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Soh RCC, Chen BZ, Hartono S, Lee MS, Lee W, Lim SL, Gan J, Maréchal B, Chan LL, Lo YL. The hindbrain and cortico-reticular pathway in adolescent idiopathic scoliosis. Clin Radiol 2024; 79:e759-e766. [PMID: 38388254 DOI: 10.1016/j.crad.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 01/09/2024] [Accepted: 01/18/2024] [Indexed: 02/24/2024]
Abstract
AIM To characterise the corticoreticular pathway (CRP) in a case-control cohort of adolescent idiopathic scoliosis (AIS) patients using high-resolution slice-accelerated readout-segmented echo-planar diffusion tensor imaging (DTI) to enhance the discrimination of small brainstem nuclei in comparison to automated whole-brain volumetry and tractography and their clinical correlates. MATERIALS AND METHODS Thirty-four participants (16 AIS patients, 18 healthy controls) underwent clinical and orthopaedic assessments and brain magnetic resonance imaging (MRI) on a 3 T MRI machine. Automated whole-brain volume-based morphometry, tract-based spatial statistics analysis, and manual CRP tractography by two independent raters were performed. Intra-rater and inter-rater agreement of DTI metrics from CRP tractography were assessed by intraclass correlation coefficient. Normalised structural brain volumes and DTI metrics were compared between groups using Student's t-tests. Linear correlation analysis between imaging parameters and clinical scores was also performed. RESULTS AIS patients demonstrated a significantly larger pons volume compared to controls (p=0.006). Significant inter-side CRP differences in mean (p=0.02) and axial diffusivity (p=0.01) were found in patients only. Asymmetry in CRP fractional anisotropy significantly correlated with the Cobb angle (p=0.03). CONCLUSION Relative pontine hypertrophy and asymmetry in CRP DTI metrics suggest central supranuclear inter-hemispheric imbalance in AIS, and support the role of the CRP in axial muscle tone. Longitudinal evaluation of CRP DTI metrics in the prediction of AIS progression may be clinically relevant.
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Affiliation(s)
- R C C Soh
- Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - B Z Chen
- Singapore General Hospital, Singapore
| | - S Hartono
- Duke-NUS Medical School, Singapore; National Neuroscience Institute, Singapore
| | - M S Lee
- Singapore General Hospital, Singapore
| | - W Lee
- Singapore General Hospital, Singapore
| | - S L Lim
- Singapore General Hospital, Singapore
| | - J Gan
- Siemens Healthineers, Singapore
| | - B Maréchal
- Advanced Clinical Imaging Technology, Siemens Healthcare AG, Lausanne, Switzerland; Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland; Signal Processing Laboratory (LTS 5), École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - L L Chan
- Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore.
| | - Y L Lo
- Duke-NUS Medical School, Singapore; National Neuroscience Institute, Singapore
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Lo YL. Letter to Editor on "Do Intraoperative Neurophysiological Changes During Decompressive Surgery for Cervical Myeloradiculopathy Affect Functional Outcome? A Prospective Study" by Akbari et al. Global Spine J 2024; 14:1082-1083. [PMID: 36734372 DOI: 10.1177/21925682231155159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Yew Long Lo
- National Neuroscience Institute, Singapore, Singapore
- Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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Koshimizu H, Nakashima H, Tomita H, Segi N, Ito S, Machino M, Ando K, Imagama S. Pedicular kinking during posterior corrective procedure for thoracolumbar kyphoscoliosis with unstable osteoporotic fracture. J Orthop Sci 2024; 29:409-412. [PMID: 35811253 DOI: 10.1016/j.jos.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/12/2022] [Accepted: 06/08/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Hiroyuki Koshimizu
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hiroaki Nakashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.
