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Liu T, Wu G, Wang W, Qi H, Zhao S, Zhang J, Wang R, Yuan T, Xiao L, Luo Z, Yang W, Wang F, Wang G, Yan L. Utility of somatosensory- and motor-evoked potential change thresholds in surgical treatment for thoracic spinal stenosis based on different pathologies. Spine J 2024; 24:1645-1659. [PMID: 38685275 DOI: 10.1016/j.spinee.2024.04.026] [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: 11/21/2023] [Revised: 03/26/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND CONTEXT Thoracic spinal stenosis (TSS) is secondary to different pathologies that differ in clinical characteristics and surgical outcomes. PURPOSE This study aimed to determine the optimal warning thresholds for combined somatosensory-evoked potentials (SSEP) and motor-evoked potentials (MEP) for predicting postoperative neurological deterioration in surgical treatment for TSS based on different pathologies. Additionally, we explored the correlation between SSEP/MEP monitoring and postoperative spinal neurological function. STUDY SETTING Retrospective study. PATIENT SAMPLE Two hundred five patients. OUTCOME MEASURES We obtained perioperative modified Japanese Orthopedic Association (mJOA) scores to assess spinal neurological function. METHODS The data collected in this study included demographic data, intraoperative neurophysiological monitoring (IONM) signals, and perioperative neurological function assessments. To determine the optimal IONM warning threshold, a receiver operating characteristic (ROC) curve was used. Additionally, Pearson correlation analysis was conducted to determine the correlation between IONM signals and clinical neurological conditions. RESULTS A total of 205 consecutive patients were eligible. Forty-one patients had thoracic disc herniation (TDH), 14 had ossification of the posterior longitudinal ligament (OPLL), 124 had ossification of the ligamentum flavum (OLF), and 26 had OPLL+OLF. The mean mJOA scores before surgery and 3 months after surgery were 7.0 and 7.9, respectively, resulting in a mean mJOA recovery rate (RR) of 23.1%. The average postoperative mJOA RRs for patients with TDH, OPLL, OLF, and OPLL+OLF were 24.8%, 10.4%, 26.8%, and 11.2%, respectively. Patients with OPLL+OLF exhibited a more stringent threshold for IONM changes. This included a lower amplitude cutoff value (a decrease of 49.0% in the SSEP amplitude and 57.5% in the MEP amplitude for short-term prediction) and a shorter duration of waveform change (19.5 minutes for SSEP and 22.5 minutes for MEP for short-term prediction). On the other hand, patients with TDH had more lenient IONM warning criteria (a decrease of 49.0% in SSEP amplitude and 77.5% in MEP amplitude for short-term prediction; durations of change of 25.5 minutes for SSEP and 32.5 minutes for MEP). However, OPLL patients or OLF patients had moderate and similar IONM warning thresholds. Additionally, there was a stronger correlation between the SSEP amplitude variability ratio and the JOA RR in OPLL+OLF patients, while the correlation was stronger between the MEP amplitude variability ratio and the JOA RR for the other three TSS pathologies. CONCLUSIONS Optimal IONM change criteria for prediction vary depending on different TSS pathologies. The optimal monitoring strategy for prediction varies depending on TSS pathologies.
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Affiliation(s)
- Tun Liu
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Gang Wu
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Wentao Wang
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Huaguang Qi
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Songchuan Zhao
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Jitao Zhang
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Ruiguo Wang
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Tao Yuan
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Li Xiao
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Zhenguo Luo
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Weizhou Yang
- Department of Spine Surgery, the first affiliated hospital of Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Fei Wang
- Institute of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Gang Wang
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Institute of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Liang Yan
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China.
