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Toleikis JR, Pace C, Jahangiri FR, Hemmer LB, Toleikis SC. Intraoperative somatosensory evoked potential (SEP) monitoring: an updated position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput 2024:10.1007/s10877-024-01201-x. [PMID: 39068294 DOI: 10.1007/s10877-024-01201-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 07/16/2024] [Indexed: 07/30/2024]
Abstract
Somatosensory evoked potentials (SEPs) are used to assess the functional status of somatosensory pathways during surgical procedures and can help protect patients' neurological integrity intraoperatively. This is a position statement on intraoperative SEP monitoring from the American Society of Neurophysiological Monitoring (ASNM) and updates prior ASNM position statements on SEPs from the years 2005 and 2010. This position statement is endorsed by ASNM and serves as an educational service to the neurophysiological community on the recommended use of SEPs as a neurophysiological monitoring tool. It presents the rationale for SEP utilization and its clinical applications. It also covers the relevant anatomy, technical methodology for setup and signal acquisition, signal interpretation, anesthesia and physiological considerations, and documentation and credentialing requirements to optimize SEP monitoring to aid in protecting the nervous system during surgery.
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Affiliation(s)
| | | | - Faisal R Jahangiri
- Global Innervation LLC, Dallas, TX, USA
- Department of Neuroscience, School of Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, TX, USA
| | - Laura B Hemmer
- Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Daroszewski P, Huber J, Kaczmarek K, Janusz P, Główka P, Tomaszewski M, Kotwicki T. "Real-Time Neuromonitoring" Increases the Safety and Non-Invasiveness and Shortens the Duration of Idiopathic Scoliosis Surgery. J Clin Med 2024; 13:1497. [PMID: 38592334 PMCID: PMC10934752 DOI: 10.3390/jcm13051497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 02/26/2024] [Accepted: 03/02/2024] [Indexed: 04/10/2024] Open
Abstract
Introduction: A practical solution to the incidental unreliability of intraoperative neuromonitoring (IONM) may be the simultaneous neurophysiological recording and control of the surgical field through a camera (the concept of "Real-time" IONM). During "Real-time" IONM, the surgeon is immediately warned about the possibility of damage to the neural structures during, but not after, standard idiopathic scoliosis (IS) corrective surgery procedures (the concept of "Surgeon-neurophysiologist" interactive, verbal IONM). This study aimed to compare the advantages, utilities, reliabilities, and time consumption of the two IONM scenarios. Methods: Studies were performed in two similar groups of patients undergoing surgery primarily due to Lenke 2 idiopathic scoliosis (N = 120), when both IONM approaches were applied. Neurophysiological evaluations of the spinal transmission were performed pre- (T0), intra- (before (T1) and after (T2) surgery), and postoperatively (T3), as well as once in healthy volunteers (control, N = 60). Non-invasive and innovative recordings of the motor evoked potentials (MEPs) bilaterally from the peroneal (PER) nerve and tibialis anterior (TA) muscle were performed with surface electrodes as a result of transcranial magnetic stimulation (TMS) or electrical stimulation (TES) at T0-T3. Results: In both groups, the MEP amplitudes and latencies recorded from the PER nerve were approximately 67% lower and 3.1 ms shorter than those recorded from the TA muscle. The MEP recording parameters differed similarly at T0-T3 compared to the control group. In all patients, the MEP parameters induced by TMS (T0) and TES (T1) did not differ. The MEP amplitude parameters recorded from the TA and PER at T1 and T2 indicated a bilateral improvement in the neural spinal conduction due to the surgical intervention. The TMS-induced MEP amplitude at T3 further increased bilaterally. In both IONM groups, an average 51.8 BIS level of anesthesia did not affect the variability in the MEP amplitude, especially in the PER recordings when the applied TES strength was 98.2 mA. The number of fluctuations in the MEP parameters was closely related to the number of warnings from the neurophysiologist during the transpedicular screw implantation, corrective rod implantation, and distraction, derotation, and compression procedures, and it was higher in the "Surgeon-neurophysiologist" IONM group. The average duration of surgery was shorter by approximately one hour in the "Real-time" IONM group. The number of two-way communications between the surgeon and the neurophysiologist and vice versa in the "Real-time" IONM group decreased by approximately half. Conclusions: This study proves the superiority of using "Real-time" IONM over the standard "Surgeon-neurophysiologist" IONM procedure in increasing the safety and non-invasiveness, shortening the time, and lowering the costs of the surgical treatment of IS patients. The modifications of the MEP nerve-conduction-recording technology with surface electrodes from nerves enable precise and reliable information on the pediatric patient's neurological condition at every stage of the applied surgical procedures, even under conditions of slight fluctuations in anesthesia.
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Affiliation(s)
- Przemysław Daroszewski
- Department of Organization and Management in Health Care, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Street, No. 135/147, 61-545 Poznań, Poland;
| | - Juliusz Huber
- Department Pathophysiology of Locomotor Organs, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Street, No. 135/147, 61-545 Poznań, Poland;
| | - Katarzyna Kaczmarek
- Department Pathophysiology of Locomotor Organs, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Street, No. 135/147, 61-545 Poznań, Poland;
| | - Piotr Janusz
- Department of Spine Disorders and Pediatric Orthopaedics, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Street, No. 135/147, 61-545 Poznań, Poland; (P.J.); (P.G.); (M.T.); (T.K.)
| | - Paweł Główka
- Department of Spine Disorders and Pediatric Orthopaedics, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Street, No. 135/147, 61-545 Poznań, Poland; (P.J.); (P.G.); (M.T.); (T.K.)
| | - Marek Tomaszewski
- Department of Spine Disorders and Pediatric Orthopaedics, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Street, No. 135/147, 61-545 Poznań, Poland; (P.J.); (P.G.); (M.T.); (T.K.)
| | - Tomasz Kotwicki
- Department of Spine Disorders and Pediatric Orthopaedics, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Street, No. 135/147, 61-545 Poznań, Poland; (P.J.); (P.G.); (M.T.); (T.K.)
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Gupta MC, Lenke LG, Gupta S, Farooqi AS, Boachie-Adjei O, Erickson MA, Newton PO, Samdani AF, Shah SA, Shufflebarger HL, Sponseller PD, Sucato DJ, Kelly MP. Intraoperative neuromonitoring predicts postoperative deficits in severe pediatric spinal deformity patients. Spine Deform 2024; 12:109-118. [PMID: 37555880 DOI: 10.1007/s43390-023-00745-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 07/26/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE To evaluate intraoperative monitoring (IOM) alerts and neurologic deficits during severe pediatric spinal deformity surgery. METHODS Patients with a minimum Cobb angle of 100° in any plane or a scheduled vertebral column resection (VCR) with minimum 2-year follow-up were prospectively evaluated (n = 243). Preoperative, immediate postoperative, and 2-year postoperative neurologic status were reported. Radiographic data included preoperative and 2-year postoperative coronal and sagittal Cobb angles and deformity angular ratios (DAR). IOM alert type and triggering event were recorded. SRS-22r scores were collected preoperatively and 2-years postoperatively. RESULTS IOM alerts occurred in 37% of procedures with three-column osteotomy (n = 36) and correction maneuver (n = 32) as most common triggering events. Patients with IOM alerts had greater maximum kyphosis (101.4° vs. 87.5°) and sagittal DAR (16.8 vs. 12.7) (p < 0.01). Multivariate regression demonstrated that sagittal DAR independently predicted IOM alerts (OR 1.05, 95% CI 1.02-1.08) with moderate sensitivity (60.2%) and specificity (64.8%) using a threshold value of 14.3 (p < 0.01). IOM alerts occurred more frequently in procedures with new postoperative neurologic deficits (17/24), and alerts with both SSEP and TCeMEP signals were associated with new postoperative deficits (p < 0.01). Most patients with new deficits experienced resolution at 2 years (16/20) and had equivalent postoperative SRS-22r scores. However, patients with persistent deficits had worse SRS-22r total score (3.8 vs. 4.2), self-image subscore (3.5 vs. 4.1), and function subscore (3.8 vs. 4.3) (p ≤ 0.04). CONCLUSION Multimodal IOM alerts are associated with sagittal kyphosis, and predict postoperative neurologic deficits. Most patients with new deficits experience resolution of their symptoms and have equivalent 2-year outcomes. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Munish C Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 S. Euclid, Campus, Box 8233, Saint Louis, MO, 63110, USA.
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Medical Center New York, New York, USA
| | - Sachin Gupta
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Ali S Farooqi
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Mark A Erickson
- Department of Orthopaedic Surgery, Children's Hospital Colorado, Aurora, USA
| | - Peter O Newton
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, USA
| | - Amer F Samdani
- Department of Orthopaedic Surgery, Shriners Hospitals for Children Philadelphia, Philadelphia, USA
| | - Suken A Shah
- Department of Orthopaedic Surgery, Nemours/Alfred I duPont Hospital for Children, Wilmington, USA
| | - Harry L Shufflebarger
- Department of Orthopaedic Surgery, Paley Orthopedic and Spine Institute at St. Mary's Medical Center, West Palm Beach, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Daniel J Sucato
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, USA
| | - Michael P Kelly
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 S. Euclid, Campus, Box 8233, Saint Louis, MO, 63110, USA
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Liu K, Ma C, Li D, Li H, Dong X, Liu B, Yu Y, Fan Y, Song H. The role of intraoperative neurophysiological monitoring in intramedullary spinal cord tumor surgery. Chin Neurosurg J 2023; 9:33. [PMID: 38031178 PMCID: PMC10685460 DOI: 10.1186/s41016-023-00348-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Abstract
Intramedullary tumors are a class of central nervous system tumors with an incidence of 2 to 4%. As they are located very deep and frequently cause postoperative neurological complications, surgical resection is difficult. In recent years, many surgeons have performed electrophysiological monitoring to effectively reduce the occurrence of postoperative neurological complications. Modern electrophysiological monitoring technology has advanced considerably, leading to the development of many monitoring methods, such as SSEPs, MEPs, DCM, and EMG, to monitor intramedullary tumors. However, electrophysiological monitoring in tumor resection is still being studied. In this article, we discussed the different monitoring methods and their role in monitoring intramedullary tumors by reviewing previous studies. Intratumorally tumors need to be monitored for a summary of the condition of the patient. Only by using various monitoring methods flexibly and through clear communication between surgeons and neurophysiological experts can good decisions be made during surgery and positive surgical results be achieved.
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Affiliation(s)
- Kai Liu
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Chengyuan Ma
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Dapeng Li
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Haisong Li
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Xuechao Dong
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Bo Liu
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Ying Yu
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Yuxiang Fan
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Hongmei Song
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China.
