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Baig Mirza A, Vastani A, Syrris C, Boardman T, Ghani I, Murphy C, Gebreyohanes A, Vergani F, Mirallave-Pescador A, Lavrador JP, Kailaya Vasan A, Grahovac G. Intraoperative Neurophysiological Monitoring for Intradural Extramedullary Spinal Tumours. Global Spine J 2024; 14:1304-1315. [PMID: 36411068 DOI: 10.1177/21925682221139822] [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] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Intraoperative neurophysiological monitoring (IONM) is widely used in spinal neurosurgery, particularly for intramedullary tumours. However, its validity in intradural extramedullary (IDEM) spinal tumours is less clearly defined, this being the focus of this study. METHODS We compared outcomes for patients that underwent resection of IDEM tumours with and without IONM between 2010 and 2020. Primary outcomes were postoperative American Spinal Injury Association (ASIA) scores. Other factors assessed were use of intraoperative ultrasound, drain placement, postoperative complications, postoperative Eastern Cooperative Oncology Group (ECOG) score, extent of resection, length of hospital stay, discharge location and recurrence. RESULTS 163 patients were included, 71 patients in the IONM group and 92 in the non-IONM group. No significant differences were noted in baseline demographics. For preoperative ASIA D patients, 44.0% remained ASIA D and 49.9% improved to ASIA E in the IONM group, compared to 39.7% and 30.2% respectively in the non-IONM group. For preoperative ASIA E patients, 50.3% remained ASIA E and 44.0% deteriorated to ASIA D in the IONM group, compared to 30.2% and 39.7% respectively in the non-IONM group (all other patients deteriorated further). Length of inpatient stay was significantly shorter in the IONM group (P = .043). There were no significant differences in extent of resection, postoperative complications, discharge location or tumour recurrence. CONCLUSIONS Research focusing on the use of IONM in IDEM tumour surgery remains scarce. Our study supports the use of IONM during surgical excision of IDEM tumours.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Amisha Vastani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Christoforos Syrris
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Timothy Boardman
- GKT School of Medical Education, King's College London, London, UK
| | - Imran Ghani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Christopher Murphy
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Axumawi Gebreyohanes
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Francesco Vergani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Ana Mirallave-Pescador
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
- Department of Clinical Neurophysiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Jose P Lavrador
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Ahilan Kailaya Vasan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Gordan Grahovac
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
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Fehlings MG, Quddusi A, Skelly AC, Brodt ED, Moghaddamjou A, Malvea A, Hejrati N, Srikandarajah N, Alvi MA, Stabler-Morris S, Dettori JR, Tetreault LA, Evaniew N, Kwon BK. Definition, Frequency and Risk Factors for Intra-Operative Spinal Cord Injury: A Knowledge Synthesis. Global Spine J 2024; 14:80S-104S. [PMID: 38526927 DOI: 10.1177/21925682231190613] [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] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN Mixed-methods approach. OBJECTIVES Intra-operative spinal cord injury (ISCI) is a devastating complication of spinal surgery. Presently, a uniform definition for ISCI does not exist. Consequently, the reported frequency of ISCI and important risk factors vary in the existing literature. To address these gaps in knowledge, a mixed-methods knowledge synthesis was undertaken. METHODS A scoping review was conducted to review the definitions used for ISCI and to ascertain the frequency of ISCI. The definition of ISCI underwent formal review, revision and voting by the Guidelines Development Group (GDG). A systematic review of the literature was conducted to determine the risk factors for ISCI. Based on this systematic review and GDG input, a table was created to summarize the factors deemed to increase the risk for ISCI. All reviews were done according to PRISMA standards and were registered on PROSPERO. RESULTS The frequency of ISCI ranged from 0 to 61%. Older age, male sex, cardiovascular disease including hypertension, severe myelopathy, blood loss, requirement for osteotomy, coronal deformity angular ratio, and curve magnitude were associated with an increased risk of ISCI. Better pre-operative neurological status and use of intra-operative neuromonitoring (IONM) were associated with a decreased risk of ISCI. The risk factors for ISCI included a rigid thoracic curve with high deformity angular ratio, revision congenital deformity with significant cord compression and myelopathy, extrinsic intradural or extradural lesions with cord compression and myelopathy, intramedullary spinal cord tumor, unstable spine fractures (bilateral facet dislocation and disc herniation), extension distraction injury with ankylosing spondylitis, ossification of posterior longitudinal ligament (OPLL) with severe cord compression, and moderate to severe myelopathy. CONCLUSIONS ISCI has been defined as "a new or worsening neurological deficit attributable to spinal cord dysfunction during spine surgery that is diagnosed intra-operatively via neurophysiologic monitoring or by an intraoperative wake-up test, or immediately post-operatively based on clinical assessment". This paper defines clinical and imaging factors which increase the risk for ISCI and that could assist clinicians in decision making.