| | - Hiroyuki Tomita
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Naoki Segi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Sadayuki Ito
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masaaki Machino
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Troyer SC, Ribaudo JG, Raynor B, Zertan C, Kelly BA, Kelly MP, Luhmann SJ. The adjunct use of descending neurogenic-evoked potentials when transcranial motor-evoked potentials degrade into warning criteria in pediatric spinal deformity surgery: minimizing false-positive events. Spine Deform 2023; 11:1427-1433. [PMID: 37535306 DOI: 10.1007/s43390-023-00743-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/22/2023] [Indexed: 08/04/2023]
Abstract
PURPOSE This studies objective was to evaluate the utility of descending neurogenic-evoked potentials (DNEPs) in the setting of transcranial motor-evoked potentials (TCeMEPs) degradation into warning criteria during pediatric spinal deformity surgery. METHODS An institutional spinal cord monitoring database was queried to identify all primary and revision pediatric spinal deformity cases, < / = 21 years of age performed from 1/2006 to 12/2021, in which TCeMEPs were the primary motor tract assessment modality which degraded into warning criteria, with subsequent initiation of adjunct DNEPs. RESULTS Fourteen surgical cases (0.42%; 3351 total cases) in fourteen patients met inclusion criteria. Mean age was 13.2 years (7.5-21.3). DIAGNOSES syndromic (n = 7), kyphosis (n = 3), congenital (n = 2), and idiopathic (n = 2). Three-column osteotomies (3CO)were done in eight patients. TCeMEPs degraded into warning criteria during screw placement (n = 7), 3CO performance/closure (n = 4), or deformity correction (n = 3). DNEPs were present in all cases of warning-criteria TCeMEPs and one case had degradation of DNEPs. Intraoperative Stagnara wake-up tests were performed in only 2/14 cases, with one transient new neurologic deficit (NND). In this specific scenario, DNEPs sensitivity was 50%, specificity 100%, positive predictive value 100%, and negative predictive value 92% to detect aNND. CONCLUSION DNEPs were useful in assessing spinal cord function in the setting of TCeMEP data degradation in complex pediatric deformity surgeries. DNEPs demonstrated a higher specificity and positive predictive value in this clinical setting than TCeMEPs when assessing long-term neurologic function after surgery. Based on this small cohort, DNEPs appear to be a useful adjunct modality to TCeMEPs, in this challenging clinical scenario.
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Affiliation(s)
| | | | | | | | - Brian A Kelly
- Department of Orthopaedics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Mike P Kelly
- University of San Diego School of Medicine, San Diego, CA, USA
| | - Scott J Luhmann
- Department of Orthopaedics, Washington University School of Medicine, St. Louis, MO, 63110, USA.
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Oh BH, Kim JY, Lee JB, Kim IS, Hong JT, Sung JH, Lee HJ. Failure to Obtain Baseline Signals of Transcranial Motor-Evoked Potentials in Spine Surgery: Analysis of the Reasons. World Neurosurg 2023; 170:e144-e150. [PMID: 36328164 DOI: 10.1016/j.wneu.2022.10.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Among the various intraoperative neurophysiologic monitoring (IONM) techniques, transcranial motor-evoked potential (Tc-MEP) has recently become the most widely used method to monitor motor function. However, we often find that Tc-MEP is not sufficiently detected at the start of surgery. Therefore, we aimed to analyze the reasons and risk factors for not detecting sufficient baseline signal of Tc-MEP from the beginning of spinal surgery. METHODS We categorized IONM data from 1058 patients who underwent spine surgeries at a single institution from 2014 to 2020 and categorized them into 2 groups: 1) "poor MEP" if Tc-MEP could not be sufficiently obtained and 2) "normal MEP" if Tc-MEP could be sufficiently obtained from the surgery. We analyzed the patient's age, gender, underlying disease, operation type, level numbers, baseline motor function, existence of pathologic reflex, myelopathy, and duration from the onset and clinical diagnosis. RESULTS The rate of failure to obtain sufficient baseline Tc-MEP signals in spine surgery was 21.8% (231/1058). Multivariate analysis showed significant associations of existence of diabetes mellitus, myelopathy, thoracic spine surgery, baseline motor deficit and tumor, and trauma disease with loss of meaningful and interpretable signals in baseline Tc-MEP (P < 0.05). Only 15 of 231 patients (6.4%) showed a trend of signal recovery after decompression procedures. CONCLUSIONS Various factors (myelopathy, diabetes mellitus, thoracic surgery, baseline motor deficit, tumor, and trauma) were closely related to not obtaining sufficient baseline signals for Tc-MEP. When operating on patients with these considerations, we need to consider the efficacy and usefulness of Tc- MEP.
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Affiliation(s)
- Byeong Ho Oh
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - Jee Yong Kim
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - Jong Beom Lee
- Department of Neurosurgery, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Il Sup Kim
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - Jae Taek Hong
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - Ho Jin Lee
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea.
