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Meneghelli P, Pasqualin A, Musumeci A, Pinna G, Berti PP, Polizzi GMV, Sinosi FA, Nicolato A, Sala F. Microsurgical removal of supratentorial and cerebellar cavernous malformations: what has changed? A single institution experience. J Clin Neurosci 2024; 123:162-170. [PMID: 38581776 DOI: 10.1016/j.jocn.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/09/2024] [Accepted: 04/02/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Features associated with a safe surgical resection of cerebral cavernous malformations (CMs) are still not clear and what is needed to achieve this target has not been defined yet. METHODS Clinical presentation, radiological features and anatomical locations were assessed for patients operated on from January 2008 to January 2018 for supratentorial and cerebellar cavernomas. Supratentorial CMs were divided into 3 subgroups (non-critical vs. superficial critical vs. deep critical). The clinical outcome was assessed through modified Rankin Scale (mRS) and was divided into favorable (mRS 0-1) and unfavorable (mRS ≥ 2). Post-operative epilepsy was classified according to the Maraire Scale. RESULTS A total of 144 were considered eligible for the current study. At 6 months follow-up the clinical outcome was excellent for patients with cerebellar or lobar CMs in non-critical areas (mRS ≤ 1: 91.1 %) and for patients with superficial CMs in critical areas (mRS ≤ 1: 92.3 %). Patients with deep-seated suprantentorial CMs showed a favorable outcome in 76.9 %. As for epilepsy 58.5 % of patients presenting with a history of epilepsy were free from seizures and without therapy (Maraire grade I) at last follow-up (mean 3.9 years) and an additional 41.5 % had complete control of seizures with therapy (Maraire grade II). CONCLUSIONS Surgery is safe in the management of CMs in non-critical but also in critical supratentorial locations, with a caveat for deep structures such as the insula, the basal ganglia and the thalamus/hypothalamus.
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Affiliation(s)
- Pietro Meneghelli
- Institute of Neurosurgery, University and City Hospital, Verona, Italy.
| | - Alberto Pasqualin
- Section of Vascular Neurosurgery, Institute of Neurological Surgery, University and City Hospital, Verona, Italy
| | - Angelo Musumeci
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Giampietro Pinna
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Pier Paolo Berti
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | | | | | - Antonio Nicolato
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neuroscience, Biomedicine and Movement, University of Verona
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Matabele MN, Kille TL, Gorelik M, Van Beek-King J, Legare JM, Stadler JA, Iskandar BJ, Wheeler BJ, Puricelli MD. Intraoperative neural monitoring during head and neck surgery in patients with concern for cervical spine instability. Int J Pediatr Otorhinolaryngol 2023; 175:111749. [PMID: 37839292 DOI: 10.1016/j.ijporl.2023.111749] [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: 07/01/2023] [Revised: 09/26/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
Cervical and craniocervical instability are associated with catastrophic procedural outcomes. We discuss three individuals who required otolaryngologic surgical intervention: two with symptomatic spinal instability and one in whom spinal stability was unable to be assessed. Two cases were managed with procedural positioning precautions and evoked potential monitoring, and the other with procedural positioning precautions alone. Methods of monitoring and triggers for repositioning are discussed. This series is intended to discuss the approach and potential added value of evoked potential monitoring for risk mitigation in pediatric patients with concern for cervical spine instability.
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Affiliation(s)
- Maya N Matabele
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Tony L Kille
- Division of Otolaryngology - Head and Neck Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Michael Gorelik
- Division of Otolaryngology - Head and Neck Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Jessica Van Beek-King
- Division of Otolaryngology - Head and Neck Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Janet M Legare
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA
| | - James A Stadler
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Bermans J Iskandar
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Bryan J Wheeler
- Department of Neurology, University of Wisconsin Health, Madison, WI, USA
| | - Michael D Puricelli
- Division of Otolaryngology - Head and Neck Surgery, University of Wisconsin-Madison, Madison, WI, USA.
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Tatagiba M, Lepski G, Kullmann M, Krischek B, Danz S, Bornemann A, Klein J, Fahrig A, Velnar T, Feigl GC. The Brainstem Cavernoma Case Series: A Formula for Surgery and Surgical Technique. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1601. [PMID: 37763720 PMCID: PMC10537097 DOI: 10.3390/medicina59091601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Cavernous malformations (CM) are vascular malformations with low blood flow. The removal of brainstem CMs (BS) is associated with high surgical morbidity, and there is no general consensus on when to treat deep-seated BS CMs. The aim of this study is to compare the surgical outcomes of a series of deep-seated BS CMs with the surgical outcomes of a series of superficially located BS CMs operated on at the Department of Neurosurgery, College of Tuebingen, Germany. Materials and Methods: A retrospective evaluation was performed using patient charts, surgical video recordings, and outpatient examinations. Factors were identified in which surgical intervention was performed in cases of BS CMs. Preoperative radiological examinations included MRI and diffusion tensor imaging (DTI). For deep-seated BS CMs, a voxel-based 3D neuronavigation system and electrophysiological mapping of the brainstem surface were used. Results: A total of 34 consecutive patients with primary superficial (n = 20/58.8%) and deep-seated (n = 14/41.2%) brainstem cavernomas (BS CM) were enrolled in this comparative study. Complete removal was achieved in 31 patients (91.2%). Deep-seated BS CMs: The mean diameter was 14.7 mm (range: 8.3 to 27.7 mm). All but one of these lesions were completely removed. The median follow-up time was 5.8 years. Two patients (5.9%) developed new neurologic deficits after surgery. Superficial BS CMs: The median diameter was 14.9 mm (range: 7.2 to 27.3 mm). All but two of the superficial BS CMs could be completely removed. New permanent neurologic deficits were observed in two patients (5.9%) after surgery. The median follow-up time in this group was 3.6 years. Conclusions: The treatment of BS CMs remains complex. However, the results of this study demonstrate that with less invasive posterior fossa approaches, brainstem mapping, and neuronavigation combined with the use of a blunt "spinal cord" dissection technique, deep-seated BS CMs can be completely removed in selected cases, with good functional outcomes comparable to those of superficial BS CM.
