroanaesthesia, Department of Anaesthesiology and Critical care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Astha Thakkar
- Department of Anaesthesiology, Zydus Hospital, Dahod, Gujrat, India
| | - Nitin Manohar
- Anaesthesiology institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Keerthi S Rao
- The Hospital for Sick Children - University of Toronto, Toronto, Canada
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Singh AK, Sheikh AI, Pandey TK, Chabbra DK. Congenital Mobile Atlantoaxial Dislocation with Cervicomedullary Astrocytoma in Pediatric Patient. Neurol India 2021; 69:194-197. [PMID: 33642301 DOI: 10.4103/0028-3886.310076] [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] [Indexed: 11/04/2022]
Abstract
Congenital mobile atlantoaxial dislocation with cervicomedullary astrocytoma has never been described. We present a case of a 7-year-old male child who presented to us with gradually progressive spastic quadriparesis following a fall from table. His lateral radiograph and magnetic resonance images showed mobile atlantoaxial dislocation with intramedullary heterogeneously enhancing cervicomedullary mass. The patient underwent suboccipital craniectomy with C1-4 laminectomy. Tumor was pinkish grey, tenacious with ill-defined plane and cyst at poles. C1-C2 fusion was done using C1 lateral mass and C2 pars screw and rod system with onlay bone graft. Histopathology revealed pilocytic astrocytoma. At the time of discharge, the patient showed improvement in spasticity. Postoperative lateral radiograph showed reduced atlantoaxial dislocation with stable construct.
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Affiliation(s)
- Ajay Kumar Singh
- Department of Neurosurgery, Vivekananda Polyclinic and Institute of Medical Sciences and Hospital, Lucknow, Uttar Pradesh, India
| | - Adiba I Sheikh
- Department of Neurosurgery, Vivekananda Polyclinic and Institute of Medical Sciences and Hospital, Lucknow, Uttar Pradesh, India
| | - Tarun Kumar Pandey
- Department of Neurosurgery, Vivekananda Polyclinic and Institute of Medical Sciences and Hospital, Lucknow, Uttar Pradesh, India
| | - Devender Kumar Chabbra
- Department of Neurosurgery, Vivekananda Polyclinic and Institute of Medical Sciences and Hospital, Lucknow, Uttar Pradesh, India
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Ruschel LG, Aragão A, de Oliveira MF, Milano JB, Neto MC, Ramina R. Correlation of Intraoperative Neurophysiological Parameters and Outcomes in Patients with Intramedullary Tumors. Asian J Neurosurg 2021; 16:243-248. [PMID: 34268146 PMCID: PMC8244684 DOI: 10.4103/ajns.ajns_234_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/09/2020] [Accepted: 10/05/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Intramedullary spinal cord tumors (IMSCT) account for about 2%-4% of all central nervous system tumors. Surgical resection is the main treatment step, but might cause damage to functional tissues. Intraoperative neuromonitoring (IONM) is an adopted measure to decrease surgical complications. Below, we describe the results of IMSCT submitted to surgery under IONM at a tertiary institution. Methods The sample consisted of consecutive patients with IMSCT admitted to the Neurological Institute of Curitiba from January 2007 to November 2016. A total of 47 patients were surgically treated. Twenty-three were male (48.9%) and 24 were female (51.1%). The mean age was 42.77 years. The mean follow-up time was 42.7 months. Results Neurological status improved in 29 patients (62%), stable in 6 (13%), and worse in 12 (25%). Patients who presented with motor symptoms at initial diagnosis had a worse outcome compared to patients with sensory impairment and pain (P = 0.026). Patients with a change in electromyography had worse neurological outcomes compared to patients who did not show changes in monitoring (P = 0.017). Discussion and Conclusion No prospective randomized high evidence study has been performed to date to compare clinical evolution after surgery with or without monitoring. In our sample, surgical resection was well succeeded mainly in oligosymptomatic patients with low preoperative McCormick classification and no worsening of IONM during surgery. We believe that microsurgical resection of IMSCT with simultaneous IONM is the gold standard treatment and achieved with good results.
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Affiliation(s)
- Leonardo Gilmone Ruschel
- Department of Neurosurgery, Neurological Institute of Curitiba, Curitiba, Paraná, Brazil.,DFV Neuro, São Paulo, Brazil.,Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Afonso Aragão
- Department of Neurosurgery, Neurological Institute of Curitiba, Curitiba, Paraná, Brazil
| | - Matheus Fernandes de Oliveira
- DFV Neuro, São Paulo, Brazil.,Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.,Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | | | - Mauricio Coelho Neto
- Department of Neurosurgery, Neurological Institute of Curitiba, Curitiba, Paraná, Brazil
| | - Ricardo Ramina
- Department of Neurosurgery, Neurological Institute of Curitiba, Curitiba, Paraná, Brazil
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15
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Lu Y, Lv B, Song Q. Transcranial electrical stimulation motor-evoked potentials in a spinal cord ischaemia rabbit model. Chin Neurosurg J 2020; 5:28. [PMID: 32922927 PMCID: PMC7398191 DOI: 10.1186/s41016-019-0174-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/09/2019] [Indexed: 11/16/2022] Open
Abstract
Background Spinal cord ischaemia animal models were established by selective ligation of the lumbar artery in a craniocaudal direction between the renal artery and the aortic bifurcation. Transcranial electrical stimulation motor-evoked potentials were measured to enable their use in future studies on spinal cord ischaemia protection. Methods Thirty-three New Zealand rabbits were randomly divided into 6 groups. Transcranial electrical stimulation motor-evoked potentials were recorded before vascular ligation, 30 min after vascular ligation, and 2 days after vascular ligation. Motor functions were assessed after surgery and 2 days after vascular ligation. The specimens were taken 2 days after ligation for histopathologic observation. Results With increased numbers of ligations, a transient extension of the latency became clear, but there were no significant differences in the statistical analysis. Analysis of variance after ligation at the same time in each group and t tests before and after ligation (P > 0.05) were not significant. One or 2 ligations did not cause spinal cord ischaemic damage. There were no significant differences before and after ligation for the amplitude (P > 0.05). With increased numbers of ligations, the amplitude before and after ligation was gradually reduced in the 3–5 ligation groups (P < 0.05). Conclusions Ligation of segmental spinal cord vessels on 1 or 2 levels did not cause ischaemic damage. Spinal cord ischaemia was observed after 3, 4, or 5 ligations. The amplitude was more sensitive to spinal cord ischaemia than latency. Spinal cord function can be predicted by early changes in the amplitude.
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Affiliation(s)
- Yucheng Lu
- Central Laboratory, Linyi People's Hospital, Shandong Province, Linyi, 276000 China
| | - Baotao Lv
- Department of Radiology, Linyi People's Hospital, Shandong Province, Linyi, 276000 China
| | - Qimin Song
- Department of Neurosurgery, Linyi People's Hospital, Shandong Province, Linyi, 276000 China
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Hussain I, Parker WE, Barzilai O, Bilsky MH. Surgical Management of Intramedullary Spinal Cord Tumors. Neurosurg Clin N Am 2020; 31:237-249. [PMID: 32147015 DOI: 10.1016/j.nec.2019.12.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Intramedullary spinal cord tumors (IMSCT) comprise a rare subset of CNS tumors that have distinct management strategies based on histopathology. These tumors often present challenges in regards to optimal timing for surgery, invasiveness, and recurrence. Advances in microsurgical techniques and technological adjuncts have improved extent of resection and outcomes with IMSCT. Furthermore, adjuvant therapies including targeted immunotherapies and image-guided radiation therapy have witnessed rapid development over the past decade, further improving survival for many of these patients. In this review, we provide an overview of types, epidemiology, imaging characteristics, surgical management strategies, and future areas of research for IMSCT.
