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Sandip C, Shankar DA, Syed K. lVentral tethering-is the prognosis worse than in dorsal tethering in the dysraphic spine? Childs Nerv Syst 2024; 40:2515-2519. [PMID: 38743268 DOI: 10.1007/s00381-024-06438-0] [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: 03/20/2024] [Accepted: 04/27/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE To compare cases of dysraphism with ventral tethering of cord with those with dorsal tethering and to find out any differences in the outcome of surgery in them. METHODS We collected the data of 188 consecutively operated tethered cord patients at our institute in the past 7 years and divided them into ventral tethering and dorsal tethering groups. Those that we felt had both dorsal and ventral tethering were excluded. Their preoperative clinical, radiological, and baseline neurophysiological parameters as well as postoperative clinical and radiological parameters were analyzed in a retrospective study. RESULTS Among the 188 tethered cord patients, 52 (28%) had ventral tethering and 136 (72%) had posterior tethering. Preoperative neurodeficit and cord signal changes as well as absent baseline MEP (of any one muscle) were significantly more associated with ventral tethered cord than the dorsal tethered cord. The neurological deterioration after surgery occurred significantly in the ventral tethered cord group than in the dorsal tethered cord group. Also, the postoperative MRI had more incomplete detethering cases in the ventral group than in the dorsal tethered cord group. CONCLUSION Ventral tethered cord is more likely to present with preoperatively neurological deficits. It should be carefully identified in the preoperative MRI, so that the intraoperative difficulties in complete detethering and postoperative deterioration can be anticipated.
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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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Pasquali C, Basaldella F, Sala F. Updates on Intraoperative Neurophysiology During Surgery for Spinal Dysraphism. Adv Tech Stand Neurosurg 2023; 47:235-272. [PMID: 37640878 DOI: 10.1007/978-3-031-34981-2_9] [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] [Indexed: 08/31/2023]
Abstract
Spinal dysraphism is a group of disorders resulting from an embryologic failure of spinal cord development which can lead to a radicular-medullary mechanical stretch that generates vascular compromise and hypoxic-ischemic damage to the nervous structures of the conus-cauda region.Thus, the clinical relevance of the different types of spinal dysraphism is related to the possible neurologic deficits resulting from spinal cord tethering. The clinical presentation is heterogenous: from asymptomatic to very compromised patients. The indications and the time of a detethering surgery are still subject of debate, although there is an agreement on the high standards of treatment that have to be offered by the surgery. Intraoperative neurophysiology (ION) contributes to the safety of tethered cord surgery in reducing the risks of iatrogenic neurological damages.
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Affiliation(s)
- Claudia Pasquali
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Federica Basaldella
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy.
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Abraham AP, Vora TK, Selvi BT, Rajshekhar V. Characterizing syringomyelia and its clinical significance in 140 patients with lipomyelomeningocele. J Neurosurg Pediatr 2022; 30:349-356. [PMID: 35901676 DOI: 10.3171/2022.6.peds2286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aims of this study were to characterize syringomyelia in patients with lipomyelomeningocele (LMMC) and investigate the association between the presence of a syrinx and patient neurological deficits. METHODS Patients with LMMC who had been admitted between 2007 and 2020 were included in the study. Syringomyelia on magnetic resonance imaging (MRI) was classified into three groups: true syrinx, early syrinx, and presyrinx. The correlation of clinical deficits (at birth, new onset, and progressive) and type of lipoma with the presence and type of syrinx was studied. RESULTS Among a total of 140 patients, the median age was 2.5 (IQR 1.3-9) years. Neurological deficits were present at birth in 75 (53.6%) patients, but 67 (47.9%) had new-onset deficits or progression of their birth deficits. The most common type of spinal lipoma was the transitional type (75.7%). Thirty-nine (27.9%) patients had a syrinx (37 with a true syrinx, 2 with an early syrinx), and 25 (17.9%) patients had a presyrinx. There was no significant correlation between the presence of a syrinx and patient neurological deficits. However, patients with a syrinx that was not adjacent to the lipoma (≥ 1 vertebral level away) had a higher incidence of deficits at birth (p = 0.045), whereas those with a syrinx spanning ≥ 5 vertebral levels had a higher incidence of progressive neurological deficits (p = 0.04). Six (75%) of 8 patients in whom serial MRI had shown syrinx progression had clinical worsening. CONCLUSIONS Syrinx location with respect to the spinal lipoma, syrinx length, and progressive syringomyelia may have clinical significance in patients with LMMC.