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Affiliation(s)
- Marcos Tatagiba
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Guilherme Lepski
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Marcel Kullmann
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Boris Krischek
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Soeren Danz
- Department of Neuroradiology, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Antje Bornemann
- Department of Neuropathology, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Jan Klein
- Institute for Medical Image Computing, Fraunhofer MEVIS, 28359 Bremen, Germany
| | - Antje Fahrig
- Department of Radiotherapy and Radiooncology, General Hospital Klinikum Bamberg, 96049 Bamberg, Germany
| | - Tomaz Velnar
- Department of Neurosurgery, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
| | - Guenther C. Feigl
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
- Department of Neurosurgery, General Hospital Klinikum Bamberg, 96049 Bamberg, Germany
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Crocoli A, Martucci C, Randi F, Ponzo V, Trucchi A, De Pasquale MD, Marras CE, Inserra A. Intraoperative Neuromonitoring for Pediatric Pelvic Tumors. Front Pediatr 2022; 10:949037. [PMID: 36110110 PMCID: PMC9468478 DOI: 10.3389/fped.2022.949037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background Tumors of the pre-sacral and sacral spaces are a rare occurrence in children. Total tumor excision is required due to the significant risk of relapse in the event of partial surgery, but the surgical procedure may lead to postoperative problems such as urinary, sexual, and anorectal dysfunctions. Intraoperative neuromonitoring (IONM) has gained popularity in recent years as a strategy for preventing the onset of neurologic impairments by combining several neurophysiological techniques. The aim of our study is to describe the experience of Bambino Gesù Children's Hospital in the use of IONM in pediatric pelvic surgery. Materials and Methods The data of patients treated for pelvic malignancies at Bambino Gesù Children's Hospital from 2015 to 2019 were retrospectively collected. All patients were assessed from a neurologic and neuro-urologic point of view at different time-points (before and immediately after surgery, after 6 months, and 1-year follow-up). They were all monitored during a surgical procedure using multimodal IONM including transcranial motor evoked potentials (TcMEP), triggered-EMG (t-EMG), pudendal somatosensory evoked potentials (PSSEP), and bulbocavernosus reflex (BCR). Results During the study period, ten children underwent pelvic tumor removal at our Institution. In all cases, intraoperative neurophysiological recordings were stable and feasible. The preservation of neurophysiological response at the same intensity during surgical procedures correlated with no new deficits for all neurophysiological techniques. Discussion Although the impact of the IONM on surgical strategies and clinical follow-up is unknown, this preliminary experience suggests that the appropriate use of several neurophysiological techniques can influence both the radicality of pelvic tumor removal and the neurological and urological outcome at clinical follow-up. Finally, because of the highly complex anatomy and inter-individual variances, this is especially useful in this type of surgery.
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Affiliation(s)
- Alessandro Crocoli
- Surgical Oncology Unit, Department of Surgery, Bambino Gesù Children’s Hospital – IRCCS, Rome, Italy
| | - Cristina Martucci
- General Surgery Unit, Department of Surgery, Bambino Gesù Children’s Hospital – IRCCS, Rome, Italy
| | - Franco Randi
- Neurosurgery Unit, Department of Neuroscience and Psychiatry Sciences, Bambino Gesù Children’s Hospital – IRCCS, Rome, Italy
| | - Viviana Ponzo
- Neurosurgery Unit, Department of Neuroscience and Psychiatry Sciences, Bambino Gesù Children’s Hospital – IRCCS, Rome, Italy
| | - Alessandro Trucchi
- Surgical Andrology Unit, Department of Surgery, Bambino Gesù Children’s Hospital – IRCCS, Rome, Italy
| | - Maria Debora De Pasquale
- Hematology/Oncology Unit, Department of Pediatric Hematology/Oncology Cell and Gene Therapy, Bambino Gesù Children’s Hospital – IRCCS, Rome, Italy
| | - Carlo Efisio Marras
- Neurosurgery Unit, Department of Neuroscience and Psychiatry Sciences, Bambino Gesù Children’s Hospital – IRCCS, Rome, Italy
| | - Alessandro Inserra
- General Surgery Unit, Department of Surgery, Bambino Gesù Children’s Hospital – IRCCS, Rome, Italy
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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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Kodama K, Kothbauer KF, Deletis V. Mapping and monitoring of brainstem surgery. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:151-161. [PMID: 35772884 DOI: 10.1016/b978-0-12-819826-1.00021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The surgical morbidity of brainstem lesions is higher than in other areas of the central nervous system because the compact brainstem is highly concentrated with neural structures that are often distorted or even unrecognizable under microscopic view. Intraoperative neurophysiologic mapping helps identify critical neural structures to avoid damaging them. With the trans-fourth ventricular floor approach, identifying the facial colliculi and vagal and hypoglossal triangles enables incising and approaching the brainstem through the safe entry zones, the suprafacial or infrafacial triangle, with minimal injury. Corticospinal tract mapping is adopted in the case of brainstem surgery adjacent to the corticospinal tract. Intraoperative neurophysiologic monitoring techniques include motor evoked potentials (MEPs), corticobulbar MEPs, brainstem auditory evoked potentials, and somatosensory evoked potentials. These provide real-time feedback about the functional integrity of neural pathways, and the surgical team can reconsider and correct the surgical strategy accordingly. With multimodal mapping and monitoring, the brainstem is no longer "no man's land," and brainstem lesions can be treated surgically without formidable morbidity and mortality.
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Affiliation(s)
- Kunihiko Kodama
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan.
| | - 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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Rauschenbach L, Santos AN, Dinger TF, Herten A, Darkwah Oppong M, Schmidt B, Chihi M, Haubold J, Jabbarli R, Wrede KH, Sure U, Dammann P. Predictive Value of Intraoperative Neuromonitoring in Brainstem Cavernous Malformation Surgery. World Neurosurg 2021; 156:e359-e373. [PMID: 34560298 DOI: 10.1016/j.wneu.2021.09.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the predictive value of intraoperative neuromonitoring (IONM) in brainstem cavernous malformation (BSCM) surgery. METHODS Surgically treated patients with BSCM were included. All patients received IONM consisting of motor-evoked potentials (MEPs) and somatosensory-evoked potentials (SSEPs). Neurologic examination was conducted preoperatively and at discharge and follow-up >3 months after BSCM removal. Demographic, radiographic, and clinical features were assessed. Study end points were new motor or somatosensory deficits and functional disability. RESULTS A total of 62 patients were included. MEP decrease was associated with new motor deficits at discharge (P = 0.022), and SSEP decrease was associated with new somatosensory deficits at discharge (P < 0.001) and follow-up (P < 0.001). Sensitivity and specificity values for MEPs (discharge: 31% and 93%; follow-up: 33% and 91%) and SSEPs (discharge: 82% and 80%; follow-up: 85% and 79%) were calculated, respectively. Receiver operating characteristic analyses with area under the curve (AUC) metrics revealed acceptable performance of MEPs (AUC, 0.75; P = 0.022) and SSEPs (AUC, 0.72; P = 0.004) in predicting early deficits. Intraoperative decrease of MEPs (P = 0.047) and SSEPs (P = 0.017) was associated with early functional disability. Surgery-related subdural air accumulation impaired IONM reliability in predicting early (P = 0.048) and long-term (P = 0.013) deficits. CONCLUSIONS Established IONM warning criteria may be valid for BSCM removal. However, surgical approaches in the sitting position significantly limit the predictive value of IONM, to some extent because of intraoperative pneumocephalus.
