1
|
Ferres A, Tercero-Uribe AI, Matas J, Alcubierre R, Codes M, Tafuto R, Camós-Carreras A, Muñoz-Lopetegi A, Tercero J, Alobid I, Sanchez-Dalmau B, Di Somma A, Enseñat J. Neurophysiologic Monitoring of Oculomotor Nerves During Transorbital Surgery: Proof of Concept and Anatomic Demonstration. Oper Neurosurg (Hagerstown) 2024; 27:287-294. [PMID: 38578710 DOI: 10.1227/ons.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/25/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Transorbital neuroendoscopic surgery (TONES) is continuously evolving and gaining terrain in approaching different skull base pathologies. The objective of this study was to present our methodology for introducing recording electrodes, which includes a new transconjunctival pathway, to monitor the extraocular muscle function during TONES. METHODS A translational observational study was performed from an anatomic demonstration focused on the transconjunctival electrode placement technique to a descriptive analysis in our series of 6 patients operated using TONES in association with intraoperative neurophysiologic monitoring of the oculomotor nerves from 2017 to 2023. The stepwise anatomic demonstration for the electrode placement and correct positioning in the target muscle was realized through cadaveric dissection. The descriptive analysis evaluated viability (obtention of the electromyography in each cranial nerve [CN] monitored), security (complications), and compatibility (interference with TONES). RESULTS In our series of 6 patients, 16 CNs were correctly monitored: 6 (100%) CNs III, 5 (83.3%) CNs VI, and 5 (83.3%) CNs IV. Spontaneous electromyography was registered correctly, and compound muscle action potential using triggered electromyography was obtained for anatomic confirmation of structures (1 CN III and VI). No complications nor interference with the surgical procedure were detected. CONCLUSION The methodology for introducing the recording electrodes was viable, secure, and compatible with TONES.
Collapse
Affiliation(s)
- Abel Ferres
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Ana Isabel Tercero-Uribe
- Department of Neurology, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Jessica Matas
- Institut Clinic Oftalmologia (ICOF), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Rafel Alcubierre
- Institut Clinic Oftalmologia (ICOF), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Marta Codes
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Roberto Tafuto
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Anna Camós-Carreras
- Institut Clinic Oftalmologia (ICOF), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Amaia Muñoz-Lopetegi
- Department of Neurology, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Javier Tercero
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Isam Alobid
- Department of Otorhinolaryngology, Institut Clinic d'Especialitats Mèdiques i Quirúrgiques (ICEMEQ), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Bernardo Sanchez-Dalmau
- Institut Clinic Oftalmologia (ICOF), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Alberto Di Somma
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Joaquim Enseñat
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| |
Collapse
|
2
|
Adams GM. Non-Invasive, Minimally-Invasive, and Deep-Invasive Extraocular Cranial Nerve Monitoring. World Neurosurg 2023:S1878-8750(23)00820-3. [PMID: 37423875 DOI: 10.1016/j.wneu.2023.06.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Affiliation(s)
- Gregory M Adams
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| |
Collapse
|
3
|
Doniz-Gonzalez A, Vigo V, Nunez MA, Xu Y, Mohyeldin A, Cohen-Gadol AA, Fernandez-Miranda JC. Microsurgical anatomy and the importance of the petrosal process of the sphenoid bone in endonasal surgery. J Neurosurg 2022; 137:1431-1442. [PMID: 35276642 DOI: 10.3171/2021.12.jns212024] [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: 08/23/2021] [Accepted: 12/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The petrosal process of the sphenoid bone (PPsb) is a relevant skull base osseous prominence present bilaterally that can be used as a key surgical landmark, especially for identifying the abducens nerve. The authors investigated the surgical anatomy of the PPsb, its relationship with adjacent neurovascular structures, and its practical application in endoscopic endonasal surgery. METHODS Twenty-one dried skulls were used to analyze the osseous anatomy of the PPsb. A total of 16 fixed silicone-injected postmortem heads were used to expose the PPsb through both endonasal and transcranial approaches. Dimensions and distances of the PPsb from the foramen lacerum (inferiorly) and top of the posterior clinoid process (PCP; superiorly) were measured. Moreover, anatomical variations and the relationship of the PPsb with the surrounding crucial structures were recorded. Three representative cases were selected to illustrate the clinical applications of the findings. RESULTS The PPsb presented as a triangular bony prominence, with its base medially adjacent to the dorsum sellae and its apex pointing posterolaterally toward the petrous apex. The mean width of the PPsb was 3.5 ± 1 mm, and the mean distances from the PPsb to the foramen lacerum and the PCP were 5 ± 1 and 11 ± 2.5 mm, respectively. The PPsb is anterior to the petroclival venous confluence, superomedial to the inferior petrosal sinus, and inferomedial to the superior petrosal sinus; constitutes the inferomedial limit of the cavernous sinus; and delimits the upper limit of the paraclival internal carotid artery (ICA) before the artery enters the cavernous sinus. The PPsb is anterior and medial to and below the sixth cranial nerve, forming the floor of Dorello's canal. During surgery, gentle mobilization of the paraclival ICA reveals the petrosal process, serving as an accurate landmark for the location of the abducens nerve. CONCLUSIONS This investigation revealed details of the microsurgical anatomy of the PPsb, its anatomical relationships, and its application as a surgical landmark for identifying the abducens nerve. This novel landmark may help in minimizing the risk of abducens nerve injury during transclival approaches, which extend laterally toward the petrous apex and cavernous sinus region.
