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Allison DW, Verma A, Holman PJ, Huang M, Trask TW, Barber SM, Cockrell AR, Weber MR, Brooks DW, Delgado L, Steele WJ, Sellin JN, Gressot LV, Lambert B, Ma BB, Faraji AH, Saifi C. Transabdominal Motor Evoked Potential Neuromonitoring of Lumbosacral Spine Surgery. Spine J 2024:S1529-9430(24)00194-3. [PMID: 38685276 DOI: 10.1016/j.spinee.2024.04.029] [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: 01/24/2024] [Revised: 04/15/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND CONTEXT Transcranial Motor Evoked Potentials (TcMEPs) can improve intraoperative detection of femoral plexus and nerve root injury during lumbosacral spine surgery. However, even under ideal conditions, TcMEPs are not completely free of false-positive alerts due to the immobilizing effect of general anesthetics, especially in the proximal musculature. The application of transcutaneous stimulation to activate ventral nerve roots directly at the level of the conus medularis (bypassing the brain and spinal cord) has emerged as a method to potentially monitor the motor component of the femoral plexus and lumbosacral nerves free from the blunting effects of general anesthesia. PURPOSE To evaluate the reliability and efficacy of transabdominal motor evoked potentials (TaMEPs) compared to TcMEPs during lumbosacral spine procedures. DESIGN We present the findings of a single-center 12-month retrospective experience of all lumbosacral spine surgeries utilizing multimodality intraoperative neuromonitoring (IONM) consisting of TcMEPs, TaMEPs, somatosensory evoked potentials (SSEPs), electromyography (EMG) and electroencephalography. PATIENT SAMPLE Two hundred and twenty patients having one, or a combination of lumbosacral spine procedures, including anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (LLIF), posterior spinal fusion (PSF), and/or transforaminal lumbar interbody fusion (TLIF). OUTCOME MEASURES Intraoperative neuromonitoring data was correlated to immediate post-operative neurologic examinations and chart review. METHODS Baseline reliability, false positive rate, true positive rate, false negative rate, area under the curve at baseline and at alerts, and detection of pre-operative deficits of TcMEPs and TaMEPs were compared and analyzed for statistical significance. The relationship between transcutaneous stimulation voltage level and patient BMI was also examined. RESULTS TaMEPs were significantly more reliable than TcMEPs in all muscles except abductor hallucis. Of the 27 false positive alerts, 24 were TcMEPs alone, and 3 were TaMEPs alone. Of the 19 true positives, none were detected by TcMEPs alone, 3 were detected by TaMEPs alone (TcMEPs were not present), and the remaining 16 true positives involved TaMEPs and TcMEPs. TaMEPs had a significantly larger area under the curve (AUC) at baseline than TcMEPs in all muscles except abductor hallucis. The percent decrease in TcMEP and TaMEP AUC during LLIF alerts was not significantly different. Both TcMEPs and TaMEPs reflected three pre-existing motor deficits. Patient BMI and TaMEP stimulation intensity were found to be moderately positively correlated. CONCLUSIONS These findings demonstrate the high reliability and predictability of TaMEPs and the potential added value when TaMEPs are incorporated into multimodality IONM during lumbosacral spine surgery.
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Affiliation(s)
- David W Allison
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston Texas.
| | - Amit Verma
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston Texas
| | - Paul J Holman
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, Texas
| | - Meng Huang
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, Texas
| | - Todd W Trask
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, Texas
| | - Sean M Barber
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, Texas
| | - Anthony R Cockrell
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston Texas
| | - Matthew R Weber
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston Texas
| | - Dalton W Brooks
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston Texas
| | - Leo Delgado
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston Texas
| | - William J Steele
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, Texas
| | - Jonathan N Sellin
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, Texas
| | - Loyola V Gressot
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, Texas
| | - Bradley Lambert
- Department of Orthopedics, Houston Methodist Health System, 6560 Fannin Street, Houston Texas
| | - Brandy B Ma
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston Texas
| | - Amir H Faraji
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, Texas
| | - Comron Saifi
- Department of Orthopedics, Houston Methodist Health System, 6560 Fannin Street, Houston Texas
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Sadrameli SS, Davidov V, Huang M, Lee JJ, Ramesh S, Guerrero JR, Wong MS, Boghani Z, Ordonez A, Barber SM, Trask TW, Roeser AC, Holman PJ. Complications associated with L4-5 anterior retroperitoneal trans-psoas interbody fusion: a single institution series. J Spine Surg 2020; 6:562-571. [PMID: 33102893 DOI: 10.21037/jss-20-579] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Lateral lumbar interbody fusion (LLIF), first described in the literature in 2006 by Ozgur et al., involves direct access to the lateral disc space via a retroperitoneal trans-psoas tubular approach. Neuromonitoring is vital during this approach since the surgical corridor traverses the psoas muscle where the lumbar plexus lies, risking injury to the lumbosacral plexus that could result in sensory or motor deficits. The risk of neurologic injury is especially higher at L4-5 due to the anatomy of the plexus at this level. Here we report our single-center clinical experience with L4-5 LLIF. Methods A retrospective chart review of all patients who underwent an L4-5 LLIF between May 2016 and March 2019 was performed. Baseline demographics and clinical characteristics, such as body mass index (BMI), medical comorbidities, surgical history, tobacco status, operative time and blood loss, length of stay (LOS), and post-op complications were recorded. Results A total of 220 (58% female and 42% male) cases were reviewed. The most common presenting pathology was spondylolisthesis. The average age, BMI, operative time, blood loss, and LOS were 64.6 years, 29 kg/m2, 214 min, 75 cc, and 2.5 days respectively. A review of post-operative neurologic deficits revealed 31.4% transient hip flexor weakness and 4.5% quadricep weakness on the approach side. At 3-week follow-up, 9.1% of patients experienced mild hip flexor weakness (4 or 4+/5), 0.9% reported mild quadricep weakness, and 9.5% reported anterior thigh dysesthesias; 93.2% of patients were discharged home and 2.3% were readmitted within the first 30 days post discharge. Female sex, higher BMI and longer operative time were associated with hip flexor weakness. Conclusions LLIF at L4-5 is a safe, feasible, and versatile approach to the lumbar spine with an acceptable approach-related sensory and motor neurologic complication rates.