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Affiliation(s)
- Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ayesha Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | | | - Ali Moghaddamjou
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Anahita Malvea
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nader Hejrati
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Nisaharan Srikandarajah
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | | | | | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
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Fehlings MG, Alvi MA, Evaniew N, Tetreault LA, Martin AR, McKenna SL, Rahimi-Movaghar V, Ha Y, Kirshblum S, Hejrati N, Srikandarajah N, Quddusi A, Moghaddamjou A, Malvea A, Pinto RR, Marco RAW, Newcombe VFJ, Basu S, Strantzas S, Zipser CM, Douglas S, Laufer I, Chou D, Saigal R, Arnold PM, Hawryluk GWJ, Skelly AC, Kwon BK. A Clinical Practice Guideline for Prevention, Diagnosis and Management of Intraoperative Spinal Cord Injury: Recommendations for Use of Intraoperative Neuromonitoring and for the Use of Preoperative and Intraoperative Protocols for Patients Undergoing Spine Surgery. Global Spine J 2024; 14:212S-222S. [PMID: 38526921 DOI: 10.1177/21925682231202343] [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] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN Development of a clinical practice guideline following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. OBJECTIVE The objectives of this study were to develop guidelines that outline the utility of intraoperative neuromonitoring (IONM) to detect intraoperative spinal cord injury (ISCI) among patients undergoing spine surgery, to define a subset of patients undergoing spine surgery at higher risk for ISCI and to develop protocols to prevent, diagnose, and manage ISCI. METHODS All systematic reviews were performed according to PRISMA standards and registered on PROSPERO. A multidisciplinary, international Guidelines Development Group (GDG) reviewed and discussed the evidence using GRADE protocols. Consensus was defined by 80% agreement among GDG members. A systematic review and diagnostic test accuracy (DTA) meta-analysis was performed to synthesize pooled evidence on the diagnostic accuracy of IONM to detect ISCI among patients undergoing spinal surgery. The IONM modalities evaluated included somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), electromyography (EMG), and multimodal neuromonitoring. Utilizing this knowledge and their clinical experience, the multidisciplinary GDG created recommendations for the use of IONM to identify ISCI in patients undergoing spine surgery. The evidence related to existing care pathways to manage ISCI was summarized and based on this a novel AO Spine-PRAXIS care pathway was created. RESULTS Our recommendations are as follows: (1) We recommend that intraoperative neurophysiological monitoring be employed for high risk patients undergoing spine surgery, and (2) We suggest that patients at "high risk" for ISCI during spine surgery be proactively identified, that after identification of such patients, multi-disciplinary team discussions be undertaken to manage patients, and that an intraoperative protocol including the use of IONM be implemented. A care pathway for the prevention, diagnosis, and management of ISCI has been developed by the GDG. CONCLUSION We anticipate that these guidelines will promote the use of IONM to detect and manage ISCI, and promote the use of preoperative and intraoperative checklists by surgeons and other team members for high risk patients undergoing spine surgery. We welcome teams to implement and evaluate the care pathway created by our GDG.