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Affiliation(s)
| | | | - Bernice T Selvi
- 2Radiology, Christian Medical College, Vellore, Tamil Nadu, India
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Akbari KK, Badikillaya V, Venkatesan M, Hegde SK. Do Intraoperative Neurophysiological Changes During Decompressive Surgery for Cervical Myeloradiculopathy Affect Functional Outcome? A Prospective Study. Global Spine J 2022; 12:366-372. [PMID: 32959684 PMCID: PMC9121159 DOI: 10.1177/2192568220951779] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
STUDY DESIGN Prospective cohort. OBJECTIVE To investigate whether intraoperative neuromonitoring (IONM) positive changes affect functional outcome after surgical intervention for myeloradiculopathy secondary to cervical compressive pathology (cervical compressive myelopathy). METHODS Twenty-eight patients who underwent cervical spine surgery with IONM for compressive myeloradiculopathy were enrolled. During surgery motor-evoked potential (MEP) and somatosensory evoked potential (SSEP) at baseline and before and after decompression were documented. A decrease in latency >10% or an increase in amplitude >50% was regarded as a "positive changes." Patients were divided into subgroups based on IONM changes: group A (those with positive changes) and group B (those with no change or deterioration). Nurick grade and modified Japanese Orthopaedic Association (mJOA) score were evaluated before and after surgery. RESULTS Nine patients (32.1%) showed improvement in MEP. The mean preoperative Nurick grade and mJOA score of group A and B were (2.55 ± 0.83 and 11.11 ± 1.65) and (2.47 ± 0.7 and 11.32 ± 1.24), respectively. The mean postoperative Nurick grade of groups A and B at 6 months was 1.55 ± 0.74 and 1.63 ± 0.46, respectively, and this difference was not significant. The mean postoperative mJOA score of groups A and B at 6 months was 14.3 ± 1.03 and 12.9 ± 0.98, respectively, and this difference was statistically significant (P = .011). Spearman correlation coefficient showed significant positive correlation between the IONM change and the mJOA score at 6 months postoperatively (r = 0.47; P = .01). CONCLUSION Our study shows that impact of positive changes in MEP during IONM reflect in functional improvement at 6 months postoperatively in cervical compressive myelopathy patients.
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Affiliation(s)
- Keyur Kantilal Akbari
- Apollo Hospital, Chennai, India,Keyur Kantilal Akbari, OPD No. 104, Counter Number 9, Apollo Hospitals, Greams Lane, Chennai 600006, India.
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Soda C, Squintani G, Teli M, Marchesini N, Ricci U, D'Amico A, Basaldella F, Concon E, Tramontano V, Romito S, Tommasi N, Pinna G, Sala F. Degenerative cervical myelopathy: Neuroradiological, neurophysiological and clinical correlations in 27 consecutive cases. BRAIN AND SPINE 2022; 2:100909. [PMID: 36248151 PMCID: PMC9560670 DOI: 10.1016/j.bas.2022.100909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/04/2022] [Accepted: 06/24/2022] [Indexed: 01/11/2023]
Abstract
New insight into prognostic factors for recovery of clinical function following posterior decompression for degenerative cervical myelopathy. An increase of IOM amplitude of at least 50% coupled with preoperative T2-only and diffuse T2 signal changes on MRI is a positive prognostic factors for clinical improvement 6 months after surgery. Clinical improvement at 6 months follow-up can be expected in patients with T1 hypo intensity if a diffuse border of the lesion on T2 images is present.