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Affiliation(s)
- Ibrahim Hussain
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Department of Neurological Surgery, Weill Cornell Medical College, 525 E. 68th St, New York, NY 10065, USA.
| | - Whitney E Parker
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Department of Neurological Surgery, Weill Cornell Medical College, 525 E. 68th St, New York, NY 10065, USA
| | - Ori Barzilai
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Mark H Bilsky
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Department of Neurological Surgery, Weill Cornell Medical College, 525 E. 68th St, New York, NY 10065, USA
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17
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Matsuoka R, Takeshima Y, Hayashi H, Takatani T, Nishimura F, Nakagawa I, Motoyama Y, Park YS, Kawaguchi M, Nakase H. Feasibility of adjunct facial motor evoked potential monitoring to reduce the number of false-positive results during cervical spine surgery. J Neurosurg Spine 2019; 32:570-577. [PMID: 31835248 DOI: 10.3171/2019.9.spine19800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/23/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE False-positive intraoperative muscle motor evoked potential (mMEP) monitoring results due to systemic effects of anesthetics and physiological changes continue to be a challenging issue. Although control MEPs recorded from the unaffected side are useful for identifying a true-positive signal, there are no muscles on the upper or lower extremities to induce control MEPs in cervical spine surgery. Therefore, this study was conducted to clarify if additional MEPs derived from facial muscles can feasibly serve as controls to reduce false-positive mMEP monitoring results in cervical spine surgery. METHODS Patients who underwent cervical spine surgery at the authors' institution who did not experience postoperative neurological deterioration were retrospectively studied. mMEPs were induced with transcranial supramaximal stimulation. Facial MEPs (fMEPs) were subsequently induced with suprathreshold stimulation. The mMEP and subsequently recorded fMEP waveforms were paired during each moment during surgery. The initial pair was regarded as the baseline. A significant decline in mMEP and fMEP amplitude was defined as > 80% and > 50% decline compared with baseline, respectively. All mMEP alarms were considered false positives. Based on 2 different alarm criteria, either mMEP alone or both mMEP and fMEP, rates of false-positive mMEP monitoring results were calculated. RESULTS Twenty-three patients were included in this study, corresponding to 102 pairs of mMEPs and fMEPs. This included 23 initial and 79 subsequent pairs. Based on the alarm criterion of mMEP alone, 17 false-positive results (21.5%) were observed. Based on the alarm criterion of both mMEP and fMEP, 5 false-positive results (6.3%) were observed, which was significantly different compared to mMEP alone (difference 15.2%; 95% CI 7.2%-23.1%; p < 0.01). CONCLUSIONS fMEPs might be used as controls to reduce false-positive mMEP monitoring results in cervical spine surgery.
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Affiliation(s)
| | | | | | - Tsunenori Takatani
- 3Division of Central Clinical Laboratory, Nara Medical University Hospital, Kashihara, Japan
| | | | | | | | - Young-Su Park
- 1Department of Neurosurgery, Nara Medical University
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18
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A practical guide for anesthetic management during intraoperative motor evoked potential monitoring. J Anesth 2019; 34:5-28. [PMID: 31630259 DOI: 10.1007/s00540-019-02698-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/05/2019] [Indexed: 12/19/2022]
Abstract
Postoperative motor dysfunction can develop after spinal surgery, neurosurgery and aortic surgery, in which there is a risk of injury of motor pathway. In order to prevent such devastating complication, intraoperative monitoring of motor evoked potentials (MEP) has been conducted. However, to prevent postoperative motor dysfunction, proper understanding of MEP monitoring and proper anesthetic managements are required. Especially, a variety of anesthetics and neuromuscular blocking agent are known to attenuate MEP responses. In addition to the selection of anesthetic regime to record the baseline and control MEP, the measures to keep the level of hypnosis and muscular relaxation at constant are crucial to detect the changes of MEP responses after the surgical manipulation. Once the changes of MEP are observed based on the institutional alarm criteria, multidisciplinary team members should share the results of MEP monitoring and respond to check the status of monitoring and recover the possible motor nerve injury. Prevention of MEP-related adverse effects is also important to be considered. The Working Group of Japanese Society of Anesthesiologists (JSA) developed this practical guide aimed to help ensure safe and successful surgery through appropriate anesthetic management during intraoperative MEP monitoring.
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Rijs K, Klimek M, Scheltens-de Boer M, Biesheuvel K, Harhangi BS. Intraoperative Neuromonitoring in Patients with Intramedullary Spinal Cord Tumor: A Systematic Review, Meta-Analysis, and Case Series. World Neurosurg 2019; 125:498-510.e2. [DOI: 10.1016/j.wneu.2019.01.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/01/2019] [Accepted: 01/02/2019] [Indexed: 10/27/2022]
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20
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Benjamin CG, Frempong-Boadu A, Hoch M, Bruno M, Shepherd T, Pacione D. Combined Use of Diffusion Tractography and Advanced Intraoperative Imaging for Resection of Cervical Intramedullary Spinal Cord Neoplasms: A Case Series and Technical Note. Oper Neurosurg (Hagerstown) 2019; 17:525-530. [DOI: 10.1093/ons/opz039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 02/19/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Intramedullary spinal cord neoplasms (ISCN) pose significant management challenges. Advances in magnetic resonance imaging (MRI) (such as diffusion tensor imaging, DTI) have been utilized to determine the infiltrative nature and resectability of ISCN. However, this has not been applied to intraoperative decision making.
OBJECTIVE
To present a case series of 2 patients with ISCN, the first to combine use of DTI, pre- and intraoperative 3-dimensional (3D) virtual reality imaging, and microscope integrated navigation with heads-up display.
METHODS
Two patients who underwent surgery for ISCN were included. DTI images were obtained and 3D images were created using Surgical Theater (Surgical Theater SRP, Version 7.4.0, Cleveland, Ohio). Fiducials were used to achieve accurate surface registration to C4. Navigation confirmed the levels of laminectomy necessary. The microscope was integrated with Brainlab (Brainlab AG Version 3.0.5, Feldkirchen, Germany) and the tumor projected in the heads-up display. Surgical Theater was integrated with Brainlab to allow for real time evaluation of the 3D tractography.
RESULTS
Case 1: All tracts were pushed away from the tumor, suggesting it was not infiltrative. Surgical Theater and Brainlab assisted in confirming midline despite the abnormal swelling of the cord so the myelotomy could be performed. The heads-up display outline demonstrated excellent correlation to the tumor. Gross total resection was achieved. Diagnosis of ependymoma was confirmed. Case 2: Some tracts were going through the tumor itself, suggesting an infiltrative process. Surgical Theater and Brainlab again allowed for confirmation of the midline raphe. Near total resection of the enhancing portion was achieved. Diagnosis of glioblastoma was confirmed.
CONCLUSION
This is a proof of concept application where multi-modal imaging technology was utilized for safest maximal ISCN resection.