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Affiliation(s)
- Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Nathan Evaniew
- Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | | | - Allan R Martin
- Department of Neurological Surgery, University of California, Davis, Davis, CA, USA
| | | | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Yoon Ha
- Department of Neurosurgery, College of Medicine, Yonsei University, Seoul, Korea
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Nader Hejrati
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Nisaharan Srikandarajah
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Ayesha Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ali Moghaddamjou
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Anahita Malvea
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ricardo Rodrigues Pinto
- Spinal Unit (UVM), Centro Hospitalar Universitário de Santo António, Hospital CUF Trindade, Porto, Portugal
| | - Rex A W Marco
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Virginia F J Newcombe
- Department of Medicine, University Division of Anaesthesia and PACE, University of Cambridge, Cambridge, UK
| | | | - Samuel Strantzas
- Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Carl M Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Sam Douglas
- Praxis Spinal Cord Institute, Vancouver, BC, Canada
| | - Ilya Laufer
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Dean Chou
- Department of Neurosurgery, Columbia University, New York, NY, USA
| | - Rajiv Saigal
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Paul M Arnold
- Department of Neurosurgery, University of Illinois Champaign-Urbana, Urbana, IL, USA
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Cleveland Clinic Akron GeneralHospital, Akron, OH, USA
| | | | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
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Antkowiak L, Putz M, Sordyl R, Pokora S, Mandera M. Predictive Value of Motor Evoked Potentials in the Resection of Intradural Extramedullary Spinal Tumors in Children. J Clin Med 2022; 12:jcm12010041. [PMID: 36614841 PMCID: PMC9821272 DOI: 10.3390/jcm12010041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/04/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
This study aimed to evaluate the predictive value of motor evoked potentials (MEP) in the resection of pediatric intradural extramedullary (IDEM) tumors. Additionally, we aimed to assess the impact of MEP alerts on the extent of tumor resection. Medical records of pediatric patients who underwent resection of IDEM tumors with the assistance of MEP between March 2011 and October 2020 were reviewed. The occurrence of postoperative motor deficits was correlated with intraoperative MEP alerts. Sixteen patients were included. MEP alerts appeared in 2 patients (12.5%), being reflective of new postoperative motor deficits. Among the remaining 14 patients without any intraoperative MEP alerts, no motor decline was found. Accordingly, MEP significantly predicted postoperative motor deficits, reaching sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 100% (p < 0.001). In the absence of MEP alerts, 11 out of 14 patients (78.6%) underwent GTR, while no patient with intraoperative IONM alerts underwent GTR (p = 0.025). Although MEP alerts limit the extent of tumor resection, the high sensitivity and PPV of MEP underline its importance in avoiding iatrogenic motor deficits. Concurrently, high specificity and NPV ensure safer tumor excision. Therefore, MEP can reliably support surgical decisions in pediatric patients with IDEM tumors.
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Yamada S, Kawajiri S, Arishma H, Isozaki M, Yamauchi T, Akazawa A, Kidoguchi M, Kodera T, Shibaike Y, Umeda H, Tsukinowa Y, Hagihara R, Kikuta K. Prediction of Post-operative Long-Term Outcome of the Motor Function by Multimodal Intraoperative Neuromonitoring With Transcranial Motor-Evoked Potential and Spinal Cord-Evoked Potential After Microsurgical Resection for Spinal Cord Tumors. Front Surg 2022; 9:883832. [PMID: 35599809 PMCID: PMC9114470 DOI: 10.3389/fsurg.2022.883832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo examine the effect of multimodal intraoperative neuromonitoring on the long-term outcome of motor function after microsurgical resection for spinal cord tumors.Materials and MethodsConsecutive fourteen patients with spinal tumors who were surgically treated at the University of Fukui Hospital between 2009 and 2020 [M:F = 10:4, ages ranging from 22 to 83 years (mean ± SD = 58 ± 21 years)] were included in this study. There were eight intra-axial tumors and six extra-axial tumors. There were four patients with hypertension, two patients with diabetes mellitus, and four patients with hyperlipidemia. Three patients were under antithrombotic medication, two were under steroid medication, four were current smokers, and four were current drinkers. Manual muscle test (MMT) of the upper and lower extremities of the patients was examined before surgery, 2 weeks after surgery, and at the final follow-up. The mean follow-up period was 38 ± 37 months. McCormick scores were examined before surgery and at the final follow-up. Microsurgical resection of the tumor was underwent through the posterior approach under transcranial motor-evoked potential (TcMEP) monitoring. The MEP of 46 extremities was recorded during the surgery. Gross total resection was achieved in 13 of 14 surgeries. Spinal cord-evoked potential (Sp-SCEP) monitoring was performed in eight of 14 patients.ResultsThe length of peritumoral edema was significantly longer in patients with deterioration of McCormick scores than in patients with preservation of McCormick scores (p = 0.0274). Sp-SCEP could not predict the deterioration. The ratio of MEP at the beginning of the surgery to that at the end of the surgery was the only significant negative factor that predicts deterioration of motor function of the extremity at the final follow-up (p = 0.0374, odds ratio [OR] 1.02E-05, 95% CI 9.13E+01–7.15E+18). A receiver operating characteristic (ROC) analysis revealed that the cutoff value of the ratio of MEP to predict the deterioration at the final follow-up was 0.23 (specificity 100%, specificity 88%, positive predictive value 100%, and negative predictive value 88%) to predict deterioration at the final follow-up.ConclusionsRatio MEP was the most significant negative factor to predict the deterioration of motor weakness at spinal tumor surgery. The setting of the cutoff value should be more strict as compared to the brain surgery and might be different depending on the institutions.