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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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Early- and long-term surgical outcomes in 109 children with lipomyelomeningocele. Childs Nerv Syst 2021; 37:1623-1632. [PMID: 33404713 DOI: 10.1007/s00381-020-05000-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
AIM To determine the functional outcomes and risk factors for outcomes following surgery for lipomyelomeningocele (LMMC). METHODS Data from 109 children with LMMC who underwent surgery from January 2008 to December 2017 were retrospectively studied to evaluate functional outcomes and possible risk factors for early- (at discharge from hospital or within 1 month of surgery) and long-term outcomes after surgery. RESULTS There were 53 boys and 56 girls with median age of 36 months (IQR 12-90 months; range, 4 months to 18 years) at surgery. At presentation, neurological function was normal (asymptomatic group) in 28 (25.7%) children while there was neurological dysfunction (symptomatic group) in 81 (74.3%). Near total or radical excision of lipoma was done in 71 (65.1%) children. Six (5.8%) children had deterioration of neurological function in the post-operative period with recovery of function in three of them. There were no statistically significant risk factors for early outcomes. At a mean follow-up of 62.5 months (IQR 35-82 months; range, 12-146 months), 21 (27.6%) of the 76 symptomatic group children (including 59.3% with incomplete bladder dysfunction) showed improvement, 52 (68.4%) remained the same, while 3 (4%) deteriorated. In 31 children (symptomatic group) who developed symptoms after 1 year of age, early surgery after development of symptoms was associated with better chances of recovery (p = 0.0008). In the asymptomatic group, 23 (88.5%) had normal neurological function at mean follow-up of 57.5 months (IQR 30-77 months; range, 12-141 months) and 3 (11.5%) had neurological deterioration. The mean time to late deterioration (re-tethering) from surgery was 51.3 months (IQR 24-75 months; range, 24-84 months). Presence of syrinx on initial MRI (p = 0.008) and partial resection of the lipoma (p = 0.02) were independent risk factors for delayed deterioration. CONCLUSION Radical resection of LMMC probably helps in preserving neurological function in > 90% of children at long-term follow-up. Fifty-five percent of children > 2 years of age with incomplete bladder dysfunction regained normal function following surgery. In children who develop symptoms after birth, early surgical intervention can reverse the neurological deficits.
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Wang S, Ren Z, Liu J, Zhang J, Tian Y. The prediction of intraoperative cervical cord function changes by different motor evoked potentials phenotypes in cervical myelopathy patients. BMC Neurol 2020; 20:221. [PMID: 32473653 PMCID: PMC7261380 DOI: 10.1186/s12883-020-01799-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 05/19/2020] [Indexed: 11/10/2022] Open
Abstract
Background Surgery is usually the treatment of choice for patients with cervical compressive myelopathy (CCM). Motor evoked potential (MEP) has proved to be helpful tool in evaluating intraoperative cervical spinal cord function change of those patients. This study aims to describe and evaluate different MEP baseline phenotypes for predicting MEP changes during CCM surgery. Methods A total of 105 consecutive CCM patients underwent posterior cervical spine decompression were prospectively collected between December 2012 and November 2016. All intraoperative MEP baselines recorded before spinal cord decompression were classified into 5 types (I to V) that were carefully designed according to the different MEP parameters. The postoperative neurologic status of each patient was assessed immediately after surgery. Results The mean intraoperative MEP changes range were 10.2% ± 5.8, 14.7% ± 9.2, 54.8% ± 31.9, 74.1% ± 24.3, and 110% ± 40 in Type I, II, III, IV, and V, respectively. There was a significant correlation of the intraoperative MEP change rate with different MEP baseline phenotypes (r = 0.84, P < 0.01). Postoperative transient new spinal deficits were found 0/31 case in Type I, 0/21 in Type II, 1/14 in Type III, 2/24 in Type IV, and 4/15 in Type V. No permanent neurological injury was found in our cases series. Conclusions The MEP baselines categories for predicting intraoperative cervical cord function change is proposed through this work. The more serious the MEP baseline abnormality, the higher the probability of intraoperative MEP changes, which is beneficial to early warning for the cervical cord injury.
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Affiliation(s)
- Shujie Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuai Fu Yuan, Beijing, 100730, PR China
| | - Zhifu Ren
- Department of Spine Surgery, Municipal Traditional Chinese Hospital, Weifang, Shandong, 261041, PR China
| | - Jia Liu
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuai Fu Yuan, Beijing, 100730, PR China
| | - Ye Tian
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuai Fu Yuan, Beijing, 100730, PR China.