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Affiliation(s)
| | | | - Michael Hoch
- Department of Radiology, NYU Langone Medical Center, New York, New York
| | - Mary Bruno
- Department of Radiology, NYU Langone Medical Center, New York, New York
| | - Timothy Shepherd
- Department of Radiology, NYU Langone Medical Center, New York, New York
| | - Donato Pacione
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
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21
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Yi YG, Kim K, Shin HI, Bang MS, Kim HS, Choi J, Wang KC, Kim SK, Lee JY, Phi JH, Seo HG. Feasibility of intraoperative monitoring of motor evoked potentials obtained through transcranial electrical stimulation in infants younger than 3 months. J Neurosurg Pediatr 2019; 23:758-766. [PMID: 30875681 DOI: 10.3171/2019.1.peds18674] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/21/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to investigate the feasibility and safety of intraoperative motor evoked potential (MEP) monitoring in infants less than 3 months of age. METHODS The authors investigated 25 cases in which infants younger than 3 months (mean age 72.8 days, range 39-87) underwent neurosurgery between 2014 and 2017. Myogenic MEPs were obtained through transcranial electrical stimulation. In all cases, surgery was performed under total intravenous anesthesia, maintained with remifentanil and propofol. RESULTS MEPs were documented in 24 infants, the sole exception being 1 infant who was lethargic and had 4-limb weakness before surgery. The mean stimulation intensity maintained during monitoring was 596 ± 154 V (range 290-900 V). In 19 of 24 infants MEP signals remained at ≥ 50% of the baseline amplitude throughout the operation. Among 5 cases with a decrease in intraoperative MEP amplitude, the MEP signal was recovered in one during surgery, and in the other case a neurological examination could not be performed after surgery. In the other 3 cases, 2 infants had relevant postoperative weakness and the other did not show postoperative neurological deficits. Postoperative weakness was not observed in any of the 20 infants who had no deterioration (n = 19) or only temporary deterioration (n = 1) in MEP signal during surgery. CONCLUSIONS Transcranial electrical MEPs could be implemented during neurosurgery in infants between 1 and 3 months of age. Intraoperative MEP monitoring may be a safe adjunct for neurosurgical procedures in these very young patients.
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Affiliation(s)
| | | | | | | | | | | | - Kyu-Chang Wang
- 3Neurosurgery, Seoul National University College of Medicine and Seoul National University Hospital; and.,4Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Seung-Ki Kim
- 3Neurosurgery, Seoul National University College of Medicine and Seoul National University Hospital; and.,4Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Ji Yeoun Lee
- 3Neurosurgery, Seoul National University College of Medicine and Seoul National University Hospital; and.,4Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Ji Hoon Phi
- 3Neurosurgery, Seoul National University College of Medicine and Seoul National University Hospital; and.,4Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
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22
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Somatosensory evoked potential changes and decompression timing for spinal cord function recovery and evoked potentials in rats with spinal cord injury. Brain Res Bull 2019; 146:7-11. [DOI: 10.1016/j.brainresbull.2018.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 12/01/2018] [Accepted: 12/07/2018] [Indexed: 12/27/2022]
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23
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Nagarajan L, Ghosh S, Dillon D, Palumbo L, Woodland P, Thalayasingam P, Lethbridge M. Intraoperative neurophysiology monitoring in scoliosis surgery in children. Clin Neurophysiol Pract 2019; 4:11-17. [PMID: 30828671 PMCID: PMC6383123 DOI: 10.1016/j.cnp.2018.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 12/24/2018] [Accepted: 12/29/2018] [Indexed: 02/08/2023] Open
Abstract
Objective Intraoperative neurophysiology monitoring (INM) is thought to reduce the risk of postoperative neurological deficits in children undergoing scoliosis and spine deformity surgery. INM is being used increasingly despite conflicting opinions, varied results, non-standard alarm criteria and concern regarding cost effectiveness. In this paper we present our experience with INM in scoliosis and spine deformation surgery in children, propose alert criteria and preferred anaesthetics in clinical practice. Methods We retrospectively analysed our experience with INM in 56 children who had 61 scoliosis and spine deformity surgeries. Results INM was successfully undertaken with transcranial electrical motor evoked potentials (TcMEP) and somatosensory evoked potentials. There were no injuries due to INM. Four children had 5 alerts during 4 surgeries. A postoperative deficit was seen in one child only. No new postoperative deficits were seen in any child who did not have an alert during INM. Total intravenous anaesthesia was better for INM compared to inhalational anaesthetics. Conclusions INM is useful in scoliosis surgery; it is likely to mitigate the risk of new deficits following surgery. We recommend alert criteria for TcMEPs that include multiple facets - amplitude, stimulus paradigm, morphology. We recommend propofol and remifentanil, in preference to sevoflurane and remifentanil for anaesthesia during INM. Significance Our study adds to the literature supporting the role of INM in scoliosis surgery in children. We provide guidelines for alarm criteria in clinical practice and recommend the use of total intravenous anaesthesia as the preferred anaesthetic option.
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Affiliation(s)
- Lakshmi Nagarajan
- Children's Neuroscience Service, Dept. of Neurology, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia.,School of Medicine, University of Western Australia, Nedlands, WA 6009, Australia.,Telethon Kids Institute, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Soumya Ghosh
- Children's Neuroscience Service, Dept. of Neurology, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia.,Centre for Neuromuscular and Neurological Disorders, University of Western Australia, Nedlands, WA 6009, Australia
| | - David Dillon
- Dept of Orthopaedics, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Linda Palumbo
- Children's Neuroscience Service, Dept. of Neurology, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Peter Woodland
- Dept of Orthopaedics, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Priya Thalayasingam
- Dept. of Anaesthetics, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Martyn Lethbridge
- Dept. of Anaesthetics, Perth Children's Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
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Abd-El-Barr MM, Huang KT, Moses ZB, Iorgulescu JB, Chi JH. Recent advances in intradural spinal tumors. Neuro Oncol 2019; 20:729-742. [PMID: 29216380 DOI: 10.1093/neuonc/nox230] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Intradural spinal tumors are rare tumors of the central nervous system. Due to the eloquence of the spinal cord and its tracts, the compact architecture of the cord and nerves, and the infiltrative nature of some of these tumors, surgical resection is difficult to achieve without causing neurological deficits. Likewise, chemotherapy and radiotherapy are utilized more cautiously in the treatment of intradural spinal tumors than their cranial counterparts. Targeted therapies aimed at the genetic alterations and molecular biology tailored to these tumors would be helpful but are lacking.Here, we review the major types of intradural spinal tumors, with an emphasis on genetic alterations, molecular biology, and experimental therapies for these difficult to treat neoplasms.
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Affiliation(s)
- Muhammad M Abd-El-Barr
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kevin T Huang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ziev B Moses
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - J Bryan Iorgulescu
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John H Chi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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25
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Appel S, Biron T, Goldstein K, Ashkenazi E. Effect of Intra- and Extraoperative Factors on the Efficacy of Intraoperative Neuromonitoring During Cervical Spine Surgery. World Neurosurg 2018; 123:e646-e651. [PMID: 30576814 DOI: 10.1016/j.wneu.2018.11.244] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/29/2018] [Accepted: 11/30/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The purpose of the present study was to examine the effect of various extra- and intraoperative factors on the ability of neuromonitoring to predict neurological complications. METHODS We reviewed the data from 592 patients who had undergone cervical spine surgery with neuromonitoring at Assuta Medical Center from 2006 to 2013. We compared the somatosensory evoked potentials, transcranial electric motor evoked potentials, and electromyographic signals collected throughout surgery with the patient surgical outcome measures, demographic data, pre-existing pathological features found on neurological examination, and radiographic findings. Descriptive and inferential analyses were used to estimate the relative explanatory power contributed by these factors. RESULTS We included 468 patients in the present study. Neuromonitoring changes occurred in 100 patients, and the appropriate clinical intervention was undertaken in all 100, with recovery of the signals in 69. A transient neuromonitoring change was not associated with a poor outcome (only 8 of 69 patients). However, a permanent neuromonitoring change was associated with a new neurological deficit (13 of 31 patients) Changes occurring during positioning or decompression were associated with better clinical outcomes than were changes occurring during the rest of the procedure. Extraoperative factors were not associated with an increased risk of neuromonitoring changes during surgery or poorer surgical outcomes. CONCLUSIONS Permanent neuromonitoring changes predicted for new neurological deficits. However, transient changes were not associated with a new deficit. Neuromonitoring changes occurring during positioning and decompression had better clinical outcomes compared with those occurring during the rest of the procedure.