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Chen J, Deng YL, Sui WY, Yang JF, Xu J, Huang ZF, Yang JL. Intraoperative Neuromonitoring Auxiliary Significance of DNEP for MEP-positive Event During Severe Spinal Deformity Surgery. Clin Spine Surg 2022; 35:E167-E174. [PMID: 34108370 PMCID: PMC8806038 DOI: 10.1097/bsd.0000000000001190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 02/24/2021] [Indexed: 12/03/2022]
Abstract
STUDY DESIGN This was a retrospective analysis. OBJECTIVE The objective of this study was to assess the intraoperative neuromonitoring auxiliary significance of descending neurogenic-evoked potential (DNEP) for motor-evoked potential (MEP) during severe spinal deformity surgery when MEP-positive event occurs. SUMMARY OF BACKGROUND DATA MEP detection is the most widely applied neurological monitoring technique in spinal deformity surgery. MEP is quite vulnerable to anesthesia, blood pressure, and other intraoperative factors, leading to a high false-positive rate of MEP (3.2%-45.0%), which has greatly interfered with the surgical process. At present, the widely used "presence-or-absence" alarm criteria of MEP is not enough to solve the problem of false positive of MEP. METHODS A total of 205 cases undergoing severe spinal deformity correction were retrospectively studied. Overall, 74 MEP-positive cases were classified as 2 subgroups: DNEP (+) and DNEP (-) groups. The MEP recovery, wake-up test, and Frankle grade were used to assess the neurological functions. The perioperative and long-term neurological outcomes were assessed. RESULTS There were significant differences in preoperative scoliosis angle and kyphosis angle between DNEP (-) and DNEP (+) groups. Patients in DNEP (-) group showed more MEP improvement (81.5%), compared with the DNEP (+) group (53.2%). The Wake-up test showed 59.3% motor function deficit cases in DNEP (-) group, which was lower than the 87.2% in DNEP (+) group. More patients in DNEP (-) group had normal nerve function (Frankel level E) than those in DNEP (+) group immediately after surgery, as well as at follow-up. CONCLUSIONS MEP-positive cases with intraoperative DNEP (-) showed superior prognosis after severe spinal deformity surgery. Intraoperative DNEP could be regarded as an important quantitative tool to assist MEP to monitor neurological injury and can serve as a temporary substitution monitoring technique after MEP is lost.
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Affiliation(s)
- Jian Chen
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai
| | - Yao-long Deng
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai
| | - Wen-yuan Sui
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai
| | - Jing-fan Yang
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai
| | - Jing Xu
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai
| | - Zi-fang Huang
- Department of Orthopaedic Surgery, the 1st Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jun-lin Yang
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai
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Kobayashi K, Ando K, Nakashima H, Machino M, Kanbara S, Ito S, Inoue T, Yamaguchi H, Koshimizu H, Imagama S. Poor derivation of Tc-MEP baseline waveforms in surgery for ventral thoracic intradural extramedullary tumor: Efficacy of use of the abductor hallucis in cases with a preoperative non-ambulatory status. J Clin Neurosci 2020; 84:60-65. [PMID: 33485601 DOI: 10.1016/j.jocn.2020.11.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/18/2020] [Accepted: 11/28/2020] [Indexed: 10/22/2022]
Abstract
Most thoracic intradural extramedullary tumors (IDEMT) are benign lesions that are treated by gross total resection and spinal cord decompression. Intraoperative transcranial-motor evoked potential (Tc-MEP) monitoring is important for reducing postoperative neurological complications. The purpose of this study is to examine the characteristics of Tc-MEP waveforms in surgery for thoracic IDEMT resection based on location of the tumor relative to the spinal cord. The subjects were 56 patients who underwent surgery for thoracic IDEMT from 2010 to 2018. The waveform derivation rate for each lower muscle was examined at baseline and intraoperatively. 56 patients had a mean age of 61.7 years, and 21 (38%) were non-ambulatory before surgery. The tumors were schwannoma (n = 28, 50%), meningioma (n = 25, 45%), and neurofibroma (n = 3, 5%); and the lesions were dorsal (n = 29, 53%) and ventral (n = 27, 47%). There was a significantly higher rate of undetectable waveforms in all lower limb muscles in the ventral group compared to the dorsal group (15% vs. 3%, p < 0.05). In non-ambulatory cases, the derivation rate at baseline was significantly lower for ventral thoracic IDMETs (47% vs. 68%, p < 0.05). The abductor hallucis (AH) had the highest waveform derivation rate of all lower limb muscles in non-ambulatory cases with a ventral thoracic IDMET. Spinal cord compression by a ventral lesion may be increased, and this may be reflected in greater waveform deterioration. Of all lower limb muscles, the AH had the highest derivation rate, even in non-ambulatory cases with a ventral IDEMT, which suggests the efficacy of multichannel monitoring including the AH.