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Kim KH, Chong S, Lee JY, Kim K, Kim SK, Wang KC. Decreased MEPs during subcutaneous dissection for untethering surgery of a "true" lipomyelomeningocele: aggravated traction of the spinal cord by release of the sac from the original nest. Childs Nerv Syst 2019; 35:529-533. [PMID: 30617616 DOI: 10.1007/s00381-019-04049-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 01/02/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE It is well known that the preoperative enlarged sac in occult spinal dysraphism, in which the spinal cord is attached to its dome, can be associated with neurological deficits by aggravation of spinal cord traction. We experienced a similar phenomenon during the early stage of untethering surgery for "lipomyelomeningocele in a strict sense (LMMC)." CLINICAL PRESENTATION We report a case of a 3-month-old girl with LMMC, which showed decreased motor evoked potentials (MEPs) in the lower extremities during the early stage of untethering surgery. The sac was released from the original nest by incision with separation of the overlying skin and dissection from the muscle fascia. The sac became rounder, and the spinal cord attached to the dome of the sac was further stretched. After aspiration of cerebrospinal fluid from the sac, the MEPs recovered. Postoperatively, the patient had no neurological deficits. CONCLUSIONS Although this phenomenon rarely occurs, release of the herniated sac of LMMC from the original nest during the early stage of untethering surgery may result in neurological changes. Application of intraoperative neurophysiological monitoring helps to detect electrophysiological deterioration and can prevent neurological deficits.
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Affiliation(s)
- Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Sangjoon Chong
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Neurosurgery, Asan Medical Center, Seoul, Republic of Korea
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Anatomy, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Keewon Kim
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Kyu-Chang Wang
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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Umemura T, Nishizawa S, Nakano Y, Saito T, Kitagawa T, Miyaoka R, Suzuki K, Yamamoto J. Intraoperative monitoring of motor-evoked potential for parenchymal brain tumor removal: An analysis of false-negative cases. J Clin Neurosci 2018; 57:105-110. [PMID: 30145081 DOI: 10.1016/j.jocn.2018.08.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 07/05/2018] [Accepted: 08/12/2018] [Indexed: 11/18/2022]
Abstract
Transcranial motor-evoked potential (tc-MEP) monitoring is unreliable for brain tumor removal due to its low sensitivity. According to previous literature, this is because transcranial stimulation seems to reach the deep pyramidal tract beyond the operation point and may thus yield false-negative results, where, although MEP recording is stable, postoperative motor deficits are encountered. Therefore, we aimed to analyze the causes for the false-negative results and investigate whether decreasing the stimulation intensity better reflects the operation point and can improve the sensitivity during parenchymal brain tumor removal. We assessed 122 patients with parenchymal brain and intraventricular tumors, who underwent surgery under tc-MEP monitoring in our hospital between 2011 and 2014. In these patients, the stimulation intensity was fixed at 200 mA. We detected 11 false-negative cases, while the sensitivity of tc-MEP monitoring was 33.9% and the specificity was 99.0%. Between 2015 and 2016, we examined 68 patients with parenchymal brain tumors, in whom the stimulation intensity was reduced to an average of 136.5 mA. Only one case was false-negative, while the sensitivity increased to 83.3% and the specificity was 98.4%. From these results, we conclude that the intensity of tc-MEP stimulation should be minimal to precisely reflect the damage to the operated location. Tc-MEP can be an easy and reliable monitor in brain tumor surgery when used at proper, lower intensity.
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Affiliation(s)
- Takeru Umemura
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan.
| | - Shigeru Nishizawa
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Yoshiteru Nakano
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Takeshi Saito
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Takehiro Kitagawa
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Ryo Miyaoka
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Kohei Suzuki
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Junkoh Yamamoto
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
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Park MK, Lee SJ, Kim SB, Lee KW, Lee HJ, Han EY, Kim BR. The effect of positive changes during intraoperative monitoring of the functional improvement in patients with cervical compressive myelopathy. Clin Interv Aging 2018; 13:1211-1218. [PMID: 30013332 PMCID: PMC6038868 DOI: 10.2147/cia.s163467] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Cervical compressive myelopathy (CCM) is a progressive, degenerative spine disease and the most common cause of spinal cord dysfunction in older individuals. Current clinical guidelines for spinal surgery recommend multimodal intraoperative monitoring (IOM) during spinal surgery as a reliable and valid diagnostic adjunct to assess spinal cord integrity. The aim of this study was to evaluate the effect of positive changes during IOM on the functional status in patients with CCM. Methods Patients who underwent spinal surgery with IOM due to CCM were enrolled. During the surgery, patients underwent IOM using motor evoked potential (MEP) and somatosensory evoked potential (SEP). MEP and SEP were checked before and immediately after decompression. A decrease in latency >10% or an increase in amplitude >50% was regarded as a “positive changes”. Subjects were divided according to the presence of positive changes. Motor scores of American Spinal Injury Association (ASIA) impairment scale and Korean version of Modified Barthel Index (K-MBI) were evaluated before and after operation. Results Twenty-nine patients underwent spinal surgery due to CCM. Eleven patients showed positive changes in MEP during IOM. When the two groups were compared, improvement rate in the ASIA motor score and K-MBI were significantly higher in patients with positive changes than in patients without positive changes at 1 month after surgery. However, 6 months after surgery, there were no significance differences between the groups. Regardless of positive change, nearly all patients suffered from neuropathic pain after operation. Conclusion Positive changes in MEP during IOM may affect functional improvement 1 month after operation and early discharge without significant complications in CCM patients. However, they do not affect the neuropathic pain and long-term functional outcome. Thus, tailored proper management is needed to achieve maximal functional recovery in each patient after cervical spinal decompression surgery.