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Transcranial Motor-evoked Potential Alert After Supine-to-Prone Position Change During Thoracic Ossification in Posterior Longitudinal Ligament Surgery: A Prospective Multicenter Study of the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research. Spine (Phila Pa 1976) 2022; 47:1018-1026. [PMID: 34610608 DOI: 10.1097/brs.0000000000004246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/19/2021] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, multicenter study. OBJECTIVE To evaluate the usefulness of transcranial motor-evoked potentials (Tc-MEPs) during supine-to-prone position change for thoracic ossification of the posterior longitudinal ligament (T-OPLL). SUMMARY OF BACKGROUND DATA Supine-to-prone position change might be a risk of spinal cord injury in posterior decompression and fusion surgeries for T-OPLL. METHODS The subjects were 145 patients with T-OPLL surgically treated with posterior decompression and fusion using Tc-MEPs in 14 institutes. Tc-MEPs were monitored before surgery from supine-to-prone position and intraoperatively in seven institutes and only intraoperatively in the other seven institutes because of disapproval of the anesthesia department. In cases of Tc-MEP alert after position change, we adjusted the cervicothoracic posture. When the MEP did not recover, we reverted the position to supine and monitored the Tc-MEPs in supine position. RESULTS There were 83 and 62 patients with/without Tc-MEP before position change to prone (group A and B). The true-positive rate was lower in group A than group B, but without statistical significance (8.4% vs. 16.1%, P = 0.12). In group A, five patients who had Tc-MEP alert during supine-to-prone position change were all female and had larger body mass index values and upper thoracic lesions. Among the patients, three underwent surgeries after cervicothoracic alignment adjustment, and two had postponed operations to 1 week later with halo-vest fixation because of repeated Tc-MEP alerts during position change to prone. The Tc-MEP alert at exposure was statistically more frequent in group B than in group A ( P = 0.033). CONCLUSION Tc-MEP alert during position change is an important sign of spinal cord injury due to alignment change at the upper thoracic spine. Tc-MEP monitoring before supine-to-prone position change was necessary to prevent spinal cord injury in surgeries for T-OPLL.
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Yoshida G, Ushirozako H, Hasegawa T, Yamato Y, Yasuda T, Banno T, Arima H, Oe S, Mihara Y, Yamada T, Ide K, Watanabe Y, Ushio T, Matsuyama Y. Selective Angiography to Detect Anterior Spinal Artery Stenosis in Thoracic Ossification of the Posterior Longitudinal Ligament. Asian Spine J 2021; 16:334-342. [PMID: 33957022 PMCID: PMC9260402 DOI: 10.31616/asj.2020.0588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/26/2021] [Indexed: 12/02/2022] Open
Abstract
Study Design Single-center prospective study. Purpose To investigate anterior spinal artery (ASA) status using preoperative selective angiography in patients undergoing surgery for thoracic ossification of the posterior longitudinal ligament (T-OPLL). Overview of Literature Surgery for T-OPLL has a high risk of neurological complications, which might be associated with insufficient spinal cord blood flow. Methods This study prospectively examined nine T-OPLL patients who underwent posterior thoracic decompression with kyphosis correction and instrumented fusion at Hamamatsu University School of Medicine between 2017 and 2019. All underwent preoperative selective angiography to detect and evaluate the Adamkiewicz artery and ASA. Intraoperative neuromonitoring and Doppler ultrasonography were performed to analyze neurological complications and spinal cord blood flow. Results All nine patients showed ASA stenosis in the area of T-OPLL. In all patients, the Adamkiewicz artery was located between T7 and L2 and the area of ASA stenosis corresponded to the level of T-OPLL and greatest spinal cord compression; intraoperative Doppler ultrasonography confirmed the ASA defect at the same spinal level. The number of spinal levels from the Adamkiewicz artery to the most compressive OPLL lesion was greater in the two patients who developed postoperative neurological deficit compared to those who did not (5.5 vs. 2.3, p=0.014). Conclusions This is the first study to report detection of ASA stenosis in patients with T-OPLL. Maintaining spinal cord blood flow is important in these patients to avoid neurological deterioration.