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Affiliation(s)
- Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.
| | - Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Thiemo F Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Annika Herten
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Marvi Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Johannes Haubold
- Institute for Diagnostic and Interventional Radiology, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
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Use of intra-operative stimulation of brainstem lesion target sites for frameless stereotactic biopsies. Childs Nerv Syst 2021; 37:1515-1523. [PMID: 33683422 DOI: 10.1007/s00381-021-05101-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/24/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Frameless stereotactic navigation is used to direct the trajectory and biopsy site of target lesions. We report on a novel intra-operative stimulating (IOS) probe that is integrated into a commercially available stereotactic biopsy needle with the rationale that stimulation of the intended biopsy site should predict functional tissue thus preventing inadvertent biopsy of eloquent tissue. METHODS Patients undergoing brainstem biopsies for atypical lesions were offered the additional stimulation procedure. The IOS probe was used to deliver stimulation in an attempt to determine the proximity of eloquent tissue. Once the desired location of the biopsy needle was achieved, the IOS probe was inserted down the centre of the biopsy needle and the stimulus applied. If no action potential was recorded, biopsies from four quadrants of the lesion were taken. If however a compound action potential was recorded, a new target was selected. RESULTS Nine patients had the biopsy and stimulation procedure performed. The median age was 36 months. A minimum of 8 samples were obtained from each patient. Biopsy material was adequate to obtain a diagnosis in all 9 patients. In 2 cases use of the device influenced the insertion trajectory or biopsy site. No patients experienced any complications directly attributable to either the biopsy procedure or application of the stimulation. CONCLUSIONS Use of the IOS probe for intra-operative stimulation of the intended brainstem biopsy site was found to be safe and feasible. The addition of stimulation using the IOS probe can be done with minimal change in workflow.
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D'Amico A, Sala F. Intraoperative neurophysiology of the cerebellum: a tabula rasa. Childs Nerv Syst 2020; 36:1181-1186. [PMID: 32246192 DOI: 10.1007/s00381-020-04565-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 02/27/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Cerebellar mutism (CM) is a condition that occurs predominantly in children, after posterior fossa surgery (PFS). It is characterized by motor, speech, and behavioral disorders. Despite widespread use of intraoperative neurophysiological monitoring (IONM), little is known about the neurophysiological aspects involved in the pathophysiology of CM. We reviewed the IONM literature to identify working hypotheses aimed to investigate intraoperatively the circuits involved in CM. METHODS A systematic review of the literature was conducted using PubMed central database. Papers describing the use of IONM techniques in the cerebellum were selected, thoroughly reviewed, and discussed. RESULTS AND DISCUSSION Only two studies reported the use of intraoperative neurophysiology of the cerebellum, suggesting a possible somatotopic motor organization of the cerebellar cortex. In addition, extra-operative studies using transcranial magnetic stimulation showed the possibility to modulate-possibly through the dentato-thalamic-cortical (DTC) pathway-primary motor cortex output using an appropriate cerebellar stimulus. In theory, the preservation of this either inhibitory or facilitatory modulation may predict the preservation of this pathway, while a loss of the effect may indicate an injury to the pathway, and predict a CM. Analogously, in the extra-operative setting, the comparison of pre-operative and post-operative transcranial magnetic stimulation of the cerebellum may predict the onset of CM whenever a pre-existing modulatory effect is lost as a result of surgery. CONCLUSION Virtually, no data exist on the intraoperative neurophysiology of the cerebellum. This limited knowledge, nevertheless, offers a unique opportunity to pediatric neurosurgeons to develop and test working hypotheses on the pathophysiology of CM, through the use of IONM.
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Affiliation(s)
- Alberto D'Amico
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Piazzale Stefani 1, 37124, Verona, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Piazzale Stefani 1, 37124, Verona, Italy.
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Intraoperative Neurophysiological Monitoring for Craniovertebral Junction Surgery. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019; 125:369-380. [PMID: 30610347 DOI: 10.1007/978-3-319-62515-7_53] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Craniovertebral junction (CVJ) surgery encompasses a wide spectrum of neurosurgical procedures ranging from transoral approaches for CVJ bone anomalies to surgery for intramedullary tumours. Intraoperative neurophysiological monitoring (IONM) has been increasingly used in recent years because of its ability to prevent neurological complications during surgery. In CVJ surgery the risk of neurological injuries is related first to the positioning of the patient and then to the surgical procedure. Application of IONM during the positioning of the patient permits fast recognition of impending causes of neurological injury. During surgery, continuous IONM permits real-time assessment of the functional integrity of the spinal tracts and provides useful feedback during surgical manoeuvres. The applications of IONM are mainly related to intradural procedures, but wider application of these techniques during surgery for CVJ instability and degenerative disorders has recently been described, leading also to better understanding of the pathophysiology of spinal cord injuries. In this paper we review and discuss the principal IONM techniques used during surgery around the CVJ.
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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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Sala F. A spotlight on intraoperative neurophysiological monitoring of the lower brainstem. Clin Neurophysiol 2017; 128:1369-1371. [PMID: 28571911 DOI: 10.1016/j.clinph.2017.04.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 04/29/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Francesco Sala
- Institute of Neurosurgery, University Hospital, Piazzale Stefani 1, 37124 Verona, Italy.
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Essayed WI, Singh H, Lapadula G, Almodovar-Mercado GJ, Anand VK, Schwartz TH. Endoscopic endonasal approach to the ventral brainstem: anatomical feasibility and surgical limitations. J Neurosurg 2017; 127:1139-1146. [PMID: 28084906 DOI: 10.3171/2016.9.jns161503] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sporadic cases of endonasal intraaxial brainstem surgery have been reported in the recent literature. The authors endeavored to assess the feasibility and limitations of endonasal endoscopic surgery for approaching lesions in the ventral portion of the brainstem. METHODS Five human cadaveric heads were used to assess the anatomy and to record various measurements. Extended transsphenoidal and transclival approaches were performed. After exposing the brainstem, white matter dissection was attempted through this endoscopic window, and additional key measurements were taken. RESULTS The rostral exposure of the brainstem was limited by the sella. The lateral limits of the exposure were the intracavernous carotid arteries at the level of the sellar floor, the intrapetrous carotid arteries at the level of the petrous apex, and the inferior petrosal sinuses toward the basion. Caudal extension necessitated partial resection of the anterior C-1 arch and the odontoid process. The midline pons and medulla were exposed in all specimens. Trigeminal nerves were barely visible without the use of angled endoscopes. Access to the peritrigeminal safe zone for gaining entry into the brainstem is medially limited by the pyramidal tract, with a mean lateral pyramidal distance (LPD) of 4.8 ± 0.8 mm. The mean interpyramidal distance was 3.6 ± 0.5 mm, and it progressively decreased toward the pontomedullary junction. The corticospinal tracts (CSTs) coursed from deep to superficial in a craniocaudal direction. The small caliber of the medulla with very superficial CSTs left no room for a safe ventral dissection. The mean pontobasilar midline index averaged at 0.44 ± 0.1. CONCLUSIONS Endoscopic endonasal approaches are best suited for pontine intraaxial tumors when they are close to the midline and strictly anterior to the CST, or for exophytic lesions. Approaching the medulla is anatomically feasible, but the superficiality of the eloquent tracts and interposed nerves limit the safe entry zones. Pituitary transposition after sellar opening is necessary to access the mesencephalon.
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Affiliation(s)
- Walid I Essayed
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Harminder Singh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Gennaro Lapadula
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York.,Departments of Neurology and Psychiatry, and Neurosurgery, "Sapienza," University of Rome, Rome, Italy
| | - Gustavo J Almodovar-Mercado
- Department of Otolaryngology, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Vijay K Anand
- Department of Otolaryngology, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Theodore H Schwartz
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
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Slotty PJ, Abdulazim A, Kodama K, Javadi M, Hänggi D, Seifert V, Szelényi A. Intraoperative neurophysiological monitoring during resection of infratentorial lesions: the surgeon's view. J Neurosurg 2017; 126:281-288. [DOI: 10.3171/2015.11.jns15991] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Methods of choice for neurophysiological intraoperative monitoring (IOM) within the infratentorial compartment mostly include early brainstem auditory evoked potentials, free-running electromyography, and direct cranial nerve (CN) stimulation. Long-tract monitoring with somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) is rarely used. This study investigated the incidence of IOM alterations during posterior fossa surgery stratified for lesion location.