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Yoo M, Park YG, Cho YE, Lim CH, Chung SY, Kim D, Park J. Intraoperative evoked potentials in patients with ossification of posterior longitudinal ligament. J Clin Monit Comput 2021; 36:247-258. [PMID: 33548015 DOI: 10.1007/s10877-020-00646-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 12/30/2020] [Indexed: 11/28/2022]
Abstract
Preoperative somatosensory evoked potentials (preSEPs) are used to evaluate the severity of myelopathy, and intraoperative neurophysiological monitoring (IONM) is used to reduce iatrogenic damage during operations. However, the correlation between preSEPs and IONM on postoperative neurologic deterioration (PND) in ossification of the posterior longitudinal ligament (OPLL) has not been studied. Thus, under the hypothesis that the patients with deteriorated preSEPs would be more likely to have significant changes in intraoperative SEPs (ioSEPs), and that this would be correlated with PND, we investigated the prognostic value of preSEPs on IONM and PND. This retrospective study included 265 patients who underwent preSEPs and IONM between January 2015 and July 2019. Muscle strength, the sensory scale of the Japanese Orthopaedic Association score examined within 3 days preoperatively, and at 48 h and 4 weeks postoperatively, was analysed. PreSEPs and intraoperative SEPs (ioSEPs) were recorded by stimulating the median and tibial nerves. Intraoperative motor evoked potentials (ioMEPs) were elicited by transcranial electrical stimulation over the motor cortex. PreSEPs latency prolongation of the median and tibial nerves showed significant correlations with ioSEPs. PMD at 48 h or 4 weeks after surgery correlated with ioSEPs and ioMEPs amplitudes. Postoperative sensory deterioration (PSD) at 48 h or 4 weeks after surgery correlated with latency prolongation of ioSEPs. There was a positive correlation between amount of blood loss and maximum percentage of ioSEPs latency prolongation and a negative correlation with PMD at 48 h and 4 weeks postoperatively. PreSEPs predict significant changes in ioSEPs. Furthermore, bleeding control is important to reduce PMD in OPLL.
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Affiliation(s)
- Myungeun Yoo
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06229, Republic of Korea
| | - Yoon Ghil Park
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06229, Republic of Korea
| | - Yong Eun Cho
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chae Hwan Lim
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06229, Republic of Korea
| | - Seok Young Chung
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06229, Republic of Korea
| | - Dawoon Kim
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06229, Republic of Korea
| | - Jinyoung Park
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06229, Republic of Korea.