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Affiliation(s)
- Go Yoshida
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroki Ushirozako
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomohiko Hasegawa
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yu Yamato
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tatsuya Yasuda
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomohiro Banno
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hideyuki Arima
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shin Oe
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuki Mihara
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomohiro Yamada
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Koichiro Ide
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuh Watanabe
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takasuke Ushio
- Department of Radiology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yukihiro Matsuyama
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Efficacy of Intraoperative Intervention Following Transcranial Motor-evoked Potentials Alert During Posterior Decompression and Fusion Surgery for Thoracic Ossification of the Posterior Longitudinal Ligament: A Prospective Multicenter Study of the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research. Spine (Phila Pa 1976) 2021; 46:268-276. [PMID: 33156280 DOI: 10.1097/brs.0000000000003774] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective, multicenter, observational study. OBJECTIVE The aim of this study was to investigate the efficacy of intervention after an alert in intraoperative neurophysiological monitoring (IONM) using transcranial motor-evoked potentials (Tc-MEPs) during surgery for thoracic ossification of the posterior longitudinal ligament (T-OPLL). SUMMARY OF BACKGROUND DATA T-OPLL is commonly treated with posterior decompression and fusion with instrumentation. IONM using Tc-MEPs during surgery reduces the risk of neurological complications. METHODS The subjects were 79 patients with a Tc-MEP alert during posterior decompression and fusion surgery for T-OPLL. Preoperative muscle strength (manual muscle testing [MMT]), waveform derivation rate at the start of surgery (baseline), intraoperative waveform changes; and postoperative motor paralysis were examined. A reduction in MMT score of ≥1 on the day after surgery was classified as worsened postoperative motor deficit. An alert was defined as a decrease in Tc-MEP waveform amplitude of ≥70% from baseline. Alerts were recorded at key times during surgery. RESULTS The patients (35 males, 44 females; age 54.6 years) had OPLL at T1-4 (n = 27, 34%), T5-8 (n = 50, 63%), and T9-12 (n = 16, 20%). The preoperative status included sensory deficit (n = 67, 85%), motor deficit (MMT ≤4) (n = 59, 75%), and nonambulatory (n = 26, 33%). At baseline, 76 cases (96%) had a detectable Tc-MEP waveform for at least one muscle, and the abductor hallucis had the highest rate of baseline waveform detection (n = 66, 84%). Tc-MEP alerts occurred during decompression (n = 47, 60%), exposure (n = 13, 16%), rodding (n = 5, 6%), pedicle screw insertion (n = 4, 5%), posture change (n = 4, 5%), dekyphosis (n = 2, 3%), and other procedures (n = 4, 5%). After intraoperative intervention, the rescue rate (no postoperative neurological deficit) was 57% (45/79), and rescue cases had a significantly better preoperative ambulatory status and a significantly higher baseline waveform derivation rate. CONCLUSION These results show the efficacy of intraoperative intervention following a Tc-MEP alert for prevention of neurological deficit postoperatively.Level of Evidence: 2.
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Ito S, Ando K, Kobayashi K, Nakashima H, Machino M, Kanbara S, Inoue T, Yamaguchi H, Segi N, Koshimizu H, Imagama S. Larger muscle mass of the upper limb correlates with lower amplitudes of deltoid MEPs following transcranial stimulation. J Clin Neurosci 2020; 81:426-430. [PMID: 33222955 DOI: 10.1016/j.jocn.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/14/2020] [Accepted: 10/03/2020] [Indexed: 11/18/2022]
Abstract
To perform spinal surgery safely, it is important to understand the risk factors, including factors that negatively influence intraoperative neuromonitoring (IONM). Transcranial motor evoked potentials (TcMEPs) are important in IONM. Therefore, we aimed to investigate whether muscle mass affects the waveforms of TcMEPs to understand the risk factors influencing TcMEPs. We enrolled 48 patients with thoracolumbar spinal diseases who underwent surgery at our facility between April 2015 and March 2018. Before surgery, the body composition, including muscle mass and fat mass, of all patients was measured using bioelectrical impedance analysis (BIA). During surgery, cranial stimulation under general anesthesia was used to derive TcMEPs, enabling us to measure the amplitude, using the control wave of the TcMEPs of the deltoid muscles and the abductor digiti minimi (ADM) muscles. We found a negative correlation between the amplitude of deltoid-muscle TcMEPs and muscle mass of the upper limb. The amplitude of deltoid-muscle TcMEPs did not correlate with the skeletal muscle index (SMI), muscle mass of the lower limb, or body fat mass. The amplitude of ADM-muscle TcMEPs did not correlate with SMI, muscle mass of any limb, or body fat mass. In conclusion, a larger muscle mass of the upper limb correlated with a lower amplitude of deltoid-muscle TcMEPs. By contrast, there was no correlation between the muscle mass of the upper limb and the amplitude of ADM-muscle TcMEPs. These findings suggest that TcMEPs of the ADM are less influenced by muscle mass and are more stable than those of the deltoid.
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Affiliation(s)
- Sadayuki Ito
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
| | - Kei Ando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
| | - Kazuyoshi Kobayashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
| | - Masaaki Machino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Shunsuke Kanbara
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
| | - Taro Inoue
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Hidetoshi Yamaguchi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Hiroyuki Koshimizu
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
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