METHODS
Standardized CN and SEP/MEP IOM was performed in 305 patients being treated for various posterior fossa pathologies. The IOM data were correlated with lesion locations and histopathological types as well as other possible confounding factors.
RESULTS
Alterations in IOM were observed in 158 of 305 cases (51.8%) (CN IOM alterations in 130 of 305 [42.6%], SEP/MEP IOM alterations in 43 of 305 [14.0%]). In 15 cases (4.9%), simultaneous changes in long tracts and CNs were observed. The IOM alterations were followed by neurological sequelae in 98 of 305 cases (32.1%); 62% of IOM alterations resulted in neurological deficits. Sensitivity and specificity for detection of CN deficits were 98% and 77%, respectively, and 95% and 85%, respectively, for long-tract deficits. Regarding location, brainstem and petroclival lesions were closely associated with concurrent CN IOM and SEP/MEP alterations.
CONCLUSIONS
The incidence of IOM alterations during surgery in the posterior fossa varied widely between different lesion locations and histopathological types. This analysis provides crucial information on the necessity of IOM in different surgical settings. Because MEP/SEP and CN IOM alterations were commonly observed during posterior fossa surgery, the authors recommend the simultaneous use of both modalities based on lesion location.
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Affiliation(s)
| | - Amr Abdulazim
- 1Neurochirurgische Klinik, Universitätsklinikum Düsseldorf
| | - Kunihiko Kodama
- 2Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Mani Javadi
- 3Klinik für Neurochirurgie, Universitätsklinikum Frankfurt am Main, Germany; and
| | - Daniel Hänggi
- 1Neurochirurgische Klinik, Universitätsklinikum Düsseldorf
| | - Volker Seifert
- 3Klinik für Neurochirurgie, Universitätsklinikum Frankfurt am Main, Germany; and
| | - Andrea Szelényi
- 1Neurochirurgische Klinik, Universitätsklinikum Düsseldorf
- 3Klinik für Neurochirurgie, Universitätsklinikum Frankfurt am Main, Germany; and
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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] [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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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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Song W, Amer A, Ryan D, Martin JH. Combined motor cortex and spinal cord neuromodulation promotes corticospinal system functional and structural plasticity and motor function after injury. Exp Neurol 2015; 277:46-57. [PMID: 26708732 DOI: 10.1016/j.expneurol.2015.12.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 12/07/2015] [Accepted: 12/15/2015] [Indexed: 11/29/2022]
Abstract
An important strategy for promoting voluntary movements after motor system injury is to harness activity-dependent corticospinal tract (CST) plasticity. We combine forelimb motor cortex (M1) activation with co-activation of its cervical spinal targets in rats to promote CST sprouting and skilled limb movement after pyramidal tract lesion (PTX). We used a two-step experimental design in which we first established the optimal combined stimulation protocol in intact rats and then used the optimal protocol in injured animals to promote CST repair and motor recovery. M1 was activated epidurally using an electrical analog of intermittent theta burst stimulation (iTBS). The cervical spinal cord was co-activated by trans-spinal direct current stimulation (tsDCS) that was targeted to the cervical enlargement, simulated from finite element method. In intact rats, forelimb motor evoked potentials (MEPs) were strongly facilitated during iTBS and for 10 min after cessation of stimulation. Cathodal, not anodal, tsDCS alone facilitated MEPs and also produced a facilitatory aftereffect that peaked at 10 min. Combined iTBS and cathodal tsDCS (c-tsDCS) produced further MEP enhancement during stimulation, but without further aftereffect enhancement. Correlations between forelimb M1 local field potentials and forelimb electromyogram (EMG) during locomotion increased after electrical iTBS alone and further increased with combined stimulation (iTBS+c-tsDCS). This optimized combined stimulation was then used to promote function after PTX because it enhanced functional connections between M1 and spinal circuits and greater M1 engagement in muscle contraction than either stimulation alone. Daily application of combined M1 iTBS on the intact side and c-tsDCS after PTX (10 days, 27 min/day) significantly restored skilled movements during horizontal ladder walking. Stimulation produced a 5.4-fold increase in spared ipsilateral CST terminations. Combined neuromodulation achieves optimal motor recovery and substantial CST outgrowth with only 27 min of daily stimulation compared with 6h, as in our prior study, making it a potential therapy for humans with spinal cord injury.
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Affiliation(s)
- Weiguo Song
- Department of Physiology, Pharmacology and Neuroscience, City College of the City University of New York, New York, NY 10031, USA
| | - Alzahraa Amer
- Department of Physiology, Pharmacology and Neuroscience, City College of the City University of New York, New York, NY 10031, USA
| | - Daniel Ryan
- Department of Physiology, Pharmacology and Neuroscience, City College of the City University of New York, New York, NY 10031, USA
| | - John H Martin
- Department of Physiology, Pharmacology and Neuroscience, City College of the City University of New York, New York, NY 10031, USA.
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Sala F, Coppola A, Tramontano V. Intraoperative neurophysiology in posterior fossa tumor surgery in children. Childs Nerv Syst 2015; 31:1791-806. [PMID: 26351231 DOI: 10.1007/s00381-015-2893-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 08/06/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Francesco Sala
- Pediatric Neurosurgery Unit, Institute of Neurosurgery, University Hospital, Piazzale Stefani 1, 37124, Verona, Italy.
| | - Angela Coppola
- Pediatric Neurosurgery Unit, Institute of Neurosurgery, University Hospital, Piazzale Stefani 1, 37124, Verona, Italy
| | - Vincenzo Tramontano
- Intraoperative Neurophysiology Unit, Institute of Neurosurgery, University Hospital, Piazzale Stefani 1, 37124, Verona, Italy
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Hussain NS. Analysis of 1014 consecutive operative cases to determine the utility of intraoperative neurophysiological data. Asian J Neurosurg 2015; 10:166-72. [PMID: 26396602 PMCID: PMC4553727 DOI: 10.4103/1793-5482.161197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Intraoperative neurophysiological monitoring (IOM) during neurosurgical procedures has become the standard of care at tertiary care medical centers. While prospective data regarding the clinical utility of IOM are conspicuously lacking, retrospective analyses continue to provide useful information regarding surgeon responses to reported waveform changes. Methods: Data regarding clinical presentation, operative course, IOM, and postoperative neurological examination were compiled from a database of 1014 cranial and spinal surgical cases at a tertiary care medical center from 2005 to 2011. IOM modalities utilized included somatosensory evoked potentials, transcranial motor evoked potentials, pedicle screw stimulation, and electromyography. Surgeon responses to changes in IOM waveforms were recorded. Results: Changes in IOM waveforms indicating potential injury were present in 87 of 1014 cases (8.6%). In 23 of the 87 cases (26.4%), the surgeon responded by repositioning the patient (n = 12), repositioning retractors (n = 1) or implanted instrumentation (n = 9), or by stopping surgery (n = 1). Loss of IOM waveforms predicted postoperative neurological deficit in 10 cases (11.5% of cases with IOM changes). Conclusions: In the largest IOM series to date, we report that the surgeon responded by appropriate interventions in over 25% of cases during which there were IOM indicators of potential harm to neural structures. Prospective studies remain to be undertaken to adequately evaluate the utility of IOM in changing surgeon behavior. Our data is in agreement with previous observations in indicating a trend that supports the continued use of IOM.