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Affiliation(s)
- Shmuel Appel
- Department of Neurology, Barzilai Medical Center, Ashkelon, Israel, affiliated with the Joyce and Irving Goldman School of Medicine, Ben Gurion University, Negev, Israel; Surgical Monitoring Services LTD, Beit Shemesh, Israel.
| | - Tali Biron
- Surgical Monitoring Services LTD, Beit Shemesh, Israel; Departmet of Pediatric Neurosurgery, Tel Aviv Sourasky Medical Center, affiliated with the Sackler School of Medicine of Tel Aviv University, Tel Aviv, Israel
| | | | - Ely Ashkenazi
- Israel Spine Center, Assuta Medical Center, Tel Aviv, Israel
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Azad TD, Pendharkar AV, Pan J, Huang Y, Li A, Esparza R, Mehta S, Connolly ID, Veeravagu A, Campen CJ, Cheshier SH, Edwards MSB, Fisher PG, Grant GA. Surgical outcomes of pediatric spinal cord astrocytomas: systematic review and meta-analysis. J Neurosurg Pediatr 2018; 22:404-410. [PMID: 30028275 DOI: 10.3171/2018.4.peds17587] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric spinal astrocytomas are rare spinal lesions that pose unique management challenges. Therapeutic options include gross-total resection (GTR), subtotal resection (STR), and adjuvant chemotherapy or radiation therapy. With no randomized controlled trials, the optimal management approach for children with spinal astrocytomas remains unclear. The aim of this study was to conduct a systematic review and meta-analysis on pediatric spinal astrocytomas. METHODS The authors performed a systematic review of the PubMed/MEDLINE electronic database to investigate the impact of histological grade and extent of resection on overall survival among patients with spinal cord astrocytomas. They retained publications in which the majority of reported cases included astrocytoma histology. RESULTS Twenty-nine previously published studies met the eligibility criteria, totaling 578 patients with spinal cord astrocytomas. The spinal level of intramedullary spinal cord tumors was predominantly cervical (53.8%), followed by thoracic (40.8%). Overall, resection was more common than biopsy, and GTR was slightly more commonly achieved than STR (39.7% vs 37.0%). The reported rates of GTR and STR rose markedly from 1984 to 2015. Patients with high-grade astrocytomas had markedly worse 5-year overall survival than patients with low-grade tumors. Patients receiving GTR may have better 5-year overall survival than those receiving STR. CONCLUSIONS The authors describe trends in the management of pediatric spinal cord astrocytomas and suggest a benefit of GTR over STR for 5-year overall survival.
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Affiliation(s)
| | | | | | | | - Amy Li
- Departments of1Neurosurgery and
| | | | | | | | | | - Cynthia J Campen
- 2Neurology, Stanford University School of Medicine, Stanford, California
| | | | | | - Paul G Fisher
- 2Neurology, Stanford University School of Medicine, Stanford, California
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Noh T, Vogt MS, Pruitt DW, Hummel TR, Mangano FT. Pediatric intramedullary spinal cord tumor outcomes using the WeeFIM scale. Childs Nerv Syst 2018; 34:1753-1758. [PMID: 29797065 DOI: 10.1007/s00381-018-3831-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/13/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE The Functional Independence Measure for children (WeeFIM) is a user-friendly functional outcomes tool that has been validated across other traditional functional scales. Historically, the significant neurologic and functional deficits of intramedullary spinal cord tumors (IMSCTs) have been monitored by coarse or overbearing functional outcomes tools that make it difficult to measure the slow improvement/decline seen in these patients. This study is the first to report WeeFIM outcomes on a series of IMSCTs with emphasis on an aggressive surgical strategy. METHODS A retrospective review from 2005 to 2014 was performed for nine patients who underwent resective surgery for intramedullary spinal cord tumors with intraoperative ultrasound and neurophysiologic monitoring. WeeFIM scales were assessed at admission and discharge to evaluate changes in severity of disability and need for assistance. RESULTS At the time of this submission, 7/9 patients are alive. The mean WeeFIM improvement was 27 points (8-50 points) with a mean WeeFIM efficiency of 2.0 points/day. CONCLUSIONS The WeeFIM scale is an appropriate and useful scale for measuring postoperative improvements in patients with IMSCTs undergoing aggressive resective surgery. Attention to intraoperative spinal cord monitoring and prevention of spinal column instability may prevent morbidity related to surgery, and functional outcomes do not appear to be compromised by an aggressive surgical approach.
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Affiliation(s)
- Thomas Noh
- Department of Neurological Surgery, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, USA
| | - Manuel S Vogt
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - David W Pruitt
- Department of Rehabilitation, Division of Pediatric Rehabilitation, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Trent R Hummel
- Cancer and Blood Diseases Institute, Division of Oncology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Francesco T Mangano
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA. .,Department of Neurological Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, MLC 2016, 3333 Burnet Avenue, Cincinnati, OH, 44529, USA.
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Dias S, Sarnthein J, Jehli E, Neidert MC, Regli L, Bozinov O. Safeness and Utility of Concomitant Intraoperative Monitoring with Intraoperative Magnetic Resonance Imaging in Children: A Pilot Study. World Neurosurg 2018; 115:e637-e644. [DOI: 10.1016/j.wneu.2018.04.123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 10/17/2022]
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Diagnostic Utility of Intraoperative Neurophysiological Monitoring for Intramedullary Spinal Cord Tumors: Systematic Review and Meta-Analysis. Clin Spine Surg 2018. [PMID: 28650882 DOI: 10.1097/bsd.0000000000000558] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE The aim of this study was to systematically evaluate the diagnostic utility of intraoperative neurophysiological monitoring (IONM) for detecting postoperative injury in resection of intramedullary spinal cord tumors (IMSCT). SUMMARY OF BACKGROUND DATA Surgical management of IMSCT can involve key neurological and vascular structures. IONM aims to assess the functional integrity of susceptible elements in real time. The diagnostic value of IONM for ISMCT has not been systematically evaluated. METHODS We performed a systematic review of the PubMed and MEDLINE databases for studies investigating the use of IONM for IMSCT and conducted a meta-analysis of diagnostic capability. RESULTS Our search produced 257 citations. After application of exclusion criteria, 21 studies remained, 10 American Academy of Neurology grade III and 11 American Academy of Neurology grade IV. We found that a strong pooled mean sensitivity of 90% [95% confidence interval (CI), 84-94] and a weaker pooled mean specificity of 82% (95% CI, 70-90) for motor-evoked potential (MEP) recording changes. Somatosensory-evoked potential (SSEP) recording changes yielded pooled sensitivity of 85% (95% CI, 75-91) and pooled specificity of 72% (95% CI, 57-83). The pooled diagnostic odds ratio for MEP was 55.7 (95% CI, 26.3-119.1) and 14.3 (95% CI, 5.47-37.3) for SSEP. Bivariate analysis yielded summary receiver operative characteristic curves with area under the curve of 91.8% for MEPs and 86.3% for SSEPs. CONCLUSIONS MEPs and SSEPs appear to be more sensitive than specific for detection of postoperative injury. Patients with perioperative neurological deficits are 56 times more likely to have had changes in MEPs during the procedure. We observed considerable variability in alarm criteria and interventions in response to IONM changes, indicating the need for prospective studies capable of defining standardized alarm criteria and responses.