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Guo X, Jiang C, Zhang Y, Chen Z, Hao D, Zhang H. Spermatogonial stem-cell-derived neural-like cell transplantation enhances the functional recovery of a rat spinal cord injury model: characterization of evoked potentials. Front Neurosci 2023; 17:1289581. [PMID: 37908621 PMCID: PMC10613671 DOI: 10.3389/fnins.2023.1289581] [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: 09/06/2023] [Accepted: 09/25/2023] [Indexed: 11/02/2023] Open
Abstract
Severe spinal cord injuries (SCIs) usually result in the temporary or permanent impairment of strength, sensation or autonomic functions below the sites of injuries. To date, a large number of therapeutic approaches have been used to ameliorate SCIs, and subsequent stem cell transplantation appears to be a promising strategy. The aim of this study was to evaluate the therapeutic effect of stem cells by changes in the evoked potentials at different time points after a transplantation of spermatogonial stem cells (SSCs) to differentiate the source neurons in a rat model with SCIs, as well as through histopathology. A modified Plemel spinal cord lateral compression model was used. The experiment was divided into a blank, a control and a SSC transplantation group. Motor activity scores, sensory evoked potentials (SEPs) and motor evoked potentials (MEPs) were assessed through motor resuscitation as well as histologic evaluation on each experimental group to determine the improvement. Consistent with our results, motor scores and evoked potentials were significantly improved in the SSC transplantation group. In addition, a histologic assessment showed that the transplanted stem cells had a significant restorative effect on the reconstruction of tissue cells. 1 week after the stem cell transplantation, the SSC transplantation group showed improvement in spinal cord functions and spinal cord pathologic injuries. After 2 weeks and beyond, the SSC transplantation group showed significant improvement in spinal cord functions and spinal cord pathology compared to the control group, meanwhile the evoked potentials and motor function of the hind limbs of rats in the SSC transplantation group were significantly improved. Therefore, the therapeutic strategies for spermatogonial stem cells will be an effective program in the study on SCIs, and we suggest the somatosensory evoked potentials as a tool to assess the degree of recovery from SCIs after the transplantation of stem cells.
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Affiliation(s)
- Xinyu Guo
- Department of Orthopedics, The Second Hospital of Lanzhou University, Lanzhou, China
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi’an, China
| | - Chao Jiang
- Department of Orthopedics, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Yongjie Zhang
- Department of Electromyography, Hong Hui Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Zhe Chen
- Department of Orthopedics, The Second Hospital of Lanzhou University, Lanzhou, China
- Translational Medicine Center, Hong Hui Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Dingjun Hao
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi’an, China
| | - Haihong Zhang
- Department of Orthopedics, The Second Hospital of Lanzhou University, Lanzhou, China
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Pardessus P, Loiselle M, Silins V, Horlin AL, Brouns K, Marsac L, Fait C, Ilharreborde B, Julien-Marsollier F, Dahmani S. The association between intraoperative fluid management and perioperative allogenic blood transfusion during adolescent idiopathic scoliosis surgery. Paediatr Anaesth 2023; 33:829-836. [PMID: 37386846 DOI: 10.1111/pan.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Bleeding and transfusion remain important concerns during surgical correction of scoliosis even when multiple conservative strategies, such as preoperative recombinant erythropoietin and/or antifibrinolytic agents, are used. The current work aimed to determine the impact of other potential risk factors, especially the volume of intraoperative fluid intake, on the perioperative risk of allogenic transfusion during surgical correction of adolescent idiopathic scoliosis. METHODS This prospective study included all cases of adolescent idiopathic scoliosis operated in a single center during 2 years (2018-2020). Predictors analyzed were as follows: body mass index, preoperative hemoglobin concentration, thoracoplasty, preoperative halo-gravity, volume of intraoperative crystalloid administration, use of esophageal Doppler (for goal-directed fluid therapy), and duration of surgery. Statistical analyses were performed using a multivariable logistic regression model. RESULTS Two hundred patients were included in the analysis. Multivariable analysis found: an increased volume of intraoperative crystalloid administration as a significant predictor of allogenic blood transfusion. Receiving operator characteristics analysis found the model exhibiting an area under the curve of 0.85 (95% confidence interval: 0.75-0.95). Optimizing stroke volume using esophageal Doppler was associated with a decrease in intraoperative crystalloid intake. CONCLUSION These results indicate a statistical association between the increase in crystalloid intake and the risk of allogenic blood transfusion during surgical correction of adolescent idiopathic scoliosis. Controlled studies are needed to address the causative relation between intraoperative fluid intake and the risk of allogenic transfusion.
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Affiliation(s)
- Pierre Pardessus
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Maud Loiselle
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Vilnis Silins
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Anne-Laure Horlin
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Kelly Brouns
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Lucile Marsac
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Charlotte Fait
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Brice Ilharreborde
- Université de Paris-Cité, Paris, France
- FHU I2D2. Robert Debré Hospital, Paris, France
- Department of orthopedic surgery, Robert Debré Hospital, Paris, France
| | - Florence Julien-Marsollier
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
- FHU I2D2. Robert Debré Hospital, Paris, France
| | - Souhayl Dahmani
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
- FHU I2D2. Robert Debré Hospital, Paris, France
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Yen Hsin L, Samynathan C VV, Yilun H. White Cord Syndrome: A Treatment Dilemma. Cureus 2023; 15:e38177. [PMID: 37252488 PMCID: PMC10224717 DOI: 10.7759/cureus.38177] [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] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Spinal cord reperfusion injury following decompressive surgery is extremely rare. This complication is known as white cord syndrome (WCS). A 61-year-old male presented with chronic neck stiffness associated with left C6/C7 radiculopathy and numbness. Magnetic resonance imaging (MRI) of the cervical spine reported a severely narrowed left C6/C7 neural exit canal. C6/C7 anterior cervical decompression and fusion (ACDF) was performed. There was no significant intraoperative injury. On postoperative day 6, the patient developed bilateral C8 numbness, which started post-operation. He was treated for surgical site inflammation and was prescribed prednisolone and amitriptyline. However, his condition progressively worsened. At postoperative six weeks, there was right hemisensory loss, right triceps atrophy, and positive right Lhermitte's and Hoffman's tests. This subsequently progressed to right C7 weakness and bilateral lower limb radiculopathy at postoperative eight weeks. Postoperative MRI of the cervical spine revealed a new focal gliosis/edema within the spinal cord at C6/C7. The patient was treated conservatively with pregabalin and was referred for rehabilitation. Early diagnosis and treatment initiation are crucial in the management of WCS. Surgeons should be aware of this potential complication and counsel patients on the risk prior to surgery. Magnetic resonance imaging (MRI) remains the gold standard in the diagnosis of WCS. The current mainstay of treatment is high-dose steroids, intraoperative neurophysiological monitoring, and early recognition of postoperative WCS.
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Affiliation(s)
- Leong Yen Hsin
- Department of Orthopaedic Surgery, Sengkang General Hospital, Singapore, SGP
| | | | - Huang Yilun
- Department of Orthopaedic Surgery, Sengkang General Hospital, Singapore, SGP
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Characteristics of Tc-MEP Waveforms for Different Locations of Intradural Extramedullary Tumors: A Prospective Multicenter Study of the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research. Spine (Phila Pa 1976) 2022; 47:172-179. [PMID: 34474444 DOI: 10.1097/brs.0000000000004112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective multicenter study. OBJECTIVE To examine transcranial motor-evoked potential (Tc-MEP) waveforms in intraoperative neurophysiological monitoring in surgery for intradural extramedullary (IDEM) tumors, focused on the characteristics for cervical, thoracic, and conus lesions. SUMMARY OF BACKGROUND DATA IDEM tumors are normally curable after resection, but neurological deterioration may occur after surgery. Intraoperative neurophysiological monitoring using Tc-MEPs during surgery is important for timely detection of possible neurological injury. METHODS The subjects were 233 patients with IDEM tumors treated surgically with Tc-MEP monitoring at 9 centers. The alarm threshold was ≥70% waveform deterioration from baseline. A case with a Tc-MEP alert that normalized and had no new motor deficits postoperatively was defined as a rescue case. A deterioration of manual muscle test score ≥1 compared to the preoperative value was defined as postoperative worsening of motor status. RESULTS The 233 patients (92 males, 39%) had a mean age of 58.1 ± 18.1 years, and 185 (79%), 46 (20%), and 2 (1%) had schwannoma, meningioma, and neurofibroma. These lesions had cervical (C1-7), thoracic (Th1-10), and conus (Th11-L2) locations in 82 (35%), 96 (41%), and 55 (24%) cases. There were no significant differences in preoperative motor deficit among the lesion levels. Thoracic lesions had a significantly higher rate of poor baseline waveform derivation (0% cervical, 6% thoracic, 0% conus, P < 0.05) and significantly more frequent intraoperative alarms (20%, 31%, 15%, P < 0.05). Use of Tc-MEPs for predicting neurological deficits after IDEM surgery had sensitivity of 87% and specificity of 89%; however, the positive predictive value was low. CONCLUSION Poor derivation of waveforms, appearance of alarms, and worse final waveforms were all significantly more frequent for thoracic lesions. Thus, amplification of the waveform amplitude, using multimodal monitoring, and more appropriate interventions after an alarm may be particularly important in surgery for thoracic IDEM tumors.Level of Evidence: 3.
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Use of postoperative neurophysiological testing to help guide management in a case of delayed neurological injury. Childs Nerv Syst 2021; 37:2911-2916. [PMID: 33782729 DOI: 10.1007/s00381-021-05071-5] [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: 04/03/2020] [Accepted: 02/04/2021] [Indexed: 10/21/2022]
Abstract
Bimodal intraoperative neuromonitoring (IONM), combining transcranial motor-evoked potentials (tcMEP) and somatosensory-evoked potentials (SSEP), enables real-time detection and prevention of spinal cord injury during pediatric spinal deformity correction. Although rare, false-positive and false-negative signal alerts have been reported. However, no previously published accounts have described the use of postoperative neurophysiological testing to both identify new-onset neurological injury and guide reintervention. Here, we describe the case of an 18-year-old young man with achondroplasia, thoracolumbar kyphosis, and L2 wedge vertebra who underwent T12-L4 posterior spinal fusion with L2 vertebral column resection. Despite two intraoperative decreases in tcMEP amplitude, corrective measures on both occasions produced a return of IONM signal. Curiously, despite movement of the bilateral lower extremities upon waking, continued observation demonstrated minimal movement of the left lower extremity. Postoperative neurophysiological testing then identified limited muscle group activation below the left quadriceps, prompting operative reintervention. After cage removal and laminectomy lengthening, the patient recovered bilateral lower extremity function. He later returned to surgery for repeat cage placement at L2 via a retroperitoneal exposure, with no noted IONM changes and subsequent neurological improvement.
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Austerman RJ, Sulhan S, Steele WJ, Sadrameli SS, Holman PJ, Barber SM. The utility of intraoperative neuromonitoring on simple posterior lumbar fusions-analysis of the National Inpatient Sample. JOURNAL OF SPINE SURGERY (HONG KONG) 2021; 7:132-140. [PMID: 34296025 DOI: 10.21037/jss-20-679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/03/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Several studies have demonstrated the utility of intraoperative neuromonitoring (IOM) including somatosensory evoked potentials (SSEPs), motor-evoked potentials (MEPs), and electromyography (EMG), in decreasing the risk of neurologic injury in spinal deformity procedures. However, there is limited evidence supporting the routine use of IOM in elective posterolateral lumbar fusion (PLF). METHODS The National Inpatient Sample (NIS) was analyzed for the years 2012-2015 to identify patients undergoing elective PLF with (n=22,404) or without (n=111,168) IOM use. Statistical analyses were conducted to assess the impact of IOM on length of stay, total charges, and development of neurologic complications. These analyses controlled for age, gender, race, income percentile, primary expected payer, number of reported comorbidities, hospital teaching status, and hospital size. RESULTS The overall use of IOM in elective PLFs was found to have increased from 14.6% in the year 2012 to 19.3% in 2015. The total charge in hospitalization cost for all patients who received IOM increased from $129,384.72 in 2012 to $146,427.79 in 2015. Overall, the total charge of hospitalization was 11% greater in the IOM group when compared to those patients that did not have IOM (P<0.001). IOM did not have a statistically significant impact on the likelihood of developing a neurological complication. CONCLUSIONS While there may conceivably be benefits to the use of this technology in complex revision fusions or pathologies, we found no meaningful benefit of its application to single-level index PLF for degenerative spine disease.