Collapse
Affiliation(s)
- Ayoze Doniz-Gonzalez
- 1Department of Neurosurgery, Stanford Hospital, Stanford, California
- 2Department of Neurosurgery, Hospital Universitario de Canarias, La Laguna, Spain
| | - Vera Vigo
- 1Department of Neurosurgery, Stanford Hospital, Stanford, California
| | - Maximiliano Alberto Nunez
- 1Department of Neurosurgery, Stanford Hospital, Stanford, California
- 3Department of Neurosurgery, Hospital El Cruce, Buenos Aires, Argentina
| | - Yuanzhi Xu
- 1Department of Neurosurgery, Stanford Hospital, Stanford, California
- 4Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ahmed Mohyeldin
- 1Department of Neurosurgery, Stanford Hospital, Stanford, California
| | - Aaron A Cohen-Gadol
- 5Department of Neurological Surgery, Indiana University, Indianapolis; and
- 6The Neurosurgical Atlas, Carmel, Indiana
| | - Juan C Fernandez-Miranda
- 1Department of Neurosurgery, Stanford Hospital, Stanford, California
- 6The Neurosurgical Atlas, Carmel, Indiana
| |
Collapse
|
4
|
López JR, Legatt AD. Monitoring surgery around the cranial nerves. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:319-351. [PMID: 35772894 DOI: 10.1016/b978-0-12-819826-1.00020-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Intraoperative neurophysiologic monitoring (IONM) of cranial nerve (CN) function is an essential component in multimodality monitoring of surgical procedures where CNs are at risk for injury. In most cases, IONM consists of localizing and mapping CNs and their pathways, and monitoring of CN motor function during surgery. However, CN VIII, which has no motor function, and is at risk for injury in many surgical procedures, can be easily and accurately monitored using brainstem auditory evoked potentials. For motor CNs, the literature is clear that function can be safely and adequately performed using basic electromyographic (EMG) techniques, such as recording of continuous EMG activity and electrically evoked compound muscle actions potentials. Newer techniques, such as corticobulbar motor evoked potentials and reflex studies, show good potential for a greater degree of functional assessment but require further study to determine their clinical utility. EMG remains the basic clinical neurophysiologic technique with the greatest clinical research supporting its utility in IONM of motor CN function and should be used as part of a comprehensive multimodality IONM protocol. Understanding the physiologic basis of EMG and the changes associated with altered motor function will allow the practitioner to alter surgical course to prevent injury and improve patient safety.
Collapse
Affiliation(s)
- Jaime R López
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States.