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Ottenhausen M, Ntoulias G, Bodhinayake I, Ruppert FH, Schreiber S, Förschler A, Boockvar JA, Jödicke A. Intradural spinal tumors in adults-update on management and outcome. Neurosurg Rev 2018; 42:371-388. [PMID: 29455369 DOI: 10.1007/s10143-018-0957-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/16/2018] [Accepted: 02/06/2018] [Indexed: 12/28/2022]
Abstract
Among spinal tumors that occur intradurally, meningiomas, nerve sheath tumors, ependymomas, and astrocytomas are the most common. While a spinal MRI is the state of the art to diagnose intradural spinal tumors, in some cases CT scans, angiography, CSF analyses, and neurophysiological examination can be valuable. The management of these lesions depends not only on the histopathological diagnosis but also on the clinical presentation and the anatomical location, allowing either radical resection as with most extramedullary lesions or less invasive strategies as with intramedullary lesions. Although intramedullary lesions are rare and sometimes difficult to manage, well-planned treatment can achieve excellent outcome without treatment-related deficits. Technical advances in imaging, neuromonitoring, minimally invasive approaches, and radiotherapy have improved the outcome of intradural spinal tumors. However, the outcome in malignant intramedullary tumors remains poor. While surgery is the mainstay treatment for many of these lesions, radiation and chemotherapy are of growing importance in recurrent and multilocular disease. We reviewed the literature on this topic to provide an overview of spinal cord tumors, treatment strategies, and outcomes. Typical cases of extra- and intramedullary tumors are presented to illustrate management options and outcomes.
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Affiliation(s)
- Malte Ottenhausen
- Department of Neurosurgery, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Georgios Ntoulias
- Department of Neurosurgery, Vivantes Klinikum Neukölln, Berlin, Germany
| | | | | | - Stefan Schreiber
- Department of Neurosurgery, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Annette Förschler
- Department of Radiology and Neuroradiology, Schlossparkklinik, Berlin, Germany
| | - John A Boockvar
- Department of Neurosurgery, Lenox Hill Hospital, New York, USA
| | - Andreas Jödicke
- Department of Neurosurgery, Vivantes Klinikum Neukölln, Berlin, Germany.
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Utility of Intraoperative Monitoring in the Resection of Spinal Cord Tumors: An Analysis by Tumor Location and Anatomical Region. Spine (Phila Pa 1976) 2018; 43:287-294. [PMID: 28658041 DOI: 10.1097/brs.0000000000002300] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of institutional data. OBJECTIVE The aim of this study was to assess the utility of somatosensory-evoked potentials (SSEP) and transcranial electric motor-evoked potentials (MEP) in the resection of spine tumors and evaluate the ability of both single and multi-modal monitoring to predict postoperative neurological deficits. SUMMARY OF BACKGROUND DATA Although the utility of intraoperative monitoring (IOM) is well established in scoliosis and degenerative surgery, studies in spine tumor patients have been limited. METHODS A series of consecutive patients who underwent resection with the use of IOM at a single institution between August 2009 and March 2013 was identified. Demographic, clinical, and neuromonitoring data were collected preoperatively, during surgery, at the moment of discharge, and at a 6-month follow-up visit. Three cohorts were established based on the anatomical location of the tumor: intramedullary, intradural extramedullary, and extradural. Additional groupings were formed based on spinal region. Patients with significant changes in SSEPs or MEPs during surgery were identified and the rate of neurological deficits was assessed. RESULTS A total of 52 patients were analyzed. A change in SSEPs or MEPs was detected in 11 (21.2%) cases whereas 14 patients (26.9%) developed permanent postoperative deficits. SSEPs predicted deficits in the resection of intramedullary tumors (P = 0.015) (area under cover, AUC = 0.83), and intradural extramedullary tumors (P = 0.048; AUC = 0.70). MEP monitoring did not predict postoperative deficits in the resection of intramedullary (P = 0.21; AUC = 0.69) or intradural extramedullary tumors (P = 0.31; AUC = 0.63). Neither SSEPs nor MEPs predicted deficits for extradural tumors. CONCLUSION The efficacy of IOM in spine tumor resection is dependent on tumor location relative to the spinal cord and dura. The accuracy of SSEPs and their ability to predict postoperative deficits was greatest for intramedullary lesions. For this series, MEP and multi-modal monitoring did not confer a benefit in predicting permanent neurological deficits. LEVEL OF EVIDENCE 4.
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Abstract
“Spinal Cord Injury without Radiographic Abnormality” (SCIWORA) is a term that denotes objective clinical signs of posttraumatic spinal cord injury without evidence of fracture or malalignment on plain radiographs and computed tomography (CT) of the spine. SCIWORA is most commonly seen in children with a predilection for the cervical spinal cord due to the increased mobility of the cervical spine, the inherent ligamentous laxity, and the large head-to-body ratio during childhood. However, SCIWORA can also be seen in adults and, in rare cases, the thoracolumbar spinal cord can be affected too. Magnetic resonance imaging (MRI) has become a valuable diagnostic tool in patients with SCIWORA because of its superior ability to identify soft tissue lesions such as cord edema, hematomas and transections, and discoligamentous injuries that may not be visualized in plain radiographs and CT. The mainstay of treatment in patients with SCIWORA is nonoperative management including steroid therapy, immobilization, and avoidance of activities that may increase the risk of exacerbation or recurrent injury. Although the role of operative treatment in SCIWORA can be controversial, surgical alternatives such as decompression and fusion should be considered in selected patients with clinical and MRI evidence of persistent spinal cord compression and instability.
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Barzilai O, Lidar Z, Constantini S, Salame K, Bitan-Talmor Y, Korn A. Continuous mapping of the corticospinal tracts in intramedullary spinal cord tumor surgery using an electrified ultrasonic aspirator. J Neurosurg Spine 2017; 27:161-168. [DOI: 10.3171/2016.12.spine16985] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intramedullary spinal cord tumors (IMSCTs) represent a rare entity, accounting for 4%–10% of all central nervous system tumors. Microsurgical resection of IMSCTs is currently considered the primary treatment modality. Intraoperative neurophysiological monitoring (IONM) has been shown to aid in maximizing tumor resection and minimizing neurological morbidity, consequently improving patient outcome. The gold standard for IONM to date is multimodality monitoring, consisting of both somatosensory evoked potentials, as well as muscle-based transcranial electric motor evoked potentials (tcMEPs). Monitoring of tcMEPs is optimal when combining transcranial electrically stimulated muscle tcMEPs with D-wave monitoring. Despite continuous monitoring of these modalities, when classic monitoring techniques are used, there can be an inherent delay in time between actual structural or vascular-based injury to the corticospinal tracts (CSTs) and its revelation. Often, tcMEP stimulation is precluded by the surgeon’s preference that the patient not twitch, especially at the most crucial times during resection. In addition, D-wave monitoring may require a few seconds of averaging until updating, and can be somewhat indiscriminate to laterality. Therefore, a method that will provide immediate information regarding the vulnerability of the CSTs is still needed.The authors performed a retrospective series review of resection of IMSCTs using the tip of an ultrasonic aspirator for continuous proximity mapping of the motor fibers within the spinal cord, along with classic muscle-based tcMEP and D-wave monitoring.The authors present their preliminary experience with 6 patients who underwent resection of an IMSCT using the tip of an ultrasonic aspirator for continuous proximity mapping of the motor fibers within the spinal cord, together with classic muscle-based tcMEP and D-wave monitoring. This fusion of technologies can potentially assist in optimizing resection while preserving neurological function in these challenging surgeries.