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Affiliation(s)
- Ryan J Austerman
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Suraj Sulhan
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - William J Steele
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Saeed S Sadrameli
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Paul J Holman
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Sean M Barber
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
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De la Maza Krzeptowsky LC, San-Juan D, Ximénez Camilli C, Alvarez Perera LÁ, Valdez Ruvalcaba H, Morales Báez JA, Anschel DJ. Neurophysiological Intraoperative Monitoring in the Elderly. J Clin Neurophysiol 2021; 38:231-236. [PMID: 32141983 DOI: 10.1097/wnp.0000000000000689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Intraoperative neurophysiological monitoring (IONM) is widely used to prevent nervous system injury during surgeries in elderly patients. However, there are no studies that describe the characteristics and changes in neurophysiological tests during the IONM of patients aged 60 years and older. The study aims to describe and compare IONM changes during surgeries in adult patients aged 18 to 59 years with those aged 60 years and older. METHODS We performed a comparative retrospective study of patients aged 18 to 59 years versus those 60 aged years and older who underwent IONM during 2013 to 2018 in Mexico City. Sociodemographic characteristics were recorded and compared. Intraoperative neurophysiological monitoring techniques, their changes, and surgical procedures for both groups were analyzed and compared using descriptive statistics, Mann-Whitney U, Fisher, and χ2 tests. The sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS In total, 195 patients were analyzed: 104 patients, 68.63 ± 6.54 years old (elderly group) and 91 patients, 42.3 ± 10.5 years old (younger group). No differences were found in the rates of signal change during IONM between the group of elderly patients and the younger group. The sensitivity, specificity, and positive and negative predictive values were 80%, 99%, 80%, and 99%, respectively. CONCLUSIONS Elderly patients have a similar rate of changes in IONM signals compared with younger patients during heterogeneous surgeries guided by IONM.
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Affiliation(s)
| | - Daniel San-Juan
- Neurophysiology Department, Hospital Ángeles del Pedregal, México City, Mexico
- Neurology Department, National Institute of Neurology, Mexico City, Mexico
| | | | - Luis Á Alvarez Perera
- Neurophysiology Department, Hospital Ángeles del Pedregal, México City, Mexico
- Neurology Department, National Institute of Neurology, Mexico City, Mexico
| | | | | | - David J Anschel
- Comprehensive Epilepsy Center of Long Island, Port Jefferson, New York, U.S.A
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Intraoperative neuromonitoring practice patterns in spinal deformity surgery: a global survey of the Scoliosis Research Society. Spine Deform 2021; 9:315-325. [PMID: 33230669 DOI: 10.1007/s43390-020-00246-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/30/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Although multimodal IONM has reached a widespread use, several unresolved issues have remained in clinical practice. The aim was to determine differences in approaches to form a basis for taking actions to improve patient safety globally. METHODS A survey comprising 19 questions in four sections (demographics, setup, routine practices and reaction to alerts) was distributed to the membership of the SRS. RESULTS Of the estimated 1300 members, 205 (~ 15%) completed the survey. Respondent demographics reflected SRS member distribution. Most of the respondents had > 10 years of experience. TcMEP and SSEP were available to > 95%. Less than 5% reported that a MD/PhD with neurophysiology background routinely examines patients preoperatively, while 19% would consult if requested. After an uneventful case, 36% reported that they would decrease sedation and check motor function if the patient was to be transferred to ICU intubated. Reactions to dropped signals that recovered or did not fully recover varied between attempting the same correction to aborting the surgery with no rods and returning another day, with or without implant removal. After a decrease of signals, 85.7% use steroids of varied doses. Of the respondents, 53.7% reported using the consensus-created checklist by Vitale et al. Approximately, 14% reported never using the wake-up test while others use it for various conditions. CONCLUSION The responses of 205 experienced SRS members from different regions of the world showed that surgeons had different approaches in their routine IONM practices and in the handling of alerts. This survey indicates the need for additional studies to identify best practices.
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Bertrand HGMJ, Middleton JA, Baker SN, Glover I, Flecknell PA. Influence of alphaxalone on motor somatosensory evoked potentials in a female rhesus macaque ( Macaca mulatta). Lab Anim 2021; 55:363-366. [PMID: 33560908 PMCID: PMC8361466 DOI: 10.1177/0023677221990706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This communication reports the effect of alphaxalone on motor somatosensory evoked potential (SEPs) in a rhesus macaque. The animal was deeply anaesthetised with an infusion of ketamine, medetomidine, midazolam and alfentanil. The median nerve was stimulated, and SEPs were recorded from the motor cortex. The successive administration of three doses of alphaxalone (0.5, 1 and 2 mg/kg) induced an increase of the latency time and a decrease of the amplitude of the SEPs. However, the structure of the waveforms was conserved, and hence alphaxalone might represent a suitable general anaesthetic option in neuroscience research as well as veterinary or human medicine.
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Kurita T, Kawashima S, Ibrahim Khaleelullah MMS, Nakajima Y. Influence of hemorrhage and subsequent fluid resuscitation on transcranial motor-evoked potentials under desflurane anesthesia in a swine model. J Clin Monit Comput 2021; 36:239-246. [PMID: 33523354 DOI: 10.1007/s10877-020-00644-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/30/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Hemorrhage increases the effect of propofol and could contribute to false-positive transcranial motor-evoked potential (TcMEP) responses under total intravenous anesthesia (TIVA). We investigated the influence of hemorrhage and subsequent fluid resuscitation on TcMEPs under desflurane anesthesia. METHODS Sixteen swine (25.4 ± 0.4 kg) were anesthetized with a 4% end-tidal desflurane concentration (EtDes), which was incrementally increased to 6%, 8%, and 10% and then returned to 4% every 15 min. This procedure was repeated twice (baseline). After baseline measurements, animals were allocated to either the hemorrhage (n = 12) or control (n = 4) group. In the hemorrhage group, 600 ml of blood was removed and the EtDes protocol described above was applied. Hypovolemia was resuscitated using 600 ml of hydroxyethyl starch and the EtDes protocol was applied again. TcMEPs were measured at each EtDes. In the control group, measurements were performed without hemorrhage or fluid infusion. RESULTS TcMEP responses were observed in all conditions in all limbs with 4% EtDes (0.4 MAC). TcMEP amplitudes decreased according to the EtDes to a greater degree in the lower limbs compared with the upper limbs. Hemorrhage enhanced the effect of desflurane on TcMEP amplitudes, and decreased TcMEP by 41 ± 12% in upper limbs and 63 ± 17% in lower limbs compared with baseline. Subsequent fluid resuscitation did not reverse TcMEP amplitudes. CONCLUSIONS TcMEP amplitudes decrease during hemorrhage under desflurane anesthesia. This phenomenon might result from an enhanced effect of desflurane on the spinal motor pathway without increasing the desflurane concentration.
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Affiliation(s)
- Tadayoshi Kurita
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan.
| | - Shingo Kawashima
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | | | - Yoshiki Nakajima
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
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Hatef J, Katzir M, Toop N, Islam M, Clark T, Roscoe C, Khan S, Mendel E. Damned if you monitor, damned if you don't: medical malpractice and intraoperative neuromonitoring for spinal surgery. Neurosurg Focus 2020; 49:E19. [PMID: 33130617 DOI: 10.3171/2020.8.focus20580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to identify trends in medical malpractice litigation related to intraoperative neuromonitoring. METHODS The Westlaw Edge legal research service was queried for malpractice litigation related to neuromonitoring in spine surgery. Cases were reviewed to determine if the plaintiff's assertion of negligence was due to either failure to use neuromonitoring or negligent monitoring. Comparative statistics and a detailed qualitative analysis of the resulting cases were performed. RESULTS Twenty-six cases related to neuromonitoring were identified. Spinal fusion was the procedure in question in all cases, and defendants were nearly evenly divided between orthopedic surgeons and neurosurgeons. Defense verdicts were most common (54%), followed by settlements (27%) and plaintiff verdicts (19%). Settlements resulted in a mean $7,575,000 damage award, while plaintiff verdicts resulted in a mean $4,180,213 damage award. The basis for litigation was failure to monitor in 54% of the cases and negligent monitoring in 46%. There were no significant differences in case outcomes between the two allegations of negligence. CONCLUSIONS The use and interpretation of intraoperative neuromonitoring findings can be the basis for a medical malpractice litigation. Spine surgeons can face malpractice risks by not monitoring when required by the standard of care and by interpreting or reacting to neuromonitoring findings inappropriately.
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Affiliation(s)
- Jeffrey Hatef
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center
| | - Miki Katzir
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center.,5Department of Neurological Surgery, The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Nathaniel Toop
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center
| | - Monica Islam
- 2Section of Child Neurology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University
| | - Trevor Clark
- 3Associate General Counsel, Office of Legal Affairs and Risk Management, The Ohio State University Wexner Medical Center
| | - Catherine Roscoe
- 3Associate General Counsel, Office of Legal Affairs and Risk Management, The Ohio State University Wexner Medical Center
| | - Safdar Khan
- 4Division of Spine Surgery, Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center; and
| | - Ehud Mendel
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center.,5Department of Neurological Surgery, The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio
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Altbuch T, Ayzenberg M, Bloze AE, Ferkel RD. The Effects of Noninvasive Traction on SSEPs During Ankle Arthroscopy. Foot Ankle Int 2020; 41:1355-1359. [PMID: 32755233 DOI: 10.1177/1071100720943866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the effects of noninvasive ankle distraction on intraoperative somatosensory evoked potentials (SSEPs) and peripheral nerve sensibility of the foot during ankle arthroscopy. METHODS Twenty patients undergoing ankle arthroscopy were prospectively evaluated using noninvasive ankle traction. All had preoperative clinical examination with baseline neurologic evaluation and static 2-point discrimination (2PD) test. Intraoperative SSEPs were monitored continuously throughout surgery. Thirty pounds of traction was applied using noninvasive traction. A 50% decrease in amplitude or a 10% increase in latency was considered significant. At 2 weeks postoperatively, the 2PD test was repeated. Pre- and postoperative 2PD was compared and subsequently correlated with intraoperative SSEPs. RESULTS Three patients sustained significant SSEP signal alterations during surgery. The changes were transient and directly related to application of traction but returned to baseline without traction release. Abnormal postoperative 2PD testing was found in the operative extremity in 12 patients but resolved by the second postoperative visit. Only 2 of 12 had intraoperative SSEP changes. Eleven patients had abnormal postoperative 2PD testing in the nonoperative limb. Nine had changes in both limbs. Routine history and clinical examination did not suggest any neurologic injury. There was no statistically significant correlation between intraoperative SSEP alterations and subsequent development of abnormal postoperative 2PD testing. CONCLUSION Transient intraoperative SSEP changes occurred with noninvasive distraction but were reversible when using 30 pounds of traction. 2PD testing changes were common postoperatively but not correlated to changes in SSEP. Patients with increased 2PD did not have sensory changes detectable on clinical exam or subjective patient history. LEVEL OF EVIDENCE Experimental level II, prospective comparative study.