| | - Alan D Legatt
- Department of Neurology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, United States
| |
Collapse
|
5
|
Kuroda N, Inenaga C, Katori N, Sameshima T, Suzuki M, Tomoto K, Tanaka T. Electrode placement into the lateral rectus muscle during intraoperative monitoring: a novel approach. Clin Neurophysiol 2022; 139:76-79. [DOI: 10.1016/j.clinph.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/12/2022] [Accepted: 04/15/2022] [Indexed: 11/03/2022]
|
6
|
Oishi T, Van Gompel JJ, Link MJ, Tooley AA, Hoffman EM. Intraoperative lateral rectus electromyographic recordings optimized by deep intraorbital needle electrodes. Clin Neurophysiol 2021; 132:2510-2518. [PMID: 34454280 DOI: 10.1016/j.clinph.2021.08.002] [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: 06/04/2021] [Revised: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We demonstrate the advantages and safety of long, intraorbitally-placed needle electrodes, compared to standard-length subdermal electrodes, when recording lateral rectus electromyography (EMG) during intracranial surgeries. METHODS Insulated 25 mm and uninsulated 13 mm needle electrodes, aimed at the lateral rectus muscle, were placed in parallel during 10 intracranial surgeries, examining spontaneous and stimulation-induced EMG activities. Postoperative complications in these patients were reviewed, alongside additional patients who underwent long electrode placement in the lateral rectus. RESULTS In 40 stimulation-induced recordings from 10 patients, the 25 mm electrodes recorded 6- to 26-fold greater amplitude EMG waveforms than the 13 mm electrodes. The 13 mm electrodes detected greater unwanted volume conduction upon facial nerve stimulation, typically exceeding the amplitude of abducens nerve stimulation. Except for one case with lateral canthus ecchymosis, no clinical or radiographic complications occurred in 36 patients (41 lateral rectus muscles) following needle placement. CONCLUSIONS Intramuscular recordings from long electrode in the lateral rectus offers more reliable EMG monitoring than 13 mm needles, with excellent discrimination between abducens and facial nerve stimulations, and without significant complications from needle placement. SIGNIFICANCE Long intramuscular electrode within the orbit for lateral rectus EMG recording is practical and reliable for abducens nerve monitoring.
Collapse
Affiliation(s)
- Tatsuya Oishi
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55902, USA.
| | - Jamie J Van Gompel
- Department of Neurosurgery, Mayo Clinic, 200 First St SW, Rochester, MN 55902, USA
| | - Michael J Link
- Department of Neurosurgery, Mayo Clinic, 200 First St SW, Rochester, MN 55902, USA
| | - Andrea A Tooley
- Department of Ophthalmology, Mayo Clinic, 200 First St SW, Rochester, MN 55902, USA
| | - Ernest M Hoffman
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55902, USA.
| |
Collapse
|
7
|
Jeong HN, Ahn SI, Na M, Yoo J, Kim W, Jung IH, Kang S, Kim SM, Shin HY, Chang JH, Kim EH. Triggered Electrooculography for Identification of Oculomotor and Abducens Nerves during Skull Base Surgery. J Korean Neurosurg Soc 2020; 64:282-288. [PMID: 33353290 PMCID: PMC7969041 DOI: 10.3340/jkns.2020.0179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/10/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Electrooculography (EOG) records eyeball movements as changes in the potential difference between the negatively charged retina and the positively charged cornea. We aimed to investigate whether reliable EOG waveforms can be evoked by electrical stimulation of the oculomotor and abducens nerves during skull base surgery. METHODS We retrospectively reviewed the records of 18 patients who had undergone a skull base tumor surgery using EOG (11 craniotomies and seven endonasal endoscopic surgeries). Stimulation was performed at 5 Hz with a stimulus duration of 200 μs and an intensity of 0.1-5 mA using a concentric bipolar probe. Recording electrodes were placed on the upper (active) and lower (reference) eyelids, and on the outer corners of both eyes; the active electrode was placed on the contralateral side. RESULTS Reproducibly triggered EOG waveforms were observed in all cases. Electrical stimulation of cranial nerves (CNs) III and VI elicited positive waveforms and negative waveforms, respectively, in the horizontal recording. The median latencies were 3.1 and 0.5 ms for craniotomies and endonasal endoscopic surgeries, respectively (p=0.007). Additionally, the median amplitudes were 33.7 and 46.4 μV for craniotomies and endonasal endoscopic surgeries, respectively (p=0.40). CONCLUSION This study showed reliably triggered EOG waveforms with stimulation of CNs III and VI during skull base surgery. The latency was different according to the point of stimulation and thus predictable. As EOG is noninvasive and relatively easy to perform, it can be used to identify the ocular motor nerves during surgeries as an alternative of electromyography.