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Affiliation(s)
- Ori Barzilai
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
| | - Zvi Lidar
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
| | - Shlomi Constantini
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
- 2Department of Pediatric Neurosurgery, “Dana” Children’s Hospital, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Khalil Salame
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
| | - Yifat Bitan-Talmor
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
| | - Akiva Korn
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
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Ares WJ, Grandhi RM, Panczykowski DM, Weiner GM, Thirumala P, Habeych ME, Crammond DJ, Horowitz MB, Jankowitz BT, Jadhav A, Jovin TG, Ducruet AF, Balzer J. Diagnostic Accuracy of Somatosensory Evoked Potential Monitoring in Evaluating Neurological Complications During Endovascular Aneurysm Treatment. Oper Neurosurg (Hagerstown) 2017. [DOI: 10.1093/ons/opx104] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Somatosensory evoked potential (SSEP) monitoring is used extensively for early detection and prevention of neurological complications in patients undergoing many different neurosurgical procedures. However, the predictive ability of SSEP monitoring during endovascular treatment of cerebral aneurysms is not well detailed.
OBJECTIVE
To evaluate the performance of intraoperative SSEP in the prediction postprocedural neurological deficits (PPNDs) after coil embolization of intracranial aneurysms.
METHODS
This population-based cohort study included patients ≥18 years of age undergoing intracranial aneurysm embolization with concurrent SSEP monitoring between January 2006 and August 2012. The ability of SSEP to predict PPNDs was analyzed by multiple regression analyses and assessed by the area under the receiver operating characteristic curve.
RESULTS
In a population of 888 patients, SSEP changes occurred in 8.6% (n = 77). Twenty-eight patients (3.1%) suffered PPNDs. A 50% to 99% loss in SSEP waveform was associated with a 20-fold increase in risk of PPND; a total loss of SSEP waveform, regardless of permanence, was associated with a greater than 200-fold risk of PPND. SSEPs displayed very good predictive ability for PPND, with an area under the receiver operating characteristic curve of 0.84 (95% CI 0.76-0.92).
CONCLUSION
This study supports the predictive ability of SSEPs for the detection of PPNDs. The magnitude and persistence of SSEP changes is clearly associated with the development of PPNDs. The utility of SSEP monitoring in detecting ischemia may provide an opportunity for neurointerventionalists to respond to changes intraoperatively to mitigate the potential for PPNDs.
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Affiliation(s)
- William J Ares
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ramesh M Grandhi
- Department of Neurological Surgery, University of Texas Health Center at San Antonio, San Antonio, Texas
| | - David M Panczykowski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gregory M Weiner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Parthasarathy Thirumala
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Miguel E Habeych
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Brian T Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ashutosh Jadhav
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Tudor G Jovin
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew F Ducruet
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Corticobulbar motor evoked potentials from tongue muscles used as a control in cervical spinal surgery. Clin Neurophysiol Pract 2017; 2:124-129. [PMID: 30214984 PMCID: PMC6123852 DOI: 10.1016/j.cnp.2017.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 05/03/2017] [Accepted: 05/20/2017] [Indexed: 11/22/2022] Open
Abstract
Objective Motor evoked potentials (MEPs) changes might be caused to the non-surgically induced factors during cervical spinal surgery. Therefore, control MEPs recorded cranially to the exit of the C5 root are highly recommendable in cervical spinal surgery. We studied whether corticobulbar MEPs (C-MEPs) from tongue muscle could be used as a control MEPs in cervical spinal surgery. Methods Twenty-five consecutive cervical spinal surgeries were analyzed. Stimulation of motor area for tongue was done by subcutaneous electrodes placed at C3/C4 (10-20 EEG System), and recording was done from both sides of tongue. Results C-MEPs were recorded successfully 24 out of the 25 (96%) tested patients. Forty-six out of fifty MEPs (92%) from tongue muscles were monitorable from the baseline. In two patients, we could obtain only unilateral C-MEPs. Mean MEPs latencies obtained from the left and right side of the tongue were 11.5 ± 1 ms and 11.5 ± 0.8 ms, respectively. Conclusions Monitoring C-MEPs from tongue muscles might be useful control in cervical spinal surgery. They were easily elicited and relatively free from phenomenon of peripheral stimulation of the hypoglossal nerves. Significance This is first study to identify the usefulness of C-MEPs as a control of cervical spinal surgery.
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Kang H, Gwak HS, Shin SH, Woo MK, Jeong IH, Yoo H, Kwon JW, Lee SH. Monitoring rate and predictability of intraoperative monitoring in patients with intradural extramedullary and epidural metastatic spinal tumors. Spinal Cord 2017; 55:906-910. [PMID: 28485386 DOI: 10.1038/sc.2017.43] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 03/12/2017] [Accepted: 03/15/2017] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Single-center retrospective study. OBJECTIVES To evaluate the monitoring rate, sensitivity and specificity of intraoperative monitoring (IOM) during removal of intradural extramedullary (IDEM) or epidural metastatic spinal tumors. Also, to assess the efficacy of monitoring somatosensory-evoked potentials (SSEP) when motor-evoked potentials (MEP) are not measurable. SETTING The Neuro-Oncology Clinic, National Cancer Center, Korea. METHODS Patients (n=101) with IDEM or epidural metastatic spinal tumors at the cord level underwent surgeries monitored with SSEP and/or MEP. The monitoring rate was defined as negative when MEP or SSEP could not be measured after reversal of the neuromuscular block under general anesthesia. Positive IOM changes included more than a 50% change in the MEP or SSEP amplitude and more than a 10% delay in SSEP latency. RESULTS MEP was measurable in 73% of patients. The MEP monitoring rate in patients with motor power grades of 3 or less was 39%, which was lower than that of SSEP (83%). The sensitivity, specificity and predictability of MEP for motor changes were 93, 90 and 91%, respectively. Conversely, the sensitivity, specificity and predictability of SSEP were 62, 97 and 89%, respectively. In patients in whom MEP was not measurable (n=24), SSEP was monitored with a predictability of 83%. CONCLUSION In cases of extramedullary spinal tumors, MEP shows a higher sensitivity than SSEP does. However, the monitoring rate of MEP in non-ambulatory patients was lower than that of SSEP. In those cases, SSEP can be useful to monitor for postoperative neurological deficits.