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Affiliation(s)
| | - Mark Ayzenberg
- Southern California Orthopedic Institute, Van Nuys, CA, USA
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Neuroanesthesia Guidelines for Optimizing Transcranial Motor Evoked Potential Neuromonitoring During Deformity and Complex Spinal Surgery: A Delphi Consensus Study. Spine (Phila Pa 1976) 2020; 45:911-920. [PMID: 32539292 DOI: 10.1097/brs.0000000000003433] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Expert opinion-modified Delphi study. OBJECTIVE We used a modified Delphi approach to obtain consensus among leading spinal deformity surgeons and their neuroanesthesiology teams regarding optimal practices for obtaining reliable motor evoked potential (MEP) signals. SUMMARY OF BACKGROUND DATA Intraoperative neurophysiological monitoring of transcranial MEPs provides the best method for assessing spinal cord integrity during complex spinal surgeries. MEPs are affected by pharmacological and physiological parameters. It is the responsibility of the spine surgeon and neuroanesthesia team to understand how they can best maintain high-quality MEP signals throughout surgery. Nevertheless, varying approaches to neuroanesthesia are seen in clinical practice. METHODS We identified 19 international expert spinal deformity treatment teams. A modified Delphi process with two rounds of surveying was performed. Greater than 50% agreement on the final statements was considered "agreement"; >75% agreement was considered "consensus." RESULTS Anesthesia regimens and protocols were obtained from the expert centers. There was a large amount of variability among centers. Two rounds of consensus surveying were performed, and all centers participated in both rounds of surveying. Consensus was obtained for 12 of 15 statements, and majority agreement was obtained for two of the remaining statements. Total intravenous anesthesia was identified as the preferred method of maintenance, with few centers allowing for low mean alveolar concentration of inhaled anesthetic. Most centers advocated for <150 μg/kg/min of propofol with titration to the lowest dose that maintains appropriate anesthesia depth based on awareness monitoring. Use of adjuvant intravenous anesthetics, including ketamine, low-dose dexmedetomidine, and lidocaine, may help to reduce propofol requirements without negatively effecting MEP signals. CONCLUSION Spine surgeons and neuroanesthesia teams should be familiar with methods for optimizing MEPs during deformity and complex spinal cases. Although variability in practices exists, there is consensus among international spinal deformity treatment centers regarding best practices. LEVEL OF EVIDENCE 5.
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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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Kurokawa R, Kim P, Itoki K, Yamamoto S, Shingo T, Kawamoto T, Kawamoto S. False-Positive and False-Negative Results of Motor Evoked Potential Monitoring During Surgery for Intramedullary Spinal Cord Tumors. Oper Neurosurg (Hagerstown) 2019; 14:279-287. [PMID: 29462450 DOI: 10.1093/ons/opx113] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 04/12/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Motor evoked potential (MEP) recording is used as a method to monitor integrity of the motor system during surgery for intramedullary tumors (IMTs). Reliable sensitivity of the monitoring in predicting functional deterioration has been reported. However, we observed false positives and false negatives in our experience of 250 surgeries of IMTs. OBJECTIVE To delineate specificity and sensitivity of MEP monitoring and to elucidate its limitations and usefulness. METHODS From 2008 to 2011, 58 patients underwent 62 surgeries for IMTs. MEP monitoring was performed in 59 operations using transcranial electrical stimulation. Correlation with changes in muscle strength and locomotion was analyzed. A group undergoing clipping for unruptured aneurysms was compared for elicitation of MEP. RESULTS Of 212 muscles monitored in the 59 operations, MEP was recorded in 150 (71%). Positive MEP warnings, defined as amplitude decrease below 20% of the initial level, occurred in 37 muscles, but 22 of these (59%) did not have postoperative weakness (false positive). Positive predictive value was limited to 0.41. Of 113 muscles with no MEP warnings, 8 muscles developed postoperative weakness (false negative, 7%). Negative predictive value was 0.93. MEP responses were not elicited in 58 muscles (27%). By contrast, during clipping for unruptured aneurysms, MEP was recorded in 216 of 222 muscles (96%). CONCLUSION MEP monitoring has a limitation in predicting postoperative weakness in surgery for IMTs. False-positive and false-negative indices were abundant, with sensitivity and specificity of 0.65 and 0.83 in predicting postoperative weakness.
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Affiliation(s)
- Ryu Kurokawa
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
| | - Phyo Kim
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
| | - Kazushige Itoki
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
| | - Shinji Yamamoto
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
| | - Tetsuro Shingo
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
| | - Toshiki Kawamoto
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
| | - Shunsuke Kawamoto
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
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Wali AR, Birk HS, Martin J, Santiago-Dieppa DR, Ciacci J. Neurosurgical Management of a Thoracic Dorsal Arachnoid Web: Case Illustration. Cureus 2019; 11:e4945. [PMID: 31453019 PMCID: PMC6701917 DOI: 10.7759/cureus.4945] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Dorsal thoracic arachnoid webs are rare clinical entities caused by a thickened intradural extramedullary band of arachnoid tissue that compresses the spinal cord, and often present with progressive back pain, paresthesias, and lower extremity weakness. In this report, we review the radiographic features of the “Scalpel Sign” and describe the case of a 47-year-old male that failed conservative therapy and was found to have dorsal thoracic arachnoid web. The patient underwent laminectomy and microsurgical release of the compressing arachnoid band. Postoperatively, the patient had complete resolution of his pain. Intraoperatively, the somatosensory evoked potentials were improved once the band was released. The prompt diagnosis of dorsal arachnoid webs remains critical because surgical treatment arrests and potentially reverses the pathology.
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Affiliation(s)
- Arvin R Wali
- Neurosurgery, University of California, San Diego, La Jolla, USA
| | - Harjus S Birk
- Neurosurgery, University of California, San Diego, La Jolla, USA
| | - Joel Martin
- Neurosurgery, University of California, San Diego, La Jolla, USA
| | | | - Joseph Ciacci
- Neurosurgery, University of California, San Diego, La Jolla, USA
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Abstract
STUDY DESIGN A retrospective design. OBJECTIVE We aim to report our experience with multimodal intraoperative neuromonitoring (IONM) in metastatic spine tumor surgery (MSTS). SUMMARY OF BACKGROUND DATA IONM is considered as standard of care in spinal deformity surgeries. However, limited data exist about its role in MSTS. METHODS A total of 135 patients from 2010 to 2017, who underwent MSTS with IONM at our institute, were studied retrospectively. After excluding seven with no baseline signals, 128 patients were analyzed. The data collected comprised of demographics, pre and postoperative American Spinal Injury Association (ASIA) grades and neurological status, indications for surgery, type of surgical approach. Multimodal IONM included somatosensory-evoked potentials (SSEPs), transcranial electric motor-evoked potentials (tcMEP), and free running electromyography (EMG). RESULTS The 128 patients included 61 males and 67 females with a mean age of 61 years. One hundred sixteen underwent posterior procedures; nine anterior and three both. The frequency of preoperative ASIA Grades were A = 0, B = 0, C = 10, D = 44, and E = 74 patients. In total, 54 underwent MSTS for neurological deficit, 66 for instability pain, and 8 for intractable pain.Of 128 patients, 13 (10.2%) had significant IONM alerts, representing true positives; 114 true negatives, one false negative, and no false positives. Among the 13 true positives, four (30%) underwent minimally invasive and nine (70%) open procedures. Eight (69.2%) patients had posterior approach. Seven (53.84%) true positive alerts were during decompression, which resolved to baseline upon completion of decompression, while five (38.46%) were during instrumentation, which recovered to baseline after adjusting/downsizing the instrumentation, and one (8.3%) during lateral approach, which reversed after changing the plane of dissection. Of the seven patients without baseline, five were ASIA-A and two were ASIA-C. The sensitivity, specificity, positive, and negative predictive values were 99.1%, 100%, 100%, and 92.9%, respectively. CONCLUSION Multimodal IONM in MSTS helped in preventing postoperative neurological deficit in 9.4% of patients. Its high sensitivity and specificity to detect intraoperative neurological events envisage its use in ASIA-grade D/E patients requiring instrumented decompression. LEVEL OF EVIDENCE 3.
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Ghadirpour R, Nasi D, Iaccarino C, Romano A, Motti L, Sabadini R, Valzania F, Servadei F. Intraoperative neurophysiological monitoring for intradural extramedullary spinal tumors: predictive value and relevance of D-wave amplitude on surgical outcome during a 10-year experience. J Neurosurg Spine 2019; 30:259-267. [PMID: 30497134 DOI: 10.3171/2018.7.spine18278] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/19/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVEThe purpose of this study was to evaluate the technical feasibility, accuracy, and relevance on surgical outcome of D-wave monitoring combined with somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) during resection of intradural extramedullary (IDEM) spinal tumors.METHODSClinical and intraoperative neurophysiological monitoring (IONM) data obtained in 108 consecutive patients who underwent surgery for IDEM tumors at the Institute for Scientific and Care Research "ASMN" of Reggio Emilia, Italy, were prospectively entered into a database and retrospectively analyzed. The IONM included SSEPs, MEPs, and-whenever possible-D-waves. All patients were evaluated using the modified McCormick Scale at admission and at 3, 6, and 12 months of follow-up .RESULTSA total of 108 patients were included in this study. A monitorable D-wave was achieved in 71 of the 77 patients harboring cervical and thoracic IDEM tumors (92.2%). Recording of D-waves in IDEM tumors was significantly associated only with a preoperative deeply compromised neurological status evaluated using the modified McCormick Scale (p = 0.04). Overall, significant IONM changes were registered in 14 (12.96%) of 108 patients and 9 of these patients (8.33%) had permanent loss of at least one of the 3 evoked potentials. In 7 patients (6.48%), the presence of an s18278 caudal D-wave was predictive of a favorable long-term motor outcome even when the MEPs and/or SSEPs were lost during IDEM tumor resection. However, in 2 cases (1.85%) the D-wave permanently decreased by approximately 50%, and surgery was definitively abandoned to prevent permanent paraplegia. Cumulatively, SSEP, MEP, and D-wave monitoring significantly predicted postoperative deficits (p = 0.0001; AUC = 0.905), with a sensitivity of 85.7% and a specificity of 97%. Comparing the area under the receiver operating characteristic curves of these tests, D-waves appeared to have a significantly greater predictive value than MEPs and especially SSEPs alone (0.992 vs 0.798 vs 0.653; p = 0.023 and p < 0.001, respectively). On multiple logistic regression, the independent risk factors associated with significant IONM changes in the entire population were age older than 65 years and an anterolateral location of the tumor (p < 0.0001).CONCLUSIONSD-wave monitoring was feasible in all patients without severe preoperative motor deficits. D-waves demonstrated a statistically significant higher ability to predict postoperative deficits compared with SSEPs and MEPs alone and allowed us to proceed with IDEM tumor resection, even in cases of SSEP and/or MEP loss. Patients older than 65 years and with anterolateral IDEM tumors can benefit most from the use of IONM.