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Affiliation(s)
- Namath Syed Hussain
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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20
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Take the A Train. Clin Neurophysiol 2015; 126:1647-9. [DOI: 10.1016/j.clinph.2015.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/09/2015] [Accepted: 01/09/2015] [Indexed: 11/21/2022]
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Osburn LL. A Guide to the Performance of Transcranial Electrical Motor Evoked Potentials. Part 1. Basic Concepts, Recording Parameters, Special Considerations, and Application. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/1086508x.2006.11079565] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Leisha L. Osburn
- Neurophysiology Lab Clarian Health Partners Methodist Hospital Indianapolis, Indiana
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22
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Cheng JS, Ivan ME, Stapleton CJ, Quinones-HinoJosa A, Gupta N, Auguste KI. Intraoperative changes in transcranial motor evoked potentials and somatosensory evoked potentials predicting outcome in children with intramedullary spinal cord tumors. J Neurosurg Pediatr 2014; 13:591-9. [PMID: 24702615 PMCID: PMC4322892 DOI: 10.3171/2014.2.peds1392] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intraoperative dorsal column mapping, transcranial motor evoked potentials (TcMEPs), and somatosensory evoked potentials (SSEPs) have been used in adults to assist with the resection of intramedullary spinal cord tumors (IMSCTs) and to predict postoperative motor deficits. The authors sought to determine whether changes in MEP and SSEP waveforms would similarly predict postoperative motor deficits in children. METHODS The authors reviewed charts and intraoperative records for children who had undergone resection for IMSCTs as well as dorsal column mapping and TcMEP and SSEP monitoring. Motor evoked potential data were supplemented with electromyography data obtained using a Kartush microstimulator (Medtronic Inc.). Motor strength was graded using the Medical Research Council (MRC) scale during the preoperative, immediate postoperative, and follow-up periods. Reductions in SSEPs were documented after mechanical traction, in response to maneuvers with the cavitational ultrasonic surgical aspirator (CUSA), or both. RESULTS Data from 12 patients were analyzed. Three lesions were encountered in the cervical and 7 in the thoracic spinal cord. Two patients had lesions of the cervicomedullary junction and upper spinal cord. Intraoperative MEP changes were noted in half of the patients. In these cases, normal polyphasic signals converted to biphasic signals, and these changes correlated with a loss of 1-2 grades in motor strength. One patient lost MEP signals completely and recovered strength to MRC Grade 4/5. The 2 patients with high cervical lesions showed neither intraoperative MEP changes nor motor deficits postoperatively. Dorsal columns were mapped in 7 patients, and the midline was determined accurately in all 7. Somatosensory evoked potentials were decreased in 7 patients. Two patients each had 2 SSEP decreases in response to traction intraoperatively but had no new sensory findings postoperatively. Another 2 patients had 3 traction-related SSEP decreases intraoperatively, and both had new postoperative sensory deficits that resolved. One additional patient had a CUSA-related SSEP decrease intraoperatively, which resolved postoperatively, and the last patient had 3 traction-related sensory deficits and a CUSA-related sensory deficit postoperatively, none of which resolved. CONCLUSIONS Intraoperative TcMEPs and SSEPs can predict the degree of postoperative motor deficit in pediatric patients undergoing IMSCT resection. This technique, combined with dorsal column mapping, is particularly useful in resecting lesions of the upper cervical cord, which are generally considered to be high risk in this population. Furthermore, the spinal cord appears to be less tolerant of repeated intraoperative SSEP decreases, with 3 successive insults most likely to yield postoperative sensory deficits. Changes in TcMEPs and SSEP waveforms can signal the need to guard against excessive manipulation thereby increasing the safety of tumor resection.
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Affiliation(s)
- Jason S. Cheng
- Department of Neurological Surgery, University of California, San Francisco
| | - Michael E. Ivan
- Department of Neurological Surgery, University of California, San Francisco
| | | | | | - Nalin Gupta
- Department of Neurological Surgery, University of California, San Francisco,Department of Pediatrics, University of California, San Francisco
| | - Kurtis I. Auguste
- Department of Neurological Surgery, University of California, San Francisco,Department of Pediatrics, University of California, San Francisco,Children’s Hospital and Research Center, Oakland, California
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23
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Results of intraoperative neurophysiological monitoring in spinal canal surgery. Neurol Neurochir Pol 2013; 47:27-31. [DOI: 10.5114/ninp.2013.32937] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
This article focuses on the application of neurophysiologic monitoring in uniquely neurosurgical procedures. Neurophysiologic monitoring provides functional testing and mapping to identify neural structures. Once identified, the functionality of the central and peripheral nervous system areas at risk for neurosurgical injury can be monitored. It discusses the use of motor-evoked potentials, sensory evoked potentials, electromyography and electroencephalography to assess neurologic change.
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Affiliation(s)
- Leslie C Jameson
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, 12401 East 17th Avenue, Aurora, CO 80045, USA.
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25
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Abstract
STUDY DESIGN Review of the literature with analysis of pooled data. OBJECTIVE To assess common intraoperative neuromonitoring (IOM) changes that occur during the course of spinal surgery, potential causes of change, and determine appropriate responses. Further, there will be discussion of appropriate application of IOM, and medical legal aspects. The structured literature review will answer the following questions: What are the various IOM methods currently available for spinal surgery? What are the sensitivities and specificities of each modality for neural element injury? How are the changes in each modality best interpreted? What is the appropriate response to indicated changes? Recommendations will be made as to the interpretation and appropriate response to IOM changes. SUMMARY OF BACKGROUND DATA Total number of abstracts identified and reviewed was 187. Full review was performed on 18 articles. METHODS The MEDLINE database was queried using the search terms IOM, spinal surgery, SSEP, wake-up test, MEP, spontaneous and triggered electromyography alone and in various combinations. Abstracts were identified and reviewed. Individual case reports were excluded. Detailed information and data from appropriate articles were assessed and compiled. RESULTS Ability to achieve IOM baseline data varied from 70% to 98% for somatosensory-evoked potentials (SSEP) and 66% to 100% for motor-evoked potentials (MEP) in absence of neural axis abnormality. Multimodality intraoperative neuromonitoring (MIOM) provided false negatives in 0% to 0.79% of cases, whereas isolated SSEP monitoring alone provided false negative in 0.063% to 2.7% of cases. MIOM provided false positive warning in 0.6% to 1.38% of cases. CONCLUSION As spine surgery, and patient comorbidity, becomes increasingly complex, IOM permits more aggressive deformity correction and tumor resection. Combination of SSEP and MEP monitoring provides assessment of entire spinal cord functionality in real time. Spontaneous and triggered electromyography add assessment of nerve roots. The wake-up test can continue to serve as a supplement when needed. MIOM may prove useful in preservation of neurologic function where an alteration of approach is possible. IOM is a valuable tool for optimization of outcome in complex spinal surgery.