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Affiliation(s)
- Kazuyoshi Kobayashi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Hiroaki Nakashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Masaaki Machino
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Shunsuke Kanbara
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Sadayuki Ito
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Taro Inoue
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Hidetoshi Yamaguchi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Hiroyuki Koshimizu
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
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Lo YL, Zhu L, Soh RC, Guo CM. Intraoperative Motor Evoked Potential Improvement in Cervical Spondylotic Myelopathy: Comparison of Cortical Stimulation Parameters. J Clin Neurol 2020; 16:102-107. [PMID: 31942765 PMCID: PMC6974831 DOI: 10.3988/jcn.2020.16.1.102] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND PURPOSE Intraoperative monitoring of the motor pathways is a routine procedure for ensuring the integrity of descending motor tracts during spinal surgery. Intraoperative motor evoked potential improvement (MEPI) may be associated with a better postsurgical outcome in cervical spondylotic myelopathy (CSM). To compare the efficacy of two cortical stimulation parameters in eliciting MEPI intraoperatively during CSM surgery. METHODS We studied 69 patients who underwent decompression surgery for CSM over a 9-month period using either 5 (Group 1) or 9 (Group 2) stimuli. MEPI was defined as the increase in the amplitude of MEPs from baseline at the end of CSM surgery just prior to skin closure. RESULTS An MEPI of 100% from baseline was observed in 10 patients (53%) in Group 1 and 36 patients (72%) in Group 2. Comparisons of the baseline mean MEP amplitudes of muscles bilaterally between Groups 1 and 2 did not reveal any significant differences. Supramaximal stimulation showed that a significantly higher mean intensity was required for Group 1 than for Group 2. CONCLUSIONS MEPI is observed in a much larger proportion of cervical decompression surgery cases than previously thought. Intraoperative MEPI with longer-train cortical stimulation may reflect adequacy of decompression and provide additional guidance for the surgical procedure.
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Affiliation(s)
- Yew Long Lo
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore.,Department of Neurology, Duke-NUS Medical School, College Road, Singapore.
| | - Lisa Zhu
- Department of Orthopedic Surgery, Singapore General Hospital, Singapore
| | - Reuben C Soh
- Department of Orthopedic Surgery, Singapore General Hospital, Singapore
| | - Chang Ming Guo
- Department of Orthopedic Surgery, Singapore General Hospital, Singapore
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kobayashi K, Ando K, Machino M, Ota K, Morozumi M, Tanaka S, Kanbara S, Ito S, Ishiguro N, Imagama S. Optimal stimulation intensity for Br(E)-MsEP waveform derivation at baseline in pediatric spinal surgery. Clin Neurol Neurosurg 2019; 180:74-78. [PMID: 30952034 DOI: 10.1016/j.clineuro.2019.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/24/2019] [Accepted: 03/03/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Br(E)-MsEP monitoring is widely used in spinal surgery for detection of spinal cord injury. However, Br(E)-MsEP waveform derivation requires high-intensity stimulation, and this raises a concern of adverse effects due to the immature corticospinal tract in pediatric patients. The purpose of this study is to determine the optimal stimulation intensity required for derivation of Br(E)-MsEP waveforms at baseline in pediatric spinal surgery. PATIENTS AND METHODS The subjects were 85 pediatric patients (4-15 years old, mean age at surgery: 11.1 years old) who were treated with spinal surgery using a posterior only approach under Br(E)-MsEP monitoring. The main diagnoses were adolescent idiopathic scoliosis (n = 44), syndromic and neuromuscular scoliosis (n = 23), and congenital scoliosis (n = 12). A total of 1513 muscles in the lower extremities were chosen for monitoring. RESULTS A baseline waveform was obtained in all 85 cases and baseline Br(E)-MsEP responses were obtained from 1437/1513 muscles (95%). The mean stimulation intensity for baseline waveform derivation was 156.4 mA (range: 100-200 mA), and the stimulation intensity was significantly correlated with age (p < 0.05). The mean stimulation intensities were 129 ± 12, 138 ± 20, and 167 ± 25 mA for children <5, 6 to 10, and 11 to 15 years old, respectively. CONCLUSION There are no criteria for derivation of Br(E)-MsEP waveforms in pediatric patients undergoing spinal surgery. The stimulation intensity increased with age, and starting at a lower stimulation strength than that used in adults is appropriate for younger children.