Collapse
Affiliation(s)
- Ha-Neul Jeong
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Myongji Hospital, Goyang, Korea
| | - Sang-Il Ahn
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Minkyun Na
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jihwan Yoo
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Woohyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - In-Ho Jung
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Soobin Kang
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Brain Tumor Center, Severance Hospital, Seoul, Korea
| | - Eui Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Brain Tumor Center, Severance Hospital, Seoul, Korea
| |
Collapse
|
8
|
A novel needle electrode for intraoperative fourth cranial nerve neurophysiological mapping. Neurosurg Rev 2020; 44:2355-2361. [PMID: 32909164 DOI: 10.1007/s10143-020-01381-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/09/2020] [Accepted: 08/28/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Trochlear nerve (CN-IV) mapping method has not been confirmed to date. The compound muscle action potential (CMAP) of CN-IV cannot be recorded because of the low mapping sensitivity and anatomical characteristics of the superior oblique muscle (SOM). The aim of this study was to evaluate the effectiveness of a novel needle electrode (NNE), for the intraoperative mapping of CN-IV. MATERIALS AND METHODS The NNEs were inserted in the target extraocular muscles in 19 patients. We compared the CMAP amplitude of the NNE with that of the conventional needle electrode (CNE). Furthermore, we investigated the dissimilarity between the CMAP of the CN-IV and other extraocular cranial nerves (ECNs) and the correlation between the readings of the CN-IV mapping and its postoperative functional outcome. RESULTS The CMAP of CN-IV has been measured in nine patients (47.4%). The CMAP of CN-IV was distinguishable from other ECNs. The CMAP of the NNE was found to be three times higher than that of the CNE. Although the NNE has shown the potential to record the CN-IV's CMAP, 4 cases ended up having a CN-IV postoperative dysfunction. CONCLUSIONS For the first time, we confirmed the possibility of intraoperative mapping the CN-IV using an NNE inserted into the SOM. The NNE can also be useful for other neurophysiological monitoring methods.
Collapse
|
9
|
Bowen RC, Possin ME, Altaweel MM. Bilateral Globe Penetration From Electromyography Electrode Placement for Intraoperative Neurophysiologic Monitoring. JOURNAL OF VITREORETINAL DISEASES 2020; 4:136-138. [PMID: 37008380 PMCID: PMC9976254 DOI: 10.1177/2474126419868888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: This interventional case report discusses inadvertent bilateral temporal globe penetration during placement of intramuscular wire electrodes to the lateral rectus muscles for intraoperative neurophysiological monitoring (IONM) via electromyography. Methods: An 11-year-old girl underwent surgical resection of massive medulloblastoma within the fourth ventricle, requiring IONM. Placement of an electrode in each lateral rectus muscle resulted in bilateral globe penetration, with choroidal rupture, retinal tears, and hemorrhage. Results: Sterile needle perforation of the globe did not result in endophthalmitis. Encircling laser retinopexy was performed, and no retinal detachments occurred. Conclusions: Insertion of needle electrodes without guidance imaging can potentially lead to globe penetration and incorrect electrode placement. Direct visualization with ultrasound, electromyography, or other advanced image-guided systems may offer a safe solution for electrode placement to avoid injury. Verbal patients should be made aware of postoperative warning signs of globe penetration. For nonverbal patients, a postoperative dilated exam is warranted.
Collapse
Affiliation(s)
- Randy C. Bowen
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Michael E. Possin
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Michael M. Altaweel
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| |
Collapse
|
10
|
Lim SH, Park SB, Moon DY, Kim JS, Choi YD, Park SK. Principles of Intraoperative Neurophysiological Monitoring with Insertion and Removal of Electrodes. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2019. [DOI: 10.15324/kjcls.2019.51.4.453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Sung Hyuk Lim
- Department of Neurology, Institute of Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Soon Bu Park
- Physiologic Diagnostic Laboratory, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dae Young Moon
- Department of Neurosurgery, Ajou University Hospital, Suwon, Korea
| | - Jong Sik Kim
- Department of Neurology, Asan Medical Center, Seoul, Korea
| | - Young Doo Choi
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Ku Park
- Department of Neurology, Institute of Neuroscience Center, Samsung Medical Center, Seoul, Korea
| |
Collapse
|
11
|
Abstract
During surgery, one of the primary functions of the anesthesiologist is to monitor the patient and ensure safe and effective conduct of anesthesia to provide the optimum operating conditions. Standard guidelines for perioperative monitoring have been firmly established by the American Society of Anesthesiologists. However, in recent years, new advances in technology has led to the development of many new monitoring modalities, especially involving the neurologic and cardiovascular systems. This article presents a targeted review to discuss the functions and limitations of these new monitors and how they are applied in the modern operating room setting.