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Affiliation(s)
- Reza Ghadirpour
- 1Department of Neurosurgery, University Hospital of Parma, and Department of Neurosurgery, Institute for Scientific and Care Research "ASMN" of Reggio Emilia
| | - Davide Nasi
- 1Department of Neurosurgery, University Hospital of Parma, and Department of Neurosurgery, Institute for Scientific and Care Research "ASMN" of Reggio Emilia
- 2Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona
| | - Corrado Iaccarino
- 1Department of Neurosurgery, University Hospital of Parma, and Department of Neurosurgery, Institute for Scientific and Care Research "ASMN" of Reggio Emilia
| | - Antonio Romano
- 1Department of Neurosurgery, University Hospital of Parma, and Department of Neurosurgery, Institute for Scientific and Care Research "ASMN" of Reggio Emilia
| | - Luisa Motti
- 3Department of Neurophysiology, IRCCS "Arcispedale Santa Maria Nuova" of Reggio Emilia; and
| | - Rossella Sabadini
- 3Department of Neurophysiology, IRCCS "Arcispedale Santa Maria Nuova" of Reggio Emilia; and
| | - Franco Valzania
- 3Department of Neurophysiology, IRCCS "Arcispedale Santa Maria Nuova" of Reggio Emilia; and
| | - Franco Servadei
- 4Department of Neurosurgery, Humanitas Research Hospital and University, Milan, Italy
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Sutter M, Eggspuehler A, Jeszenszky D, Kleinstueck F, Fekete TF, Haschtmann D, Porchet F, Dvorak J. The impact and value of uni- and multimodal intraoperative neurophysiological monitoring (IONM) on neurological complications during spine surgery: a prospective study of 2728 patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:599-610. [PMID: 30560453 DOI: 10.1007/s00586-018-5861-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 12/07/2018] [Accepted: 12/12/2018] [Indexed: 12/01/2022]
Abstract
PURPOSE We compared the value of different uni- and multimodal intraoperative neurophysiological monitoring (IONM) methods on the detection of neurological complications during spine surgery. METHODS IONM data derived from sensory spinal and cortical evoked potentials combined with continuous electromyography monitoring, motor evoked potentials and spinal recording were evaluated in relation to subsequent post-operative neurological changes. Patients were categorised based on their true-positive or true-negative post-operative neurological status. RESULTS In 2728 consecutive patients we had 909 (33.3%) IONM alerts. We had 8 false negatives (0.3%) with post-operative radicular deficit that completely recovered within 3 months, except for one. There was no false negative for spinal cord injury. 107 were true positives, and 23 were false positives. Multimodal IONM sensitivity and specificity were 93.0% and 99.1%, respectively. The frequency of neurological complications including minor deficits was 4.2% (n = 115), of which 0.37% (n = 10) were permanent. Analysis of the single IONM modalities varied between 13 and 81% to detect neurological complications compared with 93% when using all modalities. CONCLUSION Multimodal IONM is more effective and accurate in assessing spinal cord and nerve root function during spine surgeries to reduce both neurological complications and false-negative findings compared to unimodal monitoring. We recommend multimodal IONM in all complex spine surgeries. These slides can be retrieved from Electronic Supplementary Material.
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Affiliation(s)
- Martin Sutter
- Spine Unit, Department of Neurology, Schulthess Clinic, Lengghalde 2, 8008, Zurich, Switzerland
| | - Andreas Eggspuehler
- Spine Unit, Department of Neurology, Schulthess Clinic, Lengghalde 2, 8008, Zurich, Switzerland
| | - Dezsoe Jeszenszky
- Spine Unit, Department of Spine Surgery, Schulthess Clinic, Zurich, Switzerland
| | - Frank Kleinstueck
- Spine Unit, Department of Spine Surgery, Schulthess Clinic, Zurich, Switzerland
| | - Tamàs F Fekete
- Spine Unit, Department of Spine Surgery, Schulthess Clinic, Zurich, Switzerland
| | - Daniel Haschtmann
- Spine Unit, Department of Spine Surgery, Schulthess Clinic, Zurich, Switzerland
| | - François Porchet
- Spine Unit, Department of Spine Surgery, Schulthess Clinic, Zurich, Switzerland
| | - Jiri Dvorak
- Spine Unit, Department of Neurology, Schulthess Clinic, Lengghalde 2, 8008, Zurich, Switzerland.
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Melachuri SR, Kaur J, Melachuri MK, Ninaci D, Crammond DJ, Balzer JR, Thirumala PD. The diagnostic accuracy of somatosensory evoked potentials in evaluating neurological deficits during 1057 lumbar interbody fusions. J Clin Neurosci 2018; 61:78-83. [PMID: 30528129 DOI: 10.1016/j.jocn.2018.10.140] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/27/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Lumbar interbody spinal fusion (LIF) surgeries are performed to treat or prevent back pain in patients with degenerated intervertebral discs and a variety of spinal diseases. However, post-operative neurological complications may ensue. Intraoperative monitoring techniques have been used to predict and potentially reduce the risk of complications. METHODS This study examined the diagnostic accuracy of significant changes of somatosensory evoked potentials (SSEPs) to evaluate and predict post-operative neurological deficits after LIF. All patients underwent LIF at UPMC from 2010 to 2012. One thousand fifty-seven patients had pre-operative baseline and continuous intraoperative SSEP monitoring. Statistical analysis was completed using SPSS version 22. No relevant disclosure. RESULTS Patient outcomes were not significantly affected by age over 65, gender, obesity, and abnormal baselines. Lower extremity (LE) significant changes in SSEPs and LE loss of responses resulted in a sensitivity/specificity of 0.03/0.99 and 0.03/0.99; they had an AUC of 0.54/0.73 with a 95% confidence interval (CI) of [0.34, 0.74]/[0.29, 1.00]. CONCLUSIONS Significant SSEP changes during LIF are a very specific but poorly sensitive indicator of perioperative neurological deficits. The odds ratio for LE loss of responses was 29.14 with a 95% CI of 1.79-475.5, so LE SSEP loss of responses can serve as a biomarker of perioperative neurological deficits after LIF.
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Affiliation(s)
| | - Jaspreet Kaur
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manasa K Melachuri
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Ninaci
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.
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Ajiboye RM, Park HY, Cohen JR, Vellios EE, Lord EL, Ashana AO, Buser Z, Wang JC. Demographic Trends in the Use of Intraoperative Neuromonitoring for Scoliosis Surgery in the United States. Int J Spine Surg 2018; 12:393-398. [PMID: 30276097 DOI: 10.14444/5046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Intraoperative neuromonitoring (ION), such as motor-evoked potential (MEP), somatosensory evoked potentials (SSEP), and electromyography (EMG), is used to detect impending neurological injuries during spinal surgery. To date, little is known about the trends in the use of ION for scoliosis surgery in the United States. Methods A retrospective review was performed using the PearlDiver Database to identify patients that had scoliosis surgery with and without ION from years 2005 to 2011. Demographic information (such as age, gender, region within the United States) and clinical information (such as type of ION and rates of neurological injury) were assessed. Results There were 3618 patients who had scoliosis surgery during the study period. Intraoperative neuromonitoring was used in 1361 (37.6%) of these cases. The number of cases in which ION was used increased from 27% in 2005 to 46.9% in 2011 (P < .0001). Multimodal ION was used more commonly than unimodal ION (64.6% versus 35.4%). The most commonly used modality was combined SSEP and EMG, while the least used modality was MEP only. Neurological injuries occurred in 1.8 and 2.0% of patients that had surgery with and without ION, respectively (P = .561). Intraoperative neuromonitoring was used most commonly in patients <65 years of age and in the Northeastern part of the United States (age P = .006, region P < .0001). Conclusions The use of ION for scoliosis surgery gradually increased annually from 2005 to 2011. Age and regional differences were noted with neuromonitoring being most commonly used for scoliosis surgery in nonelderly patients and in the Northeastern part of the United States. No differences were noted in the risk of neurological injury in patients that had surgery with and without ION. Although the findings from this study may seem to suggest that ION may not influence the risk of neurologic injury, this result must be interpreted with caution as inherently riskier surgeries may utilize ION more, leading to an actual reduction in injuries more dramatic than observed in this study.
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Affiliation(s)
- Remi M Ajiboye
- UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, California
| | - Howard Y Park
- UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, California
| | - Jeremiah R Cohen
- UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, California
| | - Evan E Vellios
- UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, California
| | - Elizabeth L Lord
- UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, California
| | - Adedayo O Ashana
- UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, California
| | - Zorica Buser
- Keck Medicine of USC, Department of Orthopaedic Surgery, Los Angeles, California
| | - Jeffrey C Wang
- Keck Medicine of USC, Department of Orthopaedic Surgery, Los Angeles, California
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Han S, Kwon YC, Kim SM, Hyun SJ, Jahng TA, Kim KJ, Kim HJ, Choi HY, Park YS, Seok Park K. Risk Factor Analysis of Change in Intraoperative Neurophysiologic Monitoring During Cervical Open Door Laminoplasty. World Neurosurg 2018; 119:e235-e243. [PMID: 30048788 DOI: 10.1016/j.wneu.2018.07.121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The aim of this study is to determine the risk factors affecting intraoperative neurophysiologic monitoring (IONM) changes, when such changes take place, and clinical outcomes associated with IONM change during cervical open door laminoplasty (COL) for cervical compressive myelopathy. METHODS Between 2010 and 2015, 79 patients who underwent COL with IONM recording were studied. Changes in motor evoked potentials or somatosensory evoked potentials over an alarm criterion were defined as IONM change. Patients with IONM change were assigned to the alarm group, and the others were classified as the control group. Baseline data and radiographic measurements were compared between the 2 groups. Radiologic parameters including maximal compression level (MCL), area and diameter of the spinal canal and ventral compressive lesion, stenosis grade, and occupying ratio of area (ORA) and length at the MCL were measured with magnetic resonance imaging. RESULTS Thirteen patients were assigned to the alarm group and 66 patients were assigned to the control group. Multivariate analysis identified ORA at the MCL (odds ratio, 1.520; 95% confidence interval, 1.192-1.37; P = 0.001) as an independent risk factor for IONM change. Immediately after decompression, the IONM change occurred. One of 4 patients who did not fully recover from the IONM change had postoperative motor deficits. CONCLUSIONS IONM change during COL occurred immediately after decompression, and a risk factor of IONM change was ORA at the MCL. If the IONM change was not fully recovered, a new motor deficit occurred after COL.
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Affiliation(s)
- Sanghyun Han
- Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University College of Medicine, DaeJeon, Korea
| | - Yong Chul Kwon
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Min Kim
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
| | - Hyun-Jib Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ho Yong Choi
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Young-Seop Park
- Department of Neurosurgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University Graduate School of Medicine, Jinju, Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
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Wang S, Yang Y, Li Q, Zhu J, Shen J, Tian Y, Hu Y, Li Z, Xu W, Jiao Y, Cao R, Zhang J. High-Risk Surgical Maneuvers for Impending True-Positive Intraoperative Neurologic Monitoring Alerts: Experience in 3139 Consecutive Spine Surgeries. World Neurosurg 2018; 115:e738-e747. [PMID: 29729461 DOI: 10.1016/j.wneu.2018.04.162] [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: 01/17/2018] [Revised: 04/20/2018] [Accepted: 04/21/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intraoperative neurologic monitoring (IONM) has become an essential component for decreasing the incidence of spinal cord injury during spine surgeries. Many high-risk surgical maneuvers that result in significant IONM alerts have not been reported systematically. Our objective was to thoroughly summarize some common high-risk surgical points associated with IONM alerts in various spine surgeries. METHODS Between November 2010 and April 2017, 62 patients with true-positive IONM alerts from 3139 spine surgeries were enrolled. Transcranial motor evoked potentials, somatosensory evoked potentials, and free-run electromyography were used for IONM. All 62 patients were identified as true-positive IONM cases. RESULTS Of 3139 patients, 101 demonstrated significant IONM changes-62 true-positive cases, 14 false-positive cases, and 25 indeterminate IONM results. IONM alerts most often occurred in thoracic screw placement (n = 10, 16.1%), osteotomy (n = 22, 35.5%), correction (n = 19, 30.6%), and spinal cord decompression (n = 11, 17.8%). Appropriate timely measures are indicated in response to IONM alerts during high-risk surgical maneuvers. Ten (10/62, 16.1%) patients showed permanent postoperative neurologic deficits. CONCLUSIONS IONM alerts are often associated with some specific high-risk surgical maneuvers. Careful and timely observation is crucial.