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Affiliation(s)
- Saeed S Sadrameli
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | | | - Meng Huang
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Jonathan J Lee
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Srivathsan Ramesh
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jaime R Guerrero
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Marcus S Wong
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Zain Boghani
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Adriana Ordonez
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, TX, USA
| | - Sean M Barber
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Todd W Trask
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Andrew C Roeser
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Paul J Holman
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
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Wheeler LA, Manzanera AG, Bell SD, Cavaliere R, McGregor JM, Grecula JC, Newton HB, Lo SS, Badie B, Portnow J, Teh BS, Trask TW, Baskin DS, New PZ, Aguilar LK, Aguilar-Cordova E, Chiocca EA. Phase II multicenter study of gene-mediated cytotoxic immunotherapy as adjuvant to surgical resection for newly diagnosed malignant glioma. Neuro Oncol 2016; 18:1137-45. [PMID: 26843484 DOI: 10.1093/neuonc/now002] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [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: 10/31/2015] [Accepted: 01/02/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite aggressive standard of care (SOC) treatment, survival of malignant gliomas remains very poor. This Phase II, prospective, matched controlled, multicenter trial was conducted to assess the safety and efficacy of aglatimagene besadenovec (AdV-tk) plus valacyclovir (gene-mediated cytotoxic immunotherapy [GMCI]) in combination with SOC for newly diagnosed malignant glioma patients. METHODS Treatment cohort patients received SOC + GMCI and were enrolled at 4 institutions from 2006 to 2010. The preplanned, matched-control cohort included all concurrent patients meeting protocol criteria and SOC at a fifth institution. AdV-tk was administered at surgery followed by SOC radiation and temozolomide. Subset analyses were preplanned, based on prognostic factors: pathological diagnosis (glioblastoma vs others) and extent of resection. RESULTS Forty-eight patients completed SOC + GMCI, and 134 met control cohort criteria. Median overall survival (OS) was 17.1 months for GMCI + SOC versus 13.5 months for SOC alone (P = .0417). Survival at 1, 2, and 3 years was 67%, 35%, and 19% versus 57%, 22%, and 8%, respectively. The greatest benefit was observed in gross total resection patients: median OS of 25 versus 16.9 months (P = .0492); 1, 2, and 3-year survival of 90%, 53%, and 32% versus 64%, 28% and 6%, respectively. There were no dose-limiting toxicities; fever, fatigue, and headache were the most common GMCI-related symptoms. CONCLUSIONS GMCI can be safely combined with SOC in newly diagnosed malignant gliomas. Survival outcomes were most notably improved in patients with minimal residual disease after gross total resection. These data should help guide future immunotherapy studies and strongly support further evaluation of GMCI for malignant gliomas. CLINICAL TRIAL REGISTRY ClinicalTrials.gov NCT00589875.
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Affiliation(s)
- Lee A Wheeler
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - Andrea G Manzanera
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - Susan D Bell
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - Robert Cavaliere
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - John M McGregor
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - John C Grecula
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - Herbert B Newton
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - Simon S Lo
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - Behnam Badie
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - Jana Portnow
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - Bin S Teh
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - Todd W Trask
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - David S Baskin
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - Pamela Z New
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - Laura K Aguilar
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - Estuardo Aguilar-Cordova
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
| | - E Antonio Chiocca
- Brigham and Women's Hospital/Harvard Medical School, Massachusetts (L.A.W., E.A.C.); Advantagene, Inc., Auburndale, Massachusetts (A.G.M., L.K.A., E.A.-C.); Ohio State University, Columbus, Ohio (S.D.B., R.C., J.M.M., J.C.G., H.B.N.); University Hospitals Seidman Cancer Center/ Case Western Reserve University, Cleveland, Ohio (S.S.L.); City of Hope, Duarte, California (B.B., J.B.); Houston Methodist Hospital, Houston, Texas (B.S.T., T.W.T., D.S.B., P.Z.N.)
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