Collapse
Affiliation(s)
- Yi Deng
- Department of Anesthesiology and Critical Care Medicine, Baylor College of Medicine, 1 Baylor Plaza, MSC 120, Houston, TX 77030, USA.
| | - Jovany Cruz Navarro
- Department of Anesthesiology, Baylor College of Medicine, 1 Baylor Plaza, MSC 120, Houston, TX 77030, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Sandeep Markan
- Department of Anesthesiology and Critical Care Medicine, Baylor College of Medicine, 1 Baylor Plaza, MSC 120, Houston, TX 77030, USA
| |
Collapse
|
12
|
Shkarubo AN, Chernov IV, Ogurtsova AA, Chernov VE, Borisov OV, Koval KV, Andreev DN. Cranial nerve monitoring in endoscopic endonasal surgery of skull base tumors (observing of 23 cases). Chin Neurosurg J 2018; 4:38. [PMID: 32922898 PMCID: PMC7398298 DOI: 10.1186/s41016-018-0146-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/01/2018] [Indexed: 12/03/2022] Open
Abstract
Background Preservation of anatomic integrity and function of the cranial nerves during the removal of skull base tumors is one of the most challenging procedures in endoscopic endonasal surgery. It is possible to use intraoperative mapping and identification of the cranial nerves in order to facilitate their preservation. The purpose of this study was to evaluate the effectiveness of intraoperative trigger electromyography in prevention of iatrogenic damage to the cranial nerves. Methods Twenty three patients with various skull base tumors (chordomas, neuromas, pituitary adenomas, meningiomas, cholesteatomas) underwent mapping and identification of cranial nerves during tumor removal using the endoscopic endonasal approach in Department of Neurooncology of Federal State Autonomous Institution “N.N. Burdenko National Medical Research Center of Neurosurgery” of the Ministry of Health of the Russian Federation from 2013 to 2018. During the surgical interventions, mapping and identification of the cranial nerves were carried out using electromyography in triggered mode. The effectiveness of the method was evaluated based on a comparison with a control group (41 patients). Results In the main group of patients, 44 nerves were examined during surgery using triggered electromyography. During the study, the III, V, VI, VII, and XII cranial nerves were identified intraoperatively. Postoperative cranial nerve deficiency was observed in 5 patients in the study group and in 13 patients in the control group. The average length of hospitalization was 9 days. Conclusion We did not receive statistically significant data supporting the fact that intraoperative identification of cranial nerves using trigger electromyography reduces the incidence of postoperative complications in the form of cranial nerve deficits (p = 0.56), but the odds ratio (0.6) suggests a less frequent occurrence of complications in the study group. Based on our experience, the trigger electromyography methodology appears quite promising and requires further research.
Collapse
Affiliation(s)
- A N Shkarubo
- Department of Neurooncology, Federal State Autonomous Institution "N.N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - I V Chernov
- Department of Neurooncology, Federal State Autonomous Institution "N.N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - A A Ogurtsova
- Department of Neurophysiology, Federal State Autonomous Institution "N.N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - V E Chernov
- Department of Neurosurgery, N.N. Burdenko Main Military Clinical Hospital of the Ministry of Defense of the Russian Federation, Moscow, Russia
| | - O V Borisov
- Laboratory of Molecular Human Genetics, Federal Research and Clinical Center of Physical-Chemical Medicine of Federal Medical Biological Agency, Moscow, Russia
| | - K V Koval
- Department of Neurooncology, Federal State Autonomous Institution "N.N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - D N Andreev
- Department of Neurooncology, Federal State Autonomous Institution "N.N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation, Moscow, Russia
| |
Collapse
|
13
|
Sakata K, Suematsu K, Takeshige N, Nagata Y, Orito K, Miyagi N, Sakai N, Koseki T, Morioka M. Novel method of intraoperative ocular movement monitoring using a piezoelectric device: experimental study of ocular motor nerve activating piezoelectric potentials (OMNAPP) and clinical application for skull base surgeries. Neurosurg Rev 2018; 43:185-193. [PMID: 30209640 DOI: 10.1007/s10143-018-1028-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/10/2018] [Accepted: 08/28/2018] [Indexed: 11/25/2022]
Abstract
Intraoperative monitoring systems that utilize various evoked potentials for the detection and/or preservation of cranial nerves have become increasingly common due to recent technical and commercial developments, particularly during skull base surgeries. We established a novel system for the intraoperative monitoring of the extraocular motor nerves (eOMNs) using a piezoelectric device capable of detecting imperceptible vibrations induced by ocular movement, with sensors placed on the eyelids alone. We first evaluated the efficacy and reliability of this device for the intraoperative monitoring of eOMNs in two Beagle dogs. Based on the results, we then determined the appropriate stimulation parameters for use in human surgical cases involving removal of various skull base tumors. Animal experiments revealed that a 0.4 mA monopolar electrical stimulation was required to elicit significant responses and that these responses were not inferior to those obtained via the electrooculogram/electromyogram. Significant responses were also detected in preliminary clinical investigations in human patients, following both direct and indirect monopolar electrical stimulation of the oculomotor and abducens nerves, although obtaining responses from the trochlear nerve was difficult. Intraoperative monitoring using a piezoelectric device provides a simple and reliable method for detecting eOMNs, especially the oculomotor and abducens nerves. This monitoring system can be adapted to various surgeries for skull base tumor.