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Affiliation(s)
- Shujie Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Yang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Qiyi Li
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jie Zhu
- Brain Center, Logistics Academy Affiliated Hospital of Chinese People's Armed Police Force, Tianjin, China
| | - Jianxiong Shen
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Ye Tian
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yong Hu
- Department of Orthopedics and Traumatology, The University of Hong Kong, Hong Kong, China
| | - Zhi Li
- Department of Orthopedics, Shenyang Medical College Affiliated Center Hospital, Shenyang, Liaoning, China
| | - Wei Xu
- Operating Room, Peking Union Medical College Hospital, Beijing, China
| | - Yang Jiao
- Department of Spine Surgery, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang, China
| | - Rui Cao
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
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Perils of intraoperative neurophysiological monitoring: analysis of "false-negative" results in spine surgeries. Spine J 2018; 18:276-284. [PMID: 28713053 DOI: 10.1016/j.spinee.2017.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/12/2017] [Accepted: 07/06/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although some authors have published case reports describing false negatives in intraoperative neurophysiological monitoring (IONM), a systematic review of causes of false-negative IONM results is lacking. PURPOSE The objective of this study was to analyze false-negative IONM findings in spine surgery. STUDY DESIGN This is a retrospective cohort analysis. PATIENT SAMPLE A cohort of 109 patients with new postoperative neurologic deficits was analyzed for possible false-negative IONM reporting. OUTCOME MEASURES The causes of false-negative IONM reporting were determined. MATERIALS AND METHODS From a cohort of 62,038 monitored spine surgeries, 109 consecutive patients with new postoperative neurologic deficits were reviewed for IONM alarms. RESULTS Intraoperative neurophysiological monitoring alarms occurred in 87 of 109 surgeries. Nineteen patients with new postoperative neurologic deficits did not have an IONM alarm and surgeons were not warned. In addition, three patients had no interpretable IONM baseline data and no alarms were possible for the duration of the surgery. Therefore, 22 patients were included in the study. The absence of IONM alarms during these 22 surgeries had different origins: "true" false negatives where no waveform changes meeting the alarm criteria occurred despite the appropriate IONM (7); a postoperative development of a deficit (6); failure to monitor the pathway, which became injured (5); the absence of interpretable IONM baseline data which precluded any alarm (3); and technical IONM application issues (1). CONCLUSIONS Overall, the rate of IONM method failing to predict the patient's outcome was very low (0.04%, 22/62,038). Minimizing false negatives requires the application of a proper IONM technique with the limitations of each modality considered in their selection and interpretation. Multimodality IONM provides the most inclusive information, and although it might be impractical to monitor every neural structure that can be at risk, a thorough preoperative consideration of available IONM modalities is important. Delayed development of postoperative deficits cannot be predicted by IONM. Absent baseline IONM data should be treated as an alarm when inconsistent with the patient's preoperative neurologic status. Alarm criteria for IONM may need to be refined for specific procedures and deserves continued study.
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Laratta JL, Ha A, Shillingford JN, Makhni MC, Lombardi JM, Thuet E, Lehman RA, Lenke LG. Neuromonitoring in Spinal Deformity Surgery: A Multimodality Approach. Global Spine J 2018; 8:68-77. [PMID: 29456917 PMCID: PMC5810893 DOI: 10.1177/2192568217706970] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
STUDY DESIGN Literature review. OBJECTIVE The aim of this study was to provide an overview of the available intraoperative monitoring techniques and the evidence around their efficacy in vertebral column resection. METHODS The history of neuromonitoring and evolution of the modalities are reviewed and discussed. The authors' specific surgical techniques and preferred methods are outlined in detail. In addition, the authors' experience and the literature regarding vertebral column resection and surgical mitigation of neurologic alarms are discussed at length. RESULTS Risk factors for signal changes have been identified, including preoperative neurologic deficit, severe kyphosis, increased curve magnitude, and significant cord shortening. Even though no evidence-based treatment algorithm exist for signal changes, strategies are discussed that can help prevent alarms and address them appropriately. CONCLUSION Through implementation of multimodal intraoperative monitoring techniques, potential neurologic injuries are localized and managed in real time. Intraoperative monitoring is a valuable tool for improving the safety and outcome of spinal deformity surgery.
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Affiliation(s)
- Joseph L. Laratta
- Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY, USA,Joseph L. Laratta, Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, 5141 Broadway, 3 Field West, New York, NY 10034, USA.
| | - Alex Ha
- Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Jamal N. Shillingford
- Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Melvin C. Makhni
- Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Joseph M. Lombardi
- Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Earl Thuet
- Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Ronald A. Lehman
- Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Lawrence G. Lenke
- Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY, USA
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30
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Ajiboye RM, Park HY, Cohen JR, Vellios EE, Lord EL, Ashana AO, Buser Z, Wang JC. Demographic Trends in the Use of Intraoperative Neuromonitoring for Scoliosis Surgery in the United States. Int J Spine Surg 2018; 11:33. [PMID: 29372137 DOI: 10.14444/4033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Intraoperative neuromonitoring (ION) such as motor-evoked potential (MEP), somatosensory evoked potentials (SSEP) and electromyography (EMG) are used to detect impending neurological injuries during spinal surgery. To date, little is known on the trends in the use of ION for scoliosis surgery in the United States. Methods A retrospective review was performed using the PearlDiver Database to identify patients that had scoliosis surgery with and without ION from years 2005 to 2011. Demographic information (such as age, gender, region within the United States) and clinical information (such as type of ION and rates of neurological injury) were assessed. Results There were 3618 patients who had scoliosis surgery during the study period. ION was used in 1361 (37.6%) of these cases. The number of cases in which ION was used increased from 27% in 2005 to 46.9% in 2011 (p < 0.0001). Multimodal ION was used more commonly than unimodal ION (64.6% vs. 35.4%). The most commonly used modality was combined SSEP and EMG while the least used modality was MEP only. Neurological injuries occurred in 1.8% and 2.0% of patients that had surgery with and without ION, respectively (p = 0.561). ION was used most commonly in patients < 65 years of age and in the Northeastern part of the United States (age; p = 0.006, region; p < 0.0001). Conclusions The use of ION for scoliosis surgery gradually increased annually from 2005 to 2011. Age and regional differences were noted with neuromonitoring being most commonly used for scoliosis surgery in non-elderly patients and in the Northeastern part of the United States. No differences were noted in the risk of neurological injury in patients that had surgery with and without ION. Although the findings from this study may seem to suggest that ION may not influence the risk of neurologic injury, this result must be interpreted with caution as inherently riskier surgeries may utilize ION more, leading to an actual reduction in injuries more dramatic than observed in this study.
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Affiliation(s)
- Remi M Ajiboye
- UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, CA
| | - Howard Y Park
- UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, CA
| | - Jeremiah R Cohen
- UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, CA
| | - Evan E Vellios
- UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, CA
| | - Elizabeth L Lord
- UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, CA
| | - Adedayo O Ashana
- UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, CA
| | - Zorica Buser
- Keck Medicine of USC, Department of Orthopaedic Surgery, Los Angeles, CA
| | - Jeffrey C Wang
- Keck Medicine of USC, Department of Orthopaedic Surgery, Los Angeles, CA
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Melachuri SR, Kaur J, Melachuri MK, Crammond DJ, Balzer JR, Thirumala PD. The diagnostic accuracy of somatosensory evoked potentials in evaluating neurological deficits during 1036 posterior spinal fusions. Neurol Res 2017; 39:1073-1079. [DOI: 10.1080/01616412.2017.1378413] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Samyuktha R. Melachuri
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jaspreet Kaur
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manasa K. Melachuri
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald J. Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R. Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Parthasarathy D. Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Clinical Neurophysiology, Department of Neurological Surgery, UPMC Presbyterian, Pittsburgh, PA, USA
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Park T, Park J, Park YG, Lee J. Intraoperative Neurophysiological Monitoring for Spinal Cord Tumor Surgery: Comparison of Motor and Somatosensory Evoked Potentials According to Tumor Types. Ann Rehabil Med 2017; 41:610-620. [PMID: 28971046 PMCID: PMC5608669 DOI: 10.5535/arm.2017.41.4.610] [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] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/24/2016] [Indexed: 11/08/2022] Open
Abstract
Objective To identify which combination of motor evoked potentials (MEPs) and somatosensory evoked potentials (SEPs) is most reliable for postoperative motor deterioration during spinal cord tumor surgery, according to anatomical and pathologic type. Methods MEPs and SEPs were monitored in patients who underwent spinal cord tumor surgery between November 2012 and August 2016. Muscle strength was examined in all patients before surgery, within 48 hours postoperatively and 4 weeks later. We analyzed sensitivity, specificity, positive and negative predictive values of each significant change in SEPs and MEPs. Results The overall sensitivity and specificity of SEPs or MEPs were 100% and 61.3%, respectively. The intraoperative MEP monitoring alone showed both higher sensitivity (67.9%) and specificity (83.2%) than SEP monitoring alone for postoperative motor deterioration. Two patients with persistent motor deterioration had significant changes only in SEPs. There are no significant differences in reliabilities between anatomical types, except with hemangioma, where SEPs were more specific than MEPs for postoperative motor deterioration. Both overall positive and negative predictive values of MEPs were higher than the predictive values of SEPs. However, the positive predictive value was higher by the dual monitoring of MEPs and SEPs, compared to MEPs alone. Conclusion For spinal cord tumor surgery, combined MEP and SEP monitoring showed the highest sensitivity for the postoperative motor deterioration. Although MEPs are more specific than SEPs in most types of spinal cord tumor surgery, SEPs should still be monitored, especially in hemangioma surgery.