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Sala F, Manganotti P, Grossauer S, Tramontanto V, Mazza C, Gerosa M. Intraoperative neurophysiology of the motor system in children: a tailored approach. Childs Nerv Syst 2010; 26:473-90. [PMID: 20145936 DOI: 10.1007/s00381-009-1081-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Accepted: 12/30/2009] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Intraoperative neurophysiology has moved giant steps forward over the past 15 years thanks to the advent of techniques aimed to reliably assess the functional integrity of motor areas and pathways. INTRAOPERATIVE NEUROPHYSIOLOGICAL TECHNIQUES Motor evoked potentials recorded from the muscles and/or the spinal cord (D-wave) after transcranial electrical stimulation allow to preserve the integrity of descending pathways, especially the corticospinal tract (CT), during brain and spinal cord surgery. Mapping techniques allow to identify the motor cortex through direct cortical stimulation and to localize the CT at subcortical levels during brain and brainstem surgery. These techniques are extensively used in adult neurosurgery and, in their principles, can be applied to children. However, especially in younger children, the motor system is still under development, making both mapping and monitoring techniques more challenging. In this paper, we review intraoperative neurophysiological techniques commonly used in adult neurosurgery and discuss their application to pediatric neurosurgery, in the light of preliminary experience from our and other centers. The principles of development and maturation of the motor system, and especially of the CT, are reviewed focusing on clinical studies with transcranial magnetical stimulation.
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Affiliation(s)
- Francesco Sala
- Section of Neurosurgery, Department of Neurological and Visual Sciences, University Hospital, Piazzale Stefani 1, 37124 Verona, Italy.
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Ingelmo Ingelmo I, Domínguez Pérez F, Pinto Corraliza JM, Fàbregas Julià N, Rama-Maceiras P, Hernández Palazón J, Badenes Quiles R, Burgos Flores J, Hevia Sierra E, Mhaidli Hamdan H, Barrios Pitarque C, Pizá Vallespir G, Sanpera Trigueros I, Doménech Fernández P, García de Quesada IA, Riquelme García O, García Alonso M, Ramos Galea R, Gutiérrez Carbonell P, Bas Hermida P, Bagó Granell J, González Barrios I, de Blas Beorlegui G, Calvo Calleja P, Conill Ramón J, Cortés Doñate VE, González Hidalgo MM, Izura Azanza V, Maeztu Sardiña MC, Moliner Ibáñez J, Bailly-Bailliere IR, Sáenz de Cabezón-Alvarez A, Santiago Fernández C, Soler Algarra S. [Guidelines for management of acute spinal cord injury during corrective spinal surgery]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2010; 57:103-108. [PMID: 20337002 DOI: 10.1016/s0034-9356(10)70172-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- I Ingelmo Ingelmo
- Anestesiología y Reanimación, Hospital Universitario Ramón y Cajal, Madrid.
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Hyun SJ, Rhim SC. Combined motor and somatosensory evoked potential monitoring for intramedullary spinal cord tumor surgery: correlation of clinical and neurophysiological data in 17 consecutive procedures. Br J Neurosurg 2009; 23:393-400. [PMID: 19637010 DOI: 10.1080/02688690902964744] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The primary objective of neurophysiologic monitoring during surgery is to prevent permanent neurological sequelae. We prospectively evaluated whether the combined use of somatosensory- and motor-evoked potential (SEP/MEP) for intramedullary spinal cord tumor (IMSCT) surgery may be beneficial. Combined SEP/MEP monitoring was attempted in 20 consecutive procedures for IMSCT operations. Trains of transcranial electric stimulation over the motor cortex were used to elicit MEPs from limb target muscles. The tibial and median nerves were stimulated to record SEP. The operation was paused or the surgical strategy was modified in every case of significant SEP/MEP changes. Combined SEP/MEP recording was successfully achieved in 17 of 20 (85%) operations. In 3 of 17 operations, SEP and MEP were stable, and all patients remained neurologically intact after surgery. Significant MEP changes were recorded in 12 operations (70%). In 7 of these 12 operations, MEP recovered to some extent after surgical intervention, and these patients showed no neurological changes. In the remaining 5 operations, MEP did not recover and the patients had a transient (n = 2) or a permanent (n = 1) motor deficit. Significant SEP changes with stable MEP were related to a transient hypesthesia. Combined SEP/MEP monitoring provided higher sensitivity, and higher positive and negative predictive value than single-modality techniques. Detection of MEP changes and adjustment of surgical strategy may prevent irreversible pyramidal tract damage.
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Affiliation(s)
- Seung-Jae Hyun
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Krammer MJ, Wolf S, Schul DB, Gerstner W, Lumenta CB. Significance of intraoperative motor function monitoring using transcranial electrical motor evoked potentials (MEP) in patients with spinal and cranial lesions near the motor pathways. Br J Neurosurg 2009; 23:48-55. [PMID: 19234909 DOI: 10.1080/02688690802563349] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Intraoperative motor evoked potential (MEP) monitoring in patients with spinal and cranial lesions is thought to be a valuable tool for prevention of postoperative motor deficits. Aim of this study was to investigate its diagnostic value in a spinal and a cranial patient group. Ninety-six patients, 31 with spinal and 65 with intracranial lesions, were studied. Transcranial stimulation was performed with a high-frequency electrical train stimulation using two subdermal needle electrodes. MEPs were recorded from the pathology-related muscles. Decreasing amplitudes of 50% or more, increasing stimulus intensities of 20% or more or increased latencies were taken as warning criteria. MEP recording was possible in 90% of the spinal and 98% of the cranial group. With two further exclusions, 28 patients of the spinal and 62 of the cranial group were analyzed. We saw a temporary maximum amplitude reduction of 50% or more and an increase in stimulation intensity of 20% or more in 8 spinal and 29 cranial patients. Five of the spinal and nine of the cranial patients deteriorated in motor function postoperatively. One patient with normal MEP monitoring showed a temporary motor weakness postoperatively. Latencies were normal in all patients. Given both warning criteria, intraoperative MEP changes had a sensitivity of 83%/ 100% and a specificity of 86%/ 62% (spinal/ cranial group). The positive predictive value of MEP changes for postoperative motor function deterioration was 63%/ 31%, and the negative predictive value was 95%/ 100%. Transcranial electrical monitoring of MEP is a practicable and safe method. However, there are many events, which can cause amplitude changes of MEP independent from surgical manipulations. Although sensitivity is high for both groups, this results in a moderate specificity for the cranial group and a low positive predictive value for both groups.
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Affiliation(s)
- Matthias Johannes Krammer
- Department of Neurosurgery, Academic Teaching Hospital Munich Bogenhausen, Technical University of Munich, Munich, Germany.