Collapse
Affiliation(s)
- Kiyohiko Sakata
- Department of Neurosurgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka, 830-0011, Japan.
| | - Keiko Suematsu
- Department of Neurosurgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka, 830-0011, Japan
| | - Nobuyuki Takeshige
- Department of Neurosurgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka, 830-0011, Japan
| | - Yui Nagata
- Department of Neurosurgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka, 830-0011, Japan
| | - Kimihiko Orito
- Department of Neurosurgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka, 830-0011, Japan
| | - Naohisa Miyagi
- Department of Neurosurgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka, 830-0011, Japan
| | - Naoki Sakai
- Unique Medical Co., Ltd., 1-13-5, Izumihon-cho, Komae-shi, Tokyo, 201-0003, Japan
| | - Tsunekazu Koseki
- Unique Medical Co., Ltd., 1-13-5, Izumihon-cho, Komae-shi, Tokyo, 201-0003, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka, 830-0011, Japan
| |
Collapse
|
14
|
Li ZY, Li MC, Liang JT, Bao YH, Chen G, Guo HC, Ling F. Usefulness of intraoperative electromyographic monitoring of oculomotor and abducens nerves during skull base surgery. Acta Neurochir (Wien) 2017; 159:1925-1937. [PMID: 28766024 DOI: 10.1007/s00701-017-3268-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Intraoperative neurophysiologic monitoring of the extraocular cranial nerve (EOCN) is not commonly performed because of technical difficulty and risk, reliability of the result and predictability of the postoperative function of the EOCN. METHODS We performed oculomotor nerve (CN III) and abducens nerve (CN VI) intraoperative monitoring in patients with skull base surgery by recording the spontaneous muscle activity (SMA) and compound muscle action potential (CMAP). Two types of needle electrodes of different length were percutaneously inserted into the extraocular muscles with the free-hand technique. We studied the relationships between the SMA and CMAP and postoperative function of CN III and CN VI. RESULTS A total of 23 patients were included. Nineteen oculomotor nerves and 22 abducens nerves were monitored during surgery, respectively. Neurotonic discharge had a positive predictive value of less than 50% and negative predictive value of more than 80% for postoperative CN III and CN VI dysfunction. The latency of patients with postoperative CN III dysfunction was 2.79 ± 0.13 ms, longer than that with intact CN III function (1.73 ± 0.11 ms). One patient had transient CN VI dysfunction, whose CMAP latency (2.54 ms) was longer than that of intact CN VI function (2.11 ± 0.38 ms). There was no statistically significant difference between patients with paresis and with intact function. CONCLUSIONS The method of intraoperative monitoring of EOCNs described here is safe and useful to record responses of SMA and CMAP. Neurotonic discharge seems to have limited value in predicting the postoperative function of CN III and CN VI. The onset latency of CMAP longer than 2.5 ms after tumor removal is probably relevant to postoperative CN III and CN VI dysfunction. However, a definite quantitative relationship has not been found between the amplitude and stimulation intensity of CMAP and the postoperative outcome of CN III and CN VI.