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Affiliation(s)
- Taeha Park
- Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Jinyoung Park
- Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ghil Park
- Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Joowon Lee
- Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
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33
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Changes in transcranial motor evoked potentials during hemorrhage are associated with increased serum propofol concentrations. J Clin Monit Comput 2017; 32:541-548. [DOI: 10.1007/s10877-017-0057-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/19/2017] [Indexed: 10/19/2022]
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34
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Bell JE, Seifert JL, Shimizu EN, Sucato DJ, Romero-Ortega MI. Atraumatic Spine Distraction Induces Metabolic Distress in Spinal Motor Neurons. J Neurotrauma 2017; 34:2034-2044. [DOI: 10.1089/neu.2016.4779] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Jennifer E.S. Bell
- Bioengineering Department, University of Texas at Dallas, Richardson, Texas
| | | | - Eileen N. Shimizu
- Bioengineering Department, University of Texas at Dallas, Richardson, Texas
| | - Daniel J. Sucato
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Mario I. Romero-Ortega
- Bioengineering Department, University of Texas at Dallas, Richardson, Texas
- Surgery Department, University of Texas Southwestern Medical Center, Dallas, Texas
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Development of a modified model of spinal cord ischemia injury by selective ligation of lumbar arteries in rabbits. Spinal Cord 2017; 55:1028-1032. [PMID: 28607524 DOI: 10.1038/sc.2017.66] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 04/30/2017] [Accepted: 05/04/2017] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Experimental study. OBJECTIVE The aim of this study is to develop a modified model of spinal cord ischemia in rabbits. SETTINGS Shenzhen Key Laboratory of Spine Surgery, Shenzhen, China. METHODS In total, 20 New Zealand rabbits were divided into the following four groups according to the level of ligation of bilateral lumbar arteries: (1) group A, sham group, no ligation, n=5; (2) group B, ligation of bilateral lumbar arteries at three levels (L2-L4, n=5); (3) group C, ligation of bilateral lumbar arteries at four levels (L2-L5, n=5); and (4) group D, ligation of bilateral lumbar arteries at five levels (L1-L5, n=5). The latency of motor-evoked potentials was measured intraoperatively and the modified Tarlov grades were scored, followed by a histological observation of spinal cord, on the seventh day after surgery. RESULTS All 10 rabbits in Group A and Group B were electrophysiologically, neurologically and histologically normal. In Group C, moderate spinal cord ischemia injury was found in three of five rabbits: they had prolonged latency of motor-evoked potentials and neuronal karyopyknosis in the anterior horn of spinal cord, and the average Tarlov score was 4.2±0.8. In Group D, severe spinal cord ischemia injury was recorded in all the five rabbits: the latency of motor-evoked potential prolonged in one rabbit, whereas the waveform disappeared in four rabbits; loss of neurons and vacuolation of gray matter were seen in spinal cord sections, and the average Tarlov score was 0.6±0.9. CONCLUSION Selective ligation of lumbar arteries was a modified method to induce feasible and reproducible model of spinal cord ischemia in rabbits.
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Liu W, Gu R, Zhu Q, Xiao C, Huang L, Zhuang X, Zhang J, Liu L, Ma B, Yang H, Ma J, Hu Z, Tang C, Zhao S, Chen X. Rapid fluorescence imaging of spinal cord following epidural administration of a nerve-highlighting fluorophore. Am J Cancer Res 2017. [PMID: 28638473 PMCID: PMC5479274 DOI: 10.7150/thno.18962] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Iatrogenic spinal cord injury (SCI) is the most devastating complication of spine surgery, which usually results in permanent and serious disabilities of patients. Improvement of the visualization and discrimination of the spinal cord is critical for accuracy and safety during surgery; however, to date, there is no suitable technology to fulfill this clinical need. Here, we first show an efficient and rapid fluorescence imaging of the spinal cord in rabbit by epidural administration of a nerve-highlighting fluorophore, i.e. (E, E)-1,4-bis(p-aminostryl)-2-methoxy benzene (BMB). The BMB is firstly encapsulated into polymeric micelles to form a BMB-micelle (BMB-m) formulation with well-dispersion in normal saline solution. After epidural administration of BMB-m, BMB is transported by the flow of cerebrospinal fluid (CSF) and binds to the peripheral region of the white matter thus facilitating rapid staining of the spinal cord. Furthermore, this BMB imaging technology also holds great potential for visually monitoring the integrity of the spinal cord in real time and promptly identifying acute SCI during spine surgery.
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Scibilia A, Terranova C, Rizzo V, Raffa G, Morelli A, Esposito F, Mallamace R, Buda G, Conti A, Quartarone A, Germanò A. Intraoperative neurophysiological mapping and monitoring in spinal tumor surgery: sirens or indispensable tools? Neurosurg Focus 2017; 41:E18. [PMID: 27476842 DOI: 10.3171/2016.5.focus16141] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal tumor (ST) surgery carries the risk of new neurological deficits in the postoperative period. Intraoperative neurophysiological monitoring and mapping (IONM) represents an effective method of identifying and monitoring in real time the functional integrity of both the spinal cord (SC) and the nerve roots (NRs). Despite consensus favoring the use of IONM in ST surgery, in this era of evidence-based medicine, there is still a need to demonstrate the effective role of IONM in ST surgery in achieving an oncological cure, optimizing patient safety, and considering medicolegal aspects. Thus, neurosurgeons are asked to establish which techniques are considered indispensable. In the present study, the authors focused on the rationale for and the accuracy (sensitivity, specificity, and positive and negative predictive values) of IONM in ST surgery in light of more recent evidence in the literature, with specific emphasis on the role of IONM in reducing the incidence of postoperative neurological deficits. This review confirms the role of IONM as a useful tool in the workup for ST surgery. Individual monitoring and mapping techniques are clearly not sufficient to account for the complex function of the SC and NRs. Conversely, multimodal IONM is highly sensitive and specific for anticipating neurological injury during ST surgery and represents an important tool for preserving neuronal structures and achieving an optimal postoperative functional outcome.
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Affiliation(s)
| | | | | | - Giovanni Raffa
- Divisions of 1 Neurosurgery.,Department of Clinical and Experimental Medicine, University of Messina, Italy
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Posterior Correction Without Rib-head Resection for Patients With Neurofibromatosis Type 1, Dystrophic Scoliosis, and Rib-head Protrusion Into the Spinal Canal. Clin Spine Surg 2017; 30:32-37. [PMID: 28107233 DOI: 10.1097/bsd.0000000000000240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVE The objective of this study is to report the result of patients with neurofibromatosis type 1(NF-1), dystrophic scoliosis, and rib-head protrusion into the spinal canal who received posterior scoliosis correction surgery without rib-head resection. SUMMARY OF BACKGROUND DATA A total of 124 patients with NF-1 and dystrophic scoliosis were treated at our institution during the study period. Eight patients with a median age of 12 years had rib-head protrusion into the spinal canal and received surgery and were included in the analysis. METHODS All 8 patients (6 male, 2 female) were treated from 2003 to 2013 and received posterior correction with a pedicle screw-rod 3-dimensional correction system or screw-hook hybrid system. Scoliosis correction rate and percentage of spinal canal occupied by the rib head were analyzed. RESULTS The median patient age, number of segments fused, and follow-up duration were 12 years, 10.5, and 22.5 months, respectively. There were no surgery-related complications, and symptoms in all patients improved after surgery. The median postoperative and 1-year follow-up sagittal kyphotic angles were significantly smaller as compared with the preoperative value (28.5 and 31 vs. 62.5 degrees, P=0.012). The median postoperative coronal Cobb angle of the main thoracic curve was significantly smaller compared with the preoperative value (29 vs. 64.5 degrees, P=0.012). The median percentage of the spinal canal occupied by the intraspinal rib was significantly lower at 1-year follow-up compared with the preoperative value (23.1% vs. 28.6%, P=0.018). CONCLUSIONS Posterior correction without rib-head excision can provide good outcomes for patients with NF-1 and dystrophic scoliosis and rib-head protrusion into the spinal canal.
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A Multiparametric Alarm Criterion for Motor Evoked Potential Monitoring During Spine Deformity Surgery. J Clin Neurophysiol 2017; 34:38-48. [DOI: 10.1097/wnp.0000000000000323] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Diagnostic Accuracy of Neuromonitoring for Identification of New Neurologic Deficits in Pediatric Spinal Fusion Surgery. Anesth Analg 2016; 123:1556-1566. [DOI: 10.1213/ane.0000000000001503] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Verla T, Fridley JS, Khan AB, Mayer RR, Omeis I. Neuromonitoring for Intramedullary Spinal Cord Tumor Surgery. World Neurosurg 2016; 95:108-116. [DOI: 10.1016/j.wneu.2016.07.066] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/17/2016] [Accepted: 07/18/2016] [Indexed: 11/27/2022]
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Errando CL, Blanco T, Díaz-Cambronero Ó. Repeated sugammadex reversal of muscle relaxation during lumbar spine surgery with intraoperative neurophysiological multimodal monitoring. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:533-538. [PMID: 27216713 DOI: 10.1016/j.redar.2016.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/11/2016] [Accepted: 03/16/2016] [Indexed: 06/05/2023]
Abstract
Intraoperative neurophysiological monitoring during spine surgery is usually acomplished avoiding muscle relaxants. A case of intraoperative sugammadex partial reversal of the neuromuscular blockade allowing adequate monitoring during spine surgery is presented. A 38 year-old man was scheduled for discectomy and vertebral arthrodesis throughout anterior and posterior approaches. Anesthesia consisted of total intravenous anesthesia plus rocuronium. Intraoperatively monitoring was needed, and the muscle relaxant reverted twice with low dose sugammadex in order to obtain adequate responses. The doses of sugammadex used were conservatively selected (0.1mg/kg boluses increases, total dose needed 0.4mg/kg). Both motor evoqued potentials, and electromyographic responses were deemed adequate by the neurophysiologist. If muscle relaxation was needed in the context described, this approach could be useful to prevent neurological sequelae. This is the first study using very low dose sugammadex to reverse rocuronium intraoperatively and to re-establish the neuromuscular blockade.
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Affiliation(s)
- C L Errando
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
| | - T Blanco
- Servicio de Neurofisiología Clínica, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Ó Díaz-Cambronero
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Politécnico La Fe, Valencia, Spain
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Vayrynen E, Noponen K, Vipin A, Thow XY, Al-Nashash H, Kortelainen J, All A. Automatic Parametrization of Somatosensory Evoked Potentials With Chirp Modeling. IEEE Trans Neural Syst Rehabil Eng 2016; 24:981-992. [DOI: 10.1109/tnsre.2016.2525829] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Li Y, Meng L, Peng Y, Qiao H, Guo L, Han R, Gelb AW. Effects of Dexmedetomidine on motor- and somatosensory-evoked potentials in patients with thoracic spinal cord tumor: a randomized controlled trial. BMC Anesthesiol 2016; 16:51. [PMID: 27484701 PMCID: PMC4970285 DOI: 10.1186/s12871-016-0217-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 07/21/2016] [Indexed: 12/14/2022] Open
Abstract
Background We hypothesized that the addition of dexmedetomidine in a clinically relevant dose to propofol-remifentanil anesthesia regimen does not exert an adverse effect on motor-evoked potentials (MEP) and somatosensory-evoked potentials (SSEP) in adult patients undergoing thoracic spinal cord tumor resection. Methods Seventy-one adult patients were randomized into three groups. Propofol group (n = 25): propofol-remifentanil regimenand the dosage was adjusted to maintain the bispectral index (BIS) between 40 and 50. DP adjusted group (n = 23): Dexmedetomidine (0.5 μg/kg loading dose infused over 10 min followed by a constant infusion of 0.5 μg/kg/h) was added to the propofol-remifentanil regimen and propofol was adjusted to maintain BIS between 40 and 50. DP unadjusted group (n = 23): Dexmedetomidine (administer as DP adjusted group) was added to the propofol-remifentanil regimen and propofol was not adjusted. All patients received MEP, SSEP and BIS monitoring. Results There were no significant changes in the amplitude and latency of MEP and SSEP among different groups (P > 0.05). The estimated propofol plasma concentration in DP adjusted group (2.7 ± 0.3 μg/ml) was significantly lower than in propofol group (3.1 ± 0.2 μg/ml) and DP unadjusted group (3.1 ± 0.2 μg/ml) (P = 0.000). BIS in DP unadjusted group (35 ± 5) was significantly lower than in propofol group (44 ± 3) (P = 0.000). Conclusions The addition of dexmedetomidine to propofol-remifentanil regimen does not exert an adverse effect on MEP and SSEP monitoring in adult patients undergoing thoracic spinal cord tumor resection. Trial registration The study was registered with the Chinese Clinical Trial Registry on January 31st, 2014. The reference number was ChiCTR-TRC-14004229.