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Affiliation(s)
- Kazuyoshi Kobayashi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan
| | - Masaaki Machino
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan
| | - Kyotaro Ota
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan
| | - Masayoshi Morozumi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan
| | - Satoshi Tanaka
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan
| | - Shunsuke Kanbara
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan
| | - Sadayuki Ito
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan
| | - Naoki Ishiguro
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan.
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Kobayashi K, Ando K, Tsushima M, Machino M, Ota K, Morozumi M, Tanaka S, Kanbara S, Ishiguro N, Imagama S. Characteristics of multi-channel Br(E)-MsEP waveforms for the lower extremity muscles in thoracic spine surgery: comparison based on preoperative motor status. Eur Spine J 2018; 28:484-491. [DOI: 10.1007/s00586-018-5825-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 11/06/2018] [Indexed: 10/27/2022]
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Thirumala PD, Crammond DJ, Loke YK, Cheng HL, Huang J, Balzer JR. Diagnostic accuracy of motor evoked potentials to detect neurological deficit during idiopathic scoliosis correction: a systematic review. J Neurosurg Spine 2017; 26:374-383. [DOI: 10.3171/2015.7.spine15466] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE
The goal of this study was to evaluate the efficacy of intraoperative transcranial motor evoked potential (TcMEP) monitoring in predicting an impending neurological deficit during corrective spinal surgery for patients with idiopathic scoliosis (IS).
METHODS
The authors searched the PubMed and Web of Science database for relevant lists of retrieved reports and/or experiments published from January 1950 through October 2014 for studies on TcMEP monitoring use during IS surgery. The primary analysis of this review fit the operating characteristic into a hierarchical summary receiver operating characteristic curve model to determine the efficacy of intraoperative TcMEP-predicted change.
RESULTS
Twelve studies, with a total of 2102 patients with IS were included. Analysis found an observed incidence of neurological deficits of 1.38% (29/2102) in the sample population. Of the patients who sustained a neurological deficit, 82.8% (24/29) also had irreversible TcMEP change, whereas 17.2% (5/29) did not. The pooled analysis using the bivariate model showed TcMEP change with sensitivity (mean 91% [95% CI 34%–100%]) and specificity (mean 96% [95% CI 92–98%]). The diagnostic odds ratio indicated that it is 250 times more likely to observe significant TcMEP changes in patients who experience a new-onset motor deficit immediately after IS correction surgery (95% CI 11–5767). TcMEP monitoring showed high discriminant ability with an area under the curve of 0.98.
CONCLUSIONS
A patient with a new neurological deficit resulting from IS surgery was 250 times more likely to have changes in TcMEPs than a patient without new deficit. The authors' findings from 2102 operations in patients with IS show that TcMEP monitoring is a highly sensitive and specific test for detecting new spinal cord injuries in patients undergoing corrective spinal surgery for IS. They could not assess the value of TcMEP monitoring as a therapeutic adjunct owing to the limited data available and their study design.