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Affiliation(s)
- H Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - H S Gwak
- Department of System Cancer Science, Graduate School of Cancer Science and Policy, Goyang, Korea
| | - S H Shin
- Neuro-Oncology Clinic, National Cancer Center, Goyang, Korea
| | - M K Woo
- Neurology Clinic, National Cancer Center, Goyang, Korea
| | - I H Jeong
- Neurology Clinic, National Cancer Center, Goyang, Korea
| | - H Yoo
- Neuro-Oncology Clinic, National Cancer Center, Goyang, Korea
| | - J W Kwon
- Neuro-Oncology Clinic, National Cancer Center, Goyang, Korea
| | - S H Lee
- Neuro-Oncology Clinic, National Cancer Center, Goyang, Korea
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Siller S, Szelényi A, Herlitz L, Tonn JC, Zausinger S. Spinal cord hemangioblastomas: significance of intraoperative neurophysiological monitoring for resection and long-term outcome. J Neurosurg Spine 2017; 26:483-493. [DOI: 10.3171/2016.8.spine16595] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Spinal cord hemangioblastomas are rare benign tumors developing either sporadically or as part of von Hippel-Lindau (VHL) disease. Generally, resection is the treatment of choice. However, the significance of intraoperative neurophysiological monitoring (IONM) for resection and postoperative outcome is still controversial. The authors analyzed the surgical and clinical courses of patients who had undergone resection of spinal cord hemangioblastoma, with special attention to preoperative imaging, the use of IONM, and short- and long-term outcomes.
METHODS
A series of 24 patients (male/female 1:1, lesion sporadic/associated with VHL 2.4:1) who had undergone 26 operations for the resection of 27 spinal cord hemangioblastomas was analyzed. All patients had undergone pre- and postoperative contrast-enhanced MRI. In all cases, microsurgical tumor removal had been performed under continuous IONM of both somatosensory and transcranial motor evoked potentials as well as electromyographic recording. Clinical characteristics, imaging findings, and operative records were retrospectively analyzed. Outcome parameters included short- and long-term status as regards sensorimotor deficits and a questionnaire on general performance, patient satisfaction, and Oswestry Disability Index (ODI) at the end of the follow-up period. The impact of IONM findings on postoperative deficits and outcome parameters as well as risk factors affecting functional prognosis was statistically assessed.
RESULTS
Preoperative symptoms (mean duration 16.2 ± 22.0 months) included sensory changes (100.0%), pain (66.7%), spinal ataxia (66.7%), motor deficit (41.7%), and bladder/bowel dysfunction (12.5%). Average age at the first operation was 36.8 ± 12.8 years. Most tumors (21 intramedullary, 6 intra- and/or extramedullary) were located dorsally (92.6%) and cervically (77.8%) and were accompanied by peritumoral edema and/or syringomyelia (81.5%). Tumor resection was achieved via laminectomy for 15 tumors, hemilaminectomy for 5, laminoplasty for 6, and interlaminar approach for 1. Gross-total resection was accomplished for 26 tumors (96.3%) with no local tumor recurrence during follow-up. Intraoperative neurophysiological monitoring was nonpathological in 11 operations (42.3%) and pathological in 15 (57.7%). Patients with nonpathological IONM had significantly fewer new sensorimotor deficits (p = 0.005). Long-term follow-up evaluation (mean 7.9 ± 4.0 years postoperatively, 7 patients lost to follow-up) revealed a stable or improved McCormick myelopathy grade in 88.2% of the patients, and 88.2% reported a stable or improved overall outcome according to Odom's criteria. Long-term general performance was excellent with 88.2% having a WHO/Eastern Cooperative Oncology Group (ECOG) Performance Status grade ≤ 1, 76.5% a Karnofsky Performance Scale score ≥ 80, and 70.6% a Barthel Index (BI) of 100. The mean ODI (11.4% ± 12.5%) indicated only minimal disability. There was a significant correlation between pathological IONM findings and a worse long-term status according to the BI and ODI (p = 0.011 and 0.024, respectively). Additionally, VHL disease was a risk factor affecting functional prognosis (p = 0.044).
CONCLUSIONS
Microsurgical removal of spinal cord hemangioblastomas with IONM facilitates a satisfying long-term outcome for patients. Nonpathological IONM findings are associated with a lower risk of new sensorimotor deficits and correlate with a better overall long-term outcome. von Hippel–Lindau disease is a risk factor for a worse long-term prognosis.
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Czernicki T, Maj E, Podgórska A, Kunert P, Prokopienko M, Nowak A, Cieszanowski A, Marchel A. Diffusion tensor tractography of pyramidal tracts in patients with brainstem and intramedullary spinal cord tumors: Relationship with motor deficits and intraoperative MEP changes. J Magn Reson Imaging 2017; 46:715-723. [DOI: 10.1002/jmri.25578] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 11/21/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Tomasz Czernicki
- Department of Neurosurgery; Medical University of Warsaw; Warsaw Poland
| | - Edyta Maj
- 2nd Department of Clinical Radiology; Medical University of Warsaw; Warsaw Poland
| | - Anna Podgórska
- Department of Neurosurgery; Medical University of Warsaw; Warsaw Poland
| | - Przemysław Kunert
- Department of Neurosurgery; Medical University of Warsaw; Warsaw Poland
| | - Marek Prokopienko
- Department of Neurosurgery; Medical University of Warsaw; Warsaw Poland
| | - Arkadiusz Nowak
- Department of Neurosurgery; Medical University of Warsaw; Warsaw Poland
| | - Andrzej Cieszanowski
- 2nd Department of Clinical Radiology; Medical University of Warsaw; Warsaw Poland
| | - Andrzej Marchel
- Department of Neurosurgery; Medical University of Warsaw; Warsaw Poland
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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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Huang SL, Qi HG, Liu JJ, Li JL, Huang YJ, Xiang L. Alarm Value of Somatosensory Evoked Potential in Idiopathic Scoliosis Surgery. World Neurosurg 2016; 92:397-401. [DOI: 10.1016/j.wneu.2016.05.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 05/19/2016] [Indexed: 12/14/2022]
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Differences in Multimodality Intraoperative Neurophysiological Monitoring Changes Between Spinal Intramedullary Ependymoma and Hemangioblastoma. J Clin Neurophysiol 2016; 33:120-6. [DOI: 10.1097/wnp.0000000000000247] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Messerer M, Cossu G, Pralong E, Daniel RT. Intramedullary hemangioblastoma: Microsurgical resection technique. Neurochirurgie 2016; 63:376-380. [PMID: 26776665 DOI: 10.1016/j.neuchi.2015.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 11/15/2015] [Accepted: 11/17/2015] [Indexed: 11/25/2022]
Abstract
Spinal hemangioblastomas are benign and highly vascular tumors accounting for 1-5% of intramedullary spinal tumors in surgical series. Surgery is curative in sporadic cases. We present the description of a surgical technique to safely resect an intramedullary hemangioblastoma. A dorsal midline myelotomy provides an excellent exposure of the tumor and identification of the feeding arteries. Interruption of these arteries and precise dissection of the tumor from the cord tissue followed by division of the venous drainage allow the in toto excision of the tumor. Closure of the dorsal myelotomy may be achieved with sequential fusion of the pial and arachnoid edges using a "welding" technique.