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Recalde RJ, Figueiredo EG, de Oliveira E. Microsurgical anatomy of the safe entry zones on the anterolateral brainstem related to surgical approaches to cavernous malformations. Neurosurgery 2008; 62:9-15; discussion 15-7. [PMID: 18424962 DOI: 10.1227/01.neu.0000317368.69523.40] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To study the microanatomy of the brainstem related to the different safe entry zones used to approach intrinsic brainstem lesions. METHODS Ten formalin-fixed and frozen brainstem specimens (20 sides) were analyzed. The white fiber dissection technique was used to study the intrinsic microsurgical anatomy as related to safe entry zones on the brainstem surface. Three anatomic landmarks on the anterolateral brainstem surface were selected: lateral mesencephalic sulcus, peritrigeminal area, and olivary body. Ten other specimens were used to study the axial sections of the inferior olivary nucleus. The clinical application of these anatomic nuances is presented. RESULTS The lateral mesencephalic sulcus has a length of 7.4 to 13.3 mm (mean, 9.6 mm) and can be dissected safely in depths up to 4.9 to 11.7 mm (mean, 8.02 mm). In the peritrigeminal area, the distance of the fifth cranial nerve to the pyramidal tract is 3.1 to 5.7 mm (mean, 4.64 mm). The dissection may be performed 9.5 to 13.1 mm (mean, 11.2 mm) deeper, to the nucleus of the fifth cranial nerve. The inferior olivary nucleus provides safe access to lesions located up to 4.7 to 6.9 mm (mean, 5.52 mm) in the anterolateral aspect of the medulla. Clinical results confirm that these entry zones constitute surgical routes through which the brainstem may be safely approached. CONCLUSION The white fiber dissection technique is a valuable tool for understanding the three-dimensional disposition of the anatomic structures. The lateral mesencephalic sulcus, the peritrigeminal area, and the inferior olivary nucleus provide surgical spaces and delineate the relatively safe alleys where the brainstem can be approached without injuring important neural structures.
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Affiliation(s)
- Rodolfo J Recalde
- Universidad de Buenos Aires, Hospital Nacional Prof. A. Posadas, Buenos Aires, Argentina
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Neuloh G, Schramm J. Evoked potential monitoring during surgery for intracranial aneurysms. INTRAOPERATIVE MONITORING OF NEURAL FUNCTION 2008. [DOI: 10.1016/s1567-4231(07)08059-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Sala F, Manganotti P, Tramontano V, Bricolo A, Gerosa M. Monitoring of motor pathways during brain stem surgery: What we have achieved and what we still miss? Neurophysiol Clin 2007; 37:399-406. [DOI: 10.1016/j.neucli.2007.09.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2007] [Accepted: 09/30/2007] [Indexed: 10/22/2022] Open
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Deletis V, Sala F. Intraoperative neurophysiological monitoring of the spinal cord during spinal cord and spine surgery: a review focus on the corticospinal tracts. Clin Neurophysiol 2007; 119:248-64. [PMID: 18053764 DOI: 10.1016/j.clinph.2007.09.135] [Citation(s) in RCA: 246] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2003] [Revised: 09/05/2007] [Accepted: 09/07/2007] [Indexed: 12/28/2022]
Abstract
Recent advances in technology and the refinement of neurophysiological methodologies are significantly changing intraoperative neurophysiological monitoring (IOM) of the spinal cord. This review will summarize the latest achievements in the monitoring of the spinal cord during spine and spinal cord surgeries. This overview is based on an extensive review of the literature and the authors' personal experience. Landmark articles and neurophysiological techniques have been briefly reported to contextualize the development of new techniques. This background is extended to describe the methodological approach to intraoperatively elicit and record spinal D wave and muscle motor evoked potentials (muscle MEPs). The clinical application of spinal D wave and muscle MEP recordings is critically reviewed (especially in the field of Neurosurgery) and new developments such as mapping of the dorsal columns and the corticospinal tracts are presented. In the past decade, motor evoked potential recording following transcranial electrical stimulation has emerged as a reliable technique to intraoperatively assess the functional integrity of the motor pathways. Criteria based on the absence/presence of potentials, their morphology and threshold-related parameters have been proposed for muscle MEPs. While the debate remains open, it appears that different criteria may be applied for different procedures according to the expected surgery-related morbidity and the ultimate goal of the surgeon (e.g. total tumor removal versus complete absence of transitory or permanent neurological deficits). On the other hand, D wave changes--when recordable--have proven to be the strongest predictors of maintained corticospinal tract integrity (and therefore, of motor function/recovery). Combining the use of muscle MEPs with D wave recordings provides the most comprehensive approach for assessing the functional integrity of the spinal cord motor tracts during surgery for intramedullary spinal cord tumors. However, muscle MEPs may suffice to assess motor pathways during other spinal procedures and in cases where the pathophysiology of spinal cord injury is purely ischemic. Finally, while MEPs are now considered the gold standard for monitoring the motor pathways, SEPs continue to retain value as they provide specificity for assessing the integrity of the dorsal column. However, we believe SEPs should not be used exclusively--or as an alternative to motor evoked potentials--during spine surgery, but rather as a complementary method in combination with MEPs. For intramedullary spinal tumor resection, SEPs should not be used exclusively without MEPs.
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Affiliation(s)
- Vedran Deletis
- Institute for Neurology and Neurosurgery, Beth Israel Medical Center-Singer Division, 170 East End Avenue, Room 311, New York, NY 10128, USA.
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Sutter M, Eggspuehler A, Muller A, Dvorak J. Multimodal intraoperative monitoring: an overview and proposal of methodology based on 1,017 cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2007; 16 Suppl 2:S153-61. [PMID: 17653777 PMCID: PMC2072900 DOI: 10.1007/s00586-007-0417-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/07/2007] [Indexed: 10/23/2022]
Abstract
To describe different currently available tests of multimodal intraoperative monitoring (MIOM) used in spine and spinal cord surgery indicating the technical parameters, application and interpretation as an easy understanding systematic overview to help implementation of MIOM and improve communication between neurophysiologists and spine surgeons. This article aims to give an overview and proposal of the different MIOM-techniques as used daily in spine and spinal cord surgery at our institution. Intensive research in neurophysiology over the past decades has lead to a profound understanding of the spinal cord, nerve functions and their intraoperative functional evaluation in anaesthetised patients. At present, spine surgeons and neurophysiologist are faced with 1,883 publications in PubMed on spinal cord monitoring. The value and the limitations of single monitoring methods are well documented. The diagnostic power of the multimodal approach in a larger study population in spine surgery, as measured with sensitivity and specificity, is dealt with elsewhere in this supplement (Sutter et al. in Eur Spine J Suppl, 2007). This paper aims to give a detailed description of the different modalities used in this study. Description of monitoring techniques of the descending and ascending spinal cord and nerve root pathways by motor evoked potentials of the spinal cord and muscles elicited after transcranial electrical motor cortex, spinal cord, cauda equina and nerve root stimulation, continuous EMG, sensory cortical and spinal evoked potentials, as well as direct spinal cord evoked potentials applied on 1,017 patients. The method of MIOM, continuously adapted according to the site, stage of surgery and potential danger to nerve tissues, proved to be applicable with online results, reliable and furthermore teachable.
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Affiliation(s)
- Martin Sutter
- Department of Neurology, Spine Unit, Schulthess Clinic, Lengghalde 2, 8008, Zurich, Switzerland.
