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Guo J, Zheng X, Leng H, Shen Q, Pu J. Application of neurophysiological monitoring during tethered cord release in children. Childs Nerv Syst 2024; 40:2921-2927. [PMID: 38850295 PMCID: PMC11322252 DOI: 10.1007/s00381-024-06483-9] [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: 02/26/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
OBJECTIVE The objective of this study was to explore the effect of intraoperative neurophysiological monitoring (IONM) on tethered spinal cord release in children. METHODS The clinical data of 454 children with tethered cord syndrome who underwent surgery for tethered cord release were retrospectively analyzed. The children were divided into two groups: the non-IONM group and the IONM group. SPSS 26.0 software was used for statistical analysis. The evaluation indices included the effective rate and incidence of new neurological dysfunction. RESULTS The short-term results showed that the effective rate of the non-IONM group was 14.8%, while that of the IONM group was 15.2%. Additionally, the incidence of new neurological dysfunction was 7.8% in the non-IONM group and 5.6% in the IONM group. However, there was no significant difference between the two groups (P > 0.05). The medium- to long-term follow-up had significant difference (P < 0.05), the response rate was 32.1% in the IONM group and 23.7% in the non-IONM group, and deterioration rates regarding neurological dysfunction were 3.3% in the IONM group and 8.5% in the non-IONM group. CONCLUSION This study revealed that the use of IONM does not significantly improve the short-term treatment effect of patients undergoing surgery for tethered cord release or reduce the short-term incidence of postoperative new neurological dysfunction. However, the medium- to long-term prognoses of patients in the IONM group were better than those of patients in the non-IONM group.
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Affiliation(s)
- Junjun Guo
- Department of Neurosurgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, 400000, China
| | - Xianlan Zheng
- Department of Nursing, Children's Hospital of Chongqing Medical University, Chongqing, 400000, China.
| | - Hongyao Leng
- Department of Nursing, Children's Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Qiao Shen
- Department of Nursing, Children's Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Jialin Pu
- Department of Neurosurgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, 400000, China
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Squintani G, Basaldella F, Badari A, Rasera A, Tramontano V, Pinna G, Moscolo F, Soda C, Ricci U, Ravenna G, Sala F. Intraoperative Neurophysiological Monitoring in Tethered Cord Syndrome Surgery: Predictive Values and Clinical Outcome. J Clin Neurophysiol 2024:00004691-990000000-00138. [PMID: 38905022 DOI: 10.1097/wnp.0000000000001096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024] Open
Abstract
INTRODUCTION "Tethered cord syndrome" (TCS) refers to a congenital abnormality associated with neurological signs and symptoms. The aim of surgery is to prevent or arrest their progression. This study reports a retrospective case series of tethered cord syndrome surgeries, supported by intraoperative neurophysiological monitoring. METHODS The case series comprises 50 surgeries for tethered cord syndrome in which multimodal intraoperative neurophysiological monitoring was performed using motor evoked potentials (transcranial motor evoked potentials [TcMEPs]), tibial nerve somatosensory evoked potentials (TNSEPs), and pudendal-anal reflex (PAR). The intraoperative neurophysiological monitoring results are reported and correlated with clinical outcomes. RESULTS Sensitivity, specificity, and negative predictive value were high for TcMEPs and TNSEPs, while PAR exhibited low sensitivity and positive predictive value but high specificity and negative predictive value. Fisher's exact test revealed a significant correlation between changes in TcMEPs, TNSEPs, and clinical outcome ( P < 0.000 and P = 0.049 respectively), but no correlation was detected between PAR and urinary/anal function ( P = 0.497). CONCLUSIONS While TcMEPs and TNSEPs were found to be reliable intraoperative neurophysiological monitoring parameters during tethered cord syndrome surgery, PAR had low sensitivity and positive predictive value probably because the reflex is not directly related to bladder function and because its multisynaptic pathway may be sensitive to anesthetics. New onset muscle weakness and sensory deficits were related to postoperative changes in TcMEPs and TNSEPs, whereas changes in PAR did not predict bladder/urinary impairment. Urinary deficits may be predicted and prevented with other neurophysiological techniques, such as the bladder-anal reflex.