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Affiliation(s)
- Parthasarathy D. Thirumala
- Departments of 1Neurological Surgery and
- 3Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | | | - Yoon K. Loke
- 4Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | | | | | - Jeffrey R. Balzer
- Departments of 1Neurological Surgery and
- 2Neuroscience, University of Pittsburgh
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Tiruchelvarayan R, Tang MH, Perera S, Lo YL. Outcomes following Aggressive Surgical Resection of Intra-Medullary Spinal Cord Tumours with Intra-Operative Neuro-Monitoring. Proceedings of Singapore Healthcare 2016. [DOI: 10.1177/201010581302200305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Intra-medullary spinal cord tumours (IMCST) are relatively uncommon tumours of the central nervous system which can result in severe neurological disorder if untreated. Histologically, IMCSTs are often either biopsied or excised subtotal, but this may lead to early tumour recurrence and progressive neurological impairment. In an attempt to improve outcomes, the recent trend is to perform more radical tumour resection guided by intra-operative monitoring (IOM). However, there are no controlled studies comparing the resection of IMCSTs with or without IOM. In this single surgeon series, we analyse outcomes following optimal resection of IMCSTs in conjunction with IOM. Methods: In this retrospective single surgeon series, case notes and history of patients who underwent surgery between 2006–2012 at the Singapore General Hospital's Neurosurgery Department, were studied. IOM with somatosensory evoked potential (SSEP) and motor evoked potential (MEP) were utilised to facilitate optimal tumour resection. Neurological status were compared pre- and post-operatively with long-term follow-up on outcomes. Magnetic resonance imaging was used pre- and post-operatively to assess the degree of tumour resection. Results: Thirteen consecutive patients with IMCSTs (five males, mean age 36 years, range 12–60) underwent surgical treatment and were included in this study. Radical surgical resection was performed for 11 patients, while the remaining two had biopsies and partial debulking as frozen section showed high grade astrocytomas. Histology revealed six cases of ependymoma, five cases of astrocytoma, and one of hemangioblastoma and neuroenteric cyst. There was one case of wound infection which was treated successfully. There were no cases of cerebrospinal fluid leakage. Two patients had pre-existing spinal deformity, and underwent posterior instrumented fusion concomitantly. The neurological state improved or remained stable in 11 (85%) patients, and two patients had immediate post-operative neurological deterioration which improved subsequently with physiotherapy over one to two months. Favourable functional outcomes were observed in the majority of patients during follow-up. The patients with high grade tumours were treated with adjuvant radiotherapy post-operatively, however, they showed a poorer long-term outcome. The mean follow-up was 3.2 years from operation. Conclusion: Radical resection of intra-medullary tumours with IOM leads to a favourable functional outcome in selected groups of patients.
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Affiliation(s)
- Rajendra Tiruchelvarayan
- Department of Neurosurgery, Singapore General Hospital Campus, National Neuroscience Institute, Singapore
| | - Man Hon Tang
- Department of Neurosurgery, Singapore General Hospital Campus, National Neuroscience Institute, Singapore
| | - Sanjaya Perera
- Department of Neurosurgery, Singapore General Hospital Campus, National Neuroscience Institute, Singapore
| | - Yew Long Lo
- Department of Neurology, Singapore General Hospital Campus, National Neuroscience Institute, Singapore
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Lo YL, Teo A, Tan YE, Fook-Chong S, Guo CM, Yue WM, Chen J, Tan SB, Lee HW, Dan YF. Motor and somatosensory abnormalities are significant etiological factors for adolescent idiopathic scoliosis. J Neurol Sci 2015; 359:117-23. [PMID: 26671099 DOI: 10.1016/j.jns.2015.10.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/13/2015] [Accepted: 10/28/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE In adolescent idiopathic scoliosis (AIS), we explore the role of lateralized motor and somatosensory abnormalities as a possible etiological factor. METHODS Intraoperative transcranial electrical stimulation was performed in 15 AIS and 14 adult degenerative scoliosis (ADS) patients. Inter-side motor output balance (MOB) by comparing the ratios of right to left motor evoked potentials (MEP) amplitudes, and inter-side motor output excitability (MOE) computed with MEP amplitude, was determined separately for both patients groups. For somatosensory evoked potentials (SSEP), peak to peak P37 amplitudes from right and left lower limb SSEP and inter-side P37 amplitude ratios were obtained. RESULTS Inter-side MOB was significantly asymmetric in AIS patients, contributed mainly by inter-side MOB changes in the upper than the lower limbs. Inter-side MOE comparisons of ipsilateral and contralateral MEP amplitudes were significantly different between AIS and ADS patients. Mean upper limb MEP amplitudes were significantly reduced in AIS patients. Amplitude of the right upper limb MEPs were positively correlated with inter-side MEP ratio. AIS patients show larger mean MEP amplitudes on the same side as the scoliotic curve. Overall, no correlation of Cobb's angle or total levels of scoliosis involvement with inter-side MOB and MOE parameters was found. Inter-side SSEP ratios were significantly higher in AIS patients. CONCLUSIONS Primary dysfunctional and distributed motor output contributing to abnormalities of inter-side MOB and MOE changes involving the upper limbs is evident in AIS. Simultaneous but independent somatosensory and motor observations seen these patients suggest a central mechanism as an etiological factor.