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Cofano F, Giambra C, Costa P, Zeppa P, Bianconi A, Mammi M, Monticelli M, Di Perna G, Junemann CV, Melcarne A, Massaro F, Ducati A, Tartara F, Zenga F, Garbossa D. Management of Extramedullary Intradural Spinal Tumors: The Impact of Clinical Status, Intraoperative Neurophysiological Monitoring and Surgical Approach on Outcomes in a 12-Year Double-Center Experience. Front Neurol 2020; 11:598619. [PMID: 33391161 PMCID: PMC7775672 DOI: 10.3389/fneur.2020.598619] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/19/2020] [Indexed: 12/15/2022] Open
Abstract
Objective: Intradural Extramedullary (IDEM) tumors are usually treated with surgical excision. The aim of this study was to investigate the impact on clinical outcomes of pre-surgical clinical conditions, intraoperative neurophysiological monitoring (IONM), surgical access to the spinal canal, histology, degree of resection and intra/postoperative complications. Methods: This is a retrospective observational study analyzing data of patients suffering from IDEM tumors who underwent surgical treatment over a 12 year period in a double-center experience. Data were extracted from a prospectively maintained database and included: sex, age at diagnosis, clinical status according to the modified McCormick Scale (Grades I-V) at admission, discharge, and follow-up, tumor histology, type of surgical access to the spinal canal (bilateral laminectomy vs. monolateral laminectomy vs. laminoplasty), degree of surgical removal, use and type of IONM, occurrence and type of intraoperative complications, use of Ultrasonic Aspirator (CUSA), radiological follow-up. Results: A total number of 249 patients was included with a mean follow-up of 48.3 months. Gross total resection was achieved in 210 patients (84.3%) mostly in Schwannomas (45.2%) and Meningiomas (40.4%). IONM was performed in 162 procedures (65%) and D-wave was recorded in 64.2% of all cervical and thoracic locations (99 patients). The linear regression diagram for McCormick grades before and after surgery (follow-up) showed a correlation between preoperative and postoperative clinical status. A statistically significant correlation was found between absence of worsening of clinical condition at follow-up and use of IONM at follow-up (p = 0.01) but not at discharge. No associations were found between the choice of surgical approach and the extent of resection (p = 0.79), the presence of recurrence or residual tumor (p = 0.14) or CSF leakage (p = 0.25). The extent of resection was not associated with the use of IONM (p = 0.91) or CUSA (p = 0.19). Conclusion: A reliable prediction of clinical improvement could be made based on pre-operative clinical status. The use of IONM resulted in better clinical outcomes at follow-up (not at discharge), but no associations were found with the extent of resection. The use of minimally invasive approaches such as monolateral laminectomy showed to be effective and not associated with worse outcomes or increased complications.
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Affiliation(s)
- Fabio Cofano
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy.,Ospedale Humanitas Gradenigo, Turin, Italy
| | | | - Paolo Costa
- Section of Clinical Neurophysiology, Centro Traumatologico Ortopedico Hospital, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Pietro Zeppa
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Andrea Bianconi
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Marco Mammi
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Matteo Monticelli
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Giuseppe Di Perna
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Carola Vera Junemann
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Antonio Melcarne
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Fulvio Massaro
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | | | - Fulvio Tartara
- Unit of Neurosurgery, Istituto Clinico Città Studi (ICCS), Milan, Italy
| | - Francesco Zenga
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Diego Garbossa
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
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Park D, Kim BH, Lee SE, Park JK, Cho JM, Kwon HD, Lee SY. Spinal Cord Infarction: A Single Center Experience and the Usefulness of Evoked Potential as an Early Diagnostic Tool. Front Neurol 2020; 11:563553. [PMID: 33192998 PMCID: PMC7652817 DOI: 10.3389/fneur.2020.563553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/14/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Spinal cord infarction (SCI) is a rare disease and its early diagnosis is challenging. Here, we described the clinical features and imaging findings of SCI, and assessed the results of evoked potential (EP) studies to elucidate their diagnostic role in the early stage of SCI. Methods: We retrospectively analyzed 14 patients who had spontaneous SCI. The demographic, neurological, and temporal profiles of the SCI patients were identified. We reviewed the imaging findings and assessed the changes in them over time. To review EP, central motor conduction time (CMCT) and somatosensory evoked potential (SEP) values were obtained. We also enrolled 15 patients with transverse myelitis (TM), and compared the clinical, radiological and electrophysiological features between SCI and TM patients. Results: The ages of the SCI patients ranged from 54 to 73 years. Nine patients (64.3%) showed nadir deficits within 6 h. The most common type of clinical visit was via the emergency center. Nine patients (64.3%) presented with peri-onset focal pain. The median initial modified Rankin scale score was 3. For 9 patients (64.3%), initial T2 imaging findings were negative, but subsequent diffusion weighed imaging (DWI) showed diffusion restriction. Vertebral body infarction was observed in 5 patients (35.7%). EP data were available for 10 SCI patients. All 8 patients who had their CMCT measured showed abnormalities. Among them, motor evoked potentials were not evoked in 6 patients at all. SEP was measured in 10 patients, and 9 of them showed abnormalities; one of them showed no SEP response. For 5 patients, the EP studies were done prior to DWI, and all the patients showed definite abnormalities. The abnormalities in the EP findings of the SCI patients were more profound than those of the TM patients, even though the duration from the onset to the start of the study was much shorter for SCI patients. Conclusion: SCI can be diagnosed based on typical clinical manifestations and appropriate imaging studies. Our study also indicates that immediate sensory and motor EP study can have an adjuvant diagnostic role in the hyperacute stage of SCI, and can improve the accuracy of diagnosis.