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Affiliation(s)
- Yan Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, China, 100050
| | - Lingzhong Meng
- Departments of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, China, 100050
| | - Hui Qiao
- Neurophysiological Monitoring, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lanjun Guo
- Neurosurgery/Neurophysiological Monitoring Service, University of California San Francisco, San Francisco, CA, USA
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, China, 100050.
| | - Adrian W Gelb
- Departments of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
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Chang SH, Park YG, Kim DH, Yoon SY. Monitoring of Motor and Somatosensory Evoked Potentials During Spine Surgery: Intraoperative Changes and Postoperative Outcomes. Ann Rehabil Med 2016; 40:470-80. [PMID: 27446784 PMCID: PMC4951366 DOI: 10.5535/arm.2016.40.3.470] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/02/2015] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To evaluate whether the combination of muscle motor evoked potentials (mMEPs) and somatosensory evoked potentials (SEPs) measured during spinal surgery can predict immediate and permanent postoperative motor deficits. METHODS mMEP and SEP was monitored in patients undergoing spinal surgery between November 2012 and July 2014. mMEPs were elicited by a train of transcranial electrical stimulation over the motor cortex and recorded from the upper/lower limbs. SEPs were recorded by stimulating the tibial and median nerves. RESULTS Combined mMEP/SEP recording was successfully achieved in 190 operations. In 117 of these, mMEPs and SEPs were stable and 73 showed significant changes. In 20 cases, motor deficits in the first 48 postoperative hours were observed and 6 patients manifested permanent neurological deficits. The two potentials were monitored in a number of spinal surgeries. For surgery on spinal deformities, the sensitivity and specificity of combined mMEP/SEP monitoring were 100% and 92.4%, respectively. In the case of spinal cord tumor surgeries, sensitivity was only 50% but SEP changes were observed preceding permanent motor deficits in some cases. CONCLUSION Intraoperative monitoring is a useful tool in spinal surgery. For spinal deformity surgery, combined mMEP/SEP monitoring showed high sensitivity and specificity; in spinal tumor surgery, only SEP changes predicted permanent motor deficits. Therefore, mMEP, SEP, and joint monitoring may all be appropriate and beneficial for the intraoperative monitoring of spinal surgery.
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Affiliation(s)
- Shin Hye Chang
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Seoul, Korea.; Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ghil Park
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Seoul, Korea.; Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Hyun Kim
- Veteran Health Service Medical Center, Seoul, Korea
| | - Seo Yeon Yoon
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Seoul, Korea.; Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
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Tsutsui S, Yamada H. Basic Principles and Recent Trends of Transcranial Motor Evoked Potentials in Intraoperative Neurophysiologic Monitoring. Neurol Med Chir (Tokyo) 2016; 56:451-6. [PMID: 26935781 PMCID: PMC4987444 DOI: 10.2176/nmc.ra.2015-0307] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Transcranial motor evoked potentials (TcMEPs), which are muscle action potentials elicited by transcranial brain stimulation, have been the most popular method for the last decade to monitor the functional integrity of the motor system during surgery. It was originally difficult to record reliable and reproducible potentials under general anesthesia, especially when inhalation-based anesthetic agents that suppressed the firing of anterior horn neurons were used. Advances in anesthesia, including the introduction of intravenous anesthetic agents, and progress in stimulation techniques, including the use of pulse trains, improved the reliability and reproducibility of TcMEP responses. However, TcMEPs are much smaller in amplitude compared with compound muscle action potentials evoked by maximal peripheral nerve stimulation, and vary from one trial to another in clinical practice, suggesting that only a limited number of spinal motor neurons innervating the target muscle are excited in anesthetized patients. Therefore, reliable interpretation of the critical changes in TcMEPs remains difficult and controversial. Additionally, false negative cases have been occasionally encountered. Recently, several facilitative techniques using central or peripheral stimuli, preceding transcranial electrical stimulation, have been employed to achieve sufficient depolarization of motor neurons and augment TcMEP responses. These techniques might have potentials to improve the reliability of intraoperative motor pathway monitoring using TcMEPs.
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Affiliation(s)
- Shunji Tsutsui
- Department of Orthopedic Surgery, Wakayama Medical University
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Hu P, Yu M, Liu X, Liu Z, Jiang L. A circumferential decompression-based surgical strategy for multilevel ossification of thoracic posterior longitudinal ligament. Spine J 2015; 15:2484-92. [PMID: 26343248 DOI: 10.1016/j.spinee.2015.08.060] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/04/2015] [Accepted: 08/27/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Multilevel ossification of posterior longitudinal ligament (OPLL) at thoracic spine can be simultaneously symptomatic. Different approaches for thoracic decompression have been reported, among which circumferential decompression (CD) seems promising but is invasive, so methods to find approaches indicating levels for CD are also important. PURPOSE This study aimed to introduce a CD-based surgical strategy for multilevel thoracic OPLL and describe its clinical outcomes. STUDY DESIGN A retrospective clinical study was used. PATIENT SAMPLE A cohort of 26 patients were recruited, whose average age was 51.2±9.1 years old. OUTCOME MEASURES A modified Japanese Orthopedic Association (JOA) scale for thoracic spine was used to evaluate neurologic status, and final recovery rates were assessed according to Hirabayashi system. METHODS Posterior decompression was initially performed for all compressive levels, whereas CD levels were decided through combined modalities, of which intraoperative ultrasound was an important determinant. All patients were regularly followed for more than 2 years. RESULTS The average operative duration and blood loss were 279.3±54.8 minutes and 2257.7±1443.9 mL, respectively. There were 17 patients (65.4%) who achieved instant improvement and 9 (34.6%) neurologically deteriorated. Cerebrospinal fluid leakage occurred in 10 patients (38.5%), but its occurrence did not affect the final neurologic recovery. Other complications included urinary infection, incision infection and disunion, lung infection, and subcutaneous fluid collection. Late events included death from cerebrovascular accident, pseudomeningocele, unremitted intercostal pain and continuing deterioration. The final JOA score and recovery rate were correlated with OPLL levels and preoperative JOA scores (p<.05). Eventually, the average JOA score was significantly elevated from 4.5±1.8 to 8.3±2.3 (p<.05), with the recovery rate of 11 patients rated as excellent, 7 as good, 6 as fair, and 2 as unchanged or deteriorated. The average recovery rate was 60.4%. CONCLUSIONS This CD-based surgical strategy was effective for multilevel thoracic OPLL and had fair late outcomes, but its postoperative courses were quite eventful. Intraoperative ultrasound was a reliable modality to determine CD levels.
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Affiliation(s)
- Panpan Hu
- Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Rd, Haidian District, Beijing 100191, China
| | - Miao Yu
- Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Rd, Haidian District, Beijing 100191, China
| | - Xiaoguang Liu
- Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Rd, Haidian District, Beijing 100191, China.
| | - Zhongjun Liu
- Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Rd, Haidian District, Beijing 100191, China
| | - Liang Jiang
- Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Rd, Haidian District, Beijing 100191, China
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Jain A, Khanna AJ, Hassanzadeh H. Management of intraoperative neuromonitoring signal loss. ACTA ACUST UNITED AC 2015. [DOI: 10.1053/j.semss.2015.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Wang S, Zhuang Q, Zhang J, Tian Y, Zhao H, Wang Y, Zhao Y, Li S, Weng X, Qiu G, Shen J. Intra-operative MEP monitoring can work well in the patients with neural axis abnormality. 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 2015; 25:3194-3200. [PMID: 26324282 DOI: 10.1007/s00586-015-4205-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Revised: 08/22/2015] [Accepted: 08/22/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE To explain the intra-operative transcranial motor evoked potential (MEP) monitoring can work well in patients with neural axis abnormality (NAA). METHODS One hundred eighteen consecutive NAA and 334 adolescent idiopathic scoliosis (AIS) patients who underwent spinal deformity surgery between June 2010 and April 2013 in our spine center were included. The MEP data including the success rate of obtaining a baseline, amplitude, sensitivity and specificity were analyzed. RESULTS High-efficiency MEPs baseline could be obtained in 117/118 NAA (74 congenital scoliosis, 32 neuromuscular scoliosis, 8 adult scoliosis, 3 congenital kyphoscoliosis and 1 neurofibromatosis scoliosis) and 334 AIS cases. They had an approximate level in success rate of MEPs baseline (99.2 vs. 99.7 %) and MEPs amplitude (317 μV, n = 118; vs. 312 μV, n = 334). The sensitivity and specificity for MEP were 100 and 98.2 % in patients with NAA. And the MEPs amplitude value fitted positive-skewed distribution in both of NAA and AIS. CONCLUSIONS Intraoperative MEP monitoring can be used accurately and satisfactorily in NAA patients and show no difference compared with AIS.
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Affiliation(s)
- Shujie Wang
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Qianyu Zhuang
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Ye Tian
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Hong Zhao
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Yipeng Wang
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Yu Zhao
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Shugang Li
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Xisheng Weng
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Guixing Qiu
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Jianxiong Shen
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China.
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Change in body surface temperature as an ancillary measurement to motor evoked potentials. Spinal Cord 2015; 53:827-34. [PMID: 26123207 DOI: 10.1038/sc.2015.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 02/19/2015] [Accepted: 03/05/2015] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Experimental study. OBJECTIVES To study the role of surface temperature as an adjunct to motor evoked potentials (MEPs) in rabbit spinal cord injury (SCI) model. SETTING Department of Orthopedics, Korea University Guro Hospital, Seoul, Korea. METHODS Rabbits (n =18) were divided into Complete (n = 9) and Incomplete (n = 9) SCI groups. Complete SCI was defined as being non-responsive to a wake-up test with loss of MEPs after transection of spinal cord. Incomplete SCI was defined as being responsive to a wake-up test with significant attenuation (⩾ 80%) of MEPs after impaction on spinal cord. Surface temperature of upper and lower extremities, core temperature and MEPs signals were checked before, during and after SCI for 20 min. A wake-up test was conducted and spinal cord was histologicaly evaluated. RESULTS Experimental conditions between the two groups were statistically similar (P > 0.005 for all values). After SCI, upper extremity temperatures did not change in either group (P > 0.005); however, the surface temperature of the lower extremities in the Complete SCI Group elevated to 1.7 ± 0.5°C in comparison to 0.5 ± 0.1°C in the Incomplete SCI Group (P < 0.001). The scores of wake-up test in the Incomplete SCI Group were significantly different from that of the Complete SCI Group (P < 0.001), while white and gray matter damage was variable on histology. CONCLUSIONS Monitoring of changes of body surface temperature of the lower extremities can be potentially used to identify the completeness of SCI in a rabbit model.
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