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Zhuang Q, Wang S, Zhang J, Zhao H, Wang Y, Tian Y, Zhao Y, Li S, Weng X, Qiu G, Shen J. How to make the best use of intraoperative motor evoked potential monitoring? Experience in 1162 consecutive spinal deformity surgical procedures. Spine (Phila Pa 1976) 2014; 39:E1425-32. [PMID: 25387144 DOI: 10.1097/BRS.0000000000000589] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study of 1162 consecutive patients who underwent spinal deformity surgical procedures at our spine center from January 2010 to December 2013. OBJECTIVE To develop and evaluate a protocol of intraoperative motor evoked potential (MEP) monitoring with the warning criteria we had established on the basis of our clinical experiences and the review of previous literature. SUMMARY OF BACKGROUND DATA Though MEPs monitoring have become widely used in spinal deformity surgery, different alarm criteria and response protocol used in different studies compromised their comparability; Furthermore, high false-positive rate of MEP reported by previous studies has become an increasingly prominent problem that will limit its clinical use and development. METHODS The intraoperative monitoring data of 1162 consecutive patients who underwent spinal deformity surgical procedures at our spine center were retrospectively analyzed. Age, sex, diagnosis, preoperative neurological status, intraspinal anomalies, baseline MEP, and MEP change were collected. The protocol with the warning criteria we had established was used. The false-positive rate, false-negative rate, and positive predictive value were calculated. RESULTS Significant intraoperative changes were seen in the MEP data in 52 (4.4%) of all the cases. In 25 cases among which, significant MEP changes were synchronously and logically associated with high-risk surgical maneuver (pedicle screw insertion, osteotomy, correction, etc.). The false-positive rate of MEP monitoring was 0.26% (3/1140), whereas the sensitivity and specificity of MEP for detection of clinically significant intraoperative cord injury were 100% and 99.7%, respectively. The positive predictive value of a MEP alert in terms of a new postoperative neurological deficit was 83.3%. CONCLUSION Our study indicates that the appropriate use of MEP monitoring based on our protocol is able to obtain satisfying sensitivity and specificity and thus provide important information for intraoperative decision making.
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16
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Tian NF, Huang QS, Zhou P, Zhou Y, Wu RK, Lou Y, Xu HZ. Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies. Eur Spine J 2011; 20:846-59. [PMID: 20862593 PMCID: PMC3099151 DOI: 10.1007/s00586-010-1577-5] [Citation(s) in RCA: 218] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Revised: 08/28/2010] [Accepted: 09/07/2010] [Indexed: 01/06/2023]
Abstract
Studies revealed that navigation systems that provided intraoperative assistance might improve pedicle screw insertion accuracy, and also implied that different systems provided different pedicle screw insertion accuracy. A systematic review and meta-analysis was conducted to focus on the pedicle screw insertion accuracy with or without the assistance of image-guided system, and the variance among the different navigation systems. Comparative studies were searched on pedicle screw insertion accuracy between conventional and navigated method, and among different navigation systems. A total of 43 papers, including 28 clinical, 14 cadaveric and 1 model studies, were included in the current study. For clinical articles, there were 3 randomized clinical trials, 4 prospective comparative studies and 21 retrospective comparative studies. The incidence of pedicle violation among computer tomography-based navigation method group was statistically significantly less than that observed among the conventional group (OR 95% CI, in vivo: 0.32-0.60; in vitro: 0.24-0.75 P < 0.01). Two-dimensional fluoroscopy-based navigation system (OR 95% CI, in vivo: 0.27-0.48; in vitro: 0.43-0.88 P < 0.01) and three-dimension fluoroscopy-based navigation system (OR 95% CI, in vivo: 0.09-0.38; in vitro: 0.09-0.36 P < 0.01) also obtained significant reduced screw deviation rate over traditional methods. Between navigated approaches, statistically insignificant individual and pooled RR values were observed for all in vivo subgroups. Pooled estimate of in vitro studies show that computer tomography-based and three-dimension fluoroscopy-based navigation system provided more accurate pedicle screw insertion over two-dimension fluoroscopy-based navigation system. Our review showed that navigation provided a higher accuracy in the placement of pedicle screws compared with conventional methods. The superiority of navigation systems was obvious when they were applied to abnormal spinal structure. Although no strong in vivo evidence has detected significantly different pedicle screw placement accuracy among the three major navigation systems, meta-analysis revealed the variance in pedicle screw insertion accuracy with different navigation methods.