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Affiliation(s)
- Dougho Park
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Byung Hee Kim
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Sang Eok Lee
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Ji Kang Park
- Department of Radiology, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Jae Man Cho
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Heum Dai Kwon
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Su Yun Lee
- Department of Neurology, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
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Ishida W, Casaos J, Chandra A, D'Sa A, Ramhmdani S, Perdomo-Pantoja A, Theodore N, Jallo G, Gokaslan ZL, Wolinsky JP, Sciubba DM, Bydon A, Witham TF, Lo SFL. Diagnostic and therapeutic values of intraoperative electrophysiological neuromonitoring during resection of intradural extramedullary spinal tumors: a single-center retrospective cohort and meta-analysis. J Neurosurg Spine 2019; 30:839-849. [PMID: 30835707 DOI: 10.3171/2018.11.spine181095] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/09/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE With the advent of intraoperative electrophysiological neuromonitoring (IONM), surgical outcomes of various neurosurgical pathologies, such as brain tumors and spinal deformities, have improved. However, its diagnostic and therapeutic value in resecting intradural extramedullary (ID-EM) spinal tumors has not been well documented in the literature. The objective of this study was to summarize the clinical results of IONM in patients with ID-EM spinal tumors. METHODS A retrospective patient database review identified 103 patients with ID-EM spinal tumors who underwent tumor resection with IONM (motor evoked potentials, somatosensory evoked potentials, and free-running electromyography) from January 2010 to December 2015. Patients were classified as those without any new neurological deficits at the 6-month follow-up (group A; n = 86) and those with new deficits (group B; n = 17). Baseline characteristics, clinical outcomes, and IONM findings were collected and statistically analyzed. In addition, a meta-analysis in compliance with the PRISMA guidelines was performed to estimate the overall pooled diagnostic accuracy of IONM in ID-EM spinal tumor resection. RESULTS No intergroup differences were discovered between the groups regarding baseline characteristics and operative data. In multivariate analysis, significant IONM changes (p < 0.001) and tumor location (thoracic vs others, p = 0.018) were associated with new neurological deficits at the 6-month follow-up. In predicting these changes, IONM yielded a sensitivity of 82.4% (14/17), specificity of 90.7% (78/86), positive predictive value (PPV) of 63.6% (14/22), negative predictive value (NPV) of 96.3% (78/81), and area under the curve (AUC) of 0.893. The diagnostic value slightly decreased in patients with schwannomas (AUC = 0.875) and thoracic tumors (AUC = 0.842). Among 81 patients who did not demonstrate significant IONM changes at the end of surgery, 19 patients (23.5%) exhibited temporary intraoperative exacerbation of IONM signals, which were recovered by interruption of surgical maneuvers; none of these patients developed new neurological deficits postoperatively. Including the present study, 5 articles encompassing 323 patients were eligible for this meta-analysis, and the overall pooled diagnostic value of IONM was a sensitivity of 77.9%, a specificity of 91.1%, PPV of 56.7%, and NPV of 95.7%. CONCLUSIONS IONM for the resection of ID-EM spinal tumors is a reasonable modality to predict new postoperative neurological deficits at the 6-month follow-up. Future prospective studies are warranted to further elucidate its diagnostic and therapeutic utility.
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Affiliation(s)
- Wataru Ishida
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joshua Casaos
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Arun Chandra
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam D'Sa
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Seba Ramhmdani
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Nicholas Theodore
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - George Jallo
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- 4Department of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Ziya L Gokaslan
- 2Department of Neurosurgery, Brown University School of Medicine, Providence, Rhode Island
| | - Jean-Paul Wolinsky
- 3Department of Neurological Surgery, Northwestern University, Chicago, Illinois; and
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ali Bydon
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy F Witham
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sheng-Fu L Lo
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Kim JS, Jang MJ, Hyun SJ, Kim KJ, Jahng TA, Kim HJ, Kim SM, Park KS. Failure to generate baseline muscle motor evoked potentials during spine surgery: Risk factors and association with the postoperative outcomes. Clin Neurophysiol 2018; 129:2276-2283. [DOI: 10.1016/j.clinph.2018.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/20/2018] [Accepted: 08/01/2018] [Indexed: 12/01/2022]
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