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Affiliation(s)
- Giovanna Squintani
- Neurology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Andrea Badari
- Neurology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Andrea Rasera
- Neurology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- Neurology Unit, Ospedale Ca' Foncello, Treviso, Italy
- Neurology and Neurophysiology Unit, Azienda Ospedaliera Universitaria, Modena, Italy
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
- Neurosurgery Unit, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
| | - Vincenzo Tramontano
- Neurology and Neurophysiology Unit, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Giampietro Pinna
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
| | - Fabio Moscolo
- Neurosurgery Unit, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
| | - Christian Soda
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
| | - Umberto Ricci
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
| | - Giorgio Ravenna
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
| | - Francesco Sala
- Neurosurgery Unit, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
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Lin H, Su H, Li C, Zhang P, Xiu B, Bai Y, Xu R. Classification of and individual treatment strategies for complex tethered cord syndrome. Front Surg 2024; 11:1277322. [PMID: 38322409 PMCID: PMC10844385 DOI: 10.3389/fsurg.2024.1277322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/09/2024] [Indexed: 02/08/2024] Open
Abstract
Objective To study the classification, diagnosis, and treatment strategies of complex tethered cord syndrome (C-TCS) on the basis of the patients' clinical symptoms, imaging findings, and therapeutic schedule. Methods The clinical data of 126 patients with C-TCS admitted to our department from January 2015 to December 2020 were retrospectively analyzed. Classification criteria for C-TCS were established by analyzing the causes of C-TCS. Different surgical strategies were adopted for different types of C-TCS. The Kirollos grading, visual analogue scale (VAS), critical muscle strength, and Japanese Orthopaedic Association (JOA) scores were used to evaluate the surgical outcomes and explore individualized diagnosis and treatment strategies for C-TCS. Results C-TCS was usually attributable to three or more types of tether-causing factors. The disease mechanisms could be categorized as pathological thickening and lipomatosis of the filum terminal (filum terminal type), arachnoid adhesion (arachnoid type), spina bifida with lipomyelomeningocele/meningocele (cele type), spinal lipoma (lipoma type), spinal deformity (bone type), and diastomyelia malformation (diastomyelia type). Patients with different subtypes showed complex and varied symptoms and required individualized treatment strategies. Conclusion Since C-TCS is attributable to different tether-related factors, C-TCS classification can guide individualized surgical treatment strategies to ensure complete release of the tethered cord and reduce surgical complications.
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Affiliation(s)
- Hepu Lin
- Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Hui Su
- Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Cuicui Li
- Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Pengfei Zhang
- Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Bo Xiu
- Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Yunjing Bai
- Department of Neurosurgery, The Seventh Medical Center of the PLA General Hospital, Beijing, China
| | - Ruxiang Xu
- Department of Neurosurgery, Sichuan Provincial People’s Hospital, Chengdu, China
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Feasibility and diagnostic accuracy of intra-operative monitoring of motor evoked potentials in children <2 years of age undergoing tethered cord surgery: results in 100 children. Childs Nerv Syst 2021; 37:2289-2298. [PMID: 33763733 DOI: 10.1007/s00381-021-05128-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study documents the monitorability using different anesthesia regimes and accuracy of muscle motor evoked potentials (mMEPs) in children ≤2 years of age undergoing tethered cord surgery (TCS). METHODS Intraoperative mMEP monitoring was attempted in 100 consecutive children, ≤2 years of age, undergoing TCS. MEP monitoring was done under 4 different anesthetic regimes: (Total intravenous anesthesia (TIVA); balanced anesthesia with sevoflurane and ketamine; balanced anesthesia with isoflurane and ketamine; and balanced anesthesia with sevoflurane). Factors analyzed for their effect on monitorability were: age, neurological deficits, type of anesthesia, and the number of pulses used for stimulation. RESULTS Baseline mMEPs were obtained in 87% children. Monitorability of mMEPs was similar in children ≤1 year and 1-2 years of age (85.7% and 87.5%). In multivariate analysis, anesthesia regime was the only significant factor predicting presence of baseline mMEPs. Children undergoing TIVA (p=0.02) or balanced anesthesia with a combination of propofol, sevoflurane, and ketamine (p=0.05) were most likely to have baseline mMEPs. mMEPs had a sensitivity of 97.4%, specificity of 96.4%, negative predictive value of 98.2% and accuracy of 96.8%. CONCLUSIONS Baseline mMEPs were obtained in >85% of children ≤2 years of age including those who had motor deficits. TIVA and balanced anesthesia with sevoflurane and ketamine are ideal for mMEP monitoring. mMEPs have a high accuracy although, false positive and false negative results can occasionally be experienced.
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