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Affiliation(s)
- Nai-Feng Tian
- Zhejiang Spine Research Center, Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical College, 109 Xueyuanxi Road, Wenzhou 325000, China
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Abstract
STUDY DESIGN Literature review. OBJECTIVE The objective of this article is to examine current intraoperative electromyography (EMG) neurophysiologic monitoring methods and their application in minimally invasive techniques. We will also discuss the recent application of EMG and its anatomic implications to the minimally invasive lateral transpsoas approach to the spine. SUMMARY OF BACKGROUND DATA Minimally invasive techniques require that the same goals of surgery be achieved, with the hope of decreased morbidity to the patient. Unlike standard open procedures, direct visualization of the anatomy is decreased. To increase the safety of minimally invasive spine surgery, neurophysiological monitoring techniques have been developed. METHODS Review of the literature was performed using the National Center for Biotechnology Information databases using PUBMED/MEDLINE. All articles in the English language discussing the use of intraoperative EMG monitoring and minimally invasive spine surgery were reviewed. The role of EMG monitoring in special reference to the minimally invasive lateral transpsoas approach is also described. RESULTS In total, 76 articles were identified that discussed the role of neuromonitoring in spine surgery. The majority of articles on EMG and spine surgery discuss the use of intraoperative neurophysiological monitoring (IOM) for safe and accurate pedicle screw placement. In general, there is a paucity of literature that pertains to intraoperative EMG neuromonitoring and minimally invasive spine surgery. Recently, EMG has been used during minimally invasive lateral transpsoas approach to the lumbar spine for interbody fusion. The addition of EMG to the lateral approach has contributed to decrease the complication rate from 30% to less than 1%. CONCLUSION In minimally invasive approaches to the spine, the use of EMG IOM might provide additional safety, such as percutaneous pedicle screw placement, where visualization is limited compared with conventional open procedures. In addition to knowledge of the anatomy and image guidance, directional EMG IOM is crucial for safe passage through the psoas muscle during the minimally invasive lateral retroperitoneal approach.
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Lo Y, Dan Y, Tan Y, Teo A, Tan S, Yue W, Guo C, Fook-Chong S. Clinical and physiological effects of transcranial electrical stimulation position on motor evoked potentials in scoliosis surgery. Scoliosis 2010; 5:3. [PMID: 20175933 PMCID: PMC2834632 DOI: 10.1186/1748-7161-5-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 02/23/2010] [Indexed: 11/25/2022]
Abstract
Background During intraoperative monitoring for scoliosis surgery, we have previously elicited ipsilateral and contralateral motor evoked potentials (MEP) with cross scalp stimulation. Ipsilateral MEPs, which may have comprised summation of early ipsilaterally conducted components and transcallosally or deep white matter stimulated components, can show larger amplitudes than those derived purely from contralateral motor cortex stimulation. We tested this hypothesis using two stimulating positions. We compared intraoperative MEPs in 14 neurologically normal subjects undergoing scoliosis surgery using total intravenous anesthetic regimens. Methods Trancranial electrical stimulation was applied with both cross scalp (C3C4 or C4C3) or midline (C3Cz or C4Cz) positions. The latter was assumed to be more focal and result in little transcallosal/deep white matter stimulation. A train of 5 square wave stimuli 0.5 ms in duration at up to 200 mA was delivered with 4 ms (250 Hz) interstimulus intervals. Averaged supramaximal MEPs were obtained from the tibialis anterior bilaterally. Results The cross scalp stimulating position resulted in supramaximal MEPs that were of significantly higher amplitude, shorter latency and required lower stimulating intensity to elicit overall (Wilcoxon Signed Rank test, p < 0.05 for all), as compared to the midline stimulating position. However, no significant differences were found for all 3 parameters comparing ipsilaterally and contralaterally recorded MEPs (p > 0.05 for all), seen for both stimulating positions individually. Conclusions Our findings suggest that cross scalp stimulation resulted in MEPs obtained ipsilaterally and contralaterally which may be contributed to by summation of ipsilateral and simultaneous transcallosally or deep white matter conducted stimulation of the opposite motor cortex. Use of this stimulating position is advocated to elicit MEPs under operative circumstances where anesthetic agents may cause suppression of cortical and spinal excitability. Although less focal in nature, cross scalp stimulation would be most suitable for infratentorial or spinal surgery, in contrast to supratentorial neurosurgical procedures.
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Affiliation(s)
- Yl Lo
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Outram Road, Singapore 169608, Singapore.
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