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Affiliation(s)
- M Messerer
- Section of Neurosurgery, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland; Section of Neurosurgery, Kremlin-Bicêtre Hospital, University of Paris Sud, 94270 Paris, France
| | - G Cossu
- Section of Neurosurgery, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland.
| | - E Pralong
- Section of Neurosurgery, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - R T Daniel
- Section of Neurosurgery, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
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McAbee JH, Modica J, Thompson CJ, Broniscer A, Orr B, Choudhri AF, Boop FA, Klimo P. Cervicomedullary tumors in children. J Neurosurg Pediatr 2015; 16:357-66. [PMID: 26114990 DOI: 10.3171/2015.5.peds14638] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cervicomedullary tumors (CMTs) represent a heterogeneous group of intrinsic neoplasms that are typically low grade and generally carry a good prognosis. This single-institution study was undertaken to document the outcomes and current treatment philosophy for these challenging neoplasms. METHODS The charts of all pediatric patients with CMTs who received treatment at St. Jude Children's Research Hospital between January 1988 and May 2013 were retrospectively reviewed. Demographic, surgical, clinical, radiological, pathological, and survival data were collected. Treatment-free survival and overall survival were estimated, and predictors of recurrence were analyzed. RESULTS Thirty-one children (16 boys, 15 girls) with at least 12 months of follow-up data were identified. The median age at diagnosis was 6 years (range 7 months-17 years) and the median follow-up was 4.3 years. Low-grade tumors (Grade I or II) were present in 26 (84%) patients. Thirty patients underwent either a biopsy alone or resection, with the majority of patients undergoing biopsy only (n = 12, 39%) or subtotal resection (n = 14, 45%). Only 4 patients were treated solely with resection; 21 patients received radiotherapy alone or in combination with other treatments. Recurrent tumor developed in 14 children (45%) and 4 died as a result of their malignancy. A high-grade pathological type was the only independent variable that predicted recurrence. The 5- and 10-year treatment-free survival estimates are 64.7% and 45.3%, respectively. The 5- and 10-year overall survival estimate is 86.7%. CONCLUSIONS Children with CMTs typically have low-grade neoplasms and consequently long-term survival, but high risk of recurrence. Therapy should be directed at achieving local tumor control while preserving and even restoring neurological function.
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Affiliation(s)
- Joseph H McAbee
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Joseph Modica
- University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Clinton J Thompson
- George Washington University Milken Institute School of Public Health, Washington, DC; and
| | - Alberto Broniscer
- Department of Oncology, St. Jude Children's Research Hospital;,Department of Pediatrics, University of Tennessee Health Science Center
| | - Brent Orr
- Department of Pathology, St. Jude Children's Research Hospital
| | - Asim F Choudhri
- Department of Neurosurgery, University of Tennessee Health Science Center;,Department of Radiology, University of Tennessee Health Science Center;,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital
| | - Frederick A Boop
- Department of Neurosurgery, University of Tennessee Health Science Center;,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital;,Department of Surgery, St. Jude Children's Research Hospital; and.,Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center;,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital;,Department of Surgery, St. Jude Children's Research Hospital; and.,Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
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Reitz M, Burkhardt T, Vettorazzi E, Raimund F, Fritzsche E, Schmidt NO, Regelsberger J, Westphal M, Eicker SO. Intramedullary spinal cavernoma: clinical presentation, microsurgical approach, and long-term outcome in a cohort of 48 patients. Neurosurg Focus 2015; 39:E19. [PMID: 26235017 DOI: 10.3171/2015.5.focus15153] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intramedullary spinal cavernoma (ISC) is a rare entity and accounts for approximately 5%-12% of all spinal vascular pathologies. The purpose of the present study was to examine the influence of clinical presentation, localization, and different surgical approaches on long-term outcome in patients treated for ISC. METHODS The authors performed a retrospective single-center study of 48 cases of ISC treated microsurgically over the past 28 years. Analyzed factors included preoperative clinical history, microsurgical strategies, neurological outcome (American Spinal Injury Association [ASIA] grade, Epstein and Cooper grade), and the occurrence of postoperative spinal ataxia. Univariate analysis was performed to identify factors influencing long-term outcome. RESULTS Preoperatively, 18.8% of all patients experienced a slow, progressive decline in neurological function and 33.3% suffered repetitive episodes of acute neurological deterioration over a time frame of months to years. Moreover, 16.7% noted the sudden onset of a severe neurological deficit, whereas 25% experienced the sudden onset of symptoms with a subsequent gradually progressive decline in neurological function. On long-term follow-up after treatment (mean ± SD, 79.3 ± 35.2 months), 70.8% of patients showed no change in neurological function, 6.3% suffered from a decline, and 22.9% improved neurologically. Thoracolumbar localization (p = 0.043), low preoperative Epstein and Cooper grade for the lower extremities (p < 0.001), and a low preoperative ASIA grade (p < 0.001) were identified as factors associated with an unfavorable outcome (ASIA Grade A-C). The rate of spinal ataxia related to surgical approach was 16.7%. CONCLUSION Postoperative neurological function in ISC patients is determined by the preoperative neurological status. On long-term follow-up after microsurgical treatment, 93.7% of patients presented with a stable or improved condition (ASIA grade); thus, definite microsurgical treatment should be considered as long as patients present with only mild symptoms after the diagnosis of symptomatic ISC.
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Affiliation(s)
| | | | - Eik Vettorazzi
- Institute of Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf; and
| | - Frank Raimund
- Department of Spinal Surgery, Asklepios Hospital Wandsbek, Hamburg, Germany
| | - Erik Fritzsche
- Department of Spinal Surgery, Asklepios Hospital Wandsbek, Hamburg, Germany
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Current Management and Treatment Modalities for Intramedullary Spinal Cord Tumors. Curr Treat Options Oncol 2015; 16:39. [DOI: 10.1007/s11864-015-0358-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ando M, Tamaki T, Yoshida M, Kawakami M, Kubota S, Nakagawa Y, Iwasaki H, Tsutsui S, Yamada H. Intraoperative spinal cord monitoring using combined motor and sensory evoked potentials recorded from the spinal cord during surgery for intramedullary spinal cord tumor. Clin Neurol Neurosurg 2015; 133:18-23. [DOI: 10.1016/j.clineuro.2015.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/28/2015] [Accepted: 03/05/2015] [Indexed: 10/23/2022]
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Takami T, Naito K, Yamagata T, Ohata K. Surgical management of spinal intramedullary tumors: radical and safe strategy for benign tumors. Neurol Med Chir (Tokyo) 2015; 55:317-27. [PMID: 25797779 PMCID: PMC4628179 DOI: 10.2176/nmc.ra.2014-0344] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Surgery for spinal intramedullary tumors remains one of the major challenges for neurosurgeons, due to their relative infrequency, unknown natural history, and surgical difficulty. We are sure that safe and precise resection of spinal intramedullary tumors, particularly encapsulated benign tumors, can result in acceptable or satisfactory postoperative outcomes. General surgical concepts and strategies, technical consideration, and functional outcomes after surgery are discussed with illustrative cases of spinal intramedullary benign tumors such as ependymoma, cavernous malformation, and hemangioblastoma. Selection of a posterior median sulcus, posterolateral sulcus, or direct transpial approach was determined based on the preoperative imaging diagnosis and careful inspection of the spinal cord surface. Tumor-cord interface was meticulously delineated in cases of benign encapsulated tumors. Our retrospective functional analysis of 24 consecutive cases of spinal intramedullary ependymoma followed for at least 6 months postoperatively demonstrated a mean grade on the modified McCormick functional schema of 1.8 before surgery, deteriorating significantly to 2.6 early after surgery (< 1 month after surgery), and finally returning to 1.7 in the late postoperative period (> 6 months after surgery). The risk of functional deterioration after surgery should be taken into serious consideration. Functional deterioration after surgery, including neuropathic pain even long after surgery, significantly affects patient quality of life. Better balance between tumor control and functional preservation can be achieved not only by the surgical technique or expertise, but also by intraoperative neurophysiological monitoring, vascular image guidance, and postoperative supportive care. Quality of life after surgery should inarguably be given top priority.
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Affiliation(s)
- Toshihiro Takami
- Department of Neurosurgery, Osaka City University Graduate School of Medicine
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