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Abstract
Electrophysiologic techniques have become common in the neurosurgical operating room. This article reviews the methods used for mapping neural structures or monitoring during surgery. Mapping methods allow identification of target structures for surgery, or for identifying structures to allow avoidance or plot safe pathways to deeper structures. Monitoring methods allow for surgery on nearby structures to warn of encroachment, thereby reducing unwanted injury.
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Affiliation(s)
- Leslie C Jameson
- University of Colorado at Denver, Health Sciences Center, 4200 East 9th Ave, Denver, CO 80262, USA.
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Electrophysiologic Monitoring During Surgery to Repair the Thoraco-Abdominal Aorta. J Clin Neurophysiol 2007; 24:316-27. [DOI: 10.1097/wnp.0b013e31811ebc66] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Sala F, Bricolo A, Faccioli F, Lanteri P, Gerosa M. Surgery for intramedullary spinal cord tumors: the role of intraoperative (neurophysiological) monitoring. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2007; 16 Suppl 2:S130-9. [PMID: 17653776 PMCID: PMC2072903 DOI: 10.1007/s00586-007-0423-x] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/07/2007] [Indexed: 12/13/2022]
Abstract
In spite of advancements in neuro-imaging and microsurgical techniques, surgery for intramedullary spinal cord tumors (ISCT) remains a challenging task. The rationale for using intraoperative neurophysiological monitoring (IOM) is in keeping with the goal of maximizing tumor resection and minimizing neurological morbidity. For many years, before the advent of motor evoked potentials (MEPs), only somatosensory evoked potentials (SEPs) were monitored. However, SEPs are not aimed to reflect the functional integrity of motor pathways and, nowadays, the combined used of SEPs and MEPs in ISCT surgery is almost mandatory because of the possibility to selectively injury either the somatosensory or the motor pathways. This paper is aimed to review our perspective in the field of IOM during ISCT surgery and to discuss it in the light of other intraoperative neurophysiologic strategies that have recently appeared in the literature with regards to ISCT surgery. Besides standard cortical SEP monitoring after peripheral stimulation, both muscle (mMEPs) and epidural MEPs (D-wave) are monitored after transcranial electrical stimulation (TES). Given the dorsal approach to the spinal cord, SEPs must be monitored continuously during the incision of the dorsal midline. When the surgeon starts to work on the cleavage plane between tumor and spinal cord, attention must be paid to MEPs. During tumor removal, we alternatively monitor D-wave and mMEPs, sustaining the stimulation during the most critical steps of the procedure. D-waves, obtained through a single pulse TES technique, allow a semi-quantitative assessment of the functional integrity of the cortico-spinal tracts and represent the strongest predictor of motor outcome. Whenever evoked potentials deteriorate, temporarily stop surgery, warm saline irrigation and improved blood perfusion have proved useful for promoting recovery, Most of intraoperative neurophysiological derangements are reversible and therefore IOM is able to prevent more than merely predict neurological injury. In our opinion combining mMEPs and D-wave monitoring, when available, is the gold standard for ISCT surgery because it supports a more aggressive surgery in the attempt to achieve a complete tumor removal. If quantitative (threshold or waveform dependent) mMEPs criteria only are used to stop surgery, this likely impacts unfavorably on the rate of tumor removal.
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Affiliation(s)
- Francesco Sala
- Department of Neurological and Visual Sciences, Section of Neurosurgery, University Hospital, Piazzale Stefani 1, 37100, Verona, Italy.
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Eggspuehler A, Sutter MA, Grob D, Jeszenszky D, Porchet F, Dvorak J. Multimodal intraoperative monitoring (MIOM) during cervical spine surgical procedures in 246 patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2007; 16 Suppl 2:S209-15. [PMID: 17610090 PMCID: PMC2072893 DOI: 10.1007/s00586-007-0424-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/07/2007] [Indexed: 10/23/2022]
Abstract
A prospective study of 246 patients who received multimodal intraoperative monitoring during cervical spine surgery between March 2000 and December 2005. To determine the sensitivity and specificity of MIOM techniques used to monitor spinal cord and nerve root function during cervical spine surgery. It is appreciated that complication rate of cervical spine surgery is low, however, there is a significant risk of neurological injury. The combination of monitoring of ascending and descending pathways may provide more sensitive and specific results giving immediate feedback information and/or alert regarding any neurological changes during the operation to the surgeon. Intraoperative somatosensory spinal and cerebral evoked potentials combined with continuous EMG and motor-evoked potentials of the spinal cord and muscles were evaluated and compared with postoperative clinical neurological changes. A total of 246 consecutive patients with cervical pathologies, majority spinal stenosis due to degenerative changes of cervical spine were monitored by means of MIOM during the surgical procedure. About 232 patients presented true negative while 2 patients false negative responses. About ten patients presented true positive responses where neurological deficit after the operation was predicted and two patients presented false positive findings. The sensitivity of MIOM applied during cervical spine procedure (anterior and/or posterior) was 83.3% and specificity of 99.2%. MIOM is an effective method of monitoring the spinal cord functional integrity during cervical spine surgery and can help to reduce the risk of neurological deficit by alerting the surgeon when monitoring changes are observed.
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Affiliation(s)
- Andreas Eggspuehler
- Department of Neurology/Spine Unit, Schulthess Clinic, Lengghalde 2, 8008, Zurich, Switzerland.
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Sala F, Palandri G, Basso E, Lanteri P, Deletis V, Faccioli F, Bricolo A. Motor Evoked Potential Monitoring Improves Outcome after Surgery for Intramedullary Spinal Cord Tumors: A Historical Control Study. Neurosurgery 2006; 58:1129-43; discussion 1129-43. [PMID: 16723892 DOI: 10.1227/01.neu.0000215948.97195.58] [Citation(s) in RCA: 279] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
The value of intraoperative neurophysiological monitoring (INM) during intramedullary spinal cord tumor surgery remains debated. This historical control study tests the hypothesis that INM monitoring improves neurological outcome.
METHODS:
In 50 patients operated on after September 2000, we monitored somatosensory evoked potentials and transcranially elicited epidural (D-wave) and muscle motor evoked potentials (INM group). The historical control group consisted of 50 patients selected from among 301 patients who underwent intramedullary spinal cord tumor surgery, previously operated on by the same team without INM. Matching by preoperative neurological status (McCormick scale), histological findings, tumor location, and extent of removal were blind to outcome. A more than 50% somatosensory evoked potential amplitude decrement influenced only myelotomy. Muscle motor evoked potential disappearance modified surgery, but more than 50% D-wave amplitude decrement was the major indication to stop surgery. The postoperative to preoperative McCormick grade variation at discharge and at a follow-up of at least 3 months was compared between the two groups (Student's t tests).
RESULTS:
Follow-up McCormick grade variation in the INM group (mean, +0.28) was significantly better (P = 0.0016) than that of the historical control group (mean, –0.16). At discharge, there was a trend (P = 0.1224) toward better McCormick grade variation in the INM group (mean, –0.26) than in the historical control group (mean, –0.5).
CONCLUSION:
The applied motor evoked potential methods seem to improve long-term motor outcome significantly. Early motor outcome is similar because of transient motor deficits in the INM group, which can be predicted at the end of surgery by the neurophysiological profile of patients.
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Affiliation(s)
- Francesco Sala
- Department of Neurological and Visual Sciences, University Hospital, Verona, Italy.
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