Collapse
|
15
|
Preoperative simulation of the running course of the abducens nerve in a large petroclival meningioma: a case report and literature review. Neurosurg Rev 2017; 40:339-343. [DOI: 10.1007/s10143-017-0816-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 12/21/2016] [Accepted: 01/18/2017] [Indexed: 12/22/2022]
|
16
|
Singh H, Vogel RW, Lober RM, Doan AT, Matsumoto CI, Kenning TJ, Evans JJ. Intraoperative Neurophysiological Monitoring for Endoscopic Endonasal Approaches to the Skull Base: A Technical Guide. SCIENTIFICA 2016; 2016:1751245. [PMID: 27293965 PMCID: PMC4886091 DOI: 10.1155/2016/1751245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/04/2016] [Accepted: 04/11/2016] [Indexed: 06/06/2023]
Abstract
Intraoperative neurophysiological monitoring during endoscopic, endonasal approaches to the skull base is both feasible and safe. Numerous reports have recently emerged from the literature evaluating the efficacy of different neuromonitoring tests during endonasal procedures, making them relatively well-studied. The authors report on a comprehensive, multimodality approach to monitoring the functional integrity of at risk nervous system structures, including the cerebral cortex, brainstem, cranial nerves, corticospinal tract, corticobulbar tract, and the thalamocortical somatosensory system during endonasal surgery of the skull base. The modalities employed include electroencephalography, somatosensory evoked potentials, free-running and electrically triggered electromyography, transcranial electric motor evoked potentials, and auditory evoked potentials. Methodological considerations as well as benefits and limitations are discussed. The authors argue that, while individual modalities have their limitations, multimodality neuromonitoring provides a real-time, comprehensive assessment of nervous system function and allows for safer, more aggressive management of skull base tumors via the endonasal route.
Collapse
Affiliation(s)
- Harminder Singh
- Stanford Hospitals and Clinics, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Richard W. Vogel
- Safe Passage Neuromonitoring, 915 Broadway, Suite 1200, New York, NY 10010, USA
| | - Robert M. Lober
- Stanford Hospitals and Clinics, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Adam T. Doan
- Safe Passage Neuromonitoring, 915 Broadway, Suite 1200, New York, NY 10010, USA
| | - Craig I. Matsumoto
- Sentient Medical Systems, 11011 McCormick Road, Suite 200, Hunt Valley, MD 21031, USA
| | - Tyler J. Kenning
- Department of Neurosurgery, Albany Medical Center, Physicians Pavilion, First Floor, 47 New Scotland Avenue, MC 10, Albany, NY 12208, USA
| | - James J. Evans
- Thomas Jefferson University Hospital, Department of Neurosurgery, 909 Walnut Street, Third Floor, Philadelphia, PA 19107, USA
| |
Collapse
|
17
|
Intraoperative neurophysiological monitoring of microvascular decompression for glossopharyngeal neuralgia. J Clin Neurophysiol 2014; 31:337-43. [PMID: 25083845 DOI: 10.1097/wnp.0000000000000070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To evaluate if adding cranial nerves (CNs) V and VI to standard intraoperative neurophysiological monitoring (IONM) of microvascular decompressions for glossopharyngeal neuralgia improve its efficacy. METHODS We reviewed all patients who received a microvascular decompression for glossopharyngeal neuralgia at our institution between January 2008 and August 2012. All received upper extremity somatosensory evoked potentials, brainstem auditory evoked potentials, and free-running electromyography of muscles innervated by ipsilateral CNs VII, IX, and X. The sample was divided into 12 patients who received additional monitoring of CNs V and VI and 15 who did not. RESULTS No difference on neurotonic activity presence was found on CN V (standard IONM: 0% versus additional CNs IONM: 8.33%; p = 0.423), CN VI (never present on the additional CN patients), CN VII (standard IONM: 73.33% versus additional CNs IONM: 66.64%; p = 0.973), CN IX (standard IONM: 40.0% versus additional CNs IONM: 25.0%; p = 0.683), or CN X (standard IONM: 46.67% versus additional CNs IONM: 33.33%; p = 0.701) between groups. Additionally, no differences of brainstem auditory evoked potentials wave V's delay, and amplitude at the end of the decompression, or closing of the case were found between groups. CONCLUSIONS Monitoring free-running electromyography of additional CNs V and VI does not improve the efficacy of IONM of microvascular decompressions for glossopharyngeal neuralgia.
Collapse
|