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Affiliation(s)
- Min Kyu Park
- Department of Pharmacology and Clinical Pharmacology, Dong-A University College of Medicine and Hospital, Busan, Republic of Korea
| | - Sook Joung Lee
- Department of Physical Medicine and Rehabilitation, Catholic University of Korea, Daejeon St Mary's Hospital, Daejeon, Republic of Korea,
| | - Sang Beom Kim
- Department of Physical Medicine and Rehabilitation, Dong-A University College of Medicine, Dong-A University Hospital, Busan, Republic of Korea
| | - Kyeong Woo Lee
- Department of Physical Medicine and Rehabilitation, Dong-A University College of Medicine, Dong-A University Hospital, Busan, Republic of Korea
| | - Hye-Jeong Lee
- Department of Pharmacology, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Eun Young Han
- Department of Rehabilitation Medicine, Jeju National University School of Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Bo Ryun Kim
- Department of Rehabilitation Medicine, Jeju National University School of Medicine, Jeju National University Hospital, Jeju, Republic of Korea
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Dulfer SE, Drost G, Lange F, Journee HL, Wapstra FH, Hoving EW. Long-term evaluation of intraoperative neurophysiological monitoring-assisted tethered cord surgery. Childs Nerv Syst 2017; 33:1985-1995. [PMID: 28676974 PMCID: PMC5644688 DOI: 10.1007/s00381-017-3478-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/05/2017] [Indexed: 12/01/2022]
Abstract
PURPOSE Patients with tethered spinal cord have been investigated for short-term effects after tethered spinal cord surgery in the past. However, little is known about the long-term effects in this patient group. In this retrospective, longitudinal, observational study, a patient sample of a previous report of 65 patients was reassessed to observe the long-term effects of intraoperative neurophysiological monitoring-assisted tethered cord surgery. METHODS With the use of patient charts and a survey, patients were scored on four domains: (1) neurological deficits, (2) urological deficits, (3) pain symptoms, and (4) orthopedic deficits. Measurements were performed at four moments in time: (1) preoperatively, (2) postoperatively, (3) follow-up 1 (4.6 years), and (4) follow-up 2 (11.2 years). Besides this, a subgroup analysis and a quality of life questionnaire were performed. RESULTS When observing the symptom domains in the long-term, the pain domain appeared to improve most postoperatively after which it remained stable over time. The neurological and urological domains showed a stable, slightly decreasing trend in the long-term follow-up. The orthopedic domain showed a significant increase of the number of patients with scoliosis during the long-term follow-up. CONCLUSIONS Lasting effects of stability in the neurological, urological, and pain domains were observed. Close monitoring during follow-up might contribute to early recognition of progressive scoliosis, in spite of detethering, in a risk group defined by females who underwent tethered cord surgery at or under the age of 12 years old with either lipomyelomeningocele, split cord malformation, or myelomeningocele. Detethering does not appear to protect these patients against progressive scoliosis.
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Affiliation(s)
- S. E. Dulfer
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - G. Drost
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands ,Department of Neurology, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - F. Lange
- Department of Neurology, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - H. L. Journee
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - F. H. Wapstra
- Department of Orthopedics, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - E. W. Hoving
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
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Scibilia A, Raffa G, Rizzo V, Quartarone A, Visocchi M, Germanò A, Tomasello F. Intraoperative Neurophysiological Monitoring in Spine Surgery: A Significant Tool for Neuronal Protection and Functional Restoration. ACTA NEUROCHIRURGICA SUPPLEMENT 2017; 124:263-270. [DOI: 10.1007/978-3-319-39546-3_38] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Prognostic value of intraoperative MEP signal improvement during surgical treatment of cervical compressive myelopathy. 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 2016; 25:1875-80. [DOI: 10.1007/s00586-016-4477-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 